View Report 2. - Ministry of Health

Ministry of HealthOffice of the PrincipalRecipient for the GFATMReview of GFATM Programs inCambodia - Rounds 1, 2 and 4REPORT 2:Mid-Term Review - Rounds 2 and 4January 2007

Ministry of HealthOffice of the Principal Recipient for theGFATMReview of GFATM Programs inCambodia – Rounds 1, 2 & 4REPORT 2:Mid-Term Review - Rounds 2 and 4Review Team:Jan de Jong – Team LeaderNick Edwards – Finance ConsultantEm Sovannarith – Local ConsultantIm Sothearum – Ministry of Health (DPHI)Ngin Lina – National Aids AuthorityJanuary 2007

Table of ContentsPageAbbreviationsExecutive Summary 11. Introduction 82. Background 102.1 Overview of GFATM Funded Programs in Cambodia 102.2 Round 2 Grants 112.2.1 Round 2 HIV/AIDS Component 122.2.2 Round 2 Malaria Component 132.2.3 Round 2 TB Component 152.3 Round 4 Grants 162.3.1 Round 4 HIV/AIDS Component 172.3.2 Round 4 Malaria Component 182.4 GFATM Structures 202.4.1 Country Coordination Committee (CCC) 202.4.2 CCC Sub-Committee (CCC-SC) 212.4.3 Principal Recipient (PR) 222.4.4 Principal Recipient Technical Review Team (PR-TRT) 232.4.5 Sub-Recipients (SR) 242.4.6 Local Fund Agent (LFA) 243. Review Methodology 263.1 Review Activities 263.2 Limitations of the Review 274. Findings 294.1 Findings – Mid-Term Review 294.2 Findings - GFATM Structures 584.2.1 CCC, CCC-SC and PR-TRT 594.2.2 Local Fund Agent (LFA) 614.2.3 Principal Recipient (PR) 634.3 Findings - Financial Management 694.4 Findings - GFATM Additionality 765. Conclusions 80

6. Recommendations 85List of Annexes:Annex 1: Terms of Reference 92Annex 2: Work Plan for Program Review of GFATM Grants 100Annex 3: List of People Met 105Annex 4: List of Documents / Reference 107Annex 5: List of Indicators in the Consolidated M&E Plan 110Annex 6: List of Sub-Recipients by Round and by Component 115

AbbreviationsAIDSAOPARVBVACCCCCC-SCCCMCPDCRCDSFGFATMHIVIOITKHANALFAMDMM&EMoAMoHMoNDMoSVYNCHADSNGOODOIsOVCPGAPHDPLWHAPRPR-TRTPSFPSISCASHCHSRSTDAcute Immunodeficiency SyndromeAnnual Operational PlanAnti-RetroviralBudgeted Verses Actual (Expenditures)Country Coordination CommitteeCountry Coordination Committee – Sub CommitteeCountry Coordination MechanismConditions Precedent to DisbursementCambodian Red CrossDouleurs Sans FrontièresGlobal Fund to Fight HIV/AIDS, Tuberculosis and MalariaHuman Immunodeficiency VirusInternational OrganizationInformation TechnologyKhmer HIV/AIDS NGO AllianceLocal Fund AgentMedicins du MondeMonitoring and EvaluationMemorandum of AgreementMinistry of HealthMinistry of National DefenceMinistry of Social Affairs, Veterans and Youth RehabilitationNational Centre for HIV/AIDS, Dermatology and STDsNon Governmental OrganizationOperational DistrictOpportunistic InfectionsOrphans and Vulnerable ChildrenProgram Grant AgreementProvincial Health DepartmentPeople Living With HIV/AIDSPrincipal RecipientPrincipal Recipient – Technical Review TeamPharmaciens Sans FrontièresPopulations Services InternationalSave the Children AustraliaSihanouk Hospital Centre of HopeSub-RecipientSexually Transmitted Diseases

STISub-TWGHSWApSWiMTRPUHNUNVCCTYCCSexually Transmitted InfectionsTechnical Working Group for HealthSector Wide ApproachSector Wide ManagementTechnical Review PanelUnited Health NetworkUnited NationsVoluntary Confidential Counselling and TestingYouth Council for Cambodia

Executive SummaryCambodia has been very successful in getting proposals approved forfunding by GFATM. At the time this report was written, ten proposals hadbeen approved with signed grants and programs at various stages ofimplementation for nine of these proposals.This report is the output of a program review that was commissioned bythe Principal Recipient (PR) and was conducted in November/December2006 by a team of five consultants. The program review included a Mid-Term Review for Rounds 2 and 4 (presented in this report) and an End-of-Program Review for Round 1 (presented in a separate report).In addition to an analysis of program implementation and achievementsfor the six programs that are part of these three Rounds, the Review Teamwas asked to look at three cross-cutting issues: (i) The efficiency offinancial management, (ii) whether GFATM structures are fulfilling theirterms of reference, and (iii) the utilization of GFATM funding in addition toother funding sources (i.e. additionality).The proposal for Round 2 was submitted to GFATM in September 2002,and all three components (HIV/AIDS, Malaria and TB) were approved.Implementation started in January 2004, while Phase 2 implementationstarted in January 2006. The three programs have a total duration of fiveyears and a total approved budget of $30.7 million.The proposal for Round 4 was submitted to GFATM in March 2004, andthe HIV/AIDS as well as the Malaria components were approved forfunding. Implementation of Phase 1 was delayed until September 2005and has a total approved budget of $14.0 million.Program Implementation and ResultsThe main findings concerning the implementation and achievements ofRound 2 and 4 are:The M&E plans include some indicators that lack clear definitions orare defined differently by different sub-recipients. This is especiallytrue for the both HIV/AIDS programs, which is believed to be areflection of the fact that this disease area lacks an overall M&Eframework with agreed and clearly defined indicators.The Round 2 programs are largely implemented according to plan andmost of the intended results are being achieved. It should be noted,Page 1

however, that implementation slowed down during the first 6 months of2006 due to the late disbursement of funds, which was caused by thedelay in signing the PGAs and MoAs for Phase 2.After only 10 month of implementation, the Round 4 HIV/AIDScomponent appears to be largely on track in achieving its intendedresults. For the Malaria component, progress to date is more modestwith only 1 indicator reported to be on target and with malaria healtheducation activities and the procurement of bed nets well belowintended results.Similar to Round 1, programmatic results are largely achieved despitedelayed and slow rates of expenditure. This continues to raisequestions regarding the accuracy of planning and budgeting duringproposal development and illustrates that more should be done toeffectively monitor program results and expenditures.Round 2 started only 4 months after Round 1 and hence, suffers frommany of the same constraints, namely the fact that GFATM fundingwas new, and that GFATM was not always clear on its procedures andrequirements and frequently changed these procedures andrequirements. Other common constraints are linked to the proposaldevelopment process, which has produced relatively weak proposalsand included several weaker Sub-Recipients.These already considerable constraints and challenges for the PR havebecome even more pronounced given the environment of an increasingnumber of grants and Sub-Recipients, and a growing funding portfolioto be managed.The National Programs are benefiting from GFATM funding in the formof scaling up and expanding service delivery and in the form of animproved capacity to manage and implement donor funded programs.Important lessons learned from program implementation are the need:(i) To strengthen the proposal development process and to ensurethat the resulting proposals take more account of some of therequirements and challenges of the subsequent programimplementation.(ii) For CCC and CCC-SC to play a more pro-active role in overseeingprogram implementation and to supervise the work of the PR(iii) To accurately forecast end of Phase 1 savings and to include thesesaving in work plans and budgets of Phase 2 proposals(iv) For the PR to assume the role of the grants manager and to takethe responsibility to conduct regular and systematic programmaticand financial analysis of on-going grants.Page 2

GFATM StructuresAs one of three cross-cutting issues, the Review Team assessed to whatextent the PR, CCC and CCC-SC, and the LFA are fulfilling their terms ofreference:The CCC and its Sub-Committee (CCC-SC) have clearly defined rolesand responsibilities with regard to proposal development, but it wasnoted by CCC members themselves that their role in overseeingprogram implementation is not as clear.In addition, CCC and CCC-SC members are constrained by the factthat they have limited time available for the additional tasks (i.e. inaddition to their regular and full-time jobs) that are related to theirmembership of CCC and/or CCC-SC.The LFA has been criticised for its limited experience in andunderstanding of health programs, and the frequent changes in oftenvery junior staff. However, the Review Team feels that progress hasbeen made in addressing these issues, especially with the recruitmentof a medical doctor with considerable experience in GFATM fundedprograms.At the time of the review, the relationship between the LFA and the PRwas strained. This was illustrated by the PR holding the LFAresponsible for frequent delays in reporting and in the disbursement offunds, while the LFA claims that progress reports submitted by the PRare often incomplete and of poor quality. This has led the GFATM FundPortfolio Manager to intervene and to broker a proposal for remedialaction to be implemented in the months following this Program Review.During its four years of existence, the PR almost quadrupled itsnumber of professional staff, while the number of grants increasedfrom one in 2003 to six with a total value of $66 million. Despite theseconsiderable challenges, the PR is widely recognised for its success instarting up and managing program implementation in a challengingand complex managerial and organisational environment.More recently, there has been a growing concern that the PR isbecoming too stretched and that its current capacity is not sufficient tosustain continued increases in the number of grants, in the amount offunding and in the number of Sub-Recipients. The recent recruitmentof additional staff may bring some relief in dealing with the growingworkload, but more needs to be done in terms of strengthening andstandardization of the PR’s systems and procedures.Linked to this the fact that the PR perceives itself as a coordinator anda facilitator, while the nature of the Program Grant Agreements (PGAs)Page 3

dictates that the PR should act as the grants manager. The result isthat the PR does not conduct regular and systematic financial andprogrammatic analysis and fails to recommend and enforce correctivemeasures to be taken by Sub-Recipients in case of under/overachievement against targets and under-spending against agreedbudgets.Financial ManagementThe Program Review examined the efficiency of the management of GFATMfunds and assessed the capacity of relevant entities to meet GFATMrequirements. The main findings are:The GFATM structures show an adequate ability to develop budgetsand the quality of budget proposals has improved with subsequentRounds.The budget realignment process has been a work in progress and Sub-Recipients are now given the opportunity the realign their budgets oncea year.However, the PR is not clear concerning its authority to propose andinitiate budget realignments and hence, budget realignment onlyhappens when initiated by the Sub-Recipients. The large amount offunding left un-spent at the end of Round 1 was the direct result of thelack of adequate and timely budget realignment.The PR has ensured that Sub-Recipients are aware of its financial andprocurement guidelines and provided considerable training to ensurethat Sub-Recipients are able to comply with these guidelines.The PR and the Sub-Recipients are able to track and report on variousrounds separately and have adequate systems in place to segregateGFATM funds and funding from other donors.The PR and most of the Sub-Recipients are able to comply withfinancial reporting requirements and to submit reports in a timelymanner.A main concern regarding financial reporting is whether existingformats provide enough information to effectively manage the grants.Specific concerns are the fact that present reports fail to adequatelyexplain variances between the budget and actual expenditures, and donot show how unspent funds are proposed to be used during the nextperiod.Another concern is that various Sub-Recipients complete the samefinancial forms differently and often include errors. These (oftenincomplete and inaccurate) reports are annexed to the consolidatedPage 4

periodic reports and disbursement requests and forwarded to the LFA,which has caused confusion and delayed the reporting process.The disbursement of funds by the PR to the Sub-Recipients is normallytimely, provided the disbursement request was approved by GFATM.Some issues remain concerning the distribution of funds from theNational Programs to the Provincial Health Departments. This is oftenidentified as one of the main reasons for low level of spending by theNational Programs. Other Sub-Recipients (NGOs) do not have issuesconcerning the distribution of funds from Phnom Penh to the field.GFATM AdditionalityGFATM requires that its funding does not replace other sources of fundingand seeks to complement the funding provided by other donors. Thesefunding principles are referred to as “additionality”. The main findings ofProgram Review are as follows:There is sufficient evidence of additionality at the Sub-Recipient levelas most of them were already working in HIV/AIDS and used GFATMfunding to expand there activities. Other Sub-Recipients used GFATMfunding to address HIV/AIDS related needs in facilities or ingeographical areas where they were already working.At the donor level, it is more difficult to judge whether additionality isbeing achieved. The gap analysis that is now part of the proposaldevelopment helps to avoid overlap and duplication. On the otherhand, some of the stakeholders interviewed by the review teamexpressed their concerns that Cambodia’s success in obtaining GFATMfunding may result in other donors giving less priority to funding thethree disease programs.There is sufficient evidence that GFATM funding has resulted in aconsiderable expansion and scaling-up of services in the three diseaseareas.Given the key coordination (gatekeeper) role of the three NationalPrograms during proposal development as well as during programimplementation, GFATM funded program are in line with nationalpolicies and strategies.RecommendationsGiven the relatively large amounts of funds remaining unspent at theend of Round 1, Sub-Recipients and the PR are recommended toclosely monitor expenditures against budgets and to assure timelyPage 5

