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					                                                  Coopération Technique Belge




                            TERMS OF REFERENCE
  “PROVISION OF BASIC HEALTH SERVICES IN SIEM REAP &
                   ODDAR MEANCHEY
                  N° KAM 02 007 11(NAVISION CODE)
                                    &
“PROVISION OF BASIC HEALTH SERVICES IN KAMPONG CHAM”
                  N° KAM 03 009 11(NAVISION CODE)


                             COUNTRY : CAMBODIA




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                                                                                                                       Coopération Technique Belge




                                                              Table of Content

1.     INTRODUCTION................................................................................................... 3
2.     INTERVENTION BACKGROUND ...................................................................... 3
     2.1.       PBHS-SR/OMC ................................................................................................................................... 3
     2.2.       PBHS-Kampong Cham ....................................................................................................................... 8
3.     PURPOSE OF THE MID-TERM REVIEW .........................................................16
4.     STAKEHOLDER INVOLVEMENT DURING THE MID-TERM REVIEW ...16
5.     PROJECT AREA TO VISIT ...................................................................................18
6.     CRITERIA TO BE STUDIED ...............................................................................19
     6.1.       Basic criteria .........................................................................................................................................19
     6.2.       HARMO-criteria for strengthening the aid effectiveness ............................................................21
     6.3.       Transversal themes .............................................................................................................................23
7.     METHODOLOGY OF THE MID-TERM REVIEW .......................................... 25
8.     DELIVERABLES OF THE MID-TERM REVIEW ............................................ 26
9.     PERIOD AND DURATION OF THE MID-TERM REVIEW........................... 26
10.          COURSE OF THE MID-TERM REVIEW ....................................................... 26
11.          COMPOSITION OF THE MID-TERM REVIEW TEAM .............................. 27
     11.1.      Reference team ....................................................................................................................................27
     11.2.      Mid-term review team ........................................................................................................................27
     11.3.      Profiles & responsibilities of the Consultants ................................................................................27
12.          WORK PLAN AND TIME SCHEDULE .......................................................... 29
13.          ANNEXES ...........................................................................................................31
     13.1.      Annex 1: monthly inpatients by referral hospital in Kampong Cham .......................................31
     13.2.      Annex 2: HEF-supported inpatients versus total inpatients in Kampong Cham (+costing) .32
     13.3.      Annex 3: incentives ($) and staffing by contracted facility in Kampong Cham .......................33


List of abbreviations

BTC                                 Belgian Technical Cooperation
CDHS                                Cambodian Demographic and Health Survey
CPA                                 Complementary Package of Activities
HC                                  Health Centre
HEF                                 Health Equity Fund
MoH                                 Ministry of Health
MPA                                 Minimum Package of Activities
MTR                                 Mid-Term Review
OD                                  Operational Health District
OMC                                 Otdar Meanchey province
PBHS-KC                             Provision of Basic Health Services in Kampong Cham province
PBHS-SR/OMC                         Provision of Basic Health Services in Siem Reap and Otdar Meanchey
                                    provinces
PHD                                 Provincial Health Department

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                                                                     Coopération Technique Belge




PMU                  Project Management Unit
RH                   Referral Hospital
TFF                  Technical and Financial File


1. Introduction
The Provision of Basic Health Services in Siem Reap and Otdar Meanchey provinces (PBHS-
SR/OMC) and in Kampong Cham province (PBHS-KC) are two Cambodian-Belgian bilateral
co-operation health projects supporting the delivery of health services in Siem Reap, Otdar
Meanchey and Kampong Cham provinces. The timeframe of the two projects is four years,
starting respectively in June and November 2004. Although they are two separate projects,
they share most of the objective, implementation and monitoring and evaluation strategies.
According to the Technical and Financial File (TFF) of the projects, it is expected for each
project to have 3 separate assessments: baseline survey, mid-term review and end project
evaluation. The baseline surveys were done in the beginning of the projects and the reports
are available. As part of the project monitoring & evaluation, mid-term review (MTR) is “a
two-year overview on system performance, activities, internal & external auditing, and lessons
learned” to be carried out by an independent international body. It is expected that the MTR
of the two projects (PBHS-SR/OMC and PBHS-KC) will be done separately, one after
another or at the same time, by the same consultancy firm.
Based on the findings, the reviewer will make recommendations to re-orientate the project
implementation for the remaining two years and advice on the need and relevance of
continuation of the projects, referred to as „consolidation phase‟, and finally propose
amendments to TFF.


2. Intervention background
Although both projects the PBHS-SR/OMC and PBHS-KC have many similarities, the
background of the two projects may differ significantly for several dimensions. They have
been coordinated and implemented independently but have increasingly been collaborating on
the planning and implementation of several activities and in the exchange of experiences.
Since the Project Co-Director of PBHS-SR/OM has resigned with effect of July 2006 both
projects are coordinated by one person who is Project Co-Director for both projects.
At present a consultant, health economist, is developing several scenarios and their costing for
the future of the HEF and the Contracting components. This is done for the remaining period
of the project as well as for the possible consolidation phase. They will be ready before the
MTR takes place.
Because of the differences between the two projects the background of both interventions is
described separately. This results in quite some repetition but it is the only way to be clear and
complete.

    2.1. PBHS-SR/OMC
        2.1.1.      Agreements
The project « Provision of Basic Health Services in Siem Reap & Oddar Meanchey (title of the
project) » is a direct bilateral project between the Kingdom of Cambodia and The Kingdom of


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                                                                                             Coopération Technique Belge




Belgium. A Specific Agreement was signed between both parties on 16 Dec 2003 date of
signature and will last until 16 Dec 2008 (end of the Specific Convention).
          2.1.2.           Project context
It is a 4-year project, which started on 01 June 2004 and is expected to end on 31 May 2008.
The total Belgian budget for this project is € (see Specific Convention, Belgian contribution
and partner country contribution) 4,580,000 of which €3,722,000 is co-managed and €858,000
is under sole management of Belgian party (regie) (specify if the project is managed in „co-
gestion‟ or „regie‟). The project covers two provinces of Cambodia, Siem Reap and Otdar
Meanchey, where there are about 1 million inhabitants.
The fast changing provinces of Siem Reap and OMC become lands of immigration, which
speeds up the population growth in these provinces. They remain among the poorest
provinces in the country despite the development of tourism which has little impact on the
economic status of the surrounding population. Life has become quite costly, Siem Reap
being probably the most costly city of Cambodia.
According to the new health coverage plan revised in 2003, Siem Reap province is divided in 4
Operational Health Districts (OD): Siem Reap, Sotnikum, Kralanh, and Angkor Chhum.
There are 60 health centres (only 54 are functioning MPA health centres)1 and 3 functioning
referral hospitals, including the provincial hospital of Siem Reap. Angkor Chum is a newly
created OD. It is planned to develop a referral hospital for this new OD in 2006. In OMC
province, there is only one OD with 14 functioning MPA health centres and one referral
hospital, the provincial hospital of OMC. It is to notify that there are two big not-for-profit
paediatric hospitals in Siem Reap, Jayavarman VII & Angkor Children hospital.
In general, health conditions in Cambodia continue to be poor compared with other Asian
countries. Poverty, life expectancy, infant mortality and maternal mortality remain among the
highest in the continent. The performance of the public health system is jeopardized by
insufficient budget allocation, very low salaries, poor management and active competition with
an anarchic and costly private sector of bad quality.


          2.1.3.           Project objectives (see Logical Framework)
The general objective of the project is to improve the health of the population, especially of
mothers and children, thereby contributing to poverty alleviation and socio-economic
development in Siem Reap and Otdar Meanchey provinces. More specifically, the project
enhances health sector development through supporting the provincial Plans in line with the 6
key areas in the Health Sector Strategic Plan 2003-2007. The project targets especially the
most poor and vulnerable. The project consists of six major components:
     1. free quality health care for the poor through the set up of Health Equity Funds;
     2. promotion of better health behaviour;
     3. strengthening of health services delivery through contracting;
     4. support to quality improvement initiatives and training;
     5. training and capacity building; and
     6. management strengthening and institutional development.


1 The functioning MPA health centres are those being able to provide complete “Minimum Package of Activities” services as
recommended by the MoH guidelines.


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Additional to the main objective of the project to improve directly the health situation of the
population in the 2 provinces, the project also aims at contributing in a policy dialogue on
crucial health matters in order to improve the national health policy. This would influence the
health status of the country‟s population as a whole and adds a more structural and strategic
dimension to the project.


