mid-term-report - Ministry of Health

Table of ContentsExecutive Summary .................................................................................................................................3Abbreviation .............................................................................................................................................61. Introduction..........................................................................................................................................72. Background of GFATM in Cambodia .............................................................................................72.1. Description of GFATM programme activities........................................................................72.1.1. GFATM Round One ...........................................................................................................82.1.2. GFATM Round Two...........................................................................................................82.2. Programme milestones..............................................................................................................103. Mid-Term Review Process ...............................................................................................................113.1. Methodology...............................................................................................................................113.1.1. Review activities..................................................................................................................113.1.2. Limitations of the Review .................................................................................................123.2. Review activity schedule............................................................................................................124. Findings and discussion ...................................................................................................................134.1. Programme management, structure and capacity..................................................................134.1.1. Principal Recipient (PR) ....................................................................................................134.1.2. Sub Recipients.....................................................................................................................214.2. Programme components...........................................................................................................244.2.1. HIV/AIDS..........................................................................................................................244.2.2. Malaria..................................................................................................................................284.2.3. Tuberculosis ........................................................................................................................294.3. Programme achievement and financial management............................................................304.4. GFATM Cambodia structure and relationship......................................................................304.4.1. Structure of GFATM programme in Cambodia............................................................304.4.2. Relationship among the different GFATM structure ...................................................324.5. Issues raised by CCC members................................................................................................324.5.1. Additionality of GFATM to existing health activities...................................................324.5.2. Value for money .................................................................................................................334.5.3. Centralized procurement Vs. Capacity building.............................................................334.6. GFATM Cambodia and National Health Sector Strategic Plan .........................................334.7. Strength and shortfalls of PR ...................................................................................................355. Achievements ....................................................................................................................................366. Lessons learned.................................................................................................................................377. Options for improvement of current programme.......................................................................377.1. Principal Recipient Programme management, structure and capacity ...............................37(a) Term of reference (job description) of PR..........................................................................37(b) Monitoring and evaluation.....................................................................................................38(c) Procurement............................................................................................................................39(d) Finance .....................................................................................................................................407.2. SR Programme management, structure and capacity............................................................40(a) Capacity of SR..........................................................................................................................40(b) Monitoring and evaluation.....................................................................................................41(c) Procurement.............................................................................................................................41(d) Finance .....................................................................................................................................427.3 Programme components............................................................................................................428. Key recommendation for future projects.......................................................................................43Acknowledgement..................................................................................................................................43

Appendices..............................................................................................................................................45Appendix 1: Term of Reference of Mid Term Review...............................................................46Appendix 2: Summary milestones of GFATM Programme in Cambodia................................50Appendix 3: Detailed Mid Term Review Programme ................................................................51Appendix 4: List of documents reviewed .....................................................................................53Appendix 5: List of people met during the Mid Term Review..................................................55Appendix 6: Terms of Reference (Job Description) for PR team members ............................58Appendix 7: Success stories from field visits.................................................................................64Appendix 8: Detailed comments on M&E Guidelines (Working Draft)..................................65Appendix 9: Mid-Term Review activities photos .........................................................................67

Executive SummaryThe GFATM was set up in January 2002 to make additional resources available as quickly aspossible to scale up the fight against HIV/AIDS, Tuberculosis and Malaria. Cambodia hassuccessfully secured GFATM funding for proposals submitted for the first, second and fourthrounds. The Ministry of Health is the Principal Recipient (PR) and KPMG Cambodia is theLocal Fund Agent (LFA).A Mid-Term Review (MTR) was contracted by the PR and undertaken by a 3-person team ofinternational and domestic consultants from 6 December 2004 to 14 January 2005 inCambodia (total of 5 working weeks). The purposes of this Mid-Term Review were to assess,determine and report on Round 1 and 2 GFATM programme inputs, processes,accomplishments and lessons learned; and to make recommendations to the PR and CCC forthe next stages of programme implementation.The Review found strengths and weaknesses in the current rounds. The PR team was deemedable to fulfil the requirements stated in their Terms of Reference / Job Descriptions, but theseTORs are notable for being minimalist. The PR team is highly energetic, hard-working andrelatively effective. They have developed guidelines and plans for Monitoring and Evaluation(M&E), Procurement and Finance for Sub Recipients (SRs). However, these guidelines cannotovercome the limitations of lack of initial baseline data, making setting of objectives andmeasurement of change virtually impossible, leading to overwhelming reliance on processindicators. Initial delays in ARV medicine procurement arose from several factors, includingthe decision by WHO to disallow the participation of a supplier originally in the list approvedby WHO. Effective management of PR is impeded by the relatively low capacity of some SRs,putting further pressure on PR to undertake training and mentoring. The PR workload isextremely heavy, and despite strenuous efforts they are overstretched.There are a total of 11 SRs in Round 1 and 10 SRs in Round 2. Most of the SRs had a preexistingmanagement and structure system, creating synergies for some but overlapping andconfusion for others. The Review found over-achievement of intended results with significantunderspending, which shows deficiencies in setting intended results and budget estimationKey lessons learned from the Review are: (1) though the GFATM was set up to reducebureaucratic procedures for programme funding and implementation, there are bottle-neckswithin the in-country structure and system; (2) Capacity building is a cross cutting issue butusually not given priority over efficiency of project implementation; and (3) over-achievementis not necessarily a desired achievement. It is also important to note that building goodrelationships and trust is crucial for successful programme management, implementation andsustainability.The Review Team identified a series of challenges for PR and SRs and has provided optionsfor addressing each (with preferred option noted). These challenges include:Principal Recipient1. CCC/CCCSC needs a full time technical support advisor to effectively support thetechnical and management issues.2. The PR workload is extremely heavy, and despite strenuous efforts they areoverstretched. Their work output depends upon having sufficient, appropriatelyskilledstaff. The Review Team feel strongly that the PR team should be enlarged.

3. The job description of the PR team members are "minimalist" and not reflecting thecomplex duties and skills carried out by the team members. The job descriptionattached as appendix 6 should be revised.4. Some PR-TRT members are also SRs, creating a potential conflict of interest. The PR-TRT members should be independent technical resource persons.5. Most of the documents and records in the PR office are in hard copies, creatingchallenges for filing and availability in a timely fashion. A centralised database for allthe important document should be established.6. The indicators and intended results in the M&E plans were taken from the proposalswhich were developed a few years before the implementation. The current situationmight be different. These intended results/indicators should be revised.7. Some SR had delays in submission of quarterly report. This could be improved byestablishing a reminder system by CCCSC and PR for timely submission8. Most of the existing Cambodian national programmes have their own monitoringsystems. It is important that the PR monitoring system should be integrated with theexisting system, or set up to be easily extractable.9. All the guidelines and plans developed by PR are written in English which is difficultfor some SR to understand. The Review Team recommend all the referencedocuments be translated into Khmer10. Procurement has been one of the major activities of SR. The procurement guidelineswere developed by the PR team but some SRs are still lacking capacity to do theprocurement by themselves. The Review Team suggested CCC and PR to decide ifcentralized procurement is preferred over individual procurement.11. There is no clear and detailed guideline on management of income generated from theGF projects. The current guideline on income/revenue generated from the projectshould be reinforced and revised.12. It is important to monitor under/over spending of SRs through disbursement requestand progress update. The Review Team recommend that a space should be added inthe format to report reasons for significant (more than 10% or to be determined by thePR finance team) over or under-spending for each quarter.Sub-Recipients1. Limited capacity of the SR staff and frequent turn-over of trained staff are hinderingthe project implementation by some SRs. A capacity building plan for SR staffmembers should be developed.2. Some SRs do not have specific staff members fully assigned to M&E activities buttaking extra responsibilities for M&E besides their regular job. The review teamstrongly recommend that all SR should have a specific staff member fully assigned toGF M&E activities3. SRs were not consistent in reporting the indicators of achievements, i.e. some arereporting in absolute numbers, cumulative and percentages. Some intended resultsmight not be relevant to current situation. A consistent format of reporting indicatorsshould be developed.4. Some SRs are reporting their organizations' overall achievements as GF achievementespecially those SRs with multiple donors. A system should be established to track theGFATM achievement by SRs.5. Most SR expressed that the current minimum threshold for sealed quotations of US$1,500.00 was difficult to get suppliers who were willing to give sealed quotation for $1,500.00. The threshold should be increased to $ 5,000.00.6. Even though some stronger SRs have good financial system, underspending issue wasover-looked by the SRs themselves. Expenditure reviews should be conducted by SRfinance staff to determine the source of underspending and develop a plan of action totackle the problem.

7. Some SR expressed concerns over reliability of local banking system. Consultationwith other agencies and risk management plan should be developed by the SRs tominimize the risks.To improve project implementation in future rounds, the Review Team recommendsto:.1) Conduct Funding Gap Analysis during the project proposal stage;2) Calculate cost per beneficiary during the project proposal stage to obtain accuratebudget estimation;3) Explore opportunities for merging programmatic components in each programmeduring the project proposal stage. For example: VCT and PMTCT; TB DOTS andHIV/AIDS home care;4) Recruit a full time technical and management advisor for CCC/CCCSC;5) Include PR team in the proposal panel to identify issues of programme activitiesoverlapping among the rounds and among the SRs;6) Further strengthen the existing good relationship, trust and rapport among all entitiesof the GFATM structure;7) Expand the current PR team;8) Recruit a professional expatriate or local finance advisor to support the PR financeteam;9) Establish a centralised PR database system to collect record and analyse M&E,procurement and finance activities;10) Include SR communication system (email database and website management) in thecentralized database;11) Prioritise capacity building over efficient project management of SRs throughdeveloping SR capacity building plan and checklists; and12) Develop a list of criteria to decide if an organization is eligible as an SR or SSR toreduce the management responsibilities of PR. eg. SR with requested budget of lessthan $ 50,000 should be SSR instead of SR..Overall, the Mid-Term Review concluded that despite its best efforts, the PR is struggling tomeet and fulfil the tasks that comprise effective management (some of which are not explicitlypart of TORs). Many SRs are implementing quality projects, have no major problems infollowing all of the PR?s guidelines, and appear to be making an impact. However, other SRsare less successful, and all struggle with timely reporting and procurement requirements. It iscrucial that these issues be addressed in practical ways during the current Rounds, and thatefforts are made to improve systems and capacity building to increase the impact of GFATMfunds in Cambodia.

AbbreviationARV Anti retroviralBCC Behavioural Change CommunicationCCCCounty Coordination Committee (Mechanism) of CambodiaCCCSCCountry Coordination Mechanism Sub-CommitteeCDC Centre for Disease ControlCENAT National Centre for TuberculosisCNM National Centre for MalariaCRC Cambodian Red CrossDOTSDirectly Observed Therapy StrategyDSF Douleur Sans FrontierEDATEarly Diagnosis and TreatmentFRC French Red CrossGF Global FundGFATMGlobal Fund to fight AIDS, Tuberculosis and MalariaHAARTHighly Active Anti Retroviral TherapyHACCHIV/AIDS Coordination CommitteeIEC Information, Education and CommunicationNHSSPNational Health Sector Strategic PlanHSSP Health Sector Support ProjectKHANA Khmer HIV/AIDS NGO AllianceLFA Local Fund AgentM&E Monitoring and EvaluationMDM Medicin du MondeMND Ministry of National DefenceMoA Memorandum of AgreementMoH Ministry of HealthMOSVYMinistry of Social Affairs, Veteran and Youth RehabilitationMTR Mid Term ReviewNCHADS National Centre for HIV/AIDS, Dermatology and STDNGO Non governmental organizationOI Opportunistic infectionPFD Partners for DevelopmentPGA Programme Grant AgreementPLWHA/PLHAPeople Living with HIV/AIDSPMTCTPrevention of Mother to Child TransmissionPR Principal RecipientPSF Pharmaciens Sans FrontieresPSI Population Services InternationalQALYQuality adjusted life yearR1 Round OneR2 Round TwoRHACReproductive Health Association of CambodiaSHCHSihanouk Hospital Centre of HopeSR Sub-RecipientSSR Sub-Sub RecipientSTD Sexually Transmitted DiseaseSTI Sexually Transmitted InfectionTOR Term/s of referenceTRT Technical Review TeamVCCTVoluntary Counselling and Confidential TestingVCT Voluntary Counselling and TestingVHV Village Health VolunteersYCC Youth Council for Cambodia

GFATM Cambodia Mid-Term Review ReportJanuary 20051. IntroductionThe GFATM was set up in January 2002 as a financial instrument to dramatically increaseresources to fight three of the world's most devastating diseases, and to direct those resourcesto areas of greatest need (Global Fund brochure, September 2004). Cambodia was successfulin receiving GFATM funds to implements projects in first, second and fourth rounds ofproposals. The Ministry of Health in Cambodia is the Principal Recipient (PR) and the LocalFund Agent (LFA) is KPMG-Cambodia.The purpose of this Mid-Term Review was to assess, determine and report on Round 1 and 2GFATM project inputs, processes, accomplishments, lessons learned and to makerecommendations to PR and CCC for the next stages of programme implementation. Anotherpurpose of this review is to serve as a reference document for subsequent reviews andevaluations.A team consisting of an expatriate team leader, a local consultant and a representative from thePlanning and Health Information Department of the Ministry of Health, was appointed inDecember 2004 to review GFATM programme in Cambodia. The Review Team adopted theillustrative time line proposed in the terms of reference starting with briefing from PR office,project document reviews followed by meetings and field visits.This report highlights key aspects of the Mid-Term Review, i.e. programme management andother implementation issues relevant to activities of both Round 1 and 2 for all components(HIV/AIDS, Tuberculosis and Malaria) with special emphasis on performance,accomplishments, constraints, lessons learned and recommendations on the future direction ofthe programme. It is too early to assess the impact of the GFATM in Cambodia, however,evidence of successes and weaknesses has been included where available.Given the scope of the TORs (Appendix 1), requests for additional review topics from theCCC (see below) together with the sheer size of the GFATM programme, its multiple projects,locations, actors, stakeholders, and different start-up dates and rounds, this report necessarilyprovides only an overview. Appendices contain additional information.In this report, "programme" refers to the general GFATM funded activities in Cambodia beingmanaged by the PR. "Components" or "programme components" refer to the body ofactivities addressing the 3 specific diseases of focus (HIV/AIDS, Tuberculosis and Malaria)."Projects" refer to individual activities implemented by SRs. It should be noted, however, thatthese terms are used with different meanings, and sometimes interchangeably, within a numberof documents, including the TORs. It is hoped that the context will be made clear whichmeaning is intended.2. Background of GFATM in Cambodia