udget realignments resulting in funds being used to maximiseprogrammatic results.Given the budget losses that occurred during the approval process ofPhase 2 of Round 2, and the considerable under-spending for bothRound 4 programs, the PR and its Sub-Recipients should make sure tomake realistic projections of expenditures until the end of Phase 1 andto include expected savings in the requested budget for Phase 2.The CCC and the CCC-SC need to play a more prominent role insupervision of the PR and in overall decision-making. This will requireidentifying ways to overcome the time constraints that CCC and CCC-SC members are facing at the moment.Both the PR and the LFA need to continue to implement the remedialactions that have been brokered by the GFATM in a joint (PR and LFA)effort to improve the relationship between these two crucial GFATMstructures.The Review Team concludes that there are considerable advantages inthe continued use of the present PR for future GFATM Rounds andgrants. It is recognised, however, that present concerns regarding thePR’s capacity need to be addressed and that the PR will need to fulfilthe role and responsibilities of a grants manager.Therefore, it is recommended that the CCC provides the PR with theclear mandate and authority to act as the grants manager for ongoingand future GFATM funded programs in Cambodia.In order to maximise the effectiveness and efficiency of the growingnumber of PR staff, their performance needs to be managed moresystematically. The performance management system developed by theMinistry of Health may be useful in this respect.The PR needs to consider other measures that can help in coping withthe existing workload such as a regular review and prioritization oftasks, further strengthening of systems and procedures, and moreoutsourcing of routine and ad-hoc tasks that need not be implementedby the PR itself.It is recommended that the PR gets the advice and assistance of anorganizational development and/or management expert in order tofurther strengthen the management of the PR and to help identifyingmeasures to deal with the present as well as future workload.The PR needs to assume a wider role in financial management andmake sure that Sub-Recipients explain variances between budget andactual expenditures and consider budget realignment in case of slowand under-spending.Page 6

In case of requests to carry forward unspent funds, these will need tobe supported by adequate information on how funds will be spent. Onepossible way of doing so could be for Sub-Recipients to reports againstwork plans and to highlight the use of funds carried forward inupdated work plans for the next reporting period.It is recommended to review existing financial procedures and whennecessary to clarify and standardise these procedures. Such a reviewshould also take into account the need for better information sharingbetween PR, LFA and GFATM, to ensure that all parties involved havesufficient and up-to-date information.Although more centralised procurement by the PR is welcomed, it isrecommended that the PR will continue to take into consideration Sub-Recipients’ needs for items and goods with specific specifications.In order to capture additionality, Sub-Recipients should be encouragedto report overall results for selected key indicators.Additionality is already demonstrated by way of the gap analysis duringproposal development. It is recommended to consider regular up-datingof the gap analysis (e.g. during the phase 2 application process) and toreport on the actual situation as part of the annual progress reports.For the National Programs a regular gap analysis and reporting on theactual situation can be facilitated through the development of AnnualOperational Plans (AOPs) and in line with the Ministry of Healthplanning process.Page 7

1. IntroductionThe Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) wascreated to dramatically increase resources to fight three of the world’smost devastating diseases, and to direct those resources to areas ofgreatest need. As a partnership between governments, civil society, privatesector and affected communities, the Global Fund represents aninnovative approach to international health financing. To date, GFATMhas committed US $6.8 billion in 136 countries 1 .Cambodia submitted the first Country Coordinated Proposal in March2002. Since then, the country has been very successful in gettingproposals approved for funding by GFATM. In total, ten proposals havebeen approved:• Round 1: HIV/AIDS Component• Round 2: HIV/AIDS, Tuberculosis and Malaria Components• Round 4: HIV/AIDS and Malaria Components• Round 5: HIV/AIDS, Tuberculosis and Health System StrengtheningComponents• Round 6: Malaria ComponentThis report is the second of two reports and is the output of a programreview of GFATM Rounds 1, 2 and 4 in Cambodia. The Program Reviewwas commissioned by the Principal Recipient (PR) and has dual purposes(see Annex 1 for the Terms of Reference): As an End-of-Program Review forRound 1 it aims to assess the overall outputs and outcomes of the Round1 HIV/AIDS grant and to evaluate its effectiveness after three years ofimplementation. As a Mid-Term Program Review for Rounds 2 and 4 itaims to assess inputs, processes and accomplishments of the five grantsunder both Rounds, and to identify lessons learned and makerecommendations for future implementation.In addition, the Review Team was instructed to consider three commonconcerns (cross-cutting issues) for all grants under Rounds 1, 2, & 4):• First of all, the Review Team was asked to examine the efficiency offinancial management by the Principal Recipient and the Sub-Recipients (SRs).1 GFATM WebsitePage 8

• Secondly, the Review Team assessed the extent to which GFATMStructures are fulfilling their existing Terms of Reference whilesupporting program implementation.• Finally, the Review Team looked into GFATM additionality andexamined the utilization of GFATM funds in addition to other fundingsources in Cambodia.The Program Review was conducted during the months November andDecember 2006 by a team consisting of an expatriate Health ProgramConsultant / Team Leader, an expatriate Financial ManagementConsultant, a local consultant, a representative from the Ministry ofHealth Department of Planning and Health Information, and arepresentative of the National Aids Authority.In general, the Review Team followed the methodology and illustrativetimeline proposed in the Terms of Reference. The Review started with abriefing by PR management and senior staff and included a desk review ofrelevant documents, meetings with Sub-Recipients and other keystakeholders, and field visits.This second report presents the findings of the Mid Term Review forRounds 2 and 4, while the first report concerns the End of ProgramReview for Round 1. This second report also addresses the three crosscuttingissues and hence, the report can be read as a stand-alone report.Readers interested in both reports should be aware of the considerableoverlap between the reports.Page 9

2. BackgroundThis section of the report aims to provide the necessary backgroundinformation on approved GFATM grants (section 2.1) and on Round 2 and4 in particular (sections 2.2 and 2.3), as well as on the way GFATMproposal development and program implementation is managed throughseveral in-country entities or GFATM structures (section 2.4).2.1. Overview of GFATM Funded Programs in CambodiaCambodia has been very successful in getting proposals approved byGFATM and Rounds 1-4 resulted in a total of six approved grants:• Round 1: HIV/AIDS component• Round 2: HIV/AIDS, Tuberculosis and Malaria components• Round 4: HIV/AIDS and Malaria componentsThese grants are implemented by a total of 22 Sub-Recipients, i.e. takinginto considerations that several Sub-Recipients are involved in two ormore grants (see Annex 6). Table 2.1 gives an overview of the total amountof approved GFATM grants as well as the total lifetime budget. The tableshows that Rounds 1, 2 and 4 have a total lifetime budget of $92,797,031and that approved grants amount to $60,396,556.Table 2.1: Approved Grants and Lifetime Budgets (in US$)Round Component Approved GrantAmount 2 (US$)Lifetime Budget 3(US$)1 HIV/AIDS 15,714,629 15,714,6292 HIV/AIDS 14,765,625 14,765,625Malaria 9,730,345 9,730,345Tuberculosis 6,169,733 6,169,7334 HIV/AIDS 8,794,982 36,546,134Malaria 5,221,242 9,870,565Sub-Total Rounds 1, 2 & 4 60,396,556 92,797,0315 HIV/AIDS 16,292,779 34,963,654Tuberculosis 3,268,750 9,662,024Health Systems Strengthening 1,841,600 5,051,7416 Malaria - 31,191,393Total Rounds 1-6 81,799,685 173,665,843Although outside the scope of the Program Review, Cambodia receivedfurther approval for Round 5 (three Program Grant Agreements (PGAs)signed: HIV/AIDS, Tuberculosis and Health System Strengtheningcomponents) and recently also for Round 6 (Malaria component – recently2 Approved grants with signed PGAs3 Budget as in approved proposalsPage 10

approved, but the PGA has not been signed yet). This brings the totalnumber of approved grants to nine, not including the Round 6 Malariacomponent, which will be signed in the near future.Rounds 5 and 6 are/will be implemented by 28 Sub-Recipients, ten ofwhich were not involved as Sub-Recipients in previous rounds (see Annex6). Table 2.1 shows that all the approved grants (i.e. including the Round5 grants) amount to $81,799,685, while the total lifetime budget of allRounds (including Round 6) amounts to $173,665,843.2.2. Round 2 GrantsThe proposal for Round 2 included each of the three diseases and wassubmitted to GFATM in September 2002. GFATM approved all threecomponents and the respective PGAs were signed in October 2003.Implementation did not start until January 1 st 2004 (program startingdate.1) HIV/AIDS Component:• Program Title: Partnership for Going to Scale with ProvenInterventions for HIV/AIDS• Grant Number: CAM-202-G02-H-00• Approved budget for Phase 1 (initial two years): US$5,370,564• Lifetime budget (five years - Phase 1 & 2): US$ 14,765,6252) Tuberculosis Component:• Program Title: Partnership for Going to Scale with ProvenInterventions for Tuberculosis• Grant Number: CAM-202-G02-T-00• Approved budget for Phase 1 (initial two years): US$ 2,505,525• Lifetime budget (five years - Phase 1 & 2): US$ 6,169,7333) Malaria Component:• Program Title: Partnership for Going to Scale with ProvenInterventions for Malaria• Grant Number: CAM-202-G02-M-00• Approved Phase 1 budget (initial two years): US$5,013,262• Lifetime budget (five years - Phase 1 & 2): US$9,730,345The amended PGAs for Phase 2 were not signed until March 1 st 2006,which is 2 months after Phase 1 ended. The delay was caused by the factPage 11

that many clarifications and changes were required concerning the Phase2 budgets and work plans.There are 11 Sub-Recipients involved in the implementation of Round 2,and 4 of these Sub-Recipients are also involved in the implementation ofRound 1. This brings the number of Sub-Recipients for Round1 andRound 2 to a total of 18.2.2.1. Round 2 HIV/AIDS ComponentThe goal of the HIV component is to reduce morbidity and mortalityresulting from HIV/AIDS by complementing the implementation of theNational Strategic Plan for HIV/AIDS.The program has the following three objectives:1) To expand the coverage and enhance the quality of interventions for theprevention of HIV/AIDS to include under-served, vulnerablepopulations.2) To improve access to quality comprehensive care interventions,including highly active antiretroviral therapy (HAART) and thepromotion of greater involvement of people living with HIV/AIDS.3) To secure the reliable and adequate drug supplies in order to improveaccess to quality comprehensive care interventions, including thetreatment of opportunistic infections (OIs) and sexually transmittedinfections (STIs), prevention of mother to child transmission (PMTCT)and the provision of anti –retroviral (ARV) drugs. This objective wasmodified for Phase 2: To strengthen the efficient management of HIV,Malaria and TB related commodities through support to the CentralMedical Store (CMS).In summary, the Round 2 HIV/AIDS component includes the followingactivities:• Prevention and STI management: This includes peer educationimplemented by RHAC amongst youth (Phnom Penh), fishermen (KgSom), factory workers (Phnom Penh and Kg Cham) and youngentertainment workers (Phnom Penh and Kg Som). The program alsoincludes procurement of STI drugs, condoms and HIV tests for theRHAC clinics in Phnom Penh (two clinics and five health posts) and infive provinces (seven clinics in total: two clinics in Kg Cham, two clinicsin Siem Reap, Takeo, Battambang, and Kg Som). In addition, NCHADSsupports prevention and STI management in several provinces,Page 12