                2.1.4.                   Results & indicators
As the project supports the Provincial Health Departments, most of the results of the
Provincial Health Departments are the results of the project. In the table below is the
summary of the health input, process and output indicators of the two provinces from 2003 to
2005. The project formulation report also recommended 67 input, process, output & outcome
or impact indicators, of which most are overlap with the provincial indicators (See the 67
indicators in TFF). Routine data on Health Management Information System, project surveys,
and national surveys such as Cambodian Demographic and Health Surveys (CDHS) will allow
us to fill out the 67 indicators. A project baseline population-based household survey was
done in early 2005. Information related to 20 main indicators of the project were collected to
allow for project progress measurement. The survey also gives valuable information for policy
and health planning purposes in the coming years. The CDHS 2000 report, in which
information on mortality, health seeking behaviour and health expenditure can be found, has
been made available and the CDHS 2005 is being finalised.
To date, the project has produced many particular results, which can be described as follows:
Output-related Contracting is the biggest component of the project in terms of budget
allocation and technical assistance, one of the key project strategies to boost health services
delivery. The performance contracts are developed at all levels (health centres, referral
hospitals, operational district offices & provincial health department offices) of the provincial
health system. They are institutions-based contracts. The contracting addresses low staff
motivation by providing them incentives & bonus based on their performance and
achievements (in relation to an agreed set of process and output indicators). Within the
contracts, the health staff has to ensure 24 hour services, respect golden rules2 and the
internal regulations of their own institutions. Performance of contracted facilities are closely
monitored and assessed by existing supervisory teams at the district & provincial levels and by
provincial Monitoring Team.
By June 2006, 60 out of 69 operational health centres, all the 4 referral hospitals, 4 operational
district offices and 2 provincial health department offices in the two provinces have been put
under the output-related contracting.
The impact of these contracts has still to be carefully assessed. But the results in terms of staff
motivation, availability of services and increase of health activities is obvious.
Health Equity Fund for the poor is the second largest component of the project. The
objective of this activity is twofold: improve access to quality health care for the poor and
prevent them from falling into deeper poverty. This contributes to poverty alleviation in the
project‟s area.
To avoid conflicts of interests, the project contracted a local non-governmental organisation,
as a third party in health care service delivery, to operate the fund. This has been done
through a bidding procedure.


2 no cheating data (inflate the figure), no under-the-table payment, no poaching patients, no embezzlement of drugs & materials



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By June 2006, HEF is fully operational in 4 main referral hospitals of OMC, Siem Reap,
Sonikum, Kralanh and 6 health centers of Anlong Veng in OMC and Svay Lue, Kvav, Popel,
Samrong, Chansor in Sonikum operational district.
The beneficiaries (the poor) are identified by at their home before they are sick (pre-
identification) or at the hospital when they seek care (post-identification). The eligible poor
patients receive at hospital level, one or more of the following benefits: (1) reimbursement of
user fees charged by the hospitals, (2) transportation cost, (3) food and (4) other social
support (e.g. funeral).
All the facilities with HEF show an increase of utilisation mainly by the poor. On average,
42% (4,751 inpatients) of the patients hospitalized in the related facilities in 2005 (11,284
inpatients) and 26,166 outpatients have benefited from HEF support. For the whole year of
2005, the project spent US$145,000 in HEF, of which 55% contributed to the income of the
health facilities and 25% were used for the NGOs operational costs.
Behaviour Change Communication focused on six activities: (1) a quarterly health
newsletter; (2) school health education in collaboration with education project; (3) a road
safety campaign, including promotion of helmet utilisation; (4) marketing of public health
services through local media; (5) emergency preparedness, mainly for Avian Influenza
outbreak; and (6) the support to special events such as World AIDS Day, World Tobacco-
Free Day, and World Breastfeeding Day. The main activities for Quality Improvement in
2005 were: (1) Revolving Fund to bridge the gap of state budget disbursement for some
priority activities; (2) incentives for achieving quality criteria in hospitals; (3) assistance to
overall management through the Management Committee of Siem Reap Provincial Hospital;
(4) support for the purchase of necessary drugs & materials for hospitals; (5) QI Skills
Development Training; (6) QI interventions to improve hygiene and waste management,
patients records and emergency care; and (7) hospital performance assessments. Many
training sessions and workshops have been organised with the assistance of the project.
Among the most significant ones are 4-month midwife training for nurses, surgical congress in
Siem Reap, Health Services Management Training and Hospital Management Training at
National Institute of Public Health in Phnom Penh, health system research training in Hanoi
for two doctors and training on Health Sector Reform in Amsterdam for the director of
Planning Department, Ministry of Health. No proper assessment of impact of the training is
done yet. However, there is a need for better assessment of the human resources development
issues and for better planning for the future training to improve the efficiency of the training
component. As part of Institutional Development, The project provided financial and
technical support to Siem Reap and Otdar Meanchey provincial health departments for their
Annual Operational Plan development and quarterly & six monthly reviews. In country study
tours were organized in Takeo, Mongol Borey, Phnom Penh and Kirivong. The project
participated in several important discussion groups in Phnom Penh such as the National
Technical Working Group-Health, the working group on the national framework for Health
Equity Fund implementation and monitoring, the working group on harmonization of
identification of poor households, the working group on hospital reforms, and the monthly
inter-sectoral working group on avian flu preparedness.
The following are the project related data and reports which are available:
     Project baseline report,
     Project progress reports, mainly the Annual Report 2004, Annual Report 2005 and the
      Q1 & Q2 2006 report,
     Minutes of the first, second and third project Steering Committee meetings,


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         HEF consultancy reports by Mathieu Noirhomme, and
         Consultancy reports on Siem Reap provincial hospital management, master plan &
          feasibility study of health insurance.
Siem Reap and Otdar Meanchey Provincial Indicators
                                                                                                                         Siem Reap                    Otdar Meanchey
   No                                               Indicators
                                                                                                             2003           2004   2005           2003     2004    2005
Key area of work 1: Health Service Delivery
   1    % of planned HCs that are fully functioning as MPA HCs (1)                                                  96           85         85         91           91          93
   2    % of RHs providing CPA1/CPA2/CPA3                                                                         100            75         75       100          100         100
   3    New consultations per inhabitant per year                                                                0.45         0.46       0.53         0.4        0.31        0.43
   4    New consultations per child aged 0-59 months per year (2)                                                0.53         0.38       0.81       0.54         0.51        0.77
   5    New consultations per woman per year (3)                                                                   0.5        0.54       0.58       0.40         0.34        0.45
   6    % of deliveries attended by trained health staff (4)                                                        45           36         35         15           14          19
   7    % of women attending ANC identifid as at risk                                                               24           20         34         24           13          17
   8    % of pregnant women who received at least 2 ANC consulations (4)                                            47           48         57         36           47          60
   9    Return rate for ANC consultations                                                                          2.1          2.4        2.5        2.1          2.3         2.4
  10 % of pregnant women who received at least 2 TT vaccinations (4)                                                47           36         32         46           51          48
  11 % of married women aged 15-49 years using a modern contraceptive method (5)                                    19           30         20         20           24          31
  12 % of children <1 year who received BCG vaccination (6)                                                         87           89         88         86           95          87
  13 % of children <1 year who received measles vaccination (6)                                                     85           84         84         61           90          89
  14 DTC1-DTC3 drop-out rate                                                                                       2.3          4.3        4.4         10            6         2.6
  15 Average # of integrated outreach visits per village per year                                                   15           17         11    N/A          N/A         N/A
  16 # of hospital admissions per 1000 inhabitants                                                               14.4            14         13         27           17          25
  17 # of children aged 0-59 months admitted per 1000 children aged 0-59 months (2)                                1.3          1.4      0.16          37           19          33
  18 # of women admitted per 1000 women (3)                                                                        6.4        12.4       12.9     N/A          N/A         N/A
  19 Bed occupancy rate (BOR), excluding TB                                                                         67        67.8       73.9       51.2            48          65
  20 Caesarian section rate (4)                                                                                  0.07         0.02       0.04       0.47         0.70        0.48
  21 # of major surgical interventions                                                                          1165         1034       1267         311          152         141
  22 % of patients at RHs that referred from the HCs                                                                22        27.8          20        4.9          6.1       17.4
  23 BK+ case finding rate                                                                                          98           92         89         71           59          70
  24 Percentage of MPA HCs implementing DOTS                                                                      100          100        100          50         100         100
  25 TB cured rate                                                                                                  88           91         91         82           85          88
  26 Incidence of malaria                                                                                           22          8.2        6.8      35.3         23.7          9.7
Key area of work 2: Behavioural Change
  27 % of outreach visits that included health education activities                                                78          82          80          90          90          100
  28 % of health facilities having a formal system through which patients can complain                             20          70          70          85          90          100
Key area of work 3: Quality Improvement
  29 % of patients prescribed antibiotics                                                                       51.3           45          51          70           65              70
  30 Hospital mortality rate                                                                                    2.89            3        3.17         3.5          3.3               3
  31 Average length of stay (ALS), excluding TB                                                                 8.62         8.26        9.13           6            7               7
Key area of work 4: Human Resource Development
  32 # of RHs with at least 2 qualified surgens                                                                    2            1          2           1            1           1
  33 Ratio of MDs and MAs to population                                                                        6,845       12,371      7,900       4,884        6,069        8429
  34 Ratio of secondary midwives (including floating staff) to population                                      4,398        5,098      5,300      15,264       16689        14330
  35 # of staff that received clinical training during the year                                                   65          103        422         187          100         102
  36 # of staff that received management training at NIPH during the year                                          0            0          3           0            3           0
Key area of work 5: Health Financing
  37 % of government budget for running costs received (in cash and kind)                                        100          100         94          83           95               93
  38 % of government budget for running costs received (in cash and kind) by 30 June                               3           10         11       NA              24               38
  39 % of MoH expenditure spent at ODs                                                                            81           82         80       NA         NA           NA
  40 Total income from user fees (in million Riels)                                                              757          868      1,184         124         130        213.5
  41 % of patients exempted (including support by equity fund)                                                    31           15         22       NA         NA           NA
  42 Total expenditure per capita (in Riels) (8)                                                               9,319        8,498     12,000       9,200      10,400       17,600
Key area of work 6: Institutional Development
  43 % of MPA HCs with functioning HCMC                                                                          100          100         100        100          100      100.00
  44 % of MPA HCs with functioning VHSG                                                                          100          100         100        100          100         100
  45 Average # of integrated supervision visits per HC                                                            10           10          11      NA               4           4
  46 Average # of integrated supervision visits per RH                                                             5            5           6      NA               1           1
  47 Average # of integrated supervision visits per OD                                                             5            5           6      NA               1           1
  48 % of functioning MPA HCs having annual plans as MoH Planning Manual                                         100          100         100        100          100         100
  49 # of PHTAT meetings per year                                                                                 11           11          12         11           12          12
  50 # of ProCoCom meetings per year                                                                              12           12          12         11           12          12
(1) A HC considered as functioning when it meets all the MPA criteria: (i) supply of MPA drugs, (ii) at least 5 staff including 1 II midwife & 1 II nurse, (iii) open at least 4
hours everyday with staff on call 24 hours, (iv) providing all 6 basic services everyday, (v) outreach at least once per 2 months to every vilage, (vi) referral of patients, and
(vii) community participation in the management the HC. The 6 basic services are primary curative consulations, emergency care and simple surgery, care for chronic
diseases, consultations for healthy infants, care for pregnant women including delivery, and birth spacing.
(2) Total # of children aged 0-59 months is estimated to be 12.8% of the population in the province = the total population in the province * 12.8/100
(3) Total # of women is estimated to be 51.8% of the population in the province = the total population in the province * 51.8/100
(4) Total # of expected pregnancies is estimated to be 3.8% of the total population in the province = the total population in the province * 3.8/100
(5) Total # of married women aged 15-49 years is estimated to be 14% of the total population in the province = the total pop in the province * 14/100
(6) Total # of children aged <1year is estimated to be 3.4% of the population in the province = the total population in the province * 3.4/100
(7) Total # of expected new BK+ cases is estimated to be 241 per 100,000 inhabitants = the total population in the province * 241/100000
(8) Government expenditure including salaries (chapter 10), running costs (chapter 11 and/or 13), social allowances (chapter 31) and drugs.