Cambodia has been successful in obtaining approvals from GFATM for the proposalssubmitted for the first, second and forth rounds. The first round was for HIV/AIDScomponent only; the second round was for all three components (HIV/AIDS, malaria andtuberculosis; and the fourth round was for HIV/AIDS and malaria only.2.1.1. GFATM Round OneThe Programme Grant Agreement (PGA) for Round 1 (Grant number CAM -102-G01-H-00)- "Partnership for going to scale with proven interventions for HIV/AIDS, TB and Malaria"for HIV/AIDS component was signed on 27 January 2003 for the implementation of theprogramme from 3 February 2003 to 2 February 2005 with a budget of US$ 11,242,538.00.The goal of the programme is to reduce the burden of HIV/AIDS and to mitigate the impactof AIDS in specific population groups. There are 5 main objectives of the programme:1) To slow down the spread of HIV infection among vulnerable population;2) To extend the reach and improve the quality of sexually transmitted infections (STI)services;3) To provide care for and treatment to people with HIV/AIDS;4) To reduce vulnerability of selected population at higher risk; and5) To make condoms readily availableThe eleven Sub-Recipients (SRs) implementing the programme in the first round are:1. Ministry of National Defence (MND)2. Ministry of Social Affairs, Veteran and Youth Rehabilitation (MoSVY)3. Cambodian Red Cross (CRC)4. Youth Council for Cambodia (YCC)5. National Center for HIV/AIDS, Dermatology and STDs (NCHADS)6. Khmer HIV/AID NGO Alliance (KHANA)7. Sihanouk Hospital Centre of Hope (SHCH)8. Medicin du Monde (MDM)9. Douleur Sans Frontieres (DSF)10. Pharmaciens Sans Frontieres (PSF) and11. Population Services International (PSI)Even though PGA for the first round was signed in January 2003, the programmeimplementation was not started until September 2003 for various reasons which is discussed inchapter 4.1.1.5.2.1.2. GFATM Round TwoThe Round Two has three Programme Grant Agreement signed on 14 October 2003 for thefollowing components:1. Partnership for going to scale with proven intervention for HIV/AIDSGrant number : CAM-202-G02-H-002. Partnership for going to scale with proven intervention for MalariaGrant number : CAM-202-G02-M-003. Partnership for going to scale with proven intervention for TuberculosisGrant number: CAM-202-G02-T-00

The goal of the HIV/AIDS component is to reduce morbidity and mortality resulting fromHIV/AIDS by complementing the implementation of the National Strategic Plan forHIV/AIDS and has the following objectives:To expand the coverage and enhance the quality of interventions for the prevention ofHIV/AIDS to include under-served, vulnerable populations;To improve access to quality comprehensive care interventions, including highly activeanti-retroviral therapy (HAART) and the promotion of greater involvement of peopleliving with HIV/AIDS; andTo secure reliable and adequate drug supplies in order to improve access to qualitycomprehensive care interventions, including the treatment of opportunistic infections(OIs) and sexually transmitted infections (STIs), prevention of mother to childtransmission (PMTCT) and the provision of anti-retroviral (ARV) medicines.The goal of the Malaria programme component is to reduce malaria- related mortality amongthe general population in Cambodia by 50% and morbidity by 30% within five years bycomplementing the implementation of a comprehensive national malaria control strategy. TheMalaria component has the following objectives:To significantly increase community awareness and improve care taking practices onmalaria prevention and control with promotion of proper health seeking behaviour inendemic areas;To improve access to prevent measures (nets and insecticide) through a communitybasedapproach;To increase access to early diagnosis and treatment (EDAT) through a three-prongedapproach (public, private and community based); andTo strengthen the institutional capacity of the national programme at all levels.The goal of the Tuberculosis programme component is to complement the efforts of theMinistry of Health to decrease the socio-economic burden of TB by reducing the morbidity,mortality and transmission of the disease. This will be achieved through the expansion of theDOTS to the community; strengthening of DOTS in 40% of health centres by 2005; and socialmobilization through advocacy and IEC. The Tuberculosis component has the followingobjectives.To expand DOTS to the community and strengthen community involvement withhealth providers;To expand/increase the case detection and strengthen activities related to DOTS inHealth Centres and TB units;To improve knowledge about TB among the adult population;To strengthen monitoring and evaluation system;To carry out programme-based operational research and surveys; andTo improve TB awareness, case detection and treatment services in underserved areasand strengthen the capacity of TB health workers in Kratie and Kompong Champrovinces in partnership with NGOs.There are a total of 10 Sub-Recipients in implementing the Round 2 programme as follows.HIV/AIDS:1) Reproductive Health Association of Cambodia (RHAC)2) French Red Cross (FRC)3) National Centre for HIV/AIDS, Dermatology and STDs (NCHADS)4) Sihanouk Hospital Centre of Hope (SHCH)

5) Pharmaciens Sans Frontieres (PSF)Malaria6) Partners for Development (PFD)7) National Centre for Malaria (CNM)8) Health Unlimited (HU)9) Population Services International (PSI)Tuberculosis10) National Centre for Tuberculosis and Leprosy Control (CENAT)The total two-year budget of US$ 12,889,081.00 was signed in the PGA for all the threecomponents for Round 2.The following table 1 summarises the milestones and development of GFATM activities inCambodia starting from the formation CCC in February 2002 to the Mid-Term Review inDecember 2004.Table 1. Summary Milestones of GFATM programme in CambodiaCCC established February 2002R1 proposal submitted March 2002R1 proposal approved June 2002CCCSC formed September 2002R2 proposal submitted September 2002PR set up/staff appointed December 2002R1 PGA (Feb 03 ? Feb 05) signed January 2003R1 first disbursement request made January 2003R1 PGA amendment (September 03- August 05) June 2003R1 second disbursement request made June 2003R1 M&E guidelines/plan introduced July 2003R1 programme implementation September 2003R2 PGAs (Jan 04 ? Dec 05) signed October 2003Financial guidelines introduced October 2003R2 first disbursement request made November 2003R2 first disbursement of fund from GFATM December 2003TOR for management processes, structure and membership December 2003R2 Programme implementation started/M&E plan introduced January 2004Procurement guidelines (version 6) introduced February 2004Approval from the GF to start the health product procurement April 2004M&E Guidelines (2 nd Edition, Working Draft) August 2004Phase 2 funding for Round 1 preparation December -February 2004Mid-term Review of R1 and R2 December 2004 -January 2005Highlights of the programmme to date include the appointment of PR staff and establishmentof the PR office within the Communicable Disease Control Department of the Ministry ofHealth in December 2002, commencement of Round 1 program implementation in September2003, and commencement of Round 2 program implementation in January 2004. (Appendix2).

3. Mid-Term Review ProcessAccording to the terms of reference, (Appendix 1), the Review Team was to assess, determineand report on GFATM programme inputs, processes, accomplishments, lessons learned and tomake recommendation to the PR and CCC for the next stages of the programmeimplementation.The Review Team consists of:1. Dr Kyi Minn Expatriate consultant and team leader2. Dr Sopheap Oum Local consultant and team member3. Dr Savanratnak Sao Representative from the Planning and Health InformationDepartment of the Ministry of Health and team memberThe Mid-Term Review was conducted from 6 December 2004 to 14 January 2005 inCambodia for a total of 5 working weeks. The detailed Mid-Term Review programme isattached as Appendix 3.The Review Team conducted on-site review of Round 1 and Round 2 programme activities.This report contains information gathered through the review of programme documents,guidelines, plans, reports and other reference documents (Appendix 4); field visits,observations, interviews and discussion with PR staff, SR staff, CCC/CCCSC members andother relevant parties (Appendix 5).3.1.1. Review activitiesThe Review Team conducted the following activities.Primary data collection at management level - focus group discussion, in-depthinterviews, key informant interview, observation, interview with project beneficiariesand stakeholders in Phnom PenhPrimary data collection at project level - observation and in-depth interview duringfield visit to Srei Ambel district of Koh Kong province (Malaria activities); toSihanoukville (Tuberculosis and HIV/AIDS activities); and to Takeo province(HIV/AIDS activities)Secondary data review of project proposals, guidelines, check-lists, reports and otherrelevant document, guidelines and articles from GFATM Geneva, PR Cambodia, SRsand LFA CambodiaIt should be noted that during initial meetings concerning the Mid-Term Review with key CCCmembers, they suggested the team expand their focus to include following issues:"Additionality" of GFATM to existing health activities;Value for money; andCentralized procurement Vs. capacity building.The Review Team addressed these issues as time permitted; findings in relation to theseadditional points have been integrated into the report.

3.1.2. Limitations of the ReviewOne particular challenge of the Review Team was the breadth of the TORs. Although theTORs were agreed by the team, during the course of the review it became apparent that issueswere exceedingly complex and not easily synthesized given the timeframe, size of the team andmethodology of the Review. This applied in particular to Review Objectives a) i, whichrequested the team to assess whether GFATM is 'beginning to make a difference' because (1)comprehensive baseline data were not available in most projects, (2) most projects are toorecent for change to be visible, and (3) there was neither time, budget nor tools for the ReviewTeam to conduct a systematic impact evaluation using standard measures and methods. Theframework of the M&E guideline is discussed further in section 7.4. Another obstacle toreaching general conclusions about GFATM was the fact that projects had been implementedat different points of time, and thus their results were emerging unevenly.Finally, by using a wide variety of methods and sources the Review Team hoped to identifyprogress, weaknesses, outstanding issues and potential approaches for future improvements.This was achieved to some extent. It was also hoped that use of different data sources wouldenable us to corroborate findings; at times this occurred, but at others it could not becauseviews and findings were not always in agreement. It was not always possible to resolve thesecontradictions, and these discrepancies are mentioned within the report.The following table 2 summarises the activities of the Review Team and the detailedprogramme is attached as Appendix 3.Table 2. Summary activities for Mid Term ReviewTime FrameWeek 1(6 to 12 December)Week 2(13 to 19 December)Week 3(20 - 23 December)Week 4(3-9 January 2005)Week 5(10 - 15 January 2005)January 2005Review ActivitiesBriefing with PR officeFinalise and agree on TOR, work plan and review outputsDesk review of relevant documentationDiscussion with PR, SR and key stakeholdersField visits to selected SRs to see programme activitiesContinue discussion with PR, SR and key stakeholdersField visits to selected SRs to see programme activitiesDesk review of relevant documentationContinue discussion with PR, SR and key stakeholdersField visits to selected SRS to see programme activitiesInitial findings and feedback to PRDesk review of relevant documentationSynthesis of informationClarification of issuesVerification of informationFormulation of preliminary findings and recommendationsSynthesis of informationClarification of issuesVerification of informationPowerPoint presentation of draft findings andrecommendationsDraft report writingSubmit draft report

The Review Team met with all the PR office staff members, key CCC/CCCSC members, allthe SRs (of both Round 1 and 2) and visited SR/SSR project sites in Takeo, Koh Kong,Sihanoukville and Phnom Penh. The detailed list of people met can be found in Appendix 5.4. Findings and discussionThe GFATM Geneva has approved proposals submitted by Cambodia in Round one, two andfour. The executing body of the GFATM programme (Principal Recipient) is the Ministry ofHealth. The following table shows a breakdown of approved programme components andbudget for the first two years of Programme Grant Agreements for the Round 1 and 2.Table 3. Cambodia GFATM Programme Grant Agreement (Round 1 and 2)ProposalRoundProgramme Components Total approved budgetfor 2 yearsProgrammeStarting/Ending Date1 HIV/AIDS US$ 11,242,538.00 Sep 03 to Aug 052 HIV/AIDS US$ 5,370,564.00 Jan 04 to Dec 052 Malaria US$ 5,013,262.00 Jan 04 to Dec 052 Tuberculosis US$ 2,505,255.00 Jan 04 to Dec 05(Source: Principal Recipient's Office, Dept of CDC, Ministry of Health)This Mid-Term Review dealt primarily with program management issues related to PrincipalRecipient (PR) and Sub-recipients (SRs); implementation issues of program components;GFATM Cambodia structure and relationship; and GFATM Cambodia and National HealthSector Strategic Plan of the Ministry of Health.The Review findings summarized here cover Program Management, Structure and Capacity (ofPR and SRs), Program Components Implementation (HIV/AIDS, Tuberculosis and Malaria),Programme Components Achievements, GFATM Cambodia Structure and Inter-relationships,GFATM Cambodia and the National Health Sector Strategic Plan, Effectiveness and Capacityof PR, and Issues Raised by CCC members. Each sub-section summarises key findings anddiscusses these in relation to the purpose and objectives of the Review TORs. Note thatLessons Learned and Recommendations are reported separately below.This section summarises management structure, and discusses monitoring and evaluation;procurement; and finance as relevant for Principal Recipient and Sub Recipients.4.1.1. Principal Recipient (PR)The key findings are as follows:PR team members generally have fulfilled TORs;There is a conflict of interest issue in PR-TRT. Some of the team members arealso SR;PR team is small in relation to its responsibilities in management and reporting; andthough committed and highly energetic, the scale of tasks appears to stretch themto the limit;Baseline information and intended result indicators were taken mainly from theSRs' proposals which was developed a few years before the implementation;Delays in ARV medicine procurement during the initial phase was due to severalfactors which were out of control of the PR team; and

Effective management is impeded by the relatively low capacity of some SRs,putting further pressure on PR to undertake training and mentoring.The Principal Recipients for GFATM Cambodia is the Ministry of Health. The PR teammembers were appointed in December 2002 after the Round 1 proposal had been approved,but without operational funding to start the programme. Many key stakeholders such asWHO, GTZ, USAID UNAIDS, and UNDP supported the PR in setting up the office,recruitment of staff, preparation of procedure/guidelines and coordination after signing ofPGA for Round 1 but before receiving first disbursement from the GF.First disbursement request for PR activities was attached with the PGA and submitted inFebruary 2003. The funding for PR activities was received in May 2003 and for SRprogramme implementation was received in September 2003.4.1.1.1. Principal Recipient (PR) Team compositionThere are 3 main teams in the PR office namely, Monitoring and Evaluation, Procurement andFinance teams. The following table (4) shows the list of GFATM Cambodia PR members.Table 4. List of Principal Recipient Members of GFATM Cambodia ProgrammeNo. Names Positions in PR1 Dr Sok Touch Chairman2 Dr Or Vandine Manager3 Dr Hay La In M&E officer4 Dr Sinath Ouksophea M&E officer5 Dr Chea Sovann M&E officer6 Ms. Hok Chantheasy Procurement officer7 Mr Mey Bunrong Procurement officer8 Ms Sok Khim Procurement assistant9 Mr Oeurn Virak Finance officer10 Mr Reach Phanith Accountant11 Ms Maraya Monida Assistant accountant12 Mr Krang Sokhang Administrative officer13 Dr Chan Chhivnang Administrative officer14 Ms Inga Oleksy M&E International Consultant15 Mr Gunatilake Kodituwakku UNDP Procurement Consultant(Source: Principal Recipient's Office, Dept of CDC, Ministry of Health)Each team except the Finance team is supported by an international consultant advisor.4.1.1.2. Fulfilment of Principal Recipient's Term of Reference (TOR)The Principal Recipient is the legally accountable party in Cambodia that signs the ProgrammeGrant Agreement with the GFATM in Geneva. The PR acts on behalf and under the generalguidance of Country Coordination Committee (CCC). The TOR for PR addresses the maintasks and job descriptions for each member (appendix 6).a) ChairmanThe Chairman is a member both of the CCC and the CCCSC. In the early days of theGFATM he served as Chairman of the CCCSC, but relinquished this position after a Global