The Round 2 Malaria component is implemented by four Sub-Recipients:1) The National Centre for Malaria (CNM)2) Health Unlimited (HU)3) Partners for Development (PFD)4) Population Services International (PSI) 6None of the Sub-Recipients implements activities through Sub-Sub-Recipients. It should be noted, however, that CNM implements several ofits activities at provincial and district level in close collaboration withPHDs and ODs.2.2.3. Round 2 Tuberculosis ComponentThe Phase 1 goal of the Tuberculosis component was to compliment effortsof the MoH to decrease the socio-economic burden of TB by reducingmorbidity, mortality and transmission of the disease through theexpansion of the DOTS to the community, strengthening DOTS in 40% ofall HCs by 2005 and social mobilization through advocacy and IEC.For Phase 2 this goal was modified in line with recommendations of theGFATM secretariat to included standard DOTS indicators and annualimpact measure targets:1) To contribute to improving the health of the Cambodian people in orderto contribute to socio-economic development and poverty reduction inCambodia by reducing the morbidity and mortality rates due to TB2) To ensure equity and access to TB services and to maintain a high curerate of more than 85% and a high detection rate of at least 70% by theend of 2005Initially this component had six objectives, but the revised M&E plan thatwas approved in December 2004 includes five objectives:1) To expand community DOTS program from 2% to 100% by 2007.2) To expand case detection activities in 100% of the health centres by2007.3) To improve knowledge about TB among adults by increasing advocacyand through IEC strategies in the community.4) To carry out program-based operational research and surveys.5) To improve TB awareness, case detection and treatment services forpeople in under-served areas.6 PSI is also a Sub-Recipient for Round 1 (HIV/AIDS)Page 15

In summary the Round 2 Tuberculosis component includes the followingactivities:• The expansion of community DOTS• The expansion of health centre DOTS• Health education on Tuberculosis through a variety of IEC strategies.The Round 2 Tuberculosis component is implemented by one Sub-Recipient:1) National Centre for Tuberculosis and Leprosy Control (CENAT)The program is implemented in close partnership with three Sub-Sub-Recipients:• Save the Children Australia (SCA) implements community DOTSactivities in three Operational Districts in Kg Cham Province.• Partners for Health and Development (PFHAD) implements communityDOTS activities in both Operational Districts of Kratie Province.• VORORT conducts operational research in Rattanakiri Province withthe aim to assess the barriers to TB services in remote areas where themajority of the population consist of ethnic minorities.In addition, CENAT implements program activities in close collaborationwith 24 Provincial and Municipal Health Departments, 78 OperationalDistricts, 145 TB Units, and 952 Health Centres.2.3. Round 4 GrantsThe proposal for Round 4 included each of the three diseases and wassubmitted to GFATM in March 2004. GFATM approved the HIV/AIDS andMalaria proposals and the respective PGAs for Phase 1 were signed inJune 2005. Phase 1 includes a period of two years starting September 1 st2005 and ending August 31 st 2007.1) HIV/AIDS Component:• Program Title: Continuum of Care• Grant Number: CAM-405-G05-H• Approved budget for Phase 1 (initial two years): US$8,794,982• Requested budget for five years (Phase 1 & 2): US$ 36,546,1342) Malaria Component:• Program Title: Strengthening the National Malaria Control Programby broadening Partnerships and taking to Scale proven BCCPage 16

Interventions and Ushering in a ‘People’s Movement for MalariaControl’• Grant Number: CAM-405-G06-M• Approved Phase 1 budget (initial two years): US$5,221,242• Requested budget for five years (Phase 1 & 2): US$9,870,565There are a total of 13 Sub-Recipients involved in the implementation ofRound 4, and nine of these Sub-Recipients are also involved in theimplementation of Round 1 and/or Round 2. This brings the number ofSub-Recipients for Rounds 1, 2 and 4 to a total of 22.2.3.1. Round 4 HIV/AIDS ComponentThe goal of the HIV/AIDS component is:1) To increase survival of PLWHA in Cambodia, specifically, to reduce themortality rate at 12 months for people developing AIDS from a baselineof 90% to 35% by the end of the program2) To reduce the percentage of HIV infected infants born the HIV infectedmothers in Cambodia, specifically, reduce the percentage of HIVinfected infants born to HIV infected mothers from a baseline of 25% to15% by the end of the programThe program has three objectives:1) To increase the number and percentage of people with advanced HIVinfection receiving ARV treatment2) To increase access to comprehensive HIV care3) To increase the percentage of HIV infected pregnant women and theirnewborns who receive ARV prophylaxis to prevent mother to childtransmission of HIVIn summary, the Round 4 HIV/AIDS component includes the followingactivities:• Expansion of OI/ARV treatment: This includes OI/ARV treatmentprovided by MDM, PSF and SHCH, support by CARE to establishOI/ARV clinics in four Referral Hospitals (two in Koh Kong and two inBantey Mean Chey), and NCHADS support to various VCCT sites andOI/ARV clinics throughout the country. NPH provides training forhealth staff in medical care for children living with HIV/AIDS(paediatric ARV), while both CARE and NCHADS support training inHAART and OI management.Page 17

• Increased access to comprehensive HIV care: This includes training inCOC and palliative care and support to palliative care services (PhnomPenh, Kg Cham, and Tak Khmao) provided by DSF. Furthermore, Sub-Recipients support MMM (CPN+, CARE and NCHADS), support groupactivities (CPN+, MDM and CARE, and psycho-social support forPLWHAs and OVCs (CPN+)• Scaling up PMTCT: NCMCH support PMTCT services in several ReferralHospitals including training of staff, monitoring and supervision, civilworks and the provision of necessary equipment. NCMCH isresponsible for IEC and BCC activities related to PMTCT at OD level.Furthermore, SHCH started PMTCT services as part of its Round 4grant.The Round 4 HIV/AIDS component is implemented by nine Sub-Recipients:1) Care2) Cambodian PLWH Network (CPN+)3) Douleurs Sans Frontières (DSF) 74) Medicins du Monde (MDM) 55) National Centre for HIV/AIDS, Dermatology, and STDs (NCHADS) 56) National Centre for Maternal and Child Health (NCMCH)7) National Paediatric Hospital/World Vision International (NPH/WVI)8) Sihanouk Hospital Centre of Hope (SHCH) 59) Pharmaciens Sans Frontières (PSF) 5Only NCMCH implements activities through a Sub-Sub-Recipient.Calmette Hospital studies the effectiveness of PMTCT and effect ofnutrition on the effectiveness of PMTCT. NCHADS supports several PHDs,ODs, STI clinics, VCCT sites, and OI/ARV clinics. This support includesdrugs and commodities, implementation of activities, and salary incentivesfor public health staff.2.3.2. Round 4 Malaria ComponentThe goal of the Malaria component is to reduce malaria related mortalityamong the general population in Cambodia by 50% and morbidity by 30%,within five years by the implementation of a comprehensive nationalmalaria control strategy. In particular:7 DSF, MDM, NCHADS, SHCH and PSF are also Sub-Recipients for Round 1 and/orRound 2Page 18

1) The malaria mortality rate (confirmed malaria cases) per 100,000population will be reduced from 3.5/100,000 in 2002 to 1.8/100,000in 20092) The proportion of severe malaria cases among the total confirmedmalaria cases reported in the country from the public health facilitieswill be reduced from 8.9% in 2002 to 6% in 20093) The case fatality rate as a percentage of confirmed malaria deathsamong severe malaria cases will be reduced from 9.96% in 2003 to 5%in 2009The program has two objectives:1) To significantly increase community awareness and care-takingpractices on malaria prevention and control with promotion of properhealth seeking behaviour in endemic areas in Cambodia2) To improve access to preventive measures that protect the populationat risk, with a focus on complete coverage for bed net distribution andre-impregnation in targeted malaria endemic areas, employing aneffective community based approachIn summary, the Round 4 Malaria component includes the followingactivities:• Malaria BCC, health education, and school health education: CNM isresponsible for Malaria BCC and health education in 20 provinces,which includes health education through key women agents (incollaboration with the Ministry of Women Affairs – MoWA) and throughVillage Health Volunteers (in collaboration with local NGOs and PHDs),as well as health education for the military (in collaboration with theMinistry of National Defence – MoND) and for the police (in collaborationwith the Ministry of Interior – MoI). CNM implements school healtheducation in 12 provinces (in collaboration with the Ministry ofEducation, Youth and Sports – MoEYS). PFD and HU implement schoolhealth education in an additional six provinces: PFD in Kratie, KohKong, Stung Treng, and Mondulkiri (in collaboration with Nomad), andHU in Rattanakiri and Preah Vihear. HU also provides health educationthrough community video show and community theatre in Preah Vihearand Rattanakiri.• Distribution of Long Lasting Impregnated Mosquito Nets (LLIMN) andRe-impregnation: CNM is responsible for procurement and distributionof LLIMNs and for the re-impregnation of bed nets, while PSI providesLLIMNs through social marketing.Page 19

The Round 4 Malaria component is implemented by the same Sub-Recipients as Round 2:1) The National Centre for Malaria (CNM)2) Health Unlimited (HU)3) Partners for Development (PFD)4) Population Services International (PSI)There is a total of eight Sub-Sub Recipients involved in theimplementation of Round 4 Malaria Component:• CNM has a total of six Sub-Sub-Recipients:→ MoEYS: School health education in 12 provinces.→ MoWA: Malaria health education for women and children throughselected key women agents.→ MoI: Malaria health education among policemen and their families.→ MoND: Malaria health education among military and their families.→ Cambodian Development and Relief Center for the Poor (CDRCP - alocal NGO): Training for VHVs in malaria education in Odar MeanChey Province.→ Association pour le Soutien de l’Action Rurale (ASSAR – a localNGO): Training for VHVs in malaria health education in fourprovinces (Kg Chhnang, Pursat, Battambang and Kg Speu)• PSI has one Sub-Sub-Recipient: The Society for Malaria Control inCambodia (SMCC), which is a local NGO involved in the distribution ofLLIMN in remote and endemic areas.• PFD has one Sub-Sub-Recipient: Nomad is implementing malaria choolhealth education in Mondolkiri Province.2.4. GFATM StructuresGFATM requires the establishment of a Country Coordination Mechanism(CCM), which is generally known in Cambodia as the CountryCoordination Committee (CCC). Other in-country GFATM structures arethe CCC Sub-Committee (CCC-SC), the Principal Recipient (PR), thePrincipal Recipient Technical Review Teams (PRTRTs), the Sub-Recipients(SRs) and the Local Fund Agent (LFA).2.4.1. Country Coordination Committee (CCC)The CCC was established in February 2002 and acts as the supreme incountryauthority on GFATM matters. The CCC functions as a nationalconsensus group, which coordinates proposal development and overseesimplementation of approved programs.Page 20

CCC’s role as a forum to promote a multi-sectoral approach as well aspartnerships between public sector, private sector and civil society isreflected in the composition of its membership:• Approved membership ceiling of 29 members• Including six constituencies: Government (ten members), UN Agencies(three members), multi- and bi-Laterals (six members), NGOs and IOs(four members), civil society and private sector (three members,including one representative of PLWHA) and academics/scientificcommunity (two members).The CCC’s responsibilities with regard to proposal development are toannounce any new call for proposals, to coordinate appropriate support tothe preparation of proposal, to ensure that proposals are of high qualityand consistent with national policies and strategies, and to approve andsubmit final proposals to GFATM.Regarding program implementation, the CCC is responsible to select thePR, approve the PR’s annual work plans and budgets, review the PR’sprogress in implementation and formally approve the PR’s annual report,approve and submit disbursement request to GFATM, and facilitatecommunication with and information flow among all relevant partners,including relevant Ministries, Authorities and National Programmes thatprovide technical leadership for GFATM supported activities (i.e.HIV/AIDS, Tuberculosis and Malaria).The CCC meets at least four times per year (quarterly), and may convenespecial meetings as required necessary by the chairman.2.4.2 CCC Sub-Committee (CCC-SC)The CCC-SC was established in September 2002 to act as the secretariatof the CCC with limited decision-making power. The role of the CCC-SC issometimes described as “the board of directors of the PR”, while the CCCis the supreme decision making body.At present, the CCC-SC has ten members, consisting of tworepresentatives from five constituencies: Government, UN agencies,multi/bi-lateral donors, NGOs/IOs, and civil society/private sector(academics/scientific community is not represented in the CCC-SC).Detailed responsibilities of the CCC-SC as the secretariat to the CCC:Page 21

