Abstract
Closeout report of USAID/Cambodia on achievement of its strategic objective (SO) to improve reproductive and child health (RCH). The impact of activities under this SO for the period 1996 to 2000 is reflected in: decreases in infant and child mortality per 1000 live births from 115 to 95 and from 181 to 124.5, respectively; and an increase in contraceptive prevalence rate from 7% (in 1995) to 19% (29%-37% for USAID target areas in 2002). All achievements were in excess of target. Achievements in terms of intermediate results (IR) are as follows: (1) An expanded supply of RCH services is reflected in: an increase in couple years of protection (CYP) from 100,000 in 1998 to 432,000 in 2002; a decrease in the stock-out rate of essential drugs and contraceptives at health centers from 80-90% in early 1998 to 5% in 2002; .and adoption/use by the Ministry of Health (MOH) and NGOs of numerous policies, standards, training modules, guidelines, and protocols such as COPE (client-oriented, provider-efficient) and safe motherhood. (2) In terms of access to RCH services: households having access to safe water in target areas increased from less than 13% in 1996 to over 50% in 2002; 30% of deliveries were attended by trained midwives in Reproductive and Child Health Alliance (RACHA) target areas in 2001 (up from almost zero in 1997); the availability of Reproductive Health Association of Cambodia (RHAC) services in target areas increased from nearly zero in 1997 to 37% in 2002; the contribution of health centers to the contraceptive prevalence rate rose more than five-fold between 1998 and 2001; vitamin A coverage increased from less than 15% in 1997 to over 85% in USAID-supported target areas by 2002; and immunization coverage rates in CARE's project areas rose from 18% in 1995 to 84% in 2002. (3) IR 3: A strengthened demand for quality services is reflected in: CYP directly attributable to USAID-supported interventions increased from just over 100,000 in 1997 to 432,000 in 2002; the volume of services provided by RCH clinics increased from less than 100,000 clients in 1998 to over 350,000 in 2002; more than 45 health feedback committees and 30 village development committees were established and are working with health centers and target communities to improve access to health center services; there were increases in sales of 'Number One' brand condoms from zero in 1994 to 18.5 million in 2002 and of 'OK' brand oral contraceptives from zero cycles in 1997 to over 700,000 in 2001. The prospects for long-term sustainability are good. There is good reason to expect that the MOH will continue to make significant progress towards the goal of accessible health services nationwide. Since the delivery of RCH interventions is urgently needed but constrained by the level and pace of system development, RCH efforts in Cambodia must proceed on two tracks simultaneously: strengthening the nascent service delivery system, and promoting the delivery of specific interventions. Many of the gains achieved under the SO can be sustained through the efficacy of Cambodian and international partners and the strong commitment of the Cambodian government. The principal threats to sustainability are the weak institutional capacity of public health services, the overall poverty within Cambodia with increasing landlessness and inability of the poor to access adequate nutrition, and the possibility of renewed violence. Lessons learned were as follows: (1) Competency-based training of midwives has significantly improved the quality of their services and utilization. Keys to this success have been careful training selection criteria, practical training provided in a setting with a high volume of deliveries, and intensive post-training follow-up. (2) Very dramatic reductions in malarial morbidity and mortality can be achieved through a combination of information, communication, and education (IEC) programs and the distribution of insecticide-impregnated bednets when carried out by NGOs in a structured, intensive manner at the community level, accompanied by careful monitoring and evaluation of both behavioral change (maintenance and use of bednets) and impact (decrease in malaria incidence). (3) There are numerous potentials for linkages between RCH and HIV/AIDS/sexually transmitted disease (STD) interventions that would render both more effective, e.g., in joint IEC efforts; in links between maternal care and prevention of STDs and of mother to child transmission of HIV; and in links between family planning, voluntary counseling and testing, and STD/HIV prevention. (4) Social marketing is an appropriate and cost-effective strategy for increasing access and demand for family planning methods. However, current marketing strategies do not effectively reach the rural areas where the majority of the population resides. There is also untapped potential for using social marketing to improve access to and demand for RCH services, e.g., oral rehydration solution (ORS), iron/folate supplements, etc. (5) In the Cambodian context, where human resource capacity is extremely weak, and change is needed not only in information and skills but in basic attitudes and expectations, effective TA and training requires extensive, prolonged, hands-on follow-up, coaching, and mentoring at the actual service delivery point. To achieve this, it is critical that implementing agencies systemically approach, and allocate resources for, capacity-building of their own national staff so that they are well positioned to serve as mentors.