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       2.1.5.      Project Strategy – Management – Organisation
The project intervention strategy is to facilitate the Provincial Health Departments in both
provinces to implement their task of managing the health system in order to improve the
delivery of health services in the provinces.
The project is set up as a co-management system, in which the Provincial Health Department
director is the director of the project and the BTC representative is the co-director. There are
two project Directors, Dr. Dy Bun Chhem, director of the Siem Reap Provincial Health
Department (PHD) and Dr. Ouk Kim Soeun, director of the OMC (Otdar Meanchey) PHD,
and one project Co-director. With some office support staff and national technical advisors,
they form a Project Management Unit (PMU), which is the implementing body of the project.
On the top of PMU, is a Steering Committee, the decision making body of the project.


   2.2. PBHS-Kampong Cham
       2.2.1.      Agreements
The project « Provision of Basic Health Services in Kampong Cham Province» is a direct
bilateral project between the Kingdom of Cambodia and The Kingdom of Belgium. A Specific
Agreement was signed between both parties on 16th December 2003 and will last until 15th
December 2008.
       2.2.2.      Project context
It is a 4-year project, which started on 01 November and is expected to end on 30 November
2008. The total Belgian budget for this project is €4,170,000 of which €3,327,184 is co-
managed and € 842,816 is under sole management of Belgian party (regie). The project is
managed mainly in “Co-gestion” with a “Regie” component for International Technical
Assistants and part of the consultancies. The project area lies within Kampong Cham
province. With a population of 1.8 million inhabitants Kampong Cham is one of the most
populated provinces of Cambodia. According to the health care system reform, the new health
coverage plan divides the province in 10 operational districts. It has 10 referral hospitals and
134 health centers (HC). The project covers only three of the 10 Operational Health Districts
(OD) of the province –Chamkar Leu-Stueng Trang, Choeung Prey-Batheay, Prey Chhor-Kang
Meas. The focus of the project support is on strengthening these 3 ODs, with the full range of
activities.

                                                  MPA HC Non-MPA HC                 Referral
       Project OD Name             Population
                                                  (building)  (no building)         Hospital
 Chamkar Leu - Stueng Trang                                 7               6                      1
 Choeung Prey – Batheay                                    12               1                      1
 Prey Chhor - Kang Meas                                    14               0                      1
                        Total                              33               7                      3
Additional to the above 3 ODs, the Provincial Referral Hospital (PRH) located in the OD
Kampong Cham-Kampong Siem is also intensively supported by the project. With its 260
beds it is one of the most active provincial hospitals in Cambodia.
Apart from the above focus facilities, the project supports also the Provincial Health
Department especially in the area of institutional capacity building and performance related
contracting.


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Kampong Cham province has also received support from Health Sector Support Project, a
joint project of Cambodian government with World Bank, Asian Development Bank and
Dutch Fund for International Development or DFID. The Health Sector Support Project
finances the contracting arrangements for 2 ODs, namely Memut and Pnhea Krek-Dambea.
This contracting arrangement is implemented by Save the Children Australia (SCA).

     Kampong Cham Province                                                                                                                                   N


                            Baray and Santuk                                                                                                      W                       E
                                         %
                                                                                                                             Kratie
                                                                                                                                  %


                                                                                                                                                              S




                                                           %
                                                                                           %
                                               Chamkar Leu - S tueng Trang                                              Chhlong
                                                                                      Kroch Chhmar - Stueng Trang            %




                                               Prey C hhor - Kang Meas
                                     %                 %

               Choeung Prey - Batheay

                                                                             %

                                                           Kampong Cham - Kampong Siem
                                                                                     Tbong Khmum - K roch Chhmar
                                                                                                   %



                             Srei Santhor - K ang Meas                                                                                    Memut
                                         %                                                                                                 %
                                                                      O Reang Ov - K aoh S outin           Ponhea K rek - Dambae
 Ponhea Lueu                                                                     %                                  %



  Mukh K ampul               %
                        %
                       Ksach Kandal
                                             Pea Reang                                                                                                %   Odo.s hp
                                                   %                                                                                                      Na tional roa d.shp
                                                                                                                                                          Contrac ting.shp
       Cheung                                                                                                                                             Pbhskc.shp
               %                                                                                                                                          Kpc .shp
                                                                                     Kamchay Mear                                                         Od boundary.s hp
    Lech                                                                                           %
       %
                   %
             50 %Tbong                                            0                                          50                                   100 Kilometers
                                 Kean S vay
    Kandal                       %
                                                         Prey V eng




             2.2.3.                      Project objectives (see Logical Framework)
The general objective of the project is to improve the health of the population, especially of
mothers and children, thereby contributing to poverty alleviation and socio-economic
development in Kampong Cham provinces. More specifically, the project enhances health
sector development through supporting the provincial plans in line with the 6 key areas in the
Health Sector Strategic Plan 2003-2007. The project targets especially the most poor and
vulnerable. The project consists of six major components:
     1. free quality health care for the poor through the set up of Health Equity Funds;
     2. promotion of better health behaviour;
     3. strengthening of health services delivery through contracting;
     4. support to quality improvement initiatives
     5. capacity building and training
     6. strengthening of management and institutional development
The project aims to improve directly the health situation of the population in the province.
Additionally the project aims to contribute in a policy dialogue on crucial health matters in
order to improve the national health policy. This would influence the health status of the
country‟s population as a whole and adds a more structural and strategic dimension to the
project.


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                2.2.4.                   Results & indicators
As the project supports the Provincial Health Departments, most of the results of the
Provincial Health Departments can be regarded as results of the project. In the table below is
the summary of the health input, process and output indicators of the provinces from 2003 to
2005. The project formulation report also recommended 67 input, process, output &
outcomes or impact indicators, of which most overlap with the provincial indicators. Routine
data on Health Management Information System, project surveys, and national surveys such
as Cambodian Demographic and Health Surveys (CDHS) will allow us to fill out the 67
indicators. A project baseline population-based household survey was done in Mid-2005.
Information related to 23 population based baseline indicators and 12 HC facilities indicators
was collected to allow for project progress measurement. The survey also gives valuable
information for policy and health planning purposes in the coming years. The CDHS 2000
report, in which information on mortality, health seeking behaviour and health expenditure
can be found, has been made available and the CDHS 2005 is being finalised.
To date the project has produced many other particular activity results. They will be described
below for each of the 6 project components. It should be emphasized that the 2 major
components of the project are the Output-related Contracting and the Health Equity Funds.
They form the backbone of the project and clearly also absorb most of the financial and
technical inputs.
Output-related Contracting is the biggest component of the project in terms of budget
allocation and technical assistance, one of the key project strategies to boost health services
delivery. The performance contracts are developed at all levels (health centres, referral
hospitals, operational district offices & provincial health department offices) of the provincial
health system. They are institutions-based contracts. The contracting addresses low staff
motivation by providing them incentives & bonus based on their performance and
achievements (in relation to an agreed set of process and output indicators). Within the
contracts, the health staff has to ensure 24 hour services, respect golden rules3 and the
internal regulations of their own institutions. Performance of contracted facilities are closely
monitored and assessed by existing supervisory teams at the district & provincial levels and by
provincial Monitoring Team.
Initially temporary contracts with the PHD director, deputy director and the management
committee of the ODs and hospitals were put in place since May 2005. In a period of 5
months, several committees were created for preparing the contracts. These contracts with the
management were put in place to motivate management staff to involve in the development of
contracting tools such as the development of golden rules, to conduct staff assessment
regarding expectation for the contracting, involve in the feasibility studies prior to the start up
of facility contracts and to prepare and start the required changes to the management systems.
These temporary management contracts were abolished since November 2005 when the first
facility contracts started.
Monthly the PHD Monitoring Team conducts evaluations of the facilities allowing to score
and to calculate the monthly bonuses.
Since January 2006, 35 out of 42 operational health centres, all the 4 referral hospitals, 3
operational district offices and the provincial health department office were put under the
output-related contracting. On average the project contributes monthly around 21.000 USD to
the output related bonuses for some 661 staff.