Fund governance review that found a potential "conflict of interest" 1 . The Chairman appearsto have fulfilled all the TORs for this position.b) ManagerThe Manager is a key player in planning, implementation, monitoring and evaluation ofGFATM activities in Cambodia. The manager acts on behalf of the Chairman in day to daymanagement as well as liaise with GFATM in Geneva. The Manager appears to have fulfilledall the TORs for this position.c) Technical officers (M&E, Procurement, Finance and Administration)The Technical officers have separate responsibility according to the tasks assigned under thesupervision of the Manager. There are two international consultants (M&E and Procurement)supporting the technical officers. The Technical officers appear to have fulfilled all the TORsfor these positions.d) Technical review teams (PR-TRTs)The PR-TRT members were appointed by the Senior Minister and Minister of Health (DrHong Sun Hout) in 2003. Some of the TRT members also hold positions in organisations thatare sub-recipients (SRs) of GFATM. Efforts have been made by the PR team to address theconflict of interest issue. Most of the functions in the TOR for PR-TRTs have been fulfilledexcept for participating in the M&E process (eg. M&E visits).Comments: It should be pointed out that the current TORs are "minimalist", processorientedand not reflective of the complex duties and skills carried out - and required- underthe GFATM. There is little reference to human resource quality. Hence, the findings reportedhere in relation to the TORs must be viewed within this context. It is beyond the scope of thisReview to comment at greater length upon PR TORs.4.1.1.3. Management responsibilitiesContract management includes all activities that track the agreed procedure and performancein the form of contract (Memorandum of Agreement) between PR and SRs as per PGAs withGFATM. PR Manager is responsible for the supervision and performance of PR teammembers, who are working with SRs according to the MoA and build the capacity of SRs toperform their tasks.a) Recruitment of PR team membersThe PR manager is responsible for overall contract management with support from technicalofficers. The Review Team found that PR technical officers (with support from internationalconsultants) were:recruited with appropriate responsibility and accountability;able to act with due care and diligence and observe all job description;able to meet the obligations of their position ensuring compliance with GFATMguidelines, and respond timely to all the queries raised by SRs during implementation;able to maintain adequate documentation to ensure continuity and auditability; andable to monitor and review the progress of the SR's project , for the outcome andachievement regularly and give timely and appropriate feedbacks.1Improving the Governance of Global Fund Activities in Cambodia (5 December 2003) by DevelopmentBusiness Associates (Peter Connell).

There are a total of 13 national PR team members with 2 international consultants in the PRteam (Table 4).b) Capacity of PR teamThe PR team was able to fulfil the conditions proposed by LFA to Global Funds Geneva onprocurement assessment and supply management and responded appropriately 2 . Theperformance of current PR manager and team members is laudable, in managing Round 1 and2 projects. With increasing success in obtaining funds from GFATM (round 1, 2 and 4) andpreparation for Round 5 proposal, capacity building and expansion of PR team members arecrucial to maintain current levels of quality and to prevent being overstretched.c) ReportingThe system of reporting is highly specific and multi-layered, with potential delays at manypoints. Until the end of 2004, disbursement of funds for the next period could be obtainedonly after final approval of the review process; delayed disbursement has occurred on a fewoccasions.The reporting system is as follows:SRs submit reports within 2 weeks of end of quarter to PR;PR scrutinises these and seeks clarification from SRs where needed, modifies andcollates into a single report for submission to PR-TRP;PR-TRP reviews report, clarifies gaps or ambiguities in discussions with PR (typicallyinvolving communication with SRs) until agreement has been reached to submit toCCCSC;CCCSC reviews report, again seeking clarification through discussions with PR(typically involving communication with SRs) until satisfied that report may besubmitted to LFA;LFA follows a similar process of review and periodic involvement of PR (typicallyinvolving communication with SRs) until all outstanding issues have been clarified andapproval given to submit to GFATM; andPR reports it is required to submit at final stage voluminous documentation, includingMinutes, financial reports, M & E worksheets for GFATM.The potential risks for the smooth operation of reporting are several. (1) No movementtowards the next level of approval may take place until all actors have submitted documents asrequired. If even one SR report is late, or if the SR finds it difficult to respond to additionalquestions from PR, the entire process is delayed, thus adversely affecting all projects. If theCCC-SC has conflicting activities and cannot convene to consider the report, another delaymay ensue. (2) PR expresses the view that the multiple levels of review involves heavycommitment of human resources; with various delays there have been times when the nextquarterly process has commenced before the previous one has finished. (3) Those serving onthe PR-TRP and the CCC-SC are acting in a voluntary capacity, which has implications fortheir other work tasks. Note: PR reports that as of January 2005 (ie, since time of theReview), GFATM has agreed to the PR request to alter the reporting frequency from quarterlyto semi-annual. This should alleviate some of the current reporting burden for all levels.Comment: The all-or-nothing reporting process discriminates against SRs that have compliedin a timely fashion. It seems unfortunate that so many levels are required, and, in particular,2Letter from GFATM to Dr Sok Touch on 27 February 2004 on Procurement Assessment for Round 2 andresponse the response letter from HE Dr Hong Sun Huot to Mr Tom Hurley in GFATM on 17 March 2004.

that every aspect of the reporting from the myriad partners must be complete before the nextdisbursement can be approved. A more nuanced, flexible system is desirable.4.1.1.4. Capacity building responsibilitiesCapacity building is crucial for the SRs to perform their tasks well according to the MoA. ThePR team members are providing on-going assistance to SRs on individual basis, guiding themthrough various issues including planning, reprogramming, budgeting, procurement,implementation, reporting requirement, monitoring and evaluation.a) Grant Recipient Program Guidelines development and trainingThe PR has developed a series of reference guidelines according to the GFATM requirement.They are:M&E guidelinesM&E plans (including monitoring tools)procurement guidelines andfinancial guidelinesThese guidelines and plans were distributed to all the SRs. Respective PR staff conductedtraining workshops on M&E, procurement and financial management. Follow up assistance isprovided to individual SRs after the training sessions. The PR Procurement team continue toprovide workshops/clinics and on-the-job training to SRs.b) Strengthening SRs' capacityThe guidelines have been developed by PR to build the capacity and assist in projectimplementation. The capacity of SRs ranged from ?no-skill-no-experience? to ?highly-skilledhighly-experienced?and it was quite challenging for PR to plan for capacity building.PR staff members are fully stretched with their current responsibilities in every area but stillcontinue to give assistance on individual bases. Some examples of individual assistance are:reprogramming of project plan (for RHAC, MDM, PSF and NCHADS)drafting of M&E plan for most of the SRsfacilitate assistance from stronger SR to weaker SRs ( for YCC and MOSVY)facilitate coordination of activities among SRs in programme planning (forNCHADS and FRC) andre-drafting reports for NCHADS, CENAT and PSFThe procurement team is also helping and guiding SRs who are doing their own procurementusing the procurement guideline. It is hoped that formal training (through workshops) and onthe-jobtraining would improve the capacity of SRs.Comments: All the SRs appreciated the assistance and support given by the PR teammembers. The Review team also found that some SRs who did not have proper guidelines orsystem for M&E, procurement and finance, have adopted the PR guidelines and system to usein their organizations. Even though PR should train and mentor to build the capacity of SRstaff in project implementation issues, it is imperative that SRs also take the initiative to recruitreasonably skilled staff for the assigned job or provide "in-house" training supported by othernetworks and sources.

4.1.1.4. Monitoring and evaluationMonitoring is an important responsibility of the PR to ensure that programme activitiesachieve their intended results. The PR team has developed:- Monitoring and Evaluation Guidelines for HIV/AIDS (Round 1), August 2003 (1 stEdition)- Monitoring and Evaluation Plan for HIV/AIDS, Malaria and Tuberculosis (Round 1and 2), January 2004; and- Monitoring and Evaluation Guidelines for HIV/AIDS, Malaria and Tuberculosis, 2 ndEdition, Working Draft, October 2004.These documents were developed in consultation with SRs and other partners. The workingdraft is in the process of finalization.While these documents are clearly written, they were prepared after, rather than as part of thedevelopment of Round 1 proposals. These proposals, it should be remembered, weredeveloped within a short time frame and without the benefit of baseline surveys. Hence, thevast majority of Output indicators are process-level, and Outcome indicators do not seek tomeasure change from baseline. This makes them more useful for monitoring than forevaluation, particularly in the short term. This deficiency is recognised within the Guidelinessuggest that Year 1 of each project can be considered a ?baseline? for subsequent years.a) Monitoring and evaluation guidelinesThe M&E guidelines were developed after the proposal had been approved. The selection ofindicators in the guidelines was done in consultation with SRs and other partners. Trainingworkshops for M&E activities were conducted by the PR team for SRs. The baseline data forboth rounds were limited and also SR were not require to submit detailed work-plans in Round1 to the PR which makes monitoring job of PR rather challenging.Some SRs have had difficulty understanding and using the M&E guidelines because they areavailable only in English, and also include rather theoretical sections. Most SRs reported thatthe monitoring tools (7 tools) attached in appendix 6 of the revised M&E guidelines (workingdraft August 2004) are the most useful tools to date for conducting M&E activities.According to the guidelines, all the SRs need to submit their quarterly reports within 2 weeksafter the end of the quarter. The review team found reports were not always submitted ontime, and ranged from one week before to one month after the end of the quarter.b) IndicatorsCore indicators for HIV/AIDS, Malaria and Tuberculosis were included as appendix 1 of theM&E guidelines which are clear and easy to understand. But there was no clear guidelines onthe reporting the results There was no clear guideline from GF on the reporting the SRs'results. Some SRs were reporting in absolute numbers; some in percentages; and some incumulative figures. Some SRs reported the achievements/results as an overall achievement ofthe organization through multi donors' activities without specifying achievements fromactivities funded by the Global Fund. However, the Review Team found the followingmultiple changes in GFATM guidance on M&E as follows:In 2003, initially under the Round 1, all SRs were to report the results as ?actual? or?absolute? numbers, while with the commencement of Round 2, the GF told PR toreport all figures in a ?cumulative? manner;

In 2004, although it was understood that most indicators should be reported in?cumulative? manner, some still require to report the ?actual? number which wereclearly marked with the asterix in the Excel report file;In November 2004, another change was introduced by GFATM (a PDF attachment);that all the indicators should be reported in ?cumulative? mannerThe Review Team was informed that all these changes, adjustments and special considerationshad been directly communicated to the SRs by the PR M&E team (especially the relevantpoints to the specific SRs).c) Monitoring and evaluation plan and their implementationThe PR has developed 3 monitoring and evaluation plans, one for each disease (HIV/AIDS,Tuberculosis and Malaria) which SRs are expected to use. These plans are detailed and clear.However, because they are in English ? and quite lengthy ? some SR staff cannot understandthem. Second, while capacity building of M&E staff (for both PR and SR) and involvement ofbeneficiaries are mentioned as important issues within the plans, the Review found someweaknesses in both areas. The Review Team felt that M & E were not performedsystematically and energetically by some SRs, which seemed to respond only to the urgings ofthe PR during visits (see d, below). An additional complication is that some SRs who hadmultiple donors were required to conduct M & E according to the donor?s particularframeworks. Partly in response to this issue, some PR M & E Team members also attendregular meetings with donor M & E Working Groups. Some thought has been given todevelopment of shared M & E plans, but this may be difficult to achieve because of thedifferences between donors in regulations, guidelines and focus.d) Monitoring and evaluation visits and quarterly meetingsThere were no clear guidelines from GF on monitoring SRs' performance except for PR?s selfdirective to conduct quarterly visits. The PR team developed its own M&E methodology, planand M&E visits schedule to monitor all the SRs. Appropriate methodology and approacheshave been applied by PR. The PR staff gave feedback and recommendations to SR promptlyafter the project site visits; documented the findings and recommendations accordingly; furtherfollow up and clarification during quarterly meetings with SR. It was found that the SRquarterly meetings are not only to update the project progress but also to share the lessonslearned and best practices among the SRs. Issues from the quarterly reports were clarifiedduring the meeting.Comments: It should be noted that the indicators and intended results in the M&E planswere taken from the proposals which had been developed by the SRs before theimplementation was started. The current situation might be different from the proposalwriting time. It is also important to recognise that the M&E activities are responsible by all thestakeholders, not only the PR. It is acceptable to include overall or national achievementsaccomplished with all funding sources (GF and others) if it is clearly stated in the report. Eventhough there was no directive from the GF on monitoring visit, executive summary of themonitoring visits are required by the LFA as part of the entire process of assessing thequarterly reports before submission to the GF.4.1.1.5. ProcurementThe procurement guideline was finalised in February 2004. The procurement process wasexplained fairly clearly in the PR Procurement Guideline. All the SRs need to developindividual procurement plan and then sent to PR for review. The PR procurement team willreview, revised with SR if required, and submit to PR-TRT and CCC for approval. After the

CCC approves, the plan is sent to GFATM Geneva for final approval and this process couldtake up to 3 to 4 weeks. Most of the documentations for procurement are kept in hard copiesin the PR offices and a computerised database system is required in the PR.a) Delays in procurementThere were delays in procurement of project supplies, mainly ARV medicines for both rounds.There were several issues causing the delays. The main issues identified by the Review Teamare:LFA Cambodia's initial assessment of PR's capacity for procurement was notfavourable 3 which was later resolved;There were no clear guidelines for procurement and several revisions were made tocomply with the recommendations from GFATM Geneva;There were very few suppliers who could provide all the combination medicines inrequired amount requested by PRThe selected supplier was taken out from the WHO pre-qualified list afterprocurement had been done and finally;GFATM approved the PR to start the procurement of health product on 26 April2004 at the third round of re-submission of procurement plan and request.The ARV medicines were procured after the approval from GF in April 2004 and received byPR in August 2004 for distribution.b) Centralize procurement Vs. Capacity BuildingThe PR also allowed some SRs to do the procurement by themselves provided they follow theguidelines thoroughly. Most of the SRs do not have experienced or skilled staff members whocould handle procurement according to the GFATM prescribed guidelines. The PR team isalso building the procurement capacity of the SR through helping with the requirementprocurement process (open quotation, invitation for tenders and sealed quotations etc).Training workshops have been conducted by the PR team on procurement and on sitesupports are also arranged with individual SRs. Because of the increasing workload and limitedstaff members in the PR procurement team, not all the procurement processes from SR wereassisted on time, resulting in delays. For this reason, a centralized procurement had beensuggested. The centralised procurement has the following benefits.Faster procurementSuppliers response favourable because it is a bulk procurementBetter prices because of the bulk procurementPR procurement team could monitor closelyOne of the GFATM's mandates was to build the capacity of SRs (including nationalprogrammes, government ministries and local organizations) in contract management andproject implementation. Capacity of SRs to do procurement would be improved if the SRswere given the opportunity to do the procurement by themselves supervised by the PR.The benefit of centralised procurement and issues of capacity building of SRs could bediscussed with individual SRs, carefully weighing the benefits from both sides. The same issueapplied with SSR procurement which could be centralized with the SR or with PR. Because ofthe significant amount of ARV medicines required by SRs in both Round 1 and 2, PR decidedto have centralized procurement for ARV medicines to obtain the above mentioned benefits.3Letter from GFATM to Dr Sok Touch on 27 February 2004 on Procurement Assessment for Round 2 andresponse the response letter from HE Dr Hong Sun Huot to Mr Tom Hurley in GFATM on 17 March 2004.