• Facilitate administrative work of the CCC (including correspondenceand maintenance of records and documentation).• Coordinate the review of draft proposals by the Technical Review Panelsand compile accepted proposals into a draft Country CoordinatedProposal for presentation to the CCC.• Organize regular and/or special CCC meetings, including preparationand circulation of all relevant documentation and preparation ofmeeting minutes.• Assist in finding solutions for identified difficulties in implementingGFATM grantsIn addition the CCC-SC will review and approve the PR’s semi-annual andannual reports, liaise with the PR to prepare summaries of programprogress for CCC meetings, conduct periodic and objective reviews of thePR’s performance and report on that performance to the CCC, andapprove any ad-hoc requests made by the PR to GFATM.The CCC-SC meets monthly and is assisted by a full-time administrativestaff. During exceptionally busy periods, such as proposal development,CCC-SC may recruit short-term technical assistance.2.4.3. Principal Recipient (PR)The PR is the legally accountable party in Cambodia that signs theProgram Grant Agreements (PGAs) with the GFATM and Memoranda ofAgreement (MoA) with the Sub-Recipients. The PR acts on behalf of andunder the general guidance of the CCC. The PR in Cambodia is theMinistry of Health Department of Communicable Disease Control.On behalf of the MoH and while keeping the CCC informed on a regularbasis, the PR is responsible for day-to-day program implementation. ThePR’s role and responsibilities include:• Coordination of program activities with all partners• Management of funds, including the disbursements of funds to theSub-Recipients• Preparation of periodic financial and programmatic progress reportsand disbursement request, and making sure that these reports areshared with/approved by other GFATM structures in country andsubmitted in time to GFATM.• Liaison with other GFATM structures, the National Programs and otherpartners involved.Page 22

The PR team was appointed just over four years ago (30 December 2002),consisting of a Chairman (Dr. Sok Touch - Director of the MoHDepartment of Communicable Disease Control), a Manager who isresponsible for day to day management (Dr. Or Vandine – Deputy Directorof the MoH Department of Communicable Disease Control), fiveprofessional staff (all MoH staff and including two staff from the MoHDepartment of Budget and Finance).At the time of the Mid-Term Review of Rounds 1 and 2 (December 2004 /January 2005), the number of professional staff had more than doubledwith three staff in each unit (M&E, Finance and Procurement) and twoadministrative staff. In addition, two international technical advisors hadbeen recruited to assist in procurement and in M&E.At the time of the present review, additional technical and administrativestaff had just been appointed, while re-advertising two M&E positions.This will bring the total number of full-time professional staff (excludingthe Chairman) to 22:• Manager and newly appointed Assistant Manager• Three technical units with five staff each and five administrative and ITstaff• In addition, the PR employs three international technical advisors(including the newly appointed Finance Advisor).2.4.4. Principal Recipient Technical Review Team (PR-TRT)There are three PR-TRTs – one for each disease – and their role is to reportto the PR on their review and evaluation of relevant plans and reports.Membership of the PR-TRTs includes the National Programs and othermembers that have been nominated by the National Programs. On theinitiative of senior MoH management, membership of the PR-TRTs hasbeen brought in line with the existing technical working groups (Sub-TWGHs) for the three diseases.The PR-TRTs’ main tasks during program implementation are:• Review semi-annual and annual progress reports, and quarterly andannual work plans and budgets that were prepared by the PR and theSub-Recipients.• In particular, the PR-TRTs will look at any variance between plannedand actual achievements, ensure that Sub-Recipients’ activities are inPage 23

line with national policies and strategies, and coordinateimplementation by the Sub-Recipients in order to ensure coherenceand avoid overlap.Although under a different name (Technical Review Panel – TRP) and withadditional members added, the PR-TRTs also play a major role duringproposal development. After an initial screening of draft proposals, CCC-SC will instruct the TRPs to review and evaluate draft proposals.2.4.5. Sub-RecipientsThe Sub-Recipients are the actual implementers of GFATM fundedprograms. A total of 22 Sub-Recipients are involved in implementingRounds 1, 2 and 4 programs in Cambodia, and several Sub-Recipients areinvolved in two or even all three Rounds. Sub-Recipients include nationaland international NGOs, the three National Programs and Ministries.Sub-Recipients implement a program in line with intended programresults, detailed work plans, budgets, and procurement plans as includedin the Memorandum of Agreement between the Sub-Recipient and the PR.Modification of agreed activities needs to be agreed by the PR, whilebudget variations in access of 10% need to be approved by the PR.The Sub-Recipients are to report every six months and annually to the PRon financial matters as well as on progress made towards achieving agreedprogram results. In addition, Sub-Recipients need to provide a yearlyfinancial and procurement audit report.Sub-Recipients are allowed to sub-contract others to implement programactivities. However, the Sub-Recipients are fully responsible for theperformance of these Sub-Sub-Recipients.2.4.6 Local Fund Agent (LFA)The GFATM relies on the LFA to oversee, verify and report on progress inprogram implementation and makes recommendations for future funding.The role of the LFA is to provide independent and qualified advice to theGFATM at country level. GFATM has contracted KPMG to fulfil the role ofLFA in Cambodia.Before the PGA is signed, the LFA conducts a capacity assessment of thePR and reviews proposed budgets and work plans. Most relevant for thisPage 24

Program Review, the LFA is contracted to oversee program performanceand the accountable use of funds. This includes the review of the PR’speriodic reports and disbursement requests, site/field visits, and thereview of annual audit reports. In practical terms, this means that the LFAis asked to make certain recommendations, such as whether to approvedisbursement requests and how much to approve.Furthermore, the LFA makes recommendations to the GFATM in itsdecision whether to approve funding for Phase 2 of a grant. Theserecommendations are based on review of past performance and of futureplans and budgets.It should be noted here that the LFA plays an important role given the factthat GFATM funding is performance based. In order to ensure thatfunding is effectively used on programs that achieve impact, grants areinitially approved for the first two years only (Phase 1) and renewed up toanother three years based on the performance. In addition, funds aredisbursed incrementally every six months and each disbursement is basedon performance. The LFA plays an important role in verifying theperformance of GFATM funded programs.Page 25

3. Review MethodologyIn line with the Terms of Reference (Annex 1), the Program Review aims toassess the overall achievements of Round 2 and 4 (Mid-Term Review) andto identify lessons learned and make recommendations for futureimplementation.In addition, the Program Review was asked to examine the efficiency offinancial management, to assess whether GFATM Structures are fulfillingtheir roles in supporting program implementation, and to assess theadditionality of GFATM funding in Cambodia.3.1. Review ActivitiesThe Program Review took place during November and December 2006 anda detailed work plan of the Review Team’s activities can be found in Annex2.In summary, the Review Team conducted the following activities.1) Data collection through use of the following techniques/activities:• Desk review of relevant documents: Original proposal, PGA, MoAs,periodic reports (quarterly, semi-annual and annual) prepared bythe Sub-Recipients, consolidated periodic reports prepared by thePR, monitoring/field visit reports, and other relevant documents(Annex 4).• In-depth interviews with:→ Principal Recipient management, technical (finance, procurementand M&E) staff and technical assistance.→ Various Sub-Recipients: The Review Team met with nine (out of11) Round 1 Sub-Recipients.→ Representatives of GFATM structures: Selected CCC members,CCC-SC and the LFA.→ Key stakeholders in the health sector and in the NationalProgram: Senior MoH management, selected health partners,senior management of the National Program, and selectedTechnical Assistance to the National Program.→ The GFATM Fund Portfolio Manager for East Asia and the Pacific.A detailed list of people met can be found in Annex 3.• Observation and in-depth interviews during field visits:→ Three-day field visit to Kg Cham and Kratie.→ Selected project sites in Phnom Penh, such as the MDM OI/ARVclinic, SHCH OI/ARV clinic and the SHCH chronic care hospice.Page 26

2) Synthesis and analysis of information resulting in the formulation ofpreliminary findings and recommendations:→ Presentation of preliminary finding, conclusions andrecommendations to PR management and the CCC-SC3) Writing of a draft report, finalised based on feedback received from thePR.3.2. Limitations of the Program ReviewThis Program Review provides an overall assessment of the effectivenessand outcomes of Round 1 and of achievements to date for Rounds 2 and4. This assessment is based on the semi-annual and annual reportsprovided by the Sub-Recipients, consolidated reports that are prepared bythe PR, and in-depth interviews with key Sub-Recipient staff.Given the complexity of implementation of various Rounds andComponents by a relatively large number of Sub-Recipients, a detailedassessment of the effectiveness of program implementation of individualSub-Recipients was felt to be outside the scope of this Program Review.Some Sub-Recipients faced more difficulties in implementing agreedactivities than others, and in some cases this Program Review doescomment on this. By and large, however, the Review Team was not able tovisit all the different project sites and to make an objective assessment ofthe quality and relevance of activities implemented by each of the Sub-Recipients.In addition, the review of Round 4 (Report 2) is based on progress asreported in the first two semi-annual reports, which cover ten months ofimplementation (September 2005 – June 2006). Although progress madeto date may give a good indication of how quickly and efficiently thevarious Sub-Recipients have been able to establish their projects and startimplementation, it is considered too early to provide a realistic assessmentof achievements made.It should also be noted that the submission of the applications for Round4 Phase 2 funding has been postponed by three months. This will allow anassessment of the performance of the Round 4 Sub-Recipients after anadditional six months of program implementation (September 2005 –December 2006, or after 16 months of program implementation). ThisPage 27

means that, although the findings presented here may still be valid, theanalysis will need to be up-dated based more recent progress reports.Page 28

4. FindingsThe main findings of the Mid-Term Review of the three Round 2programmes and the two Round 4 programmes are discussed here,together with findings regarding the three cross-cutting issues; financialmanagement, GFATM structures and GFATM additionality.4.1. Findings – Mid-Term Program ReviewThis section describes to what extent the five on-going Round 2 and 4programs are being implemented according to plan and working towardsachieving stated outputs and objectives. The TOR includes seven specificobjectives (or review questions/issues) and each of these objectives isaddressed here.Review Objective:Assess whether program activities for Rounds 2 (3 grants) andRound 4 (2 grants) are being implemented according to the agreedplans (as specified in the PGAs and MoAs); Assess programeffectiveness in terms of working towards achieving its statedoutputs and objectives.The three grants under Round 2 started implementation on January 1 st2004 and had almost completed the first year of Phase 2 at the time of theProgram Review. The starting date (September 1 st 2005) of the two grantsunder Round 4 had been delayed with almost 9 months and at the time ofthe Program Review implementation both programs had just started theirsecond year of implementation.The semi-annual reports that cover the first six months of 2006 give themost recent account of progress made to date. It follows that progressreports for Round 2 give an account of progress made after 30 months ofimplementation, while the same reports for Round 4 cover only the first 10months of program implementation.Mid-Term Results: Round 2 - HIV/AIDS ComponentThe consolidated M&E plan that was developed by the PR includes a totalof 20 indicators (see Annex 5 for a list of indicators). Similar to Round 1,several of these indicators are lower level (output and process) indicators,which can be explained by the need of the PR and the Sub-Recipients toreport progress every three or six months.Page 29

Also similar to Round 1, several indicators lack clear definitions or appearto have been defined differently by different Sub-Recipients. This isbelieved to be a reflection of a relatively weak proposal (weaker incomparison to the proposal for the Malaria component) and of a complexdisease area with many stakeholders and lacking a clear and agreed M&Eframework.The six Sub-Recipients are reporting a total 75 pieces of data, 28 of whichare linked to the 20 indicators in the consolidated M&E plan. Theremaining data concerns indicators that are included in the M&E plans ofindividual Sub-Recipients, but it appears that the PR has limited use forthis data.Concerning programmatic results, the main finding is that activities arelargely implemented according to plan and that most of the indicatorsincluded in the consolidated M&E plan are being achieved. This is in linewith the assessment included in the grant score card, which was preparedin October 2005 and is based on observations of the LFA.Figure 4.1 shows only two indicators with considerable underachievement:• Indicator 1.9: The number of condoms sold and distributed (by RHAC)was reported to be 84% of the intended result by the end of June 2006.• Indicator 2.17: The number of self-support groups established (byRHAC) was reported to be 25% of the intended result by the end ofJune 2006. It should be noted that this is a new indicator, which wasintroduced with the start of Phase 2, and is linked to a newly startedactivity (home based care by RHAC).Figure 4.1 also shows that several indicators are over-achieved:• All indicators that reflect activity at the RHAC clinics showconsiderable over-achievement, which is believed to be a reflection ofincreased utilization of existing clinics and the increased number ofclinics (opened with support from USAID):→ Indicator 1.4: Number of clients receiving VCCT at RHAC urbanclinics and health posts - Achieved 184% of intended result.→ Indicator 1.5: Number of pregnant women who received VCCT -Achieved 154% of intended result.→ Indicator 1.8: Number of STI cases treated in RHAC clinics andhealth posts - Achieved 131% of intended result.Page 30