3 no cheating data (inflate the figure), no under-the-table payment, no poaching patients, no embezzlement of drugs & materials



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The impact of these contracts has still to be carefully assessed. But the results in terms of staff
motivation and attitudes, availability of services and increase of health activities is obvious.
The table in Annexe 1 shows the increase in service utilization in the RHs. Sharp increases
appeared shortly after the almost simultaneous introduction of the HEF and the Contracting.
Health Equity Fund for the poor is the second largest component of the project. The
objective of this activity is twofold: improve access to quality health care for the poor and
prevent them from falling into deeper poverty. This contributes to poverty alleviation in the
project‟s area.
To avoid conflicts of interests, the project contracted a local non-governmental organisation,
as a third party in health care service delivery, to operate the fund. This has been done
through a bidding procedure.
The first project HEF started on 1st September 2005 in the PRH. By January 2006 HEFs
were established and operational in all 4 RH., HEF is fully operational in 4 main referral
hospitals (PRH, Cheung Prey RH, Chamkar Leu RH and Prey Chhor RH). All 4 HEF are
implemented by a single operator, Action For Health which was selected through a public
bidding procedure.
Until today beneficiaries (the poor) are only identified at the hospitals when they seek care
(post-identification). In the future the project will possibly conduct pre-identification surveys
identifying possible beneficiaries at their home before they are sick. The eligible poor patients
receive at hospital level, one or more of the following benefits: (1) reimbursement of user fees
charged by the hospitals, (2) transportation cost, (3) food and (4) other social support (e.g.
funeral).
All the facilities with HEF show an increase of utilisation mainly by the poor. See Annexe 3.
On average, 31% (3,768 inpatients) of the patients hospitalized in the related facilities in 2005
(12,203 inpatients) from HEF support. Since the start of the HEF in the PRH in September
2005 until 31 June 200 6 the project spent US$ 122,757. in HEF, of which 37% contributed to
the income of the health facilities and 38% were used for the NGOs operational costs.
In July 2006 an assessment of the HEF has been conducted and resulted in interesting
observations and proposal for changes.
Behaviour Change Communication.
 School Health Education. The 3 BTC projects BETT, PBHS-SROM and PBHS-KC
  together support the development of a health education curriculum for schoolchildren and
  a related teaching materials toolkit. This health education curriculum will be regarded as
  life skills local curriculum and piloted in the three provinces. This activity will be piloted in
  the 3 provinces Siem Reap, Otdar Meanchey and Kampong Cham. Due to a structural
  approach with inter-sectoral cooperation and reworking of the trainings tools the progress
  has been very slow. Piloting is now expected to start early 2007. The possibility exists that
  some parts would be integrated in the National Curriculum later. The MTR of the BETT
  project commented this activity.
 Support to Handicap International Road Safety Campaign. The project has introduced and
  supported collaboration with HIB to the PHDO and RH. HIB collaborates with different
  RH along the national road and in each of the 3 OD to collect data on traffic accidents.
  This data are entered and analyzed monthly and presented to the ProTWGH meeting.
 HEF and RH Publicity Campaign. The project organized several activities for promoting
  the utilization of the services of the Public Hospitals and HEF through leaflets, press and



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   dissemination conferences, and the construction of sign posts, sign boards billboards for
   the PHD and the 4 RHs.
 Video Health Education Library. The project supported the PHD to develop a collection
  of all existing video and audio health education materials and assisted with the distribution
  of it.
 Video Health Education Campaign. In each of the 4 RH video health education systems
  have been set up which targets mothers, pregnant women on child health and pregnancy
  related topics.
 Provincial Health Newsletter. At present the project is supporting the PHD to prepare its
  first edition of the Provincial Health Newsletter.
 Avian Influenza Health Education. The project supports the PHD to organize IEC
  meetings for the village authorities of all villages in the project ODs
Most emphasis of Quality Improvement was put on Continuous Quality Improvement with
as objective to give institutions a sustainable tool to address quality problems. Initially this
involved several trainings; this was followed by the setting up of CQI working groups in each
of the 4 RHs. These CQI working groups are meeting twice monthly and are coached by the
project TA-CQI. These groups have identified several problems with the functioning of their
institutions for which came up with solutions. As at present this has resulted in improved
hygiene of the institutions, in some short term trainings (Emergency, ICU, etc.) and in a list of
proposals for small infrastructural works and equipment purchases (incinerator, toilets, water-
supply, etc.).
 The development of clinical quality standards for RH and HC has been delayed. Hospital
  staff and TA were involved in too many other tasks, especially the management of the
  facility is not yet appropriate organised thus this issues have to be tackled first.
 Recently the most burning problem is high expenditure of hospital for drug and hospital
  equipment, inappropriate financial management thus the project is putting more focus on
  the improvement of pharmacy management, rational use of drug and financial
  management.
 For several reasons little progress was made with earlier planned infrastructural works and
  equipment purchases for the improvement of the Maternal, Surgical and emergency
  departments of 4 RH and with the purchase of an ambulance.
 The project has organized and supports a routine system for anatomic-pathological
  examinations for PRH biopsies by Pasteur Institute.
Many training sessions and workshops have been organised and/or supported with the
assistance of the project. Among the most significant are:
 Surgical training by an International TA, surgical expert. He has been supporting both
  PBHS projects. His major contribution goes to the surgical in-service (on the job) training
  in the PRHs
 Health Services Management Training at National Institute of Public Health in Phnom
  Penh,
 Hospital Management Training at National Institute of Public Health in Phnom Penh,
 Health Sector Reform training in Amsterdam for the director of Planning Department,
  Ministry of Health and the Head of the PHD Planning Unit,.


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 A 3-year 3-level comprehensive English language course for 98 staff of the PHS, PHR and
  Regional Training Center.
 Participation of Medical Doctors to Annual National and Regional Medico-Surgical
  Conferences
 Participation of the PRH Director to the International Conference on Hospital
  Management in Singapore
 Seminar for the Improvement of Private Pharmacy Management (Kampong Cham
  Province)
 ETAT (Emergency Triage Assessment Treatment) Training for pediatric staff (PRH)
 Emergency Pediatric Care Provided by Angkor Children Hospital Siam Reap.
However, there is a need for better assessment of the human resources development issues
and for better planning for the future training to improve the efficiency of the training
component in line with project strategies.
No proper assessment of impact of the training is done yet.
The project is actively collaborating with another BTC project, Training Facilities, which is a
regional scholarship project. Health staff of the province has benefited from several training
opportunities financed by the Training Facility project.
Strengthening of management and institutional development. The project has
supported/organized several activities in the field of institutional development of the PHD,
among the most significant are the following:
 The computerized HIS system had been put in place for all the 10 OD.20 Staffs from the
  10 ODOs were trained in the utilization of the software of HIS.
 Financial support for the PMTCT evaluation workshop PMTCT (Protection Mother To
  Child Transmission)
 The limping drug management system of the PRH has been evaluated with support of the
  central level of the MOH and is being improved and computerized..
 Support the integrated supervision visit system of PHD to ODOs and RHs. Project
  initiated a review of the PHD supervision system. This resulted in a training on the new
  integrated supervision checklist and in more frequent and regular supervision visits.
 The project supported the PHD to reform of the PROCOCOM to the Provincial
  Technical Working Group Health and based on the MOH guidelines.
 The project has supported the Annual Provincial Health Review Meeting and the Annual
  Provincial Health Congress.
 Development of internal monitoring system by consolidating and integration of HIS,
  Quality Assessment and Resource management for OD level. The OD monitoring system
  are improved through the strategy of having the ODO monitoring it‟s HCs performance
  contracts with the backup from the project monitoring team. An integrated data
  management system is developed and put in place at OD level.
 Review and improve the functioning of PHTAT (members, secretariat, quality of minutes,
  progress follow up) and Provincial Senior Management Meeting. This is very important in
  order to improve the internal communication which is weak at present.


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 Project TAs and the Co-director are actively involved in several National Health Policy
  Developing and Coordination Forums (Quality Improvement, TWGH, Provincial Health
  Advisors, Client and Provider Rights, HEF, Hospital Management Reform). Participation
  in these meetings is very important in order to assure that feedback from the field is
  considered when policies and regulations are reviewed.