Comments:It should be noted that PR team prefers centralized procurement with active participation fromrespective SRs because of the above mentioned benefits, but CCC members preferdecentralised procurement to build the capacity of SRs in project management includingprocurement.4.1.1.6. FinanceThe financial guideline developed by the PR finance team is clear and precise. The guidelinescontain attachment for monthly expenditure summary which gives expenditure status (underor over spending) at a glance. There are detailed guides on permissible rates for per-diem,incentives and allowance for project counterparts. The PR finance team also conductedtraining workshops for SRs in financial management and PR financial guidelines.a) Interest and income generated from GFATM projectsGlobal Fund discourages earning revenues from programme activities such as keeping funds ininterest earning accounts. However, there is evidence that some SRs are earning some revenue(eg.. social marketing income) according to the nature of project activities. There is no detailedprocedure in the finance guideline on what should be done with the income generated fromthe project to be a total transparency of financial accounting systems.b) Monitoring financial managementPrior to dispersal of Round 1 funds to SRs, the PR assessed the capacity if 11 SRs to managefinances and procurement.. The PR reported that three were found to have weak or nonexistentaccounting systems; these SRs are now managed and supervised closely by the PRfinance team. The PR received all quarterly financial reports along with narrative reports fromSRs. The PR financial team reviewed the financial reports and met with SR for clarification.The Review Team found significant under-spending in almost all of the SRs. The details arediscussed in section 4.1.2.3. The financial team members are stretched, overloaded and unableto review and follow up, especially the underspending issues with the SRs.Comments: The lack of strict and detailed guidelines on disposition of revenue generatedthrough project activities creates ambiguity and the potential for conflict of interest. Weak SRfinancial capacity is impeding progress and creating additional burdens for PR.4.1.2. Sub RecipientsThe following are the key findings:The capacity of SR staff members varied with different SR;Some of the SRs do not have specific staff members fully assigned to M&E activitiesbut taking extra responsibilities for M&E besides their regular job;Most SRs expressed concern for the low threshold set for procurement requiringsealed quotations; andMost SRs had under-spending against planned budget.The programme management of SR was reviewed in terms of Monitoring and Evaluation,Procurement and Financial Management.4.1.2.1. Capacity of SRsThe SR staff capacity ranges from "no skill-no experience" to "highly skilled, wellexperienced". Most of the SR staff in "no skill-no experience" category do not have enough

technical skills required to perform their jobs. Another issue observed was the frequent turnoverof SR staff. Some of the SR staff members who had been trained by the PR, weretransferred to other programme areas or resigned from their jobs, replaced by newly recruitedstaff members, requiring orientation and training. This has created difficulty in building upcapacity of some SRs.4.1.2.2. Monitoring and EvaluationAssessment of the capacity requirement of SRs for Round 1 was conducted in June 2003.Another assessment capacity was done in February 2004 for Round 2. According to theassessments, most of the SRs have reasonable M&E system to collect data. All SR have M&Eperson identified but some of M&E staff members are not full time but taking extraresponsibility besides their regular jobs. All the SR had attended the training workshops onM&E conducted by the PR team.The Review Team found that SRs were not consistent in reporting the indicators ofachievements, i.e. some are reporting in absolute numbers, cumulative and percentages andsome are reporting their organizations' overall achievement funded by multiple donors, as GFprogramme achievements. This issue has been discussed in section 4.1.1.4.According to the guidelines, all the SRs need to submit their quarterly reports within 2 weeksafter the end of the quarter. But not all the SRs submitted the quarterly reports on time asdiscussed in section 4.1.1.3.c. According to the analysis of the report submission dates to PR,the submission dates ranged from one week earlier to one month later from the end of thequarter.4.1.2.3. ProcurementAll the SRs for both Round 1 and 2 were assessed for capacity to procure project supplies.Inventory procedure was also considered during the assessment. Some SRs already have goodprocurement structure and system in place where other weaker SRs have no capacity orstructure for procurement. There were delays in some of the procurement which have beenaddressed in chapter 4.1.1.5 (a). The procurement guidelines have been developed by the PRteam but some SRs are still lacking capacity to do the procurement by themselves. All the SRsreceived full support and assistance from PR team in procurement issues and are hopeful thatthey could do procurement by themselves with supervision. All the sealed quotations andtendering process required PR procurement team to assist in the process.Some SRs expressed concerns over the minimum threshold of procurement for sealed quotescurrently set at US$ 1,500.00. The reasons being, (1) limited suppliers who can provide sealedquotations, and (2) some suppliers would not want to give sealed quotations for purchaseswhich are less than $ 5,000.00.Comments: The Review Team suggested CCC and PR to decide if centralized procurement ispreferred over individual procurement if an individual SR is unable to do. The Review Teamwas informed by the PR that the minimum threshold of US$ 1,500 for sealed quotation wasadvised by KPMG/LFA.4.1.2.4. FinanceMost of the stronger SRs have good internal control and able to comply with PR financialguidelines, but underspending has been an issue for most of the SRs.

a) Financial performanceThere are underspending from both Round 1 and 2 by SRs. The following tables show thesummary statement of expenditure for both rounds as of September 2004.Table 5. Statement of expenditures Round 1 and 2 as of September 2004Components Grant Amount Actual Expenses Percentage BalanceHIV/AIDS R1 $ 11, 242,538.00 $ 2,537,890.45 23% $ 8,704,647.55HIV/AIDS R2 $ 5,370,564.00 $ 701,562.12 13% $ 4,669,001.88TB R2 $ 2,505,255.00 $ 523,841.57 21% $ 1,981,413.43Malaria R2 $ 5,013,262.00 $ 629,500.49 13% $ 4,383,761.51(Source: Principal Recipient's office, Department of CDC, Ministry of Health)Table 6. Statement of expenditure for Year 1 for Round 1 and 2 as of September 2004Components Year 1 Budget Actual Expenses Percentage BalanceHIV/AIDS R1 $ 5,573,289.00 $ 2,537,890.45 46% $ 3,035,398.55HIV/AIDS R2 $ 2,634,866.00 $ 701,5562.12 27% $ 1,933,303.88TB R2 $ 1,182,799.00 $ 523,841.57 44% $ 658,957.43Malaria R2 $ 2,694,679.00 $ 629,500.49 23% $ 2,065,178.51(Source: Principal Recipient's office, Department of CDC, Ministry of Health)Almost all the components have considerable underspending against total budget. The Round1 HIV/AIDS component, which will end in August 2005, has spent only 23% of the totalPGA budget for 2 years. The Round 2 HIV/AIDS, Tuberculosis and Malaria components,which will end in December 2005, have spent only 13%, 21% and 13% respectively toSeptember 2004. The following figure 1 shows the summary of budget and expenditures.Figure 1. Summary of budget and expenditure as of September 2004(Source: Principal Recipient's office, Department of CDC, Ministry of Health)Review Team was told that this issue had been communicated to the SRs for following upand/or to consider re-programming.b) Reliability of some banking institutions in CambodiaThere has been closing down of some private banks in Cambodia without any compensationto the clients. Some SRs expressed concern over reliability of local banking institutions inCambodia. There were no clear criteria from GFATM or PR on the selection of bankinginstitutions to deposit the project funds.

Comments: Even though some stronger SRs have good financial system, the under-spendingissue was over-looked by the SRs themselves. Sometimes, the rigid internal control couldhinder the implementation of activities. The Review Team was explained that theunderspending had been partly due to pending procurement of health supplies from some SRs.It was expected by the PR that a significant amount would be spent before the end of thequarter to catch up with the budget and procurement plan. Reprogramming of the SRactivities have been planned to address the issues of underspending.The key findings include the following:Good opportunities for merging programmatic components among the SRs (eg.. VCTand PMTCT; home based care and DOTS) were lost in planning stage because of theinsufficient technical inputs to SRs;Programme implementations were relevant to the National Health Sector StrategicPlan and it is a positive feature to have national programmes (centres) for HIV/AIDS,Tuberculosis and Malaria as SRs; andMost of the intended targets have been over-achieved in all the programmecomponents.The programme components were reviewed in terms of implementation strategy and activityprocess according the disease components: HIV/AIDS, tuberculosis and malaria, along withmeasurable achievement to the last reporting period (to September 2004).4.2.1. HIV/AIDSThe HIV/AIDS component is being implemented by eleven Sub-Recipients in Round 1 andfive Sub-recipients in Round 2.(a) HIV Programme linked to the National StrategyThe HIV/AIDS prevention plan and objectives in both Round 1 and 2 is relevant and cogentin connection with national context and priority according to the National Strategic Plan for aComprehensive and Multi-Sectoral Response to HIV/AIDS (2001-2005) by National AIDS Authority;and Strategic Plan for HIV/AIDS and STI Prevention and Care (2004-2007) by the Ministry ofHealth. It is a strength that national programme was also an implementation partner ofGFATM Cambodia.(b) Programme implementationThe prevention intervention through peer education programme with young people is welldesigned and implemented well by the SRs. Home based care, access to OI treatment andARV treatment activities have greatly improve the quality of life of PLWHA (see appendix 7)for success stories documented during project visits). Prevention programmes targeting youth(MoSVY, YCC, MND and RHAC) are well intended but knowledge and demonstrablebehaviour change remain unclear. It should be noted that the behavioural change was a resultof inputs from various stakeholders in HIV prevention efforts.(c) HIV/AIDS Round 1 Achievements to September 2004Most of the targets were generally achieved. The results against the intended targets wereranging from

Figure 2. Achievements of objective 1 of Round 1 HIV(Source: Principal Recipient's office, Department of CDC, Ministry of Health)The peer beneficiaries activity was the highest achievement with a result of achieving 145% ofintended target for the year. The other activities, such as number of core trainers and peereducators trained also achieved 86% of the intended target, and supervision visits achieved84% of the intended results.Figure 3. Achievements of objective 2 of Round 1 HIV(Source: Principal Recipient's office, Department of CDC, Ministry of Health)The STI consultations for sex workers have achieved about 152% of intended results for theyear.Figure 4. Achievements of objective 3 of Round 1 HIV(Source: Principal Recipient's office, Department of CDC, Ministry of Health)

The objective 3 has achievements ranging from 41% to 247% of the intended targets. Numberof home care teams, PLHA under health care teams and OVC under home care team haveachieved more than the intended targets as 121%, 182% and 247% respectively.Figure 5. Achievements of objective 4 of Round 1 HIV(Source: Principal Recipient's office, Department of CDC, Ministry of Health)This objective 4 was not fully achieved because of the delays in construction of communitycentres as planned.Figure 6. Achievements of objective 5 of Round 1 HIV(Source: Principal Recipient's office, Department of CDC, Ministry of Health)Most of the condoms and lubricant sales exceeded the intended results especially for lubricantsales reaching 593% of the intended results.(d) HIV/AIDS Round 2 Achievements to September 2004The following figures 7 to 9 show the achievements of objective 1, 2 and 3 from HIV/AIDSRound 2 programme shown in percentage of intended results. Most of the indicators are overachieved.It should be noted that the Round 2 was started only in January 2004 and theseresults are from 3 quarters only.

Figure 7. Achievement of Objective 1 for HIV Programme(Source: Principal Recipient's office, Department of CDC, Ministry of Health)The HIV/AIDS/STI education indicators achieved the highest with 306% of intended targetfollowed by VCT service achieving 225%, STI treatment 179% and peer education 138% ofintended results.Figure 8. Achievement of Objective 2 for HIV Programme(Source: Principal Recipient's office, Department of CDC, Ministry of Health)The indicator for ?doctors and nurses trained in HAART? was achieved about 118% of theintended result, whereas some activities such as ?patients on ART? and ?PLHA on ART?under this objective are not reaching their targets.The following figure 9 shows the achievements of objective 3 with the highest achievement ofclients referral as 216% of the intended target. Most of the activities have reached or overachieved the intended targets.

Figure 9. Achievement of Objective 3 for HIV Programme(Source: Principal Recipient's office, Department of CDC, Ministry of Health)Comments: The achievements in HIV/AIDS components are mostly output orientatedactivities such as: number of training sessions conducted, number of peer educators trained,number of STI consultations, number of PLHA treated and number of condoms sold. TheReview Team tried to assess the quality and immediate impact of these outputs during the fieldvisits when possible. The provision of ARV has significant impact in PLHA who received theARV. The quality of life was much better and well integrated back to the community withoutstigma and discrimination (see appendix 7).4.2.2. MalariaThe malaria component in Round 2 is being implemented by 5 Sub-Recipients covering all theprovinces in Cambodia.(a) Malaria Programme linked to the National StrategyThe goal and objectives of the Malaria component are in line with the Health Sector StrategicPlan (HSSP) by strengthening the behavioural change strategy through IEC and advocacy touse insecticides-treated bed-nets; and health service delivery strategy of HSSP by improvingaccess to early diagnosis and treatment such as social marketing approach of malaria test kitand antimalarial drugs.(b) Programme ImplementationThe National Centre for Malaria plays an important role in coordination malaria programmeactivities nation-wide. Communities from malaria endemic areas are willing to use theinsecticide treated bed-nets because they saw benefit of prevention (more sickness-free days)and able to work and improve their household incomes. The health education activities andIEC activities were conducted quite well. There were some delays to purchase more bed-netsfrom CNM with the funds from GFATM. There were no coordination among implementingagencies (including other non-GFATM programmes) in recruitment and training of villagehealth volunteers (VHV). Some VHVs were taken from existing volunteers supported byVillage Health Support Groups but some were recruited for different groups.(c) Malaria programme Achievements to September 2004Most of the targets were generally achieved. Program achievements ranged from 50% to1,180% of intended year end results.