400%Figure 4.1: Round 2 HIV/AIDS Component – Progress to Date(Actual vs. Intended Results)300%200%100%0%1.11.21.31.41.51.61.71.81.92.102.112.122.132.142.152.162.172.183.193.20• All indicators that are linked to peer education activities implementedby RHAC:→ Indicator 1.1: Number of peer educators that received initial andrefresher training in HIV/AIDS, sexual health and inter-personalcommunication - Achieved 120% of intended results.→ Indicator 1.2: Number of people that received education onHIV/AIDS and sexual health - Achieved 168% of intended result.→ Indicator 1.8: Number of clients referred to referral hospitals,HIV/AIDS and STI services by peer educators and healthdevelopment teams - Achieved 136% of intended result.• All indicators linked to OI and ARV treatment:→ Indicator 2.11: Number of patients on ARV Therapy - Achieved141% of intended result.→ Indicator 2.13: Number of children living with HIV/AIDS receivingARV treatment – Achieved 300% of intended result.→ Indicator 2.15: Number of patients provided treatment for OIsduring the reporting period - Achieved 156% of the target for thereporting period, and has shown over-achievement since the thirdquarter of the program.• Actual results for indicator 1.7 (number of STI cases among militarymen treated for STIs) are almost four times higher than the intendedresult. As a matter of fact, the result to date is almost two times theintended result for year four (note that the M&E plan does not includea year five intended result for this indicator).• Finally, it is noted that the two indicators that are based on totalachievement for the country also show achievements that are higherthan intended results:Page 31

→ Indicator 1.6: Number of clients receiving HIV counselling andtesting - Achieved 133% of intended results.→ Indicator 2.12: Number of people living with advanced HIV/AIDSinfection receiving ARV according to national guidelines - Achieved111% of intended results.In terms of program expenditures, the Sub-Recipients had spent 47% oftheir joint budget by the end of June 2006. Figure 4.2 shows that thispercentage ranges from only 8% for CMS to 90% for SHCH. Apart fromCMS, NCHADS and FRC are the other two Sub-Recipients withconsiderable under-spending to date:• FRC spent 38% of its budget to date, and is under-spent inprocurement and payment of salaries.• NCHADS is significantly under-spent in most of the budget line-items,but with the bulk of under-expenditure consisting of delayed (not yetcommitted) procurement.Slow spending during the first six months of 2006 was caused by the twoto three months delay in signing of the Phase 2 PGA and MoAs. Thisresulted in delayed procurement for year three (the first year of Phase 2)and late disbursement of funds. It appears that some of Sub-Recipientssuch as SHCH, PSF and RHAC were able to use funds from other sources(including Round 1 funds) in order to continue implementation, whileother Sub-Recipients had no choice but to postpone planned activities.Figure 4.2: Round 2 HIV/AIDS Component – Mid-Term ActualExpenditures vs. Budget to DateUS$ Thousands4,0003,0002,0001,000-38%20%75%80% 90%8%CMS NCHADS PSF SHCH FRC RHACBudget 310,500.00 2,385,158.1 783,383.40 622,847.96 2,942,756.6 1,736,568.7Actual 24,320.00 479,630.35 626,236.87 559,349.54 1,116,959.9 1,309,260.1While developing the Phase 2 proposal, considerable savings wereanticipated by the end of Phase 1 due to delayed and slowimplementation. Most of the PR’s savings were used to fund an additionalPage 32

Phase 2 Sub-Recipient (CMS), while additional (unallocated) end of Phase1 savings were used towards funding of the Phase 2 proposal. Thisresulted in a modified budget for the total five years, which is $111,670 (or1.2%) lower than the budget included in the original proposal.Similar to what was concluded for Round 1, under-spending to date hasnot prevented the Sub-Recipients from achieving the intended results, as17 of the 20 indicators have been achieved or even over-achieved.Mid-Term Results Round 2 - Malaria ComponentThe consolidated M&E plan includes a total of 23 indicators (see Annex 5for a list of indicators). Although several of these indicators are lower level(output and process) indicators, the M&E plan also includes 10 indicatorsthat are either coverage or impact indicators. It should be noted that thesehigher level indicators require data collection through special surveys andhence, cannot be reported on a regular basis (i.e. in each semi-annualreport). These indicators are marked NA in Figure 4.5.In addition, four impact indicators are reported on an annual basis:• Proportion of severe malaria cases among the total confirmed malariacases reported in the country from the public health facilities (intendedresult by the end of 2005 :

data concerns indicators that are included in the M&E plans of individualSub-Recipients, but it appears that the PR has limited use for this data.Programmatic results show that the program is implemented according toplan and that most of the indicators have been (almost) achieved. Again,this is in line with the Grant Scorecard that was prepared in October 2005and is based on observation of the LFA.The graph (figure 4.3) shows that the most of the 13 indicators that arereported in the most recent semi-annual report were either achieved orclose to being achieved, while three indicators were clearly under-achieved(indicators 3.9, 3.10 and 4.23) and another 3 indicators were clearly overachieved(indicators 2.5, 3.12 and 4.21):• The most recent semi-annual report includes actual results for three ofthe indicators for objective one (Malaria BCC and malaria healtheducation). These indicators are reported to be on target (indicator 1.3)or slightly behind target (indicator 1.1: 92% achieved & indicator 1.2:93% achieved).200%Figure 4.3: Round 2 Malaria Component – Progress to Date(Actual vs. Intended Results)150%100%50%0%NANANANANANANANANANA1.11.21.31.42.52.62.72.83.93.103.113.123.133.143.153.163.173.184.194.204.214.224.23• For objective two (distribution of impregnated bed nets and reimpregnationof bed nets) two indicators are included in the mostrecent semi-annual report:→ Indicator 2.5: The number of impregnated bed nets procured anddistributed to the target villages. This indicator was over-achieved(126%) by the end of June 2006.Page 34

→ Indicator 2.6: The number of service providers (health staff & VHVs)trained in treatment of nets. This indicator was slightly underachieved(91%) by the end of June 2006.• Objective three: (To increase access to EDAT) includes ten indicators(3.9-3.18), but only five indicators are reported in the semi-annualreport. Two indicators show considerable under-achievement(indicators 3.9 and 3.10) while indicator 3.12 shows considerable overachievement:→ Indicator 3.9: The number of RDT used (based on 300 hyperendemicvillages). This indicator was under-achieved with 74% ofthe intended result actually achieved→ Indicator 3.10: The number of treatments used based on 300 hyperendemicvillages). This indicator was under-achieved with 79% ofthe intended result actually achieved→ Indicator 3.12: The number of Malarine sold. This indicator showsconsiderable over-achievement with 142% of the intended resultactually achieved.• Objective four (To strengthen the institutional capacity of nationalprogramme at all levels) includes five indicators (4.19- 4.23). The mostrecent semi-annual reports shows the following results for indicators4.21 – 4.23:→ Indicator 4.21: Number of supervision visits made to the provincesand peripheral facilities by CNM staff. This indicator was overachievedwith 142% of the intended result achieved.→ Indicator 4.22: Number of supervision visits made to the ODsfacilities by PHD staff. This indicator was reported to be 112% of theintended result.→ Indicator 4.23: Number of supervision visits made to the healthfacilities by OD staff. This indicator was under-achieved with 79% ofthe intended result achieved.Concerning program expenditures, it is noted that especially CNM hasbeen slow in spending its budget during the first year of the program, butmanaged to catch up by spending 86% of its Phase 1 budget. By the endof Phase 1, 85% of the available budget had been spent and GFATMallocated $268,026 in savings towards funding of the Phase 2 proposal.This resulted in a modified budget for the total five years, which is$268,026 (or 2.7%) lower than the budget included in the originalproposal.Page 35

By the end of June 2006, the Sub-Recipients spent 72% of their jointbudget to date. Figure 4.4 shows that PSI in particular was only able tospend 48% of their budget, partly because of the fact that funds obligatedfor procurement are not reported as actual expenditures.The delays in spending during the first six months of 2006 are the resultof late signing of the Phase 2 PGA and MoAs. Most of the Sub-Recipients,including CNM, were able to draw on other funds and to continue at leastsome of the planned activities and ended the most recent reporting periodwith negative cash balances.Figure 4.4: Round 2 Malaria Component – Mid-Term ActualExpenditure vs. Budget to DateUS$ Thousands4,0003,0002,0001,00087%48%100% 92%-CNM PSI PFD HUBudget 2,448,897.78 2,893,333.00 697,914.20 765,038.00Actual 2,135,858.93 1,385,179.26 699,057.86 700,514.13Possibly as a result of Sub-Recipients’ ability to use other funds andsimilar to findings for the HIV/AIDS component, the Sub-Recipientsmanaged to achieve intended results for most of the indicators.Mid-Term Results Round 2 - Tuberculosis ComponentAt present, CENAT reports against 33 indicators in its periodic reports tothe PR, and only 16 of these indicators are included in the consolidatedM&E plan (see Annex 5 for list of indicators). Similar to Round 1 and theother Round 2 components, the remaining data concerns indicators thatare included in the M&E plans of the Sub-Recipient, but it appears thatthe PR has limited use for the reported data.The changes made to the M&E plan were a considerable improvement,especially the decision to include standard DOTS indicators in additionthe mainly lower level (output and process) indicators that were alreadyincluded in the M&E plan. Given the fact that CENAT is the only Sub-Page 36

Recipient, development of the M&E plan must have been morestraightforward and hence, free of problems such as the use of differentdefinitions for similar indicators.In line with the assessment included in the score card it is concluded thatprogrammatic results are largely according to plan, and most of theindicators included in the consolidated M&E plan are either achieved orclose to being achieved.Both impact indicators (detection rate and cure rate) are reported on anannual basis. By the end of 2005 the reported detection rate was 70%(against an intended result of 70%), while the cure rate was reported to be90% (against a national target of >85%).As shown in figure 4.5, the results for the remaining 14 indicators (asreported in the most recent semi-annual report covering the periodJanuary to June 2006) are largely in line with intended results:• Objective one (to expand community DOTS from 2% to 100% by 2007)includes four indicators (1.1 – 1.4.):→ The number of community DOTS supporters trained (indicator 1.1)has been in line with the intended result throughout Phase 1 of theprogram, but implementation had fallen behind target during thefirst half of 2006.Figure 4.5: Round 2 TB Component – Progress to Date(Actual vs. Intended Results)300%250%200%150%100%50%0%1.11.21.31.42.52.63.73.84.94.104.114.125.135.14→ However, the percentage of the population covered with communityDOTS (indicator 1.2) is still on target (71% against an intendedresult of 70%). It should be noted, however, that the considerablePage 37

over-achievements reported for this indicator throughout Phase 1was largely cancelled out during the first six months of 2006.→ Indicators 1.3 and 1.4 (the number of new smear positive casesdetected and the number of new smear positive cases registeredunder DOTS) were newly introduced at the start of Phase 2 and areslightly under-achieved.• Objective two (To expand case detection activities in all HCs by 2007)includes two indicators (2.5 and 2.6):→ These indicators concern the training / retraining of TB Unit staff(indicator 2.5) and HC staff (indicator 2.6) in basic TB control andDOTS. The cumulative results reported in the most recent semiannualreport are just over the intended results, which is acontinuation of the trend seen throughout Phase 1• Objective three (To improve knowledge about TB among adults byincreasing advocacy and through IEC strategies in the community)includes two indicators (3.7 and 3.8). Figure 4.5 shows considerableover-achievement for both these indicators:→ The number of adult population who received community basedhealth education on TB and DOTS (indicator 3.7) reported to dateamounts to almost 92% of the intended result at the end of theprogram (31 December 2008).→ For the number of high school students who received basicinformation on TB and DOTS this percentage is 66%.• Objective four (To carry out program based operational research andsurveys) includes four indicators (4.9 – 4.10):→ Indicators 4.9, 4.10 and 4.11 are reported results of operationalresearch that is being conducted by an NGO in Rattanakiri. Theseindicators aims to measure the proportion of TB patients with ageneral understanding on TB and DOTS (indicator 4.9), theproportion of indigenous people with exposure to specially developedIEC materials that understand what TB is (indicator 4.10), and theproportion of government health staff with a thoroughunderstanding of TB guidelines and protocols for treatment andfollow-up (indicator 4.11). Figure 4.7 shows that intended results todate are not being achieved, which is a continuation of trends seenthroughout Phase 1.→ Indicator 4.12 (the number of studies / surveys conducted byCENAT) is on track. It should be noted that CENAT managed tocatch up during the first six months of 2006 on delayed activitiesfrom last year.Page 38