Kampong Cham Provincial Health Indicators
                                             Indicators                                  2003          2004         2005
1    Health Service Delivery
1.1 % of planned HCs that are fully functioning as MPA HCs (1)                                72.70     73.90            80.00
1.2 % of RHs providing CPA1/CPA2/CPA3                                                     100.00       100.00        100.00
1.3 New consultations per inhabitant per year                                                  0.37         0.42          0.52
1.4 New consultations per child aged 0-59 months per year (2)
1.5 New consultations per woman per year (3)
1.6 % of deliveries attended by trained health staff (4)                                      18.30     26.70            28.10
1.7 % of women attending ANC identifid as at risk
1.8 % of pregnant women who received at least 2 ANC consulations (4)                          35.80     48.80            50.80
1.9 Return rate for ANC consultations                                                          2.40         2.60          2.70
1.10 % of pregnant women who received at least 2 TT vaccinations (4)                          29.30     31.30            26.60
1.11 % of married women aged 15-49 years using a modern contraceptive method (5)              19.00     18.60            18.40
1.12 % of children <1 year who received BCG vaccination (6)                                   79.00     98.00            95.00
1.13 % of children <1 year who received measles vaccination (6)                               69.00     85.00            88.00
1.14 DTC1- DTC3 drop-out rate                                                                  3.40         2.80         (1.90)
1.15 Average # of integrated outreach visits per village per year
1.16 # of hospital admissions per 1000 inhabitants                                            17.00     17.00            17.00
1.17 # of children aged 0-59 months admitted per 1000 children aged 0-59 months (2)
1.18 # of women admitted per 1000 women (3)
1.19 Bed occupancy rate (BOR), excluding TB                                                   66.30     70.50            63.60
1.20 Caesarian section rate (4)
1.21 # of major surgical interventions
1.22 % of patients at RHs that referred from the HCs
1.23 % of MPA HCs implementing DOTS
1.24 TB cured rate                                                                      >85           >85          >85
2    Behavioural Change
2.1 % of outreach visits that included health education activities                        100.00       100.00        100.00
2.2 % of health facilities having a formal system through which patients can complain     100.00       100.00        100.00
3    Quality Improvement
3.1 % of patients prescribed antibiotics
3.2 Hospital mortality rate                                                                    1.70         1.60          1.60
3.3 Average length of stay (ALS), excluding TB                                                 5.70         5.80          5.70
4    Human Resource Development
4.1 # of RHs with at least 2 qualified surgens                                                 2.00         2.00          3.00
4.2 Ratio of MDs and Mas to population                                                        7,641     8,459            9,088
4.3 Ration of secondary midwives (including floating staff) to population                     9,354     9,886        10,347
4.4 # of staff that received clinical training during the year
4.5 # of staff that received management training at NIPH during the year
5    Health Financing
5.1 % of government budget for running costs received (in cash and kind)                      99.94     70.15            89.28
5.2 % of government budget for running costs received (in cash and kind) by 30 June
5.3 % of MoH expenditure spent at Ods                                                         66.37     55.06            67.20
5.4 Total incomes from user fees (in million Riels)                                           23.61    831.67       1,276.50
5.5 Total expenditure per capita (in Riels) (8)                                               8,047     8,518        11,235
6    Istitutional Development
6.1 % of MPA HCs with functioning HCMC
6.2 % of MPA HCs with functioning VHSG
6.3 Average # of intergrated supervision visits per HC                                         4.00         4.00          4.00
6.4 Averge # of integrated supervision visits per RH                                           4.00         4.00          4.00
6.5 Average # of intergrated supervision visits per OD                                         4.00         4.00          4.00
6.6 % of functioning MPA HCs having annual plans as MoH Planning Manual                   100.00       100.00        100.00
6.7 # of ProCoCom meeting per year                                                            12.00     12.00            12.00




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The following are the project related data and reports, which are available:
    Specific Agreement
    Technical and Financial File
    Preparatory Document for the second project Steering Committee meetings (contains
     Annual report 2004), Marc 2005
    Preparatory document for the third project Steering Committee meeting (contains
     Annual report 2005), April 2006
    Minutes of the first, second and third project Steering Committee meetings,
    Quarterly Project progress reports
    “Baseline Health Surveys, Kampong Cham Province BTC project areas” by Domrei
     Consulting
    “Feasibility Study for Health Financing Scheme PRH” by Jean-Marc Thome, June
     2005
    “Feasibility Study for Health Financing Scheme PRH” by Jean-Marc Thome, October
     2005
    “Performance Contracting Review” by Jean-Marc Thome, June 2006
    “HEF Assessment Report” by Maurits Van Pelt, July 2006
    “HEF Forum Report” by Wim Van Damme, February 2006
    “Health Financing System in PRH” by Chhim Sarath, August 2006


       2.2.5.      Project Strategy – Management – Organisation
The project intervention strategy is to facilitate the Provincial Health Department to
implement their task of managing the health system in order to improve the delivery of health
services in the provinces.
The project is set up as a co-management system, in which the Provincial Health Department
director is the director of the project and the BTC representative is the co-director. Dr Ngoun
Sim An & Dr Dirk Horemans are respectively the director & co-director. Dr. Lon Chan
Rasmey, the Deputy PHD Director is assistant director of the project who has delegated
power of the project director. With some office support staff and national technical advisors,
they form a Project Management Unit (PMU), which is the implementing body of the project.
On the top of PMU, is a Steering Committee. Where the PMU is responsible for the daily
management, the Steering Committee is the decision making body of the project.




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3. Purpose of the Mid-term review
The aim of the MTR is to look at the progress of the project from the onset till current
period, which allows re-orientation of the project implementation for the remaining 2 years
and advice on the need and relevance of the extension. To do this, the MTR will specifically:
     extract information on the project activities, direct or indirect outputs and to some
      extent outcomes of the project implementation from mid 2004 till mid 2006 and
      highlight the major achievements;
     assess the relevance and effectiveness of the current project core activities and
      strategies in helping to achieve the project objectives with an emphasis on
      performance-based contracting and health equity fund;
     propose alternative strategies with budget reallocation toward achieving the project
      objectives as well as to fit with the current national policy and priorities. The
      recommendations made by the consultancy group on the hospital
      management/master plan/social health insurance should also be considered;
     review modalities, priorities, profiles of national and international assistance;
     assess the present monitoring/auditing system and make recommendations for
      improvement;
     propose a framework with terms of reference for the formulation of a 'consolidation
      phase' of the project after the completion of the current phase of the project. This
      framework should be based on the concept notes in annex.


4. Stakeholder involvement during the Mid-term review
The main stakeholders of the project include the primary beneficiaries (mainly the most poor
and vulnerable), the secondary beneficiaries (health staff & leaders and Project Management
Unit staff) of the project, the project Steering Committee (or Joint Local Consultative Body),
local authorities, village health volunteers, the key health partners who are members of the
Provincial Technical Working Group-Health & some indirect stakeholders in Phnom Penh
such as central Ministry of Health, WHO & some donors/NGOs such as GTZ, DFID, AFD,
URC, SRC, HNI.
The primary & secondary beneficiaries should be consulted at least about their perception on
the project, their willingness, motivation & commitment to participate in the project-related
activities (utilisation & provision of health services) and their perspective for future
development of the project. They are the main source of information and data.
Similarly, the perception & participation of local authorities & village health volunteers should
be asked.
The Steering Committee is a decision making body of the project. It is necessary to get their
ideas about the project performance & future development.
The key health partners in the Provincial Technical Working Group-Health are supporting
and participating in provision of health services in the project areas, Siem Reap, Otdar
Meanchey and Kampong Cham provinces. They are described in the table below.


No.    Name          Fields of involvement                     Catchment areas

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PBHS-SR/OMC In Siem Reap and Otdar Meanchey provinces
1     RACHA         Maternal & child health, micro-credit   Kralanh, Angkor Chum & Siem
                                                            Reap
2     URC           Health system strengthening             Siem Reap & Sotnikum
3     MSF           HIV/AIDS institutional care             Siem Reap & Sotnikum
4     Caritas       School health, primary health care &    Siem Reap & Angkor Chum
                    HIV/AIDS home care
5     ARC           Primary health care & community         Angkor Chum
                    participation in health
6     PSI           Social marketing of condom, birth       The whole project area
                    spacing pills & antimalaria
7     CHHRA         Health Equity Funds & consumer          The whole project area
                    rights
8     RHAC          Youth & reproductive health             Siem Reap
9     Esther        HIV/AIDS institutional care             Siem Reap
10    Friends       Run a not-for-profit Angkor Children    Siem Reap
      without       Hospital in Siem Reap town
      borders
11    Jayavarma     Run a big not-for-profit paediatric &   Siem Reap
      n VII         obstetric hospital in Siem Reap town
12    Malteasa      Consumers rights & primary health       Samrong, Otdar Meanchey
                    care
PBHS-KC in Kampong Cham province
No.   Name          Fields of            Catchment          Contact
                    involvement          areas
1     MFS           Communicable         KPC provincial     Cathy Laceau
                    disease, clinical    hospital
                                                            Tel: 012250820
                    care & education
2     RHAC          Reproductive         Kampong            Soum Phally
                    health, clinical     Cham province      Tel: 012523243
                    services &
                    education                               E mail: kpclinic@rhac.org.kh
3     SCA           Health System        Memut and          Reginald Xavier
                    Development,         Pogneakrek         Tel: 012777482
                    Contractor           ODs
                                                            E mail: hssp_mgr@sca-
                                                            cambodia.org
4     FHI           Reproductive         Kampong            Ea Rithy
                    health               Cham Province      Tel: 012928852
                                                            E mail: rithy@fih.org.kh


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5      SPEAN         HIV home based         Prey Chhor-  Heang Koy
                     care and               Kong Meas OD Tel: 011423007
                     orphanage
                                                               E mail:
                                                               heangkoy@camshin.com.kh
6      PLAN          Improving health       Pogneakey –        Tel: 023217214
                     practices              Domber OD          E mail: Cambodia.CO@plan-
                                                               international.org
7      AFA           Promotion of           Kampong            Nuth Mony
                     consumer rights        Cham, Prey
                                                               Tel: 012612005
                                            Chhor, Cheung
                                            Prey ODs
8      SHARE         Community health       Krouchmar          In Thnam Sokuma
                     promotion, health      District           Tel: 016877528
                     system
                     strengthening                             E mail: sharek@online.com.kh
9      NAS           Community              Kampong            Savun Sam Ol
                     Development and        Cham               E mail:
                     health promotion                          savunsamol@yahoo.com