Figure 10. Selected Malaria Component Achievement for Round 2(Source: Principal Recipient's office, Department of CDC, Ministry of Health)The highest achievement was in mass media spots, training in EDAT, health staff training,VHV training and VHV meetings.Comments: The National Centre for Malaria plays the key role in the implementation ofMalaria component in Round 2 working closely with NGOs. There is a strong linkagebetween national strategic plan and the Global Funds activities. Most of the over-achievedactivities were output orientated activities such as mass media production, meetings andtrainings.4.2.3. TuberculosisThe tuberculosis component of Round 2 is being implemented by one SR - National Centrefor Tuberculosis (CENAT).(a) Tuberculosis Programme linked to the National StrategyThe goal and objectives of the tuberculosis component are in line with the Health SectorStrategic Plan (HSSP) by strengthening the health service delivery strategy through expansionof community DOTS programme; behavioural change through IEC for awareness andknowledge on tuberculosis symptoms and prevention; and improving human resourcesdevelopment through training of central, provincial and district supervisors.(b) Programme ImplementationCENAT has been key actors in planning, organizing with the provincial players, intendedtargets have been generally achieved in all 6 objectives. Significant overachievement has beennoticed for some process indicators (eg. IEC). This could be from under-estimation of targetpopulation and/or the actual unit cost for IEC production was lower in the market comparedin the proposal budget.(c) Tuberculosis programme AchievementsMost of the targets were generally achieved with results ranged from 105% to 150% ofintended year end targets 4 .4The reported results in tuberculosis were not clear because it was difficult to tell if the numbers were absolute orcumulative. For some indicators, no achievement (zero) was reported but the reason for no achievement was

Figure 11. Selected Tuberculosis Programme Achievement for Round 2(Source: Principal Recipient's office, Department of CDC, Ministry of Health)The above figure shows that the Tuberculosis training and DOTS supporter training wereover-achieved with 125% and 101% of the intended results. Other activities have achievedover 90% against the intended targets.Comments: All the intended targets have been nearly achieved, achieved and over-achievedwithin three quarters of implementation for the tuberculosis component in Round 2. Most ofthe over-achieved activities are output orientated activities.Even though there were significant underspending reported by SRs in both Round 1 and 2, theoverall project's results were mostly over-achieved. This indicates:good value for moneythe intended results were under estimatedprogramme activities were over budgetedsame activity was funded by other donorsdata collection that was not fully reliableperformance monitoring was not linked to financial managementIt is important to assess the quality of those achievements and not to emphasis too much onthe output and coverage indicators.4.4.1. Structure of GFATM programme in CambodiaAll projects funded by the GFATM are coordinated by the Country Coordinating Committee(CCC). Similar entity is known as Country Coordination Mechanism (CCM) in other countries.In addition to CCC, there are several other bodies taking part in the GFATM activities, forinstance, Country Coordinating Sub-Committee (CCCSC), Technical Review Teams (TRTs),Ministry of Health as Principal Recipient (PR), various Sub-Recipients (SRs) and Sub-Sub-Recipients (SSRs).given as "soon-to-happen". This could lead to inaccurate year-end total results if one does take into account thelater achievement of "zero" in certain quarter of the year.

a) Principal Recipient (PR)The Principal Recipient is the Communicable Disease Control (CDC) Department of theMinistry of Health (MoH). It is the legally accountable party that signs the Programme GrantAgreement (PGA) with GFATM and acts on behalf of and under the general guidance of theCCC. Overall role and responsibilities of the PR include all matters pertaining to thesubstantive progress of the implementation of the programme grant, such as receiving,managing and disbursing regular financial and programmatic progress reports. The PR isgenerally overloaded with monitoring and procurement issues for both rounds. PR teammembers are giving on-going assistance to SRs to implement according to the GFATMguidelines. The relationship between PR and the SRs is generally very good.b) Sub-Recipient/Sub-Sub Recipient (SR/SSR)The GFATM programme in Cambodia is implemented by SRs who receive fund directly fromPR, and by SSRs who receive fund from SRs. Both SRs and SSRs work in cooperation andcollaboration with many other local implementing partners to ensure their activities arecontributing to the overall success of the GFATM programme. The relationship between SRsand PR is generally very good.c) Country Coordinating Committee (CCC)It was established in February 2002, and with a broad range of high level representatives (27 intotal) from different constituencies, the CCC has played an important role in overseeing andensuring the proposals approved by GFATM is properly implemented and relevant actors areinvolved in the whole process. It also functions as a national consensus group, whichcoordinates the whole process of proposal development and submission and acts as thesupreme authority in-country on GFATM matters.d) Country Coordinating Committee Sub-Committee (CCCSC)The CCCSC came into existence in September 2002 in response to the need for having asmaller group (10 in total) of the CCC who can serve as its secretariat and assisting PR inmaking the executive decisions on implementation and management issues such as approval ofquarterly reports and disbursement requests, and re-programming. One of the CCCSC?s mainresponsibilities is to liaise with all partners involved in order to ensure good quality level ofpartnership and regular flow of information/communication. The CCCSC is like the Board ofDirectors of the PR while the CCC is the supreme decision making body. Some SRs are alsomembers of CCC and CCCSC, which could be a conflict of interest.e) Technical Review Teams (TRTs)There are three TRTs (one for each disease) whose main responsibility is to provide technicalreview of new proposals, and of PR, SR and SSR workplans and progress reports. The threeteams are convened by the PR and key items approved by CCCSC are submitted to CCC. Theteam?s remit is technical ? i.e. programme, project and proposal design, approaches andmethodologies, consistency with national strategy, adequacy and desirability of outputs,outcomes and impact, etc. Most the memberships are nominated by the Minster of Health in2003. Some of the TRT members are also SRs (especially with the national programme).

f) Local Fund Agent (LFA): KPMGLocal Fund Agent is appointed as a local agent of Global Fund at country level, by theGFATM. The main role of LFA is to be the "eyes and ears" of the Global Fund. LFAobjectively assesses the nominated PR (in Cambodia is the Ministry of Health); identifiescapacity building needs and recommendations to GFATM directly. It also reviews budgetsand planned activities with PR and establishes milestones and expenditure schedule; and assistwith grant negotiations.4.4.2. Relationship among the different GFATM structureCountry Coordinating Committee (CCC) oversees the management of Principal Recipient ofthe GFATM. The PR oversees the project management of Sub-recipients (SRs). Each SR willsubmit a quarterly progress report to the PR within two weeks from the end of each reportingquarter. On receipt of the quarterly reports from SR, the technical officers from PR office willscrutinize the information and seek clarifications/additional information from concerned SRs.Then the M&E staff of the PR office will compile the information from SRs reports into aPR's quarterly report and circulate this to the members of the PR-TRT, within four weeksfrom the end of each quarter.The PR-TRT will review the reports of the SR/PR quarterly progress report together with PRand provide feedback. The PR M&E staff will then finalise the report and submit to theCCCSC within a week (within 6 weeks from the end). Once the report is approved by CCCSC,the PR will submit the quarterly report to GFATM through LFA. The final report will betransmitted to the GFATM Geneva through LFA within 90 days after the end of the quarter.Comments: All the CCC/CCCSC members have other main responsibilities and most ofthem felt that it was difficult to give full commitment. Some of the local organizations andinstitutions felt marginalized because of the language barrier in CCC/CCCSC and SR meetings.Some local organizations felt that not many local organizations and community-basedorganizations were successful in GF funding because of the lack of technical support andlanguage ability which impedes the capacity building purpose of the Global Fund. These localorganizations needed help in proposal writing, report writing and M&E.The role of LFA was not clear and it was seen as another bottle-neck of bureaucracy. As theLFA is a purely Management Accountants/Auditors agency, it was not clear how the LFA hadreviewed the technical/public health (malaria, tuberculosis, HIV) aspect of the report.There were some conflict of interest issues identified in the membership. Some SRs areCCC/CCCSC members. Because of the limited pool of technical resource persons inCambodia, particularly in Malaria and Tuberculosis, some SRs are also PR-TRT members - theconflict of interest issue in the PR-TRT membership - is inevitable.The Review Team addressed the following issues suggested by key CCC members to include inthe Review.4.5.1. Additionality of GFATM to existing health activitiesThe Global Fund was set up out of the recognition that there is a considerable gap betweenthe resources currently available for the fight against AIDS, Tuberculosis and Malaria. In

accordance with the criteria governing the selection and award of this Grant, the Global Fundhas awarded the Grant to the Principal Recipient on the condition that the Grant is in additionto the normal and expected resources that the host country usually receives or budgets fromexternal or domestic sources. The issue is very broad and it is out of the scope of the ReviewTeam to address in details within limited time frame, but the following topics were explored.4.5.1.1. Substitution/replacement of exiting fundingAlmost all the donor funding agencies met with the Review Team saw Global Fund as anadditional support to Cambodia. The donor agencies also have coordinating meetings wherethey could discuss funding issues and gaps. Some donors are also members of CCC wherethey could obtain GFATM funding information. So far, all the donor agencies will continue tosupport what has already been planned.4.5.1.2. Multiplier effectsIt is still early to determine the multiplier effects of GFATM in Cambodia. But it is expectedthat GFATM would improve the management and technical capacity of local institutions inCambodia. This will result in improvement of health services performance and quality.4.5.2. Value for moneyWith the limited time, the Review Team was unable to determine in details of "Value forMoney" such as cost per beneficiary, cost effectiveness analysis, improvement in health careperformance and other analysis like QALY. With the findings of (over) achievement within orless than the allocated budget it appeared to have good outputs. But the quality of achievementand other factors should be considered. Further detailed studies are essential to determine?Value for Money?.4.5.3. Centralized procurement Vs. Capacity buildingPlease see section 4.1.1.5. (b).The vision of National Health Sector Strategic Plan (NHSSP) is to really make a difference, forthe better, to the health of the people of Cambodia. An assessment of health anddemographic indicators in Cambodia 5 shows the following incidence rates for the three majordiseases:Tuberculosis incidence rate (2001) was 540 per 100,000 population;Malaria incidence rate (2001) was 8 per 1000 population; andHIV seroprevalence rate among 15-19 years (2000) was 2.8%.National Health Sector Strategic Plan has spelled out 6 priority areas of work for the period of2003 to 2007. They are:Health service deliveryBehavioural changeQuality improvementHuman resource development5Health Sector Strategic Plan, 2003 - 2007, Ministry of Health, Kingdom of Cambodia

All the SRs that the Review Team met appreciated and acknowledged the leadership andsupport the PR team. The following are the summary of strength and shortfall of PR.4.7.1. PR team is strongThe whole PR team is technically competent, hard working and has a strong management.The ?strong-ness? of the PR team could be a pressure for some SRs. The PR team wasdirecting SRs for better efficiency in implementation and reporting according to the MoAssigned between the PR and SRs. In some instances, some of the PR staff members maydemonstrate their lack of experience in their interactions with the SRs. This could strain therelationship and trust between PR and the SRs in the long run.4.7.2. Quantitative plans and guidelines well writtenAll the M&E guidelines and plans were well written with measurable quantitative benchmarksfor key activities for all the rounds. Most of the indicators were well measured and the settargets were achieved. There could be many quality work and achievements by the PR and SRsbut there was no clear format for qualitative assessment of those achievements except for asection on "Success stories" in the Annual Progress Report.Some of the examples of quality issues, besides the success stories, that could be included inthe quarterly and annual reports are:clients' satisfaction of clinical services provided by SRs (some SRs were starting toinclude this but more standardized questionnaire format is required)quality of IEC materials (understanding of the messages by the target audience)summary findings from the monitoring checklist (monitoring tool # 1 to 7 of theM&E guidelines) which are excellent for qualitative assessment.Some SRs were reporting success stories but not all of them. A simple and frequentparticipatory assessment with the beneficiaries (including those people living with the diseases)would also serve as a qualitative assessment.4.7.3. Able to manage all the GFATM roundsThe PR team is able to manage effectively both round 1 and 2. The team is currentlyoverloaded and need more staff to maintain effective management for subsequent rounds.Unless the team composition is expanded or improved, the current PR will not be able tohandle subsequent rounds.4.7.4. Capacity buildingThe PR team did very well with the supervision/monitoring and follow up SRs according tothe set plans and guidelines. Strengthening SRs to efficiently follow all the implementationguidelines does not correspond to capacity building. It is important to recognise that capacitybuilding through supporting their visions is more helpful for long term.

4.7.5. Reactive to proactiveThe PR team is overloaded with day-to-day management of all the rounds and meeting thereporting requirements from the GF. All the supervision and monitoring work have beenmostly "reactive" to arising issues and problems. The PR team can play more proactivemonitoring role if there are enough staff and time eg. overachievement and under-spendingissue could be identified earlier and corrected if the PR team is more pro-active.5. AchievementsThe Review Team recognised the good work of the PR team. The team started with initialfunding support from important stakeholders such as WHO, USAID, GTZ, UNAIDS, UNDPand many other donors before the funding received from the Global Fund. The PR team was"thrown-into-deep-water" to manage the multi-million dollars programme without fully clearguidelines in the initial stage. The following are main achievements of the PR team:The PR was able to recruit well trained, competent and hard working staff as teammembers with good leadership and supervision from CCC;All the pre-conditions required by LFA had been fulfilled;All systems for implementations in place on time (M&E, Procurement, and Finance);Guidelines for grant recipient programme (M&E, Procurement and Finance) havebeen developed for SRs;M&E plans have been developed with SRs for HIV/AIDS, Tuberculosis and Malaria;PR was able to comply with all the TOR and guidelines; andAlmost all of the PR reports are submitted within the acceptable timeframe to GF.The Review Team also recognise the good work of all the SRs in the communities especiallyfor the people living with HIV/AIDS and preventive effort for tuberculosis and malaria.The following are the summary achievements of the SRs:All of the SRs were able to follow the guidelines and requirement (M&E, procurementand finance) of the GF;Most of the SRs were able to achieve the intended targets according to the M&E plan(refer sections 4.2.1. to 4.2.3.);Even though there were constraints with various implementation issues, good qualityprojects are being implemented by the SRs. (Some selected SRs achievements aredocumented on the Global Fund websites: -http://www.theglobalfund.org/en/in_action/stories/hiv_cambodia/):There was a higher acceptance of PLHAs in the community where Review Teamvisited which shows a significant achievement in elimination of stigma anddiscrimination by the SRs;Some SRs were able to establish their own M&E, procurement and financial systembased on the guidelines developed by PR for other non-GF projects; andThere were good collaborations among the SRs such as stronger SRs were helpingweaker SRs; giving constructive feedbacks in the quarterly meetings; and sharing ofinformation among SRs within the same programme component.The Review Team witnessed the impact and changes in the life of those marginalised peoplethrough the Global Fund. Please see appendix 7 for success stories. However, the ReviewTeam was unable to assess in depth the achievements of the individual SR.