• Objective five (To improve TB awareness, case detection and treatmentfor people in under-served areas) refers to activities implemented bySCA in KG Cham and PFHAD in Kratie:→ Although the number of DOTS watchers trainer (indicator 5.13) isbehind target, the number of suspected TB cases referred (indicator5.14) was overachieved. Reported cumulative results to date (by theend of June 2006) represent 75% of the intended result by end ofprogram (31 December 2008)Concerning program expenditures it is noted that CENAT spent its budgetmore slowly than planned and as a result, it had spent 60% of itscumulative budget by the end of year one. During the final six months of2005, CENAT was able to increase its rate of spending, and by the end ofthe year they had spent 94 % of the Phase 1 budget.Figure 4.6: Round 2 TB Component – Budget to Date vs.Actual Expenditure to DateUS$ Thousands4,0003,0002,0001,00087%-CENATBudget 2,987,147Actual 2,592,048During the Phase 2 approval process, GFATM forecasted considerablesavings by the end of Phase 1, which were earmarked to contribute tofunding of the Phase 2 proposal. As it turned out, actual savings by theend of Phase 1 were much lower than expected and hence, available funds(GFATM approved incremental amount for Phase 2 and end of Phase 1savings) were not enough to cover the total requested Phase 2 budget. As aresult, the Phase 2 budget had to be reduced and the modified budget forthe total five years ended up $469,268 (or 7.1%) less than the total budgetincluded in the original proposal.The Review Team was not able to verify the reasons for the discrepancybetween estimated and actual end of Phase 1 savings. Based on review ofthe available financial reports and budget request and of the score cardPage 39

posted on the GFATM website, the most obvious explanations appears tobe inaccurate recommendations made by the LFA.The PGA for Phase 2 was signed two months after the period began andsigning of the MoA was delayed with almost three months. Delays indisbursement of funds resulted in CENAT running out of funds, which isillustrated by the fact that CENAT was only able to spend 49% of theirbudget for the first six months of 2006. As shown in figure 4.6, CENAThad spent 87 % of its cumulative budget by the end of June 2006.Similar to the HIV/AIDS and Malaria components, slow spendingthroughout Phase 1 and the present level of under-spending have notprevented the Sub-Recipients from achieving intended results for most ofthe indicators.The slow down in spending during the first six months of 2006 (87% ofbudget spent by 30 June, against 94% by the end of 2005) did have anegative impact on program results. Several indicators fell slightly behindtarget during this period and over-achievements reported by the end of2005 were largely cancelled out.Preliminary Results Round 4 - HIV/AIDS ComponentThe consolidated M&E plan includes a total of 21 indicators (see Annex 5for a list of indicators). Several of these indicators are lower level (outputand process) indicators.The start of Round 4 saw the introduction of a much improved format forthe M&E plan, which contributed to much improved M&E. However, theM&E plan still includes several indicators that lack clear definitions orappear to have been defined differently by different Sub-Recipients. This isbelieved to be a reflection of a relatively weak proposal (although muchbetter than previous HIV/AIDS proposals, but still weak in comparison tothe proposal for the Malaria component) and of a complex disease area(HIV/AIDS) with many stakeholders and lacking a clear and agreed M&Eframework.The nine Sub-Recipients are reporting a total 108 (!) pieces of data, 42 ofwhich are linked to the 21 indicators in the consolidated M&E plan. Theremaining data concerns indicators that are included in the M&E plans ofPage 40

individual Sub-Recipients, but it appears that the PR has limited use forthis data.The (preliminary) programmatic results presented in Figure 4.1 show thatafter ten months of implementation all but three indicators are beingachieved:• Indicator 1.4: Number of health staff trained on HAART adherence andin counselling and OI management (achieved 99% of intended result by30 June 2006)• Indicator 1.9: (Non Cumulative) Number of medical consultations forOIs (25% of the expected number of consultation during the first sixmonths of 2006)• Indicator 2.15: Number of OVCs receiving psycho-social support andcare (achieved only 39% of intended result by 30 June 2006).Figure 4.1: Round 4 HIV/AIDS Component – Progress to Date(Actual vs. Intended Results)500%400%300%200%100%0%1.11.21.31.41.51.61.71.81.92.102.112.122.132.142.153.163.173.183.193.203.21Figure 4.1 also shows a number of indicators that are considerably overachieved:• Indicators 1.1: Number of ODs with at least one ARV site. The actualresult to date (28 sites) is already higher than the end-of-Phase 1intended result.• Indicators 1.2: Number of ARV sites with sufficient ARV drug supplies.The actual result to date is already more than 90% of the end-of-Phase1 intended result.• Indicator 2.13: Number of PLWHA participating in support groupactivities (non-cumulative). The result achieved during the first sixmonths of this year is more than four times the expected result. CPN+recently re-programmed this indicator in line with achievements todate.Page 41

• Indicators 2.14: Number of PLWHAs receiving psycho-social care andsupport. Achievement to date amounts to 143% of the intended result.Recent reprogramming by CPN+ resulted in increased targets for thisindicator, in line with achievements to date.• Indicators 3.16 – 3.21 concern PMTCT services and are linked to theactivities of the NCMCH. It is noted that all six indicators report actualresults that are well above the intended results. Two indicators arenoted in particular:→ Indicators 3.19: Number of health care workers, counsellors, andPLWHAs trained/retrained in PMTCT (able to demonstratecompetency in their areas of delivering PMTCT services within ANCservices (achieved 145% of the intended result by 30 June 2006).→ Indicator 3.20: Number of ANC clients in target health facilities whoreceived VCCT (achieved 155% of the intended result by 30 June2006 and almost 94% of the end-of-phase 1 intended result).Concerning program expenditures, the rate of spending variesdramatically among the Sub-Recipients (see Figure 4.2). Taking intoconsideration that some of the unspent funds have been obligated in theform of procurement commitments, Sub-Recipients have spent 33% of theavailable budget by the end of June 2006 (i.e. after ten months of programimplementation). This can partly be explained by the fact that this is acomparison of a 12-month budget with expenditures made during tenmonths of implementation.Figure 4.2: Round 4 HIV/AIDS Component – Actual Expenditures andOutstanding Commitments vs. BudgetUS$ Thousands1,4001,2001,000800600400200-67%31%69%66%5%43%62%96%65%CARECPNDSFMDMNCHADSMCHNPHPSFSHCHBudgetActual Expenditures & CommitmentsPage 42

It should be noted, that the budgeted amounts shown in Figure 4.2 do notinclude procurement of ARVs and OIs. These items are centrally procuredand hence, are not reported as expenditures by the Sub-RecipientsAs a result of the slow rate of spending, Sub Recipients requested to carryforward unspent funds from the previous period to cover procurementcommitments (45%) as well as other expenditure categories (55%). Thetotal amount that is requested to be carried forward to cover nonprocurementcommitments amounts to 21% of the total budget for thenext three months. It should be noted that most Sub-Recipients fail toprovide sufficient justification regarding the amounts of un-spent funds tobe carried forward. The issue is discussed in more detail in the financialmanagement section.Preliminary Results Round 4 – Malaria ComponentThe consolidated M&E plan includes a total of 13 indicators (see Annex 5for a list of indicators). Although several of these indicators are lower level(output and process) indicators, the M&E plan also includes severalindicators that are of a higher level. Six of these indicators require datacollection through surveys and hence, cannot be reported on a regularbasis, while the M&E plans also includes two impact indicators that arereported on an annual basis:• Indicator 1.5: The proportion of severe malaria cases among the totalconfirmed malaria cases reported in the country from the public healthfacilities (Baseline: 8.9% in 2002; Intended result by end 2006: 8%).• Indicator 1.6: The case fatality rate as a percentage of confirmed malariadeaths among severe malaria cases (Baseline: 9.96% in 2003; Intendedresult by end 2006: 9.5%The four Sub-Recipients are reporting a total of 55 pieces of data, 21 ofwhich are linked to the consolidated M&E plan. The remaining dataconcerns indicators that are included in the M&E plans of individual Sub-Recipients, but it appears that the PR has limited use for this data.The programmatic results presented in Figure 4.3 show the progress madeto date (end of June 2006) in achieving objectives and results. Asmentioned, both impact indicators (1.5 and 1.6) are reported on an annualbasis, while several other indicators (2.8 – 2.13) require data collectionthrough surveys and hence, cannot be reported on a regular basis.Page 43

Therefore, the most recent semi-annual report did not include data forthese indicators, which are marked NA in figure 4.3.Figure 4.3: Round 4 Malaria Component – Progress to Date(Actual vs. Intended Results)150%100%50%0%1.11.21.31.41.51.62.72.82.92.102.112.122.13NANANANANANANANAFigure 4.3 shows that after ten months of implementation intendedresults have been achieved for one indicator (indicator 1.1), while resultsfor the remaining three (1.2 - 1.4 and 2.7) were far behind the target:• For Objective one (To increase community awareness and care takingpractices on malaria prevention and control) indicator 1.1 (Number ofVHVs/key women health educators trained in Malaria IEC) wasoverachieved with 124% of the intended result.• The three remaining indicators for objective one were under-achieved:→ Indicator 1.2: Number of people reached by Malaria educationdiscussion sessions (achieved 69% of the intended result).→ Indicator 1.3: Number of trainers trained/school teachers trained inMalaria school health education (achieved 30% of the intendedresult).→ Indicator 1.4: Number of pupils/students reached by Malaria schoolhealth education (achieved only 4% of the intended result)• The most recent semi-annual report includes information for only oneindicator under objective two (distribution of impregnated LLIMN andre-impregnation of bed nets):→ Indicator 2.7: Number of Long Lasting Insecticide Mosquito Net(LLIMN) procured. By the end of June 2006 nets had been orderedby CNM and PSI, but had not been received yet and were notavailable for distribution/sale.Page 44

Program expenditures are presented in Figure 4.4, which showsconsiderable under-spending by the Sub-Recipients, with especially CNM(7%) and PSI (12%) spending only a small part of the budgets available tothem. By the end of June 2006, only 10% of the total cumulative budgethad been spent.Similar to what was noted for the Round 4 HIV/AIDS component, some ofthe discrepancy between budget and actual expenditures may beattributed to the fact that this is a comparison of a 12-month budget withexpenditures made during ten months of implementation.Figure 4.4: Round 4 Malaria Component – ActualExpenditures vs. BudgetUS$ Thousands2,5002,0001,5001,00012%7%500-68% 59%CNM PSI PFD HUBudget 1,485,603 2,084,151 186,051 147,322Actual 177,197 138,357 126,572 86,571When taking into consideration outstanding procurement commitments(Figure 4.5), 55% of the budget was either spent or obligated by the end ofJune 2006.By the end of June 2006, the Sub-Recipients request to carry forwardunspent funds from the previous period, mostly to cover procurementcommitments (82%), but also to cover other expenses (18%). The amountsthat are requested to be carried forward to cover non-procurementcommitments are quite substantial in comparison with Sub-Recipientsbudgets for the next three months. On average the total sum requested tobe carried forward amounts to 146% of the budget for the next quarter,while this percentage varies from only 26% for HU and 32% for PFD, to ashigh as 328% for CNM. The issue of justifying amounts carried forward isdiscussed in detail in the financial management section.Page 45