5. Project area to visit
The project is supporting the whole health system in Siem Reap, and Otdar Meanchey
provinces and 3 operational districts in Kampong Cham province. So, the MTR will mainly
take place in provincial health department offices, operational district offices, referral
hospitals, health centres, health partners‟, local authorities and the community in these three
provinces. The MTR-team will have also to spend some time in Phnom Penh capital where
central offices of some direct & indirect stakeholders are based such as central Ministry of
Health, RACHA, URC, WHO, and some Steering Committee members. It is clear that the
consultants cannot visit all the above places in such a short period, but some of these places
that will be selected by the consultants during the mission (See more detail




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Work plan and time schedule).
6. Criteria to be studied

   6.1. Basic criteria
        6.1.1.      Relevance
Relevance makes reference to the degree in which the cooperation intervention still responds
to the expectations and priorities of the main actors involved in the project, in particular the
national and Belgian policy-makers.
Two aspects should be examined: (1) is the conception of the project still in line with national
policies and strategies (PRSP, Development plans, national sector strategies, policies on
gender, environment, social economy, children‟s rights and the MDG)? (2) is the project in
tune with the policies and strategies of the Belgian donor?
The MTR-team should give an answer to the question whether the project is still relevant and
which eventual measure should be taken to re-actualise the project taking into account
possible new conditions and situations.
        6.1.2.      Efficiency
Efficiency refers to the way in which the resources of the cooperation intervention are
transformed through the project activities into the awaited results. The MTR assesses the
physical and the financial progress of the cooperation intervention. The following questions
are crucial in order to verify the respect of the schedule in different fields and at different
levels:
     Are the inputs (finances, human and material resources) implemented as planned?
     Are the activities implemented within the planned timeframe?
     Are the inputs managed adequately, what could be done better, cheaper, more quickly?
     Are the results achieved, when referring to the indicators?
     A statement is expected regarding the efficiency of the cooperation intervention and
      the certitude that activities and results will be achieved within the timeframe and
      according to the planned means.
The MTR-team will explain any delay, constraint or problem and will make recommendations
on approaches and additional means to overcome these delays, constraints and/or problems.
If needed, recommendations about possible modifications and alternatives should be made by
the MTR-team and the original planning of the activities and the results should be
reconsidered.
        6.1.3.      Effectiveness
Effectiveness refers to the extent to which the results of the project are delivered and
contribute to the achievement of the specific objective. Effectiveness examines if the intended
changes that occurred in the project area have been caused by the project itself. Effectiveness
also supposes that the beneficiaries make use of the delivered results. The key questions are:
     To what extent and referring to the indicators, is the specific objective realised?
     Is the realisation of the specific objective caused by the project (results) or have
      external factors been influencing the achievement of the specific objective?


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    To what degree does the project implementation responds to the problems, needs and
     priorities of the beneficiaries?
    To what extent are the beneficiaries satisfied with the delivered results?
The MTR-team will make a statement about the achievement of the specific objective and the
use beneficiaries (can) make of the results. The MTR-team explains - if necessary - the raisons
for not achieving the specific objective and or results.
If appropriate, the MTR-team will make recommendations on more effective ways to realise
the specific objective, by examining the factors restraining the project achievements.
       6.1.4.      Sustainability
Sustainability refers to the likelihood that the benefits emerging from a development
intervention will be maintained by the Partner Countries at an appropriate level for a long
period after the withdrawal of donor support.
Sustainability measures the confidence of the MTR-team that the benefits and the support
produced during the project will be maintained and reproduced for the beneficiaries, once the
project has ended. The assessment of „sustainability‟ implies the following elements:
    To what extent did the project contributed to sustainability in the social, cultural,
     political, technical, economical, environmental, institutional and/or organisational
     dimension?
    To what extent are the involved parties willing and able to keep the facilities
     operational and continue the activities?
    Is the project providing the appropriate capacity building strengthening the
     sustainability?
    To what extent are the proposed solutions and approaches accepted and mastered by
     the beneficiaries?
The MTR-team will give an indication of the confidence they have concerning the
continuation in the stream of benefits and support produced by the project. The MTR-team
should focus on recommendations increasing the sustainability.
       6.1.5.      Coherence
The criterion of coherence means that the intervention logic or the intervention itself does not
contradict with other development interventions with similar objectives. We distinguish three
levels: projects and programmes of BTC (direct bilateral level), projects and programmes
executed by other Belgian organisations as NGO‟s or Universities (indirect bilateral level) and
projects and programmes from other donors (international level). The questions that should
be asked are:
    Are strategies and approaches of other donors (international level or indirect bilateral
     level) coherent with BTC strategies and approaches for projects with similar
     objectives?
    Are BTC strategies and approaches coherent for their projects in the same region?
    Is there any contradiction among projects in the region, regardless the objectives?
    Is there any synergy to be promoted between projects or programs in the region?




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The MTR-team will comment the coherence of the project and will make recommendations –
if possible – regarding contradictions or synergies between projects that should be respectively
avoided and promoted.
        6.1.6.      Impact
Impact refers to the long-term implications of the development intervention on its wider
environment and its contribution to the objectives initially planned. Impact goes beyond the
project area and the beneficiaries initially planned.
Impact is more than a simple reference to the effects, positive or negative, direct or indirect,
intentionally or unintentionally generated by the project.
Impact is also broader than effectiveness, since the latter only refers to the planned objectives
and impact refers also to the unintended consequences that take place in the lives of the
beneficiaries, partner institutions and non-target groups outside the project area. A causal
relationship is supposed between the project presence and the influences detected. The issue
to be studied are:
     What are the effects/impacts that the beneficiaries, partner institutions and non-target
      groups experience from the project? Are these changes sustainable?
     What is the nature of these changes: positive, negative, direct, indirect, intended,
      unintended? Is there a causal relation between occurred changes and the project?
     Do all stakeholders experience the changes introduced by the project in the same way?
     Do the changes contribute to the realisation of the global objective?
The MTR-team is requested to give indications on the possible impacts/effects that can occur
after the project. Within the possibilities, the MTR-team should make recommendations on
approaches that strengthen the positive impacts and avoids the negative implications of the
project, for the beneficiaries, the partner institutions and also for the non-target groups.


    6.2. HARMO-criteria for strengthening the aid effectiveness
        6.2.1.      Harmonisation
The principle of harmonisation refers to the donor‟s agreement to harmonise their
development actions and to make these more transparent. To this end donors will initiate -
together - effective incentives for collaborative behaviour. This criterion has in the first place a
focus on operational aspects of the development intervention. Following questions assess the
harmonisation criterion:
     Is the project making any common arrangement with other donors, concerning one or
      more of the following items: planning, funding, disbursement, monitoring, evaluation,
      reporting training?
     Is there any division of responsibilities between BTC and other donors, regarding the
      implementation of the project, in function of the comparative advantage of BTC?
     Is the project giving incentives for collaborative behaviour for management or staff to
      work towards harmonisation?
If appropriate, the MTR-team should make recommendations for the project, the JLCB and
BTC-HQs regarding actions that can be taken to improve the harmonisation between donors.



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In assessing the harmonisation efforts of the project, the MTR-team will pay special attention
to the situation in fragile states.
        6.2.2.      Alignment
Alignment means that donors base their overall support on partner countries‟ national
development strategies, institutions, systems and procedures. Donors will strengthen –where
necessary – these strategies, institutions, systems and procedures. When questioning the
criterion of „alignment‟, following issues should be considered:
If available, is the project relying on national systems and procedures regarding: public
financial management, accounting, procurement, auditing, reporting, monitoring and
evaluation?
     Is the project making efforts to increase the use of local systems for project
      implementation, financial management, monitoring and evaluation?
     Is the partner institution coordinating donor procedures for reporting, budgeting,
      financial management and procurement?
     Is the partner institution implementing the project or is the project managed through a
      parallel implementing unit (PIU)? Is the Partner Country taking the leadership?
     Is the project building the capacities of members of the partner institutions?
     Is the project giving incentives for collaborative behaviour for management or staff to
      work towards alignment?
The MTR-team should give clear indication on possible measures strengthening the alignment
of the project.
        6.2.3.      Managing for results
Managing for results means that partner countries and donors manage and implement aid in
such a way that their cooperation focuses on the desired results and uses the information from
monitoring and evaluation to improve decision-making.
The Result-oriented framework is a key element for this criterion. It refers to transparent and
measurable performance assessment frameworks (PAF) to assess progress against the national
development strategies and sector programmes. The PAF matrix is a set of key policies,
actions, output and outcome indicators for dialogue, monitoring and assessing performance
(basis for joint reviews). Following items should be evaluated with respect to the criterion of
managing for results:
     Are all project phases linked to partner country performance assessment frameworks?
      Is the dialogue in all phases of the project oriented towards the achievement of
      results?
     Is the project providing a consistent framework for implementation based on learning
      and accountability?
     Is the projects‟ monitoring system oriented towards achieving the expected results,
      taking into account the result chain?
     Is the project working with harmonised monitoring, evaluation and reporting
      procedures and systems (f.ex. joint formats for periodic reporting)? Are these
      procedures and systems aligned with Partner Country results?