6. Lessons learnedThe following were gathered by the Review Team for key lessons learned:1) Even though GFATM was setup to reduce bureaucratic procedure for programmeimplementation, there could be bottlenecks within the in-country GF structure andsystem;2) Monitoring and evaluation could still be perceived as "policing" activities even thoughthe purpose and procedure are well explained;3) Strict expenditure control and stringent procurement procedures (which are difficult tocomply) could affect project implementation;4) Capacity building is a cross cutting issue but usually not given priority over efficiencyof project implementation;5) Over-achievement is not necessarily the desired achievement; and6) Building good relationship, partnership and trust are important for successfulprogramme management, implementation and monitoring.7. Options for improvement of current programmeThe GFATM Programme in Cambodia is very large and disparate, involving numerousstakeholders and activities, and is being implemented from different starting points in time.Our consultations with stakeholders revealed a range of opinions on perceived strengths,weaknesses, lessons learned and suggested future directions. The relatively short time-framefor undertaking a comprehensive review made it challenging for the Review Team to reachdefinitive agreement on the best ways forward for the current Rounds. In this section we havechosen to offer a range of options to address particular issues, rather than provide directiverecommendations. The Review Team recognise that it will be up to various stakeholders tomake decisions on future actions. However, where we feel the evidence points strongly to onecourse of action, we have presented this as our preference.The programme management is important for the overall success of the GFATM projects inCambodia. Key aspects relating to management are dealt with in turn, with options listedunderneath.(a) Term of reference (job description) of PR7.1.1. CCC/CCCSC needs a full time technical support advisor to effectively support thetechnical and management issues. The options are:OPTION A (preferred): An external expatriate or local advisor should be recruited(would require an additional budget);OPTION B: A member from the CCC/CCCSC could be nominated to be theadvisor.7.1.2 The PR workload is extremely heavy, and despite strenuous efforts they areoverstretched. Their work output depends upon having sufficient, appropriately-skilled staff.The Review Team feel strongly that the PR team should be enlarged. The options are:OPTION A (preferred): Recruit an expatriate or local finance advisor to (i) supportcurrent and subsequent rounds and (ii) to provide capacity building for PR financeteam, AND recruit more technical officers for M&E, procurement and finance (withor without assigning them to specific round or target disease);

OPTION B: Establish a system of ?Sub-PRs? (a model used in other recipientcountries) (with or without assigning to specific rounds or target disease) under thecurrent PR management; andOPTION C: Establish a totally new PR team for new rounds (eg.. round 5)Note: If any of these options are selected an additional budget will be required.7.1.3 The job description of the PR team members are "minimalist" and not reflecting thecomplex duties and skills carried out by the team members. The job description attached asappendix 6 should be revised. The options are:OPTION A (preferred): Review PR team members' current activities and projectfuture activities with subsequent rounds to assess the gaps and revise accordingly. Therevised job description should also include qualifications and skills required for eachposition for capacity building purpose; andOPTION B: Develop new job descriptions for new PR staff members but keeping thesame job description for existing members.7.1.4 Some PR-TRT members are also SRs, creating a potential conflict of interest. The PR-TRT members should be independent technical resource persons. The options are:OPTION A (preferred): Independent resource persons should be recruited withspecific allocated budget from PR to review proposals and reports (new budget linewould be required);OPTION B: A careful arrangement should be made to avoid PR-TRT membersreviewing their own or their organizations' proposals or reports; andOPTION C: PR team members should be included in the PR-TRT because they areindependent; and familiar with the guidelines, and existing programme implementationissues.(b) Monitoring and evaluation7.1.5 Most of the documents and records in the PR office are in hard copies, creatingchallenges for filing and availability in a timely fashion. The Review Team recommendsBOTH of the following steps, which would require additional budget for staffing and ITsupport:Establish a centralised database for all the important documentEstablish a user-friendly monitoring database system to assist in M & E7.1.6 Process indicators make up the bulk of the current SR monitoring framework. It isdesirable to broaden and strengthen the scope and rigour of monitoring by assessing issues ofquality and ? to some extent ? impact, but this will require new frameworks, indicators, anddata collection tools. Recognition by the PR that it takes time for good-quality data collectionand analysis is also required. A stronger framework could be established by the following(which will require M & E team expansion and additional budget):Conduct participatory appraisal with local beneficiary during monitoring visitsEncourage SRs to include qualitative reports (participatory appraisal, stories of?success? and ?failure?) from the project in their quarterly reportsEncourage SRs to include qualitative indicators (eg.. clients' satisfaction), which can begathered with both quantitative and qualitative tools

7.1.7 The indicators and intended results in the M&E plans were taken from the proposalswhich were developed a few years before the implementation. The current situation might bedifferent. These intended results/indicators should be revised as follows:Select indicators which have been achieved/over-achieved by SRsTake the current quarter achievement as a baseline for next quarter and developSMART (Specific, Measurable, Attainable, Realistic and Time-bound) indicators for theend-of-project targets7.1.8 Some SR had delays in submission of quarterly report. This could be improved by:A reminder system to be established by CCCSC and PR for timely submissionSRs emailing system reminding to list the SR who fails to submit on time for morethan 2 occasions.7.1.9 Timely submission of reports by all the SR is important for PR because the PR could notcomplete the composite report if one SR is late. Report reminder system could be integratedwith the establishment of communication system with SRs. All the following communicationoptions can be considered:EmailsGFATM Cambodia website andRegular newsletter7.1.10 Most of the existing Cambodian national programmes have their own monitoringsystems. It is important that the PR monitoring system should be integrated with the existingsystem, or set up to be easily extractable. This could be achieved through the followingprocess:Strengthen existing good relationship, trust and rapport with national programmemonitoring teamJointly review the exiting system and requirement from GFATMAgree on the indicators and target to be included for GFATM monitoringInclude other donor agencies supporting the national programme because they alsohave their own donor's requirement for monitoring.The PR monitoring team should be also a member of M&E working group of thenational programme if there is one.7.1.11 All the guidelines and plans developed by PR are written in English which is difficult forsome SR to understand. The Review Team recommend all the reference documents betranslated into Khmer.(c) Procurement7.1.12 Procurement has been one of the major activities of SR. The procurement guidelineshave been developed by the PR team but some SRs are still lacking capacity to do theprocurement by themselves. The issue of centralized procurement vs. capacity building wasdiscussed in length with PR as well as CCC. The following are the options recommended bythe Review Team members.OPTION A (preferred): Major procurement items such as ARV medicines should becentralized to gain the benefits mentioned in section 4.1.1.5; but other items should bedecentralized to SRs to have experience in procurement. The definition of majorprocurement items should be decided by the CCC;

(d) FinanceOPTION B: All the procurement items are decentralized but if the responsible SRsare unable to procure by the required date, the PR team should assist throughcentralized procurement with the participation of the SRs; andOPTION C: All the items are procured centrally or assisted procurement by the PRteam with the participation of SRs. This option will require expansion of procurementteam.7.1.13 There is no clear guideline on income generated from the GF projects. The existingguideline on the management of income from the project could be revised through thefollowing steps.Determine SR who might have received income from the GF project;Assess the amount of income and decide if the amount is significant; andCCC and PR should decide if the income should be (i) kept by the respective SR -"Carte Blanche" (ii) returned to GF or (iii) used the project .7.1.14 It is important to monitor under/over spending of SRs through disbursement requestand progress update. The Review Team recommend that a space should be added in theformat to report reasons for significant (more than 10% or to be determined by the PR financeteam) over or under-spending for each quarter.There are a total of 11 SRs in Round 1 and 10 SRs in Round 2. Most of the SRs already havetheir own management and structure to implement GF projects but some issues wereidentified by the Review Team which could hinder the project implementation. Key optionsfor improvement in SR program management, structure and capacity are discussed with theissues identified.(a) Capacity of SR7.2.1 Limited capacity of the SR staff and frequent turn-over of trained staff are hindering theproject implementation by some SRs. The following steps are recommended by the ReviewTeam to SR representatives improve the capacity of SR staff members.Develop job descriptions for the SR project staff positions and match the jobdescriptions with qualifications, skills and experiences of the existing staff members ofthe SRConduct training needs assessment of SR staff member; develop staff developmentplan and; identify training sources (eg. from PR team, other organizations, agencies orinstitutions)Conduct internal performance review regularly to adjust the training needs anddevelopment plan accordinglyObtain agreement from staff members to work for at least 2 years in the project afterthe training by PR teamDevelop and implement succession plan for essential positions (eg. project managers,M&E coordinators).

(b) Monitoring and evaluation7.2.2 Some SRs do not have specific staff members fully assigned to M&E activities but takingextra responsibilities for M&E besides their regular job. The Review Team stronglyrecommend that all SR should have a specific staff member fully assigned to GF M&Eactivities.7.2.3 SRs were not consistent in reporting the indicators of achievements, i.e. some arereporting in absolute numbers, cumulative and percentages. Some intended results might notbe relevant to current situation (see also section 7.1.7). A consistent format of reportingindicators should be developed. The options are:OPTION A (preferred): The intended targets are set in cumulative figures andreported accordingly;OPTION B: The intended targets are set in percentages for those indicators withknown denominators; andOPTION C: No changes made but wait for GF's guidelinesIt is important to obtain denominators (eg. population at risk) for individual target so that theissue of over/under achievement could be minimized.7.2.4 Some SRs reporting their organizations' overall achievements as GF achievementespecially those SRs with multiple donors. The following steps would ensure the transparencyof achievement by SRs.SRs should mention other donors who are funding the same activities and hence theachievements are properly credited to all the donorsAn information system should be developed by SRs, if possible, where the results andachievements could be tracked to individual donors7.2.5 Some SR had delays in submission of quarterly report. This could be improved by SRthrough the following steps:M&E staff of the SR should take initiative in gathering project information forquarterly report before the end of the quarter.An internal reminder system should be established for SR with SSRs for timelysubmissionElectronic information system (email and internet connections) with project siteswhere possible to exchange reports and data.7.2.6. A detailed review of Monitoring and Evaluation guidelines has been conducted by theReview Team according to the explicit request was made by the PR M&E Consultant foradditional technical inputs before finalizing the Working Draft. The detailed comments areattached as appendix 8.(c) Procurement7.2.7 Most SR expressed that the current minimal threshold for sealed quotations (US$ 1,500)was difficult to get suppliers who were willing to provide sealed quotation for purchasesamount to $ 1,500. The minimal threshold should be increased. The following options aresuggested by the Review Team.OPTION A (preferred): The minimum threshold for sealed quotations be raised toUS$ 5,000.00 from US$ 1,500.00 as suggested by most SRs, i.e. sealed quotations will

(d) Financebe required only for purchases of amount between US$ 5,000.00 to US$ 25,000.00;andOPTION B: Keeping the same threshold but encourage the SRs to have centralizedprocurement (with the active participation from SRs) through the PR. These optionsshould be considered with issues discussed in section 7.1.12.7.2.8 Even though some stronger SRs have good financial system, underspending issue wasover-looked by the SRs themselves. The following steps are recommended to improve thefinancial monitoring.Expenditure reviews should be conducted by SR finance staff to determine the sourceof underspending and develop a plan of action to tackle the problemIf there is potential for under or overspending, it should be discussed with PR to reprogrammethe activities7.2.9 Some SR expressed concerns over reliability of local banking system. The following stepsare recommended to ensure that SRs are banking with reliable banking institutions.Consult with UN agencies and bilateral agencies on current banking situation inCambodia and obtain advice from themSelect banks which fulfil the government's criteria to conduct banking business inCambodiaAssess regularly the potential risks and develop plan for risk management with PRteam7.3.1 Some opportunities were missed during the proposal stage to merge activities in theprogramme components. The following options should be considered for reprogrammingamong the SRs to have maximum benefits for current activities or future programme.OPTIONS (A): HIV positive pregnant mothers identified through VCCT in theprogramme could be followed up with PMTCT activities in the same areas; andOPTIONS (B): Integration of TB-DOTS team and AIDS home care team in the sameareas to could be arranged to reduce the workload and effective use of resources7.3.2 Most of the SRs have very high achievement and significant under-spending. This couldbe due to different donors are funding the same activities or outputs and or over-budgeting theactivities. The following steps are recommended by the Review Team to ensure that theintended results and allocated budget are realistic.Conduct Funding Gap Analysis for each component during the proposal stage todetermine current/future funding commitment and forecast in HIV/AIDS, TB andMalaria in Cambodia;Conduct cost per beneficiary for each activity and components to determine therequired budget accurately during the proposal stage;Coordinate printing and distribution of IEC and training materials with other donoragencies as most of the over-achieved activities are in IEC and training materials; andGive more flexibility to SRs, to revise their budget and activities after the first yearbased on actual achievement and expenditure (eg.. re-programming).