Figure 4.5: Round 4 Malaria Component – Actual Expenditures& Outstanding Commitments vs. BudgetUS$ Thousands2,5002,0001,5001,000500-43%67%85% 59%CNM PSI PFD HUBudget 1,485,603 2,084,151 186,051 147,322Actual Expenditures &Commitments1,000,008 890,160 158,552 86,571Review Objective:Assess the main challenges and constraints faced by the GFATMgrants in Cambodia, and recommend specific solutions to addressthem.One of the main challenges faced by GFATM grants in Cambodia has beenthe rapid growth in number of grants, amount of funding, and number ofSub-Recipients and the challenge for the PR to manage this:• Round 2 started only four months after the start of Round 1 and addedthree grants, doubled the size of the funding portfolio, and added sevennew Sub-Recipients. This expansion took place at a time that the PRand the Sub-Recipients were still familiarising themselves with GFATMprocedures and requirement, with the additional complication thatGFATM was not always clear about its procedures and requirements.• The start of Round 4 meant two additional grants and 13 Sub-Recipients (four of which did not have any previous experience inGFATM programs), and brought the total funding portfolio to over $60million.In terms of GFATM procedures and requirements, two issues need specialmentioning:(i) GFATM funding is performance based, which means thatdisbursements are based on whether Sub-Recipients are achievingintended results and are spending available funds. The lowexpenditure rates of some Sub-Recipients can be seen an indicationof the limited understanding of the concept of performance basedfunding.Page 46

(ii)Procurement was still a major challenge during the early stages ofRound 2. The PR and most Sub-Recipients lacked experience inprocurement and were not familiar with international procurementstandards. In addition, GFATM did not always provided clearguidance, which was most pronounced in the fact that it was not ableto approve the procurement of health products until April 2004 (fourmonths after the start of Round 2).Given the fact that the implementation of Rounds 2 and 4 overlapped intime with Round 1, the various programs face similar challenges andconstraints.• Several Sub-Recipients continue to have limited capacity to comply withGFATM procedures and requirements and the frequent changes byGFATM continue to put additional burden on Sub-Recipients capacity.• As a result, the PR needs to continue its considerable inputs instrengthening the capacity of new and existing Sub-Recipients. Thisincludes up-dating of M&E, procurement and financial guidelines andthe provision of training and hands-on support to Sub-Recipients in theuse of these guidelines.• The M&E plans of the HIV/AIDS components remain an issue,especially in comparison with the Malaria components. The M&E plansstill include several low level indicators and some indicators still lackclear definitions. It is expected that M&E plans for present and futureHIV/AIDS programs will benefit from the forthcoming overall M&Eframework for HIV/AIDS and the resulting agreement on commonindicators.A specific challenge at the start of Round 2 implementation was that oneof the Sub-Recipients (PSF) needed to change its original proposal before itcould even start implementation. This was the first time reprogrammingwas required, which proved to be a major challenge in the absence of clearguidelines from GFATM. It is recognised that the PR played a crucial rolein facilitating this first ever reprogramming process.Finally, it needs to be mentioned here that delays in signing grantagreements (PGAs and MoAs) have disrupted program implementation forseveral of the Round 2 and 4 Sub-Recipients:• The two or three months delay in the signing of the PGAs and MoAs forPhase 2 of Round 2 meant that there was no disbursement of funds,which resulted in a funding gap, delayed procurement andPage 47

postponement of planned activities. Several Sub-Recipients managed tocontinue implementation by “borrowing” funds from either Round 1 orfrom their other projects. It should be noted that they took aconsiderable risk in doing so without having a legal contract thatguaranteed continued GFATM funding for Phase 2.• Round 4 was supposed to have started in January 2005, but wasdelayed until September of that year. The delayed start of bothprograms proved to be a considerable challenge for several of the Sub-Recipients:- Malaria school health activities were not ready and hence, could notstart at the beginning of the new school year.- Given the time required to procure LLIMNs, LLIMNs were notavailable for distribution at the start of the 2006 rainy season.- DSF had planned to continue Round 1 activities as part of Phase 2of Round 4. As a result of the delayed start of Round 4, DSF faced afunding gap at Round 1 end of program (August 2006).- Several Sub-Recipients in the HIV/AIDS component had planned totake over Round 2 activities as part of the final year of Round 4.Due to the delays, these Sub-Recipients now plan to cover 20months (instead of 12) of continued Round 2 activities and hence,considerable re-programming is required in order to make sure thatthere will be sufficient funds for this.Outstanding IssuesAlthough many of the constraints and challenges have been resolved,several issues remain:(i) Frequent changes by GFATM: GFATM has continued to frequentlychange its procedures and requirements, which has given Sub-Recipients only limited opportunity to familiarise themselves and toconsolidate the required knowledge and experience. Frequent staffchanges within certain Sub-Recipients has had the same effect andput additional burden on the PR’s role in capacity building.(ii) Weak Sub-Recipients: Subsequent Rounds (Rounds 4 and 5) includesome new Sub-Recipients that lack the necessary experience andcapacity, resulting in additional needs for capacity building. It shouldbe noted here that the PR has no influence on the selection of Sub-Recipients during the proposal development process.(iii) Quality of proposals: Partly as a result of guidelines provided by theGFATM, but also as the result of a better coordinated proposaldevelopment process in country, proposals for subsequent RoundsPage 48

have been of a higher standard. However, the proposals showconsiderable variation in the quality of proposed indicators. WhileMalaria proposals have been of much better quality, HIV/AIDSproposals have been much weaker in this respect. This is believed tobe caused by the fact that this disease area lacks an overall M&Eframework and is still in the process of reaching agreement oncommon indicators.Review Objective:Examine the coordinating and monitoring role of the PR; Assess itseffectiveness in managing the GFATM portfolio in the Cambodiancontext and propose any improvements as needed.The PR is the legally accountable party in Cambodia, which signs thePGAs with the GFATM and MoAs with the Sub-Recipients, and isresponsible for day-to-day program implementation. Similar to what wassaid by the majority of the Sub-Recipients and other stakeholders, theReview Team concludes that the PR has been successful in starting upand implementing the GFATM funded programs despite the challengingand complex environment.The next section of this report (section 4.2) provides a more detaileddiscussion of the effectiveness of the PR in managing the GFATM fundedprograms in Cambodia. It suffices here to give a brief summary of PR’ssuccess in performing its coordination and monitoring role:Timely submission of annual and semi-annual progress report anddisbursement requests.Timely disbursement of funds to the Sub-Recipients.The development and disbursement of comprehensive guidelines, andtraining for Sub-Recipients in the use of these guidelines.The facilitation and processing of Sub-Recipients’ requests for programmodification and budget realignment.The organization of quarterly meetings with the Sub-Recipients, whichprovide a forum for networking and sharing of experiences between theSub-Recipients.Regular monitoring visits, which often focus on the weaker Sub-Recipients and are a means to provide additional supervision andsupport.It is explained in the next section of this report why the Review Teamconcludes that (despite its successes) the PR has only partly fulfilled itsPage 49

terms of reference and should act more as the grants manager. The PRrather sees itself as the coordinator and facilitator and has not taken fullresponsibility to conduct financial and programmatic analysis and torecommend and enforce corrective actions to be taken by Sub-Recipientsin case of under/over achievements of intended results and underspendingagainst agreed budgets.Furthermore the PR’s effectiveness in managing the GFATM portfolio hasbeen constrained by the sheer size of this portfolio and the considerablework load of having to manage 8 grants (at the time of the program review)that are implemented by a large number of Sub-Recipients. Although thenumber of PR staff quadrupled since the start of Round 1, it is concludedthat the development and strengthening of the necessary systems andprocedures has not kept pace with increases in workload andresponsibilities.Review Objective:Assess the relationship among different in-country GFATMstructures (SRs-PR-CCM-LFA), and in turn, their relationship withGFATM-Geneva, and how all of those affect implementation of theGFATM grants in Cambodia.Despite regular complaints by Sub-Recipients regarding the slowness ofvarious procedures (including procurement) and delayed disbursement offunds, it is generally believed that much of this is outside the directcontrol of the PR. As a result, these common complaints do not appear tohave affected the relationship between the PR and the SRs, which isgenerally regarded as good and supportive.Contact between the PR and the CCC is usually through the CCC-SC,which meets more regular and has been delegated the authority to reviewand approve periodic progress reports and disbursement requests, andrequest for program modification and budget realignment. CCC-SCmembers themselves expressed concerns that due to time constraintstheir involvement in overseeing program implementation and insupervising the PR has been limited.The relationship between the PR and the LFA has been problematic and isdescribed as “strained” in the next section of this report. The main issuehas been around the periodic progress reports and disbursementrequests. The PR maintains that it submits these reports and requests inPage 50

time and that delays (and subsequent delays in the disbursement offunds) can be attributed to the LFA’s limited understanding of healthprograms and its demand for clarifications that don’t have sufficienttechnical basis and justification. The LFA, on the other hand, maintainsthat these clarifications are justified, because progress reports and budgetrequests submitted by the PR are often incomplete and even inaccurate.A recent intervention by the GFATM Fund-Portfolio Manager has resultedin an agreement regarding proposed remedial action (see next section).The LFA is contracted by the GFATM and has a direct relationship withthe GFATM in Geneva. However, communication with the GFATM appearsto be mostly the responsibility of LFA managers that are based outsideCambodia. As a result, the Review Team was not able to examine therelationship between the LFA and the GFATM.Of all the other in-country GFATM structures, the PR has the most directand frequent contact with the GFATM, especially with the Geneva basedFund-Portfolio Manager. The Review Team was only able to examine thisrelationship from the point of view of the PR:PR staff often complains about the GFATM’s frequent changes inprocedures and requirements and about other (often ad-hoc) tasksgiven to them to implement.PR staff is able to ask GFATM for clarifications regarding proceduresand requirement at an almost ad-hoc basis.Review Objective:Assess GFATM program’s fit into the MoH National Health SectorStrategic Plan 2003-07 and other national programs and policies.Are the GFATM grants consistent with the relevant nationalstrategic plans.Based on the stated goals and objectives of the five GFATM grantsincluded in Rounds 2 and 4, it is concluded that these are consistent withthe priorities as identified by HSP2003-07:• The Strategic Plan puts emphasis on the need to expand andstrengthen service delivery, especially for the poor.• The Strategic Plan includes a policy statement that stresses the priorityof prevention and control of communicable diseases, especiallyHIV/AIDS, Malaria and TB.Page 51

• The Strategic Plan includes a strategy to strengthen the management ofcost effective interventions to control communicable diseases (strategy#4).Furthermore, the objectives as included in the Round 2 and 4 proposalssubmitted to GFATM and in the PGAs between GFATM and the PR areconform to disease specific national policies and have been formulatedwith the aim to contribute to achievement of goals and objectives as statedin disease specific national strategies. This is a direct result of the factthat the three National Programs had a key coordination and technicalrole during proposal development, which allowed them to act asgatekeepers and to make sure that national policies and strategies areadhered to. The National Programs are playing a similar role duringprogram implementation as all requests for program modification andbudget alignment require their approval.Some of the stakeholders pointed out that the project approach of GFATMfunded programs is in conflict with Sector Wide Management (SWiM)approach advocated by the HSP2003-07 and with the possibility of thehealth sector moving towards a Sector Wide Approach (SWAp).The GFATM funding rounds are regarded by some of the health partnersas a distortion and driven by the development of ad-hoc proposals thathave limited linkage with existing Annual Operational Plans (AOPs) andThree-Year Rolling Plans for the health sector as a whole. Furthermore,the implementation of GFATM programs through the PR is regarded bysome as having encouraged fragmentation (as opposed to harmonization)in planning, budgeting, procurement, and reporting.In summary, GFATM funded programs are believed to be consistent withthe priorities and strategies of HSP2003-07, especially in terms of theirstated goals, objectives and activities. There are some concerns, however,regarding conflicting approaches with the health sector moving towardsincreased harmonization and integration as part of the present SWiM, andGFATM funded programs that have a clear project based approach.It should be noted that there are examples of countries that implementGFATM funded programs as part of a SWAp. GFATM does not requireimplementation through a project approach and leaves it to individualcountries to decide on the implementation approach to be followed.Page 52