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    Is the project applying a participatory approach strengthening partner institutions
     capacities for result based-management?
    Is the project giving incentives for collaborative behaviour for management or staff to
     work towards managing for results?
The MTR-team should give feed back on the use of the monitoring, evaluating and reporting
systems and should propose possible improvements in order to link the management of the
project in a stronger way with the expected results.
       6.2.4.      Mutual accountability
Mutual accountability refers to the enhancement of the responsibility and transparency for
development of results. When partner countries and donors are accountable for the
development results, the following issues should be assessed positively:
    Is the project providing timely transparent and comprehensive information on aid
     flows?
    Is the partner institution communicating project achievements with beneficiaries?
    Is mutual responsibility integrated in the functioning of the JLCB?
    Are agreed commitments on aid effectiveness assessed within the JLCB?
The MTR-team can make recommendations towards the JLCB, in order to improve mutual
accountability of all concerned parties.
       6.2.5.      Ownership
Ownership is the degree in which the partner country exercises effective leadership over their
development policies and strategies. It also refers to their efforts in coordinating the
development actions. On the level of projects, following questions can assess ownership:
    Is the partner institution co-ordinating the aid projects?
    If there is any coordination, is the civil society and or private sector participating?
    Is the project strengthening the leadership capacities of the members of the partner
     institutions, concerning these coordination tasks?
    Is the position of the partner institution in the JLCB autonomous?
The MTR-team should be able to indicate lacunas in the level of ownership of the partner
institution and to propose measures to improve the empowerment of the partner institution.


   6.3. Transversal themes
       6.3.1.      Gender equality
Gender equality contributes to the promotion of the role of women and men aimed at
sustainable development. Gender itself refers to the social construction of the differences
between women and men. These differences are appropriated through education (family,
tradition, …) and social institutions (school, church, …). The gender roles change over time
and manifest variations within and between cultures.
Since gender is a transversal concept, the MTR-team assures the gender differentiation in its
methodological approach (data-collection, meetings with beneficiaries,…). Additionally the
MTR-team should develop a gender analysis with following aspects:

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    Do women and men benefit in equal terms from the project (training, capacity
     building, …)? Are some women or men negatively affected by the project?
    Did the project change the gender relations within the beneficiaries‟ households (with
     respect to the economical, social, political status)? Are there any changes in traditional
     patterns, values or standards since the project started?
    Did the project reduce existing gender gaps (income, access to basic education or
     health, economic participation, political participation)?
    Are women playing an active role in the project or do they only participate in an
     passive way? Are women and men supportive to the project?
The MTR-team should be able to give an insight in the level of empowerment of women. The
MTR-team should verify to what extent the project change what women „have‟, what women
„can‟, what women „want‟ and what women „know‟, compared to the situation before the
project started.
       6.3.2.      Environment
Environment as a transversal theme refers to the links between the project activities and
results and the respect of the principles of rational and sustainable management of the natural
resources. The dimension of environment takes into account the respect for ecosystems and
habitats, the conservation and wise use of resources, the potential risks for the environment,
the adaptation of technologies, in a long-term and sustainable perspective. Aspects that should
be studied are:
    the use of services, technologies, products or methods affecting the environment;
    the respect of safety measures during activities;
    the consideration of the working habitat of beneficiaries (and non-target groups);
    the sustainable use and or management of natural resources;
    the positive and negative environmental side-effects of activities and results;
The MTR-team should be able to point out critical issues affecting the environment. If
possible, the MTR-team should be able to propose measures to improve the respect of the
environment.
       6.3.3.      Socio-economy
Socio-economy refers to the finality of the services and results delivered by the project and the
degree to which the project calls upon the interaction with the civil society. The criterion
„socio-economy‟ questions whether the activities and results are socially oriented or whether
they aim (only) economic profit. Socio-economy focuses on collective benefits and avoids
individual beneficiaries. Social economy gives priority and recompenses labour rather than
capital. The dimension of socio-economy analyses following aspects of the project:
    What is the finality of the services and results delivered by the project (social or
     economic)?
    What is the nature of the benefits, are these oriented to social services or economic
     benefits? How are these benefits distributed among the beneficiaries?
    To what extend is the project facilitating the participation of civil society?
    Is the project respecting democratic decision-making processes?


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     What are the characteristics of the beneficiaries, is the project aiming the better off or
      poor(est)?
The MTR-team should focus on sites of pain, in order to propose measures enhancing the
participation of the civil society and strengthen the social economy criterion.
        6.3.4.      Children’s rights
„Children‟s‟ rights‟ is a new transversal theme that can be considered during a MTR. The
evaluation of this criterion refers to the circumstances the project or program provides for
improving the living conditions of children. 5 basic rights should be examined in a gender
differentiated way (segregated data and information fro girls and boys). In order to assess this
transversal theme, the MR-team should focus on following questions:
     Is the project facilitating education for children?
     Is the project strengthening basic health care for children?
     Is the project increasing the access to drinking-water for children?
     Is the project protecting children against violence?
The MTR-team should be able to verify the respect of these rights and should be able to
recommend - on the basis of the findings - measures for improvement on the level of the
project.
7. Methodology of the Mid-term review
Some methods for the MTR can be proposed as follows:
     Review of project related documents & related policy & guidelines,
     In-depth discussion with key informants,
     2 focus group discussions with health staff, village health volunteers & patients,
     Interviews with stakeholders,
     Workshop with key stakeholders to present preliminary findings & gather feedback
      and reactions,
     Writing the final report which include key findings & recommendations for further
      development of the project with ToR for project 'consolidation phase' formulation,
However, the International consultant will have to suggest – after taking into account the
BTC-methodology – the study design and the tools for measuring the above-mentioned
criteria. This suggestion will be one of the selection standards for the quality of the offer
introduced by the International consultant.
The MTR starts with a revision of the project strategy with reference to the logical framework.
At this level it is also important to consider the pre-conditions formulated during the
identification and formulation and to verify on the other hand if the assumptions are still
accurate. The MTR-team will also assess the project management performance and its
organisation.
The core of the MTR is however the analysis of the basic criteria (1), of the criteria for the
strengthening of the effectiveness (2) and of the transversal themes (3). In function of the
needs of the MTR the set of criteria to be assessed will differ from project to project. It is
possible that other criteria are added.


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The study design which the International consultant will suggest - includes the transformation
of the assessment criteria into evaluation questions, which will be in turn translated into a set
of indicators, to be verified with the help of data-collection instruments. The MTR-team
assures the production of valid and reliable information by applying the triangulation as
method for data-collection, meaning that different data-collection instruments generate similar
findings.
These findings will provide answers to the evaluation questions. These answers engender
conclusions for each assessment criterion. These conclusions will be translated into
recommendations, which can be used for decision-making.4
8. Deliverables of the Mid-term review
     Aide-mémoire (see template Aide-mémoire)
     Draft report (see template for the MTR report)
     Presentation during de-briefing (see template PPT-presentation)
     Final report
9. Period and duration of the Mid-term review
It is estimated that totally 35 man days of international consultant and 25 man days of national
consultant are needed for the MTR. See the detail of the duration of the mission in the table
below.


                                                                               Europe
                                                       Field mission
                                Travel time                                    (or outside partner
                                                       (in partner country)
                                                                               country)
      International
                                3 man-day              22 man-day              10 man-day
      consultant
      Local consultant                                 25 man-day
      Other participant
10. Course of the Mid-term review
The MTR-team leader will be responsible for following activities:
     Briefing at BTC HQs and at the Representation (with the partner institution, Resident
      Representative, MTR-team, project).
     Discussion of the MTR purposes, programme and methodology.
     Review of the documents.
     Field visits to all key health facilities & administrative offices of operational districts in
      Siem Reap & Otdar Meanchey provinces
     Data collection at the level of the beneficiaries, the project staff, the authorities and
      the partner institutions.
     Restitution workshop with stakeholders at the end of the field mission.

4



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    De-briefing at the Representation and handing over of the Aide-mémoire.
    Draft the MTR-report and dispatch a draft to BTC HQs.
    De-briefing at BTC-HQs, present findings, conclusions and recommendations.
    Integrate comments of the Advisory committee in the MTR-report.
    Draft the final report and send it to BTC-HQs.
    Finalise administrative and financial formalities.


11. Composition of the Mid-term review team

   11.1.       Reference team
A reference team supports the MTR-team and consists of the following members:
In the Partner country : Prof Eng Huot, Dr Lo Veasna Kiry, Dr Alain Devaux, Dr Dy Bun
Chhem, Dr Ouk Kim Soeun, Dr Dirk Horemans, Dr. Lon Chan Rasmey, Dr Him Phannary,
Dr Kross Sarath, Dr Nguon Sokomar, Dr Ir Por…(the Resident Representative)
In Brussels : Dr Paul Bossyns and… (Sectoral/Thematic Advisor or Geographical Advisor)


   11.2.       Mid-term review team
The MTR-team consists of the following members:
    Team leader: an international consultant International consultant
    National consultant: Dr…National consultant(s)
    BTC: … BTC Sectoral/Thematic Advisor


   11.3.       Profiles & responsibilities of the Consultants
          11.3.1. International consultant
Profile
    The International consultant has a degree in public health. He/she has vast experience
     in the field of health system organisation and health financing systems.
    He/she has good experience in project evaluation.
    It is an asset if the International consultant has experience with the Cambodian health
     system.
    The International consultant will have at least 10 years of experience in development
     cooperation. The International consultant has experience with the methods of project
     evaluation.
    The International consultant is familiar with the participative approach.
    The International consultant speaks and writes fluently the English language.