8. Key recommendation for future projectsThe following are the key recommendation for future projects:1) Conduct Funding Gap Analysis during the project proposal stage;2) Calculate cost per beneficiary during the project proposal stage to obtain accuratebudget estimation;3) Explore opportunities for merging programmatic components in each programmeduring the project proposal stage. For example: VCT and PMTCT; TB DOTS andHIV/AIDS home care;4) Recruit a full time technical and management advisor for CCC/CCCSC;5) Include PR team in the proposal panel to identify issues of programme activitiesoverlapping among the rounds and among the SRs;6) Further strengthen existing good relationship, trust and rapport among all entities ofthe GFATM structure;7) Expand the current PR team;8) Recruit a professional expatriate or local finance advisor to support the PR financeteam;9) Establish a centralised PR database system to collect record and analyse M&E,procurement and finance activities;10) Include SR communication system (email database and website management) in thecentralized database;11) Prioritise capacity building over efficient project management of SRs throughdeveloping SR capacity building plan and checklists; and12) Develop a list of criteria to decide if an organization is eligible as an SR or SSR toreduce the management responsibilities of PR. Eg.. SR with requested budget of lessthan & 50,000 should be SSR instead of SR.AcknowledgementThe Review Team would like to thank Dr Sok Touch, Dr Or Vandine, Dr Hay La In, DrSinath Ouksophea, Dr Chea Sovann, Ms Hok Chantheasy, Ms Mey Bunrong, Ms Sok Khim,Mr Oeurn Virak, Mr Reach Phanith, Ms Maraya Monida, Mr Krang Sokhan, Dr ChanChhivnang, Mr Kit Vanthy, Ms Inga Oleksy, Mr Gunatilake Kodituwakku, Mr Markus Buhherand all the staff members of PR office for their help with the review process and theirhospitality in many ways among their very busy work schedule.Thanks are also due to CCC and CCCSC members especially Dr Jim Tulloch, Dr SinSoumuny, Dr Regine Lefait-Robin, Ms Geetha Sethi, Dr Sok Bunna, Mr Seng Sopheap, MrHeng Sokrithy, Ms Elizabeth Smith, Mr Rodney Hartfield and Ms Muroi Maki for theirvaluable insights; Mr David King, Mr Richard Lim and Ms Sar Khun Leakhena from KPMGCambodia for their indispensable inputs; all the SR Heads and staff members for their openand honest discussions.Special thanks to PLHAs, and field project staff met during field visits for their life stories andtheir commitment; Dr Tith Khimuy from KHANA, Dr Ou Vun from PFD, and Dr KhunKim Eam for logistic arrangement and accompanying the Review Team during field visits.Last but not least, the Review Team would like to thank H.E Dr Eng Huot, Secretary of Statefor Health, Ministry of Health, Cambodia and GFATM for the opportunity to conduct thisMid-Term Review and learn the good work of GFATM programme in Cambodia.

Appendices

GFATM in CambodiaMid-Term Programme ReviewTerms of ReferenceSeptember 2004A. Programme Background:1. GFATM Globally; HIV/AIDS, TB and malaria together account for nearly 6 million deathsper year and cause immeasurable suffering and damage to families, communities andeconomies. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), a non-profitfoundation was established under the laws of Switzerland (also referred to as the ?GlobalFund?) in January 2002 as a financial instrument, complementary to existing programmesaddressing HIV/AIDS, tuberculosis and malaria.The purpose of the GFATM is to attract, manage and disburse additional resources through anew public-private partnership that will make a sustainable and significant contribution to: thereduction of infections, illness and death, thereby mitigating the impact caused by 3 majordiseases in countries in need, and contributing to poverty reduction as part of the MillenniumGoals. Since 2001, the Global Fund has attracted US$ 4.7 billion in financing through 2008. Inits first two rounds of grant-making, it has committed US $ 1.5 billion in funding to support154 programmes in 93 countries worldwide.2. GFATM in Cambodia; In Cambodia, the GFATM has approved proposals submittedduring the first, second and fourth rounds of proposals. The executing body of the GFATMprogrammes is called the Principal Recipient (PR), which, in Cambodia, is the Ministry ofHealth (MOH). Thus, under Rounds 1 and 2 four Programme Grant Agreements (PGAs)between the GFATM and the PR were signed, as follows:a) Round 1; 1 PGA for HIV/AIDS component for US $ 11,242,538 over 2 years,b) Round 2; 3 PGAs for HIV/AIDS, Malaria and Tuberculosis for the following US $amounts: 1. HIV/AIDS for 5.4 million, Malaria for 5.0 million, and TB for 2.5 million,or total amount of US $12.9 million/2 years.c) Round 4; 2 Programme Components were approved (HIV/AIDS and Malaria) inJuly 2004. The grant negotiations and signing of 2 PGAs are anticipated forOctober/November 2004, with the proposed start date of January 2005.B. Mid-Term Review Purpose and Objectives:3. Purpose of the Review; This Mid-Term Review is planned to enable the team to assess,determine and report on GFATM project inputs, processes, accomplishments, lessons learnedand to make recommendations to the PR and CCC for the next stages of the programmeimplementation. To generate this information, the Mid-Term Review should specifically:a) Examine the implementation processes of all 4 PGAs under Round 1 and 2, whichencompassing programmes in all three diseases; HIV/AIDS, malaria and TB.b) Assess the main problems and constraints faced by the GFATM project on differentlevels, and recommend solutions.c) Examine the coordinating, contracts and procurement, finance and monitoring role of thePR managing the GFATM portfolio in Cambodian context.

d) Assess the relationships among different in-country GFATM structures (SRs ? PR ? CCM- LFA), and in turn, their relationship with GFATM-Geneva, and how all of those affectimplementation of the programmes.e) Assess GFATM programme?s fit into the MOH?s National Health Sector Strategic Plan2003-07 and other national programmes and policies.4. Mid-Term Review Objectives:a) To examine GFATM-funded activities, processes and accomplishments as implemented bythe SRs under both Rounds 1 and 2 (all 4 PGAs); specifically, the review should assess:i. whether the additional funding from GFATM is beginning to make a difference in thefield and is effectively used to strengthen/magnify the effects of other foreignassistance funding for 3 major diseases in Cambodia.b) The activities of the PR and the fulfillment of its Terms of Reference as specified inthe CCC document 6 , and assess its effectiveness in each functional area designed to supportthe implementation of the programmes, including:a. timely disbursement of funds and processing the requests for the subsequentdisbursements from the SRs;b. contracts and procurement management, including effectiveness of processes toprocure goods according to Principal Recipient?s/GFATM-approved guidelines,and capacity building among SRs to apply similar standards in their operations;c. programme monitoring and evaluation, including data collection, analysis, synthesisand effective monitoring to verify that results are achieved as stated;i. Appropriateness of indicators used to measure project progress and, ifnecessary, recommend additional/revised indicators.d. The project had a modest and slow start due to several problems and constraintsfaced; the mid-term review should pay special attention to these and assess how thePR has dealt with them.b) Project effectiveness in terms of working towards achieving its stated outputs andobjectives for both Rounds 1 and 2.C. Mid-Term Review Methodology:Mid-Term Review will use the combination of quantitative and qualitative methods, includingthe desk reviews of multiple background documentation (Proposals, Reports, PR Terms ofReference, etc.), interviews with project staff (SR and PR) and relevant stakeholders (CCC,WHO, UNAIDS, MOH, etc.), and field visits to select project activities.5. Mid-term Review Team;The review team will consist of: an expatriate consultant (team leader), a local consultant,and a representative of the Department of Planning, within the Ministry of Health (MOH).The review team will include the professionals with the following fields of expertise andextensive experience in:Primary Health Care, especially community-based health education,HIV/AIDS programing including prevention, care and community support,Programme design and strategic planning, preferably with large scale projects,Grants management and oversight; familiarity with financial functions.International procurement procedures and systems and monitoring and evaluationmythology.Modern training concepts related to procurement especial emphasis to the presentenvironment.6GFATM-Cambodia; Terms of Reference for the Management Processes, Structure and Membership inCambodia. Prepared by the Sub-Committee of the CCC; Version 4, December 19, 2003. Conducted with TAthrough GTZ?s BACKUP Initiative and USAID/Cambodia.

Monitoring and Evaluation systems; development of sound M&E plans and oversight oftheir implementation and overall functioning,Capacity building in complex environments, linking both government and nongovernmentsources,Functioning of health system and health services in Cambodia,English language fluency and excellent writing skills,Prior experience with GFATM processes and/or programmes considered a strong asset.6. Illustrative Timeline for the Mid-Term Review:The Mid-Term Review will be conducted after the completion of about 1.5 years of theimplementation of Round 1 projects, under its currently approved 2-year funding, thereforeanticipated for the month of November-December. The timing has been moved slightlyforward, to accommodate the deadline for the official submission of the Phase 2 fundingapplication for the Round 1, due in February 2005.Since this review is envisioned as a process evaluation to assess GFATM processes inCambodia and their efficiency to administer programmes, it will also examine experiences andlessons learned of the 1 st year of the implementation of the Round 2 grants. As more fundingis being earmarked for Cambodia under GFATM, it is deemed valuable to demonstrate that allthe necessary systems are in place, or to propose mid-course adjustments and corrections.The assignment is envisioned to last 4 weeks, to be completed between November 2004 andmid January 2005, with the proposed timeline as follows:1. Week 1: Desk reviews of the relevant documentation and discussions with keystakeholders (list to be provided by PR) in Phnom Penh, with the initial meeting todiscuss TOR and reach consensus.2. Week 2: Field Visits to select SRs to see programme activities.3. Week 3: Synthesis of information; clarification of issues, formulation of preliminaryfindings and recommendations, with a Power Point presentation of thereof by the endof this week.4. Week 4; Writing of the draft Report, with a clear set of recommendations for thesubsequent years of the programme implementation and any additional PGAs. Draftreport is to be submitted to the PR by the end of Week 4 (or 15 January 2005) forreview. After PR provides specific feedback, the consultant is expected to finalize thereport within 1 week.Throughout the course of this assignment, the consultant will take the following issues underconsideration ?Key Factors for Recommendations on Future Direction?below.a) Key Factors for Recommendations on Future Direction of projectBy the time the mid-term review will take place, the project will have one more year ofimplementation ahead, under the currently approved funding. In order to maximizethe effectiveness of the project the mid term review should result in recommendationswhich are based on the experience of the past year and take into consideration thecontext (problems and constraints) of the project:Priorities; the health needs the project has to address,Strategy; the strategy or approach the project should apply in order to addressidentified needs, the best practices methodology to obtain the best results.Project framework: possible changes in project?s objectives, outputs and activities.Project area: the geographical areas to be included in the project during theremaining two years.Counterparts; the organizations/groups the project should work with.Resources; staff requirements of the project as well as other resources required bythe project.

Decentralized contracts procurement on health and non health products isassisting the programme implementation in timely manner.D. Anticipated Final Outputs of the Mid-Term Review:It is envisioned that the Mid-Term Review team will produce at the end of their assignment, but nolater than 10 January, will produce the following outputs:1. Power Point presentation of the findings and recommendations (2 nd week).2. Draft Report form the Mid-term Review (4 th week)3. Final Report from the Mid-term Review. (5 th week)

Date Organization NameDr Or VandineGFATM PR Office/MoH Ms Inga Olesky6/12/2004Mr Gunatilake Kodituwakku(Monday)Introductory meeting with GFATMGFATMMalaria SR groupGFATMMr Markus BuhlerCNMDr Doung Socheat7/12/2004 KHANAMs Pok Panhavichetr(Tuesday) Health UnlimitedDr Em SovannarithGFATMIntroductory meeting with SRs fromRound 1 Phase 29/12/2004Field Visit (HIV/AIDS)KHANA(Thursday)Takeo10/12/2004 USAIDDr Sok Bunna(Friday) PFD Dr Philippe Guyant11/12/2004(Saturday)Document review12/12/2004(Sunday)Document reviewPSFJean Yves Dufour13/12/2004Sihanouk HospitalDr Gary Jacques(Monday)UNAIDSMs Geeta SethiCENATDr Mao Tan Eang14/12/2004 MNDDr Tan Sokhey(Tuesday) DSFDr Auk PhanyNCHADSDr Ly Penh Sun15/12/2004 PSIAndrea Fearneyhough(Wednesday) GFATM PR office/MoH Meeting with M&E officersCRCDr Sok Long16/12/2004 MDMDr Pierre-Regis Martin(Thursday) MoSVYMs Em SophonDFIDMs Elizabeth Smith17/12/2004Project visit for MalariaPFD(Friday)Srei Ambel, Koh Kong18/12/2004(Saturday)Document review19/12/2004(Sunday)Document review20/12/2004 FRCCara Wilkins(Monday) WHOJim TullochKPMGDavid King21/12/2004 MEDICAMDr Sin Somuny(Tuesday) UNICEFDr Rodney HatfieldRHACDr Var Chivorn22/12/2004CENAT / FRCField Visit (HIV/AIDS, TB)(Wednesday)Sihanoukville

Date Organization Name23/12/2004(Thursday)Document review, information verification4/01/2005(Tuesday)CCC-SCKith Vanthy5/01/2005 French Cooperation Dr Régine Lefait-Robin(Wednesday) YCC Mak Sarath6/01/2005 GFATMGunatilake Kodituwakku(Thursday) GFATM Markus Buhler7/01/2005(Friday)Document review and presentation preparation8/01/2005(Saturday)Document review, information verification and presentationpreparation9/01/2005Sunday)Document review, information verification and presentationpreparation10/01/2005(Monday)PR office debriefing Dr Or Vandine11/01/2005 JICAMs Muroi Maki(Tuesday) Presentation at SR meetings SRs from R2: Malaria and TBSRs from R1 and R2: HIV/AIDSPresentations at SR meetings12/01/2005prevention and mitigation(Wednesday)SRs from R1 and R2: HIV/AIDSPresentations at SR meetingsclinical programmes13/01/2005Document review, information verification and report preparation(Thursday)14/01/2005(Friday)Presentation and debriefingwith CCCSC

1. Health Sector Strategic Plan, 2003 - 2007, Ministry of Health, Kingdom of Cambodia(August 2002)2. KHANA, An evaluation of the MoH/NGO Home Care Programme for People withHIV/AIDS in Cambodia, June 20003. Ministry of Health, Framework for Monitoring and Evaluation, 1st Edition, HealthSector Strategic Plan 2003-2007 (August 2002)4. Ministry of Health, Medium Term Expenditure framework, Health Sector StrategicPlan 2003-2007 (August 2002)5. Cambodia Coordinating Committee (CCC), Country Coordinated Proposal (CC)) forthe GFATM, Kingdom of Cambodia (September 2002)6. Cambodia Coordinating Committee (CCC), Country Coordinated Proposal (CC)) forthe GFATM, 4th Round - 2004, Kingdom of Cambodia (April 2004)7. Local Fund Agent, Role of LFA in Pre-Grant Agreement, GFATM (no date)8. National Centre for Parasitology, Entomology and Malaria Control, Strengthening ofthe Cambodian National Malaria Control Programme by taking to Scale ProvenIntervention, Proposal for GFATM (July 2002)9. NCHADS, Second quarterly report, 2004, HIV/AIDS and STI Prevention and CareProgramme (July 2004)10. National Centre for Tuberculosis and Leprosy Control (CENAT), Cambodia,Decentralization of DOTS to the health centres and the community and socialmobilization to boost the National Tuberculosis Control Programme in Cambodia(July 2002)11. KHANA, Entertainment workers and HIV/AIDS: An appraisal of HIV/AIDSrelated work practices in the informal entertainment sector in Cambodia (May 2001)12. KHANA, Strategic Plan 2004-200813. KHANA, Improving access to ART in Cambodia (September 2003)14. KHANA, Community Monitoring Groups in HIV/AIDS Prevention and Care (May2001)15. KHANA, When you are ill, you always hope, an exploration of the role of traditionalhealers in HIV/AIDS care and prevention in Cambodia (September 2001)16. Department of Planning and Health Information, Ministry of Health, National healthStatistics Report, Ministry of Health, 200217. Department of Planning and Health Information, Ministry of Health, National healthStatistics Report, Ministry of Health, 200318. Ministry of Health, Join Annual Health Sector Review 200419. Principal Recipient for GFATM (Cambodia), Financial Guidelines (October 2003)20. Principal Recipient for GFATM (Cambodia), Procurement Guidelines (February 2004)21. Principal Recipient for GFATM (Cambodia), Disbursement Requests and Progressupdates (Round 1 and 2)22. Principal Recipient for GFATM (Cambodia), Monitoring Field Visit Reports (2004)23. Sub-recipient Disbursement Requests and Progress Updates (Round 1 and Round 2)24. Principal Recipient for GFATM (Cambodia), Assessment report of the capacities andrequirements of the sub-recipients of round 2 (February 2004)25. Principal Recipient for GFATM (Cambodia), Report on the assessment of the 11approved 1 HIV/AIDS programme sub recipients (2003)26. Memoranda of agreement between Principal Recipient for GFATM (Cambodia) andSub-recipients (Round 1 and 2)27. Principal Recipient for GFATM (Cambodia), Monitoring and Evaluation Plan (2003)28. Principal Recipient for GFATM (Cambodia), Monitoring and Evaluation Guidelines(July 2003)