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Tasks
The International consultant is responsible for her or his findings, conclusions and
recommendations. S/he is in charge of the following tasks:
    Coordinate the MTR-team;
    Supervise the redaction of the draft MTR-report, guarantee technical quality;
    Assure that all relevant stakeholders are involved in the mission;
    Assure the assessment of the basic criteria (coherence, relevance, efficiency,
     effectiveness, sustainability and impact) and other criteria as mentioned in chapter 6;
    Produce a summary of the main conclusions and recommendations to be presented
     during the debriefing meetings;
    Edit and complete the MTR-report;
          11.3.2. National consultant
Profile
    The National consultant has preferably a degree in public health, level of education
    With good experience in project evaluation.
    The National consultant will have a large experience within and good knowledge of
     the Cambodian health system.
    The National consultant will have at least 4 years of experience in development
     cooperation and will be familiar with the methods of evaluation.
    The National consultant is familiar with the participative approach.
    The National consultant speaks fluently languages and writes in Khmer & English
     languages.
Tasks
The National consultant will support the International consultant in following tasks:
    prepare the field visits and arrange the appointments
    translation during meetings;
    comprehension of the socio-cultural context;
    drafting of the MTR-report;




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12. Work plan and time schedule
Field mission in Cambodia
        Date                                 Activities                                 Concerned actors
 1   26/11/2006 Arrival of the international consultant in Phnom Penh
 2   27/11/2006 Briefing in Phnom Penh by the Representation, GAO &                Prof Eng Huot, Dr Lo
                Chairman of the JLCB (Steering Committee)                          Veasna Kiry & Alain Devaux,
                Meeting WHO & other key stakeholders in Phnom Penh                 Dr Maryam Bigdely…
 3   28/11/2006 Flight to Siem Reap & briefing by the PMU & PHD                    PMU staff & Siem Reap &
                                                                                   OMC PHD key staff
 4   29/11/2006 Working in Siem Reap on data & information collection              Siem Reap PHD, OD &
                through visits & meeting key people                                hospital directors, HE Ung
                                                                                   Oeun, Monitoring Team…
 5   30/11/2006   Field visit to Angkor Chum & Kralanh ODs & continue the trip Angkor Chum & Kralanh
                  to OMC                                                           OD directors, Kralanh RH
                                                                                   director
 6   01/12/2006   Working in OMC on data & information collection through          Siem Reap PHD, OD &
                  visits & meeting key people                                      hospital directors, HE Yim
                                                                                   Thin, Monitoring Team, Dr
                                                                                   Nguon Sokomar…
 7   02/12/2006   Trip back to Siem Reap with stops in many HCs, including         Nguon Sokomar
                  Anlong Veng
 8   03/12/2006   Rest in Siem Reap
 9   04/12/2006   Data & information collection from the beneficiaries (patients & Monitoring Team
                  health staff)
10 05/12/2006     Field visit to Sotnikum OD and Travel to Kampong Cham            Sotnikum OD & RH
                                                                                   directors
11 06/12/2006     Briefing by the PMU & PHD, Field visit to PRH and discussion PMU staff & Kampong
                  with provincial stakeholders (possible visit to HSSP supported Cham PHD key staff
                  OD)
12 07/12/2006     Working in Kampong Cham on data & information collection Kampong Cham PHD &
                  through visits & meeting key people                              provincial hospital leaders,
                                                                                   HE…deputy governor…
13   08/12/2006   Field visit to Chamkar Leu                                       … OD & RH directors
14   09/12/2006   Field visit to Cheung Prey                                       … OD & RH directors
15   10/12/2006   Prepare restitution or feedback workshop for PBHS-SROM and PHD Monitoring Team
16   11/12/2006   PBHS-KC;
17   12/12/2006    Data & information collection from the beneficiaries (patients
                  & health staff)
18 13/12/2006     Restitution workshop in Kampong Cham                             All the above-mentioned
                                                                                   people in Kampong Cham
19 14/12/2006 Travel to Siem Reap, Restitution workshop in the afternoon           All the above-mentioned
                                                                                   people in Siem Reap & OMC
20            Working on the draft report
     15/12/2006
21            Working on the draft report
     16/12/2006
22            Working on the draft report
     17/12/2006
23            Debriefing & presentation of the draft report for PBHS-SROM Two SC + Stakeholders
     18/12/2006
              and PBHS-KC in Siem Reap
24 19/12/2006 Final work with & debriefing to the PMU & flight to Phnom   PMU key staff
              Penh
25 20/12/2006 Departure of the international consultant




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       Chronogram of the mission (indicative)




                                                         21/11/2006


                                                                      25/11/2006
                                                                                   26/11/2006
                                                                                                27/11/2006
                                                                                                             28/11/2006
                                                                                                                          29/11/2006
                                                                                                                                       30/11/2006
                                                                                                                                                    01/12/2006
                                                                                                                                                                 02/12/2006
                                                                                                                                                                              03/12/2006
                                                                                                                                                                                           04/12/2006
                                                                                                                                                                                                        05/12/2006
                                                                                                                                                                                                                     06/12/2006
                                                                                                                                                                                                                                  07/12/2006
                                                                                                                                                                                                                                               08/12/2006
                                                                                                                                                                                                                                                            09/12/2006
                                                                                                                                                                                                                                                                         10/12/2006
                                                                                                                                                                                                                                                                                      11/12/2006
                                                                                                                                                                                                                                                                                                   12/12/2006
                                                                                                                                                                                                                                                                                                                13/12/2006
                                                                                                                                                                                                                                                                                                                             14/12/2006
                                                                                                                                                                                                                                                                                                                                          15/12/2006
                                                                                                                                                                                                                                                                                                                                                       16/12/2006
                                                                                                                                                                                                                                                                                                                                                                    17/12/2006
                                                                                                                                                                                                                                                                                                                                                                                 18/12/2006
                                                                                                                                                                                                                                                                                                                                                                                              19/12/2006
                                                                                                                                                                                                                                                                                                                                                                                                           20/12/2006
                                                                                                                                                                                                                                                                                                                                                                                                                        21/12/2006
                                                                                                                                                                                                                                                                                                                                                                                                                                     22/12/2006
                                                                                                                                                                                                                                                                                                                                                                                                                                                  23/12/2006


                                                                                                                                                                                                                                                                                                                                                                                                                                                               02/01/2007
                                                                                                                                                                                                                                                                                                                                                                                                                                                                            03/01/2007


                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         15/01/2007
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      16/01/2007
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   17/01/2007
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                18/01/2007
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             19/01/2007
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          20/01/2007
                                                            1            5            6            7            8            9         10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33                                                                                                                                                                                                                                                 43 44                     56 57 58 59 60 61
Briefing at BTC-HQs (International consultant)
Preparation of the mission (Local consultant)
Travel (International consultant)
Preparation of the mission (Local consultant)

Briefing at the Representation


Field mission, data-collection, analysis and synthesis


Preparation of the restitution workshops


Restitution workshops


Redaction Aide-mémoire

                                                                                                                                                                                                                                                                                                                                                                                    x
De-briefing and presentation of Site report


Travel (International consultant)

Redaction of the draft report
Forward draft report to BTC                                                                                                                                                                                                                                                                                                                                                                                                                                       x
Comments from BTC (HQs, Field)*
De-briefing at BTC-HQs
Redaction final report**
Forward final report to BTC-HQs***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           x
             Expert International
             Expert national
        x    Deliverables
             Days that the international consultant is not under contract


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13. Annexes

   13.1.      Annex 1: monthly inpatients by referral hospital in Kampong Cham




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   13.2. Annex 2: HEF-supported inpatients versus total inpatients in Kampong Cham
      (+costing)




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      13.3.         Annex 3: incentives ($) and staffing by contracted facility in Kampong Cham
                    Staff       May-05   Jun-05   Jul-05   Aug-05    Sep-05    Oct-05    Nov-05    Dec-05    Jan-06      Feb-06    Mar-06    Apr-06      May-06    Jun-06    Jul-06
PHD    TASC                        975    1,018    1,033    1,008       988       981       922       937       962         933       938       974         974       990     990.09
                         23
PRH    PHIC                         96      159      162      164       161       160       160
PRH    PRH               203                                                               4,444     3,748     3,781       5,897     6,076     6,049       6,031     5,793   5483.72
PHD    PMT                  6                                                                         600       600         600       600       600         600       600        600
PHD    Accounting           2                                                                         160       160         160       160       160         160       160        160
PHD    M&E                  1                                                               300       300       300         300       300       300         300       300        300
CKL    HC                69                                                                                    1,195       1,633     1,613     1,327       1,493     1,491   1528.53
CKL    ODO               15                                    481       573       573      573       567          653       916       911      849         895       868        848
CKL    RH                31                                                                                        683       958       963      814         938       891        920
CP     HC                103                                                                         2,220     2,951       3,272     3,155     2,836       3,086     2,956   3011.52
CP     ODO               15                                    499       574       573      574        653         782       823       929      615         880       835        826
CP     RH                34                                                                            680         887       968       816      716         889       872        892
PC     HC                119                                                                                   2,561       3,249     3,179     2,710       3,156     2,963    3104.2
PC     ODO               13                                    499       573       573      573       573          653       894       838      716         813       755        817
PC     RH                27                                                                                    2,561       3,249     3,179      733         712       644        721
       Total             661     1,071    1,177    1,195    2,650      2,868    2,859      7,546   10,437    18,727      23,853    23,657    19,399       20,926   20,118    20,202
      Accumulative sum           1,071    2,248    3,443    6,092      8,961    11,820    19,366    29,803    48,530      72,382    96,039   115,437     136,363   156,481   176,683




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