29. NCHADS, Annual Operational Comprehensive Plan 2004 (AOCP 2004), Kingdom ofCambodia30. Council for Development of Cambodia, Cambodia's approach to tackling theharmonization issues, (February 2003)31. The Global Fund, Monitoring and Evaluation Toolkit, HIV/AIDS, Tuberculosis andMalaria (June 2004)32. Kober K and Damme WV: The Early Steps of the Global Fund in Cambodia, January2002- July 2003, Institute of Tropical Medicine, Dept of Public Health, Antwerp,Belgium (September 2003)33. Cambodia Country Coordinating Mechanism, A Case Study, Report prepared forGFATM (February 2004)34. Connell P, Improving the governance of Global Fund activities in Cambodia(December 2003)35. LFA reporting format36. The Global Fund, Guidelines for the Principal Recipient Assessment (December 2003)37. WHO Geneva, Framework for Monitoring Progress Evaluating Outcomes and Impact,Roll Back Malaria (2000)38. Hewitt K and Whitworth J: Epidemiological evidence and policy implications ofHIV/AIDS and malaria interactions in non-pregnant adults, presentation at meetingon HIV/AIDS and malaria interactions and policy implications, WHO, Geneva,Switzerland (June 2004)39. Global Fund Geneva, A Force for Change: The Global Fund at 30 months.40. Strategic Plan for HIV/AIDS and STI Prevention and Care, 2004-2007, NCHADS,Ministry of Health (June 2004)41. National Strategic Plan for a Comprehensive and Multi-Sectoral Response toHIV/AIDS, 2001-2005, National AIDS Authority (December 2001).

No Full Name Job Title Organization1 Kith Vanthy Secretary CCCSC2 Dr Doung Sochet Director CNM3 Dr Mao Tan Eang Director CENAT4 Dr Khun Kim Eam Deputy Chief of Statistics, CENATPlanning and IEC Unit5 Dr Tieng Sivanna Deputy Chief of Technical CENATBureau6 Heng Sokrithy Coordinator CPN+7 Dr Sok Long HIV/AIDS Programme CRCManager8 Elizabeth Smith Head of Office and Health DFIDAdvisor9 Dr Philippe Poulain Vice President DSF10 Anneli Vainio Medical Coordinator DSF11 Auk Phany Programme Coordinator DSF12 Cara Wilkins Admin & Logistics FRC13 Ros Oeun Care Giver FRC ProgrammeBeneficiary14 Dr Som Dara Medical Coordinator FRC Sihanouk Ville15 Dr Régine Lefait-Robin Technical Advisor at MoH French Government16 Inga L. Oleksy M & E Intl Consultant MoH-PR17 Dr Or Vandine Deputy Director of CDC MoH-PRdepartment and Manager ofPR18 Gunatilake Kodituwakku TechnicalMoH-PRAdvisor/Procurement19 Markus Bühher Consultant for Phase II MoH-PRRound 120 Seng Sopheap Coordinator HACC21 Dr Em Sophanarith Malaria Programme Health UnlimitedCoordinator22 An Virrak Rithy Procurement/Admin Officer Health Unlimited23 Chan Soknay Finance Officer Health Unlimited24 Muroi Maki Assistant Residence Rep JICA25 Keo Samon TB Supervisor Kg Chnang26 Pok Panhavichetr Executive Director KHANA27 Dr Tith Khimuy Programme Director KHANA28 David King Director, Tax & Corporate KPMGServices29 Richard Lim Audit Manager KPMG30 Sar Khun Leakhena Senior Auditor KPMG31 Dr Pierre-Régis Martin Director General MDM32 Dr Jean-Philippe Dousset Medical Coordinator MDM33 Joël Durand General Administrator MDM34 Dr Sin Somuny Executive Director MEDICAM35 Dr Tan Sokhey Team Leader MND36 Dr Eng Veasna M&E Officer MND

No Full Name Job Title Organization37 Tom Sotheary Finance Officer MND38 Em Sophon Project Manager (PGF) MOSVY39 Veth Valda Finance Officer (PGF) MOSVY40 Oum Sophannara Procurement Officer (PGF) MOSVY41 Keo Maly M & E Officer (PGF) MOSVY42 Rith Bunroeun TA (PGF) MOSVY43 Dr Ly Penh Sun Deputy Director NCHADS44 Dr Lim Yee Chief of Monitoring, NCHADSReporting & Evaluation Unit45 Wayne Dale Matthysse Co-Founder/Adviser Partners inCompassion46 Khut Chantha Home Care Project Officer Partners inCompassion47 Dr Philippe Guyant Malaria Programme Manager PFD48 Dr Ou Vun Malaria Programme PFDCoordinator49 My Malaysak Village Health Volunteer PFD Sre Ambel50 Sao Soy PFD Sre Ambel beneficiary PFD Sre Ambel51 Sous Sam Ol Manager PFD Sre Ambel52 Jean Yves Dufour Head of Mission PSF53 Nicole Allard Technical Advisor (R1) PSF54 Antony Vautier Technical Advisor (R1) PSF55 Emmanuel Wintz Technical Advisor (R2) PSF56 Meas Phally Programme Leader/SSR PSFCoordinator (R1)57 Andrea Fearneyhough Admin/Finance PSI58 Khim Keovathanak M & E Manager PSI59 Samol Mean Product Manager (Malarine) PSI60 Dr Var Chivorn Associate Executive Director RHAC61 Ly Seak Meng Financial Officer RHAC62 Sek Sisokhom M&E Officer RHAC63 Dr Tuon Bunnarith Male Health Service RHACProvider64 Nou Pheakdey Youth Team Leader RHAC65 Dr Gary Jacques Executive Director SHCH66 Ian Tootill Director of Finance SHCH67 Dr Jack Middlebrooks Internal Medicine SHCH68 Khem Saron PHD Deputy Director and Sihanouk VilleHealth Center Manager69 Dr Koet Phanarith Deputy Chief of PAO Sihanouk Ville70 Long Nget TB Supervisor Sihanouk Ville71 Dr Mak Kim Ly Deputy Director of SreAmbel OD in charge ofMalaria ProgrammeSre Ambel, KohKong72 Vong Sarin Takavet Health CenterManager73 Geeta Sethi Country Coordinator UNAIDS74 Rodney Hatfield Representative UNICEF75 Dr Sok Bunna Development Assistant USAIDSpecialist for HIV/AIDSSre Ambel, KohKong

No Full Name Job Title Organization76 Dr Jim Tulloch Representative WHO77 Mak Sarath Programme Coordinator YCC78 Sok Sopha Health Programme Officer YCC79 Nong Veasna Admin & Finance Asst YCC80 Mr Peter Connell Independent Consultant DevelopmentBusiness Associates,Singapore

Tum Theary, 32, from Prey Kabas district of Takeo province used to work in a garmentfactory while her husband, Bit Virak, was a motor-taxi driver in Phnom Penh. Having had anunexplained skin problem, Theary one day decided to seek health service but only found outthat she was infected with HIV. She was quite sure that she got the virus from her husbandand felt very angry with him. With hopelessness, Theary once thought of committing suicide toend all her problems; but her father, who was village deputy chief, knew her intention and triedto convince her that death was not the best choice. He then brought her to a home care teamof Partners for Compassion who was operating in the area not far from his village. The teamfirst sought to understand her problems and then assessed her needs. Later on, they come tovisit her at her place. They found that there was serious discrimination against persons withHIV/AIDS like Theary in addition to her economic and health problems. Many people madenegative remarks about her and spread the news about her HIV status across the village just tomake her look ashamed and guilty of being a bad woman/wife and daughter of the villageofficial. To combat with the problem, the team started to counsel her and provided her withsome medicine for her opportunistic infections while informally educating her relatives, friendsand neighbors about HIV/AIDS basic information and about how to care and support forPLHA. Months later, discrimination against PLHA, which once was widespread in thecommunity, gradually disappeared. She is now also receiving ART from MSF in Takeo as well.She feels much better and has her hope back. She lives happily with her husband and her 6-year-old son. Both Theary and her husband, Virak, become very active in helping others likethemselves and joined a support group of PLHA which is now led by Virak.Ros Oeun, 63, widowed farmer from Ang Snuol district of Kandal province, has to wake upat 4 am everyday to take her collection of cotton-like material (Kor) to sell in Phnom Penh.The income from her business is barely enough to pay for her grandchildren?s schooluniforms, stationeries, and some small fees of their classes. Her annual rice harvest can notfeed her extended family. She has 7 children and 4 grandchildren who had been left behind forher to take care of? ?Seven years ago my son-in-law died of AIDS and just two years ago mydaughter also died of the same disease. They both died with all their savings, their house andtheir paddy field. Their disease and death took everything from them and from me as well,?said Oeun.Oeun?s youngest grandkid is a 9-year-old boy. His name is Phang Sophal. He has been knownto live with HIV for 4 years during which he was once put on TB treatment for 2 years.Sophal?s condition was not stable. He developed lots of signs and symptoms of opportunisticinfections. Oeun tried her best to keep grandson?s life goes on as long as possible. She heardabout ARV from a World Vision home care team in Ang Snuol who had been helpful to herfamily for years. She desperately wanted it for Sophal. She traveled to various places just insearch for the miracle medicine, but unfortunately always failed to find one as very few healthservice providers offered ART and very few PLHA had their luck, this is not to mention ARTfor children with AIDS. However, in mid 2004 Oeun eventually had her day. Her grandsonwas selected for ART among the first few dozens of patients at a new pediatric AIDS wardlocated inside the compound of National Pediatric Hospital. The new ward is run by FrenchRed Cross, a sub-recipient of GFATM in Cambodia, who has similar services in the provincialhospital of Sihanouk Ville. ?I feel relieved to see him on ART. With the help of the medicine, Ihope he?ll be with me and his siblings much longer. Look at him; he?s as healthy as other boysof his age now. He weighs 21 kg now, up from 13 kg before starting ART seven months ago.It will be a blessing if he can keep up to fulfill his dream of becoming a teacher,? Oeun told theReview Team with a big smile.

Summary of Suggestions for M&E Working draft GuidelineChapter Description Comments SuggestionslocationA.1-4 Introduction to Very useful NoneGFATM M&EguidelinesA.4 GFATM performance This was not clear ifbased grantsthe performancemeasurement is forPR or SRs.Mentioning LFA'srole was not veryclear.A.5 and 6 Results baseddisbursement policyIt was not clear andhow the result basedwill be implemented.eg.. current issue ofover-achievementand underspending.B Key concepts of M&E These are theoreticalportion.C 20 Responsibilities of This is not directlydifferent agencies for related to M&EM&Emethodology butthe role andresponsibilities.C 21-23 Reporting system, These are usefulimplementation andcontents of M&EreportsD Key start up This is an importantrequirementsection on how toplan and selectAppendix1IndicatorsHIV/AIDSCondom distributionforindicators.BCC - mass mediaCondomdistribution or saledoes not equalTo clarify who is measuringperformance for whom; eg. IsLFA measuring performance ofSRs?To include clearly what results willbe measured in dot points. eg..timely submission of reportsWithin 80% of intended resultsExpenditure in line with projecttimelineThe details should be included asan attachment.This could move to annexes.This could move to annexesNo commentsThis chapter should come earlieras chapter BTo develop one checklist for BCCmaterials to determine if needsassessment done for the BCC andthe materials is pre-tested andhow the intended target group isusing the material. This isimportant as there are manymaterials funded by differentdonor agenciesTo interpret the results withcaution.

ChapterlocationDescription Comments SuggestionsCounselling and testingProphylaxistreatment for OIandApp 2 Indicators fortuberculosis(Prevention)Indicatorstuberculosis(Treatment)forApp 3 Indicators forHIV/TBApp 4 Indicators for malaria(Prevention)Indicators for malaria(Treatment)condom promotionOther target groupsshould also receivetesting andcounselling, not onlywomenThere was aMonitoring tool 5on communitybased activity but nodescription onappendix 1There is no IEC andBCC componentsincluded inprevention eventhough IEC andBCC were reportedby the SRsNo trainingcomponent wasmentioned in thecapacity buildingThis is difficult tomeasure in practiceIt was not clear whatthe BCC services areSocial marketingcomponent ofantimalarial was notincluded in theindicatorsTo include condom use for nonbrothelbased sex workers (asNCHADS strategic plan) as anoutcomeTo include specific target groupsfor testing and counselling (eg..pregnant women, couplesplanning to get married, selfreported risks)Should also include home basedcare services under prophylaxisand treatment.To include IEC/BCC indicatorsTo include training of staff forcorrect diagnosis and appropriatetreatment according to thenational guidelines under capacitybuildingNo commentsTo specify in dot points on BCCservicesTo include availability of selfadministered antimalarialmedicines through socialmarketingAnd to consider way to linkavailability of anti malarial drugsin health centre and socialmarketed anti-malarial drugs.In general, as stated in the guidelines itself, the indicators should be simple and easy tomeasure. It is also important to include a chapter on how to obtain baseline information.

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Health education activity in a villageInterview with a GF programme beneficiary

Interview with GF programme beneficiaries

Interview with GF programme beneficiariesMeeting with a VHV