Review Objective:Assess the degree to which the GFATM grants have impacted theprograms adversely, in duplication of systems, processes, etc.With regard to the implementation of GFATM funded programs, theNational Programs have multiple roles and responsibilities:• The National Programs coordinate the proposal development processand make sure that proposals are in line with national policies,strategies and guidelines (gatekeeper role)• The National Programs are members of the CCC• The National Programs are key members of the PR-TRT• The National Programs review and approve requests for programmodification and budget realignment of other Sub-Recipients• As Sub-Recipients, the National Programs channel funding throughPHDs, ODs and health facilities and also have sub-contracts withNGOs (in the case of CNM and NCHADS).The Guidance on Strengthening of Integration of GFATM Grants into theNational Programs (14 December 2005), developed with involvement of theCCC and approved by senior MoH management, promotes reinforcementof the National Programs’ leadership and encourages closer relationshipsbetween the respective National Programs and the PR. In particular, itrecommends a larger role of the National Programs in joint monitoring andsupervision of program activities, in order to benefit from particulartechnical skills and knowledge of the National Programs and to strengthenimplementation of GFATM funded programs. Some efforts have been madeby the PR to involve the National Programs in the regular monitoringvisits, but without much success to date.There appears to be general consensus that the National Programs havebenefited from GFATM funding, not only in terms of scaling up andexpanding the delivery of services, but also in terms of havingstrengthened the management and implementation capacity of theNational Programs.(i) GFATM funding has allowed the three National Programs to take toscale and dramatically expand the availability of and access to services.For example:• NCHADS has been able to expand the number of VCCT sites, STIclinics, and OI/ARV clinics, and to some extend this expansion hasPage 53

een faster than expected. As a result, the number of patients makinguse of and having access to these services has increased as well.• CENAT has been able to sustain and expand DOTS at Health Centrelevel and has dramatically scaled up DOTS at community level throughDOTS supervisors (throughout the country) and DOTS watchers (inselected ODs and in partnership with NGOs).• GFATM funding allowed CNM to scale-up malaria health education andthe distribution and re-impregnation of bed nets. Furthermore, it hasbeen able to establish timely diagnosis (RDT) and treatment atcommunity level in 300 highly endemic villages.In terms of capacity building, the National Programs have benefited fromthe specific training and support given by the PR as well as from theexperience of having to implement a large and externally funded project.(ii) The National Programs (and other Sub-Recipients) received formaltraining in the use of the PR guidelines and with the aim to provide thenecessary knowledge and skills to comply with GFATM financial,procurement, and M&E requirements. Although this training includesgeneral background and principles of M&E, procurement and financialmanagement, the main focus is on making sure that National Programsand other Sub-Recipients are able to provide timely and adequate reportsto the PR.(iii) In addition to formal training, the PR has provided hands-on supportwhen and where necessary and in order to make sure that NationalPrograms were going to be in compliance with GFATM requirements. Thistype of support has been most obvious in the area of procurement as thethree National Programs had only limited experience and were not familiarwith international procurement standards.(iv) The National Programs acknowledge the impact of having gonethrough the experience of implementing a large donor funded project withits very specific requirements in terms of M&E, procurement, financialmanagement and reporting. The impact of “learning by doing” togetherwith the hands-on support provided by the PR is recognised by theNational Programs as a major contribution to their management andimplementation capacity.Page 54

(v) It should also be noted that the Round 2 Malaria component includesfunding for building the institutional capacity of CNM. The Round 5 TBcomponent includes funding for similar capacity building activities forCENAT.(vi) An additional positive impact of GFATM funded programs on theNational Programs has been the building of linkages and partnershipswith other organizations. Proposal development and programimplementation are the joint effort of several government and nongovernmentorganization, with the National Programs in a keycoordination (in proposal development) and technical (review of periodicreports and requests for program modification and budget realignment)role. It is recognised by several Sub-Recipients this has resulted in amuch closer technical relationship with the National Programs.In terms of possible negative impact of GFATM funding, the NationalPrograms expressed concerns regarding the “heavy” reportingrequirements and the additional strain this puts on already scarce humanresources. This is illustrated by the fact that NCHADS has assigned six(more or less) full-time staff to the management of its three GFATM grants.Furthermore, the lack of qualified staff has forced National Programs torecruit staff from outside the NP in order to deal with the management ofGFATM grants. Given the increasing number of grants being managed bythe three National Programs, these trends are likely to continue.Although not studied in detail by the Review Team, several other possiblenegative impacts of GFATM funding on National Programs were mentionedduring interviews with key informants:• NCHADS recognises the distortions caused by the GFATM Rounds andmentioned that as a result it has not taken forward the idea of poolingfunds provided by different donors.• The timing and specific requirements of periodic reports cannot alwaysbe met by National Programs, which puts pressure on their M&Esystems and potentially jeopardises the quality of data reported to thePR.• Health partners mentioned that the bulk of GFATM funding to theNational Programs may have contributed to increased verticalisation(as opposed to integration), and reduced efficiency.Page 55

Looking at the future, it is likely that the National Programs will beincluded in an increasing number of grants and that the scope and size oftheir GFATM funded programs will increase. Furthermore, it is expectedthat GFATM requirements will continue to change and the forthcomingconsolidation of Rounds may be the next challenge in this respect. Finally,it has been recommended that the National Programs take on a largertechnical role in the implementation of GFATM funded programs,especially with regard to monitoring and supervision.It is the expectation of the Review Team that the National Programs willcontinue to require considerable capacity building in order to cope withthese increasing demands:• Training and hands-on support from the PR in order to deal with(changing) GFATM specific requirements.• Qualified technical staff and technical assistance in order to review andimprove program management and implementation.• An expanded technical role may require additional knowledge andskills. This requires training needs assessments and a training strategyon how identified needs can be met.Although the above concerns strategic decisions to be made by theNational Programs themselves, it is expected that GFATM and the PR willneed to play a considerable role in meeting future capacity building needsof the National Programs.Review Objective:Identify lessons learned and make recommendations to the PR andCCC for the next stages of the GFATM grants’ implementation.Similar to what is noted in the first report (End-of-Program Review forRound 1), it was difficult for the Review Team to identify specific lessonslearned from Rounds 2 and 4, due to the fact that Round 2 started only 4months after Round 1 and hence, has been implemented simultaneously.Both the PR and the Sub-Recipients have shown an impressive ability tolearn by doing, which is an on-going process. Unfortunately, this learningcurve has been constrained by the fact that GFATM has continued tofrequently change its procedures and reporting requirements.Nevertheless, the following lessons learned and recommendations forfuture implementation are given here:Page 56

(i) At proposal developmentThe lack of a clear link between proposal development and programimplementation was identified as one of the constraints. This resulted insome weaker Sub-Recipients (i.e. without the required management andimplementation capacity) being included in proposals, work plans thatwere either unrealistic and sometimes not very ambitious, and M&E plansthat show considerable variation in the quality of proposed indicators.The CCC is aware of these issues and has already taken measures toimprove the proposal development process. The process is now not onlybetter coordinated, but also considerable investments have been made tosupport the proposal development process in the form of adequatetechnical assistance.It is recommended here to continue to improve the proposal developmentprocess, especially with an eye on implementation. Although it isunderstood that the PR does not play a role in the proposal developmentprocess, it is believed that the advice of senior PR staff could contribute tobetter proposals. This is especially true in terms of the capacity of Sub-Recipients to be included in proposals, formats to be used to developbudgets and work plans of proposals, and the quality of the M&E plansthat are part of the proposals.(ii) More oversight by and involvement of the CCC and CCC-SC inprogram implementationCriticism on the functioning of the PR has usually come from “outside”,and mainly from the LFA. This often had a polarising effect, which waspartly caused by the fact that the LFA had its own problems andshortcomings.As the “supreme in-country authority of GFATM matters” and “the boardof directors of the PR” the CCC and CCC-SC should have been able toidentify at an early stage some of the issues that are raised in this report(section 4.2) concerning the functioning of the PR.It is recognised by CCC and CCC-SC members themselves that they haveplayed a very limited role in supervising the PR and in overseeing programimplementation. CCC and CCC-SC need to further analyse this situationin order to find realistic and workable ways to better support programimplementation by the PR.Page 57

(iii) Preparations for Phase 2The main lesson learned from Round 1 and Round 2 (the only Rounds sofar that have started Phase 2 implementation) is the importance of anaccurate and realistic forecasting of expected savings at the end of Phase1. When expected savings are known at the time the proposal for Phase 2is being developed, they can be included in work plans and budgets forPhase 2 (rather than being lost)The main obstacles standing in the way of forecasting expected end ofPhase 1 savings is the limited programmatic and financial analysis by theSub-Recipients as well as by the PR. With such an analysis in place at anystage of program implementation, it would not be very difficult to forecastexpected Phase 1 saving at the time of Phase 2 proposal development.(iv) PR to assume the role of grants managerLinked to the previous issue of Phase 2 proposal development andexplained in much more detail in section 4.2 of this report, the ReviewTeam is of the opinion that the PR has not taken the responsibility toconduct regular and systematic programmatic and financial analysis ofon-going grants.It is concluded that the PR sees itself as the coordinator and thefacilitator, and fails to recommend and enforce corrective actions in caseof under/over achievement of intended results and under-spendingagainst agreed budgets. The PR has only partly fulfilled its terms ofreference and is recommended to assume the role of the grants manager.As mentioned, the performance of the PR is one of the main issuesdiscussed in section 4.2 of this report.4.2. Findings - GFATM StructuresAs discussed in section 2.3., there are several structures (entities) involvedin the implementation of GFATM funded programs in Cambodia. Severalof these structures have been established for a purpose solely linked tothe implementation of GFATM funded programs and hence, do notperform other (additional) roles and responsibilities (e.g. CCC, CCC-SC).Other structures are already existing organizations (Sub-Recipients andthe National Programs) or were merged with existing structures at a laterdate (the PR-TRTs and the sub-TWGHs for the three diseases).Page 58

The PR is a special case as it concerns a newly established unit within theMoH Department of Communicable Disease Control (CDC). The LFA inCambodia is a company (KPMG) that was contracted by the GFATM tofulfil its specific role and functions.In line with the TOR, the following Review Objectives are discussed here:• To what extent are existing GFATM structures fulfilling theirexisting Terms of Reference while supporting programimplementation, especially the PR, CCC-SC and the LFA.• The role of the PR in M&E, procurement and financialmanagement, especially its future capacity in dealing with anincreasing number of grants in an environment that is changingand becoming more complex.The TOR also instructs the Review Team to provide recommendations onhow to strengthen the main functions (i.e. M&E, procurement and financialmanagement) of the PR. These recommendations are included in section 6of this report.4.2.1. CCC, CCC-SC and PR-TRTThe Review Team met with several members of these three GFATMstructures and was able to participate in a CCC-SC monthly meeting(November 2006).CCC and the CCC-SC have clearly defined roles and responsibilities withregard to proposal development and it is clear that most members spendconsiderable time coordinating and facilitating this process every timeGFATM calls for proposals.It was noted by both CCC and CCC-SC members that roles andresponsibilities in overseeing program implementation are not as clear. Aparticular problem in this respect appears to be the lack of a cleardefinition of the CCC-SC’s “limited decision-making power”.In particular, CCC members expressed a number of concerns:• Not clear about the level of authority of the CCC• Limited involvement in supervision of the PR• Reactive (responding to specific requests) and limited progress indeveloping a vision and corresponding strategies for futuremanagement of GFATM grants in Cambodia.Page 59

Apart from its authority to approve requests for program modification andbudget realignment, CCC-SC members are not clear about the level ofauthority that has been delegated to it by the CCC. Related to this, severalmembers mentioned that they are not clear about the relationshipbetween the CCC and the CCC-SC. According to CCC and CCC-SCmembers, these issues have been discussed and several recommendationshave been made, most of which have not been followed up and actedupon.The Review Team observed some additional challenges and constraintsregarding the functioning of the CCC and the CCC-SC:• The membership of both the CCC and the CCC-SC representsconsiderable dependency on expatriate staff of various internationalorganizations. As a result there is regular turn-over of membership,which effects the institutional memory and hence, the effectiveness ofboth the CCC and the CCC-SC• All members are volunteers with full-time jobs in government and nongovernment,national and international organizations. As a result, mostmembers are constrained by the fact that they have limited timeavailable for additional tasks related to their membership of CCCand/or CCC-SC.• Both the CCC and the CCC-SC represent a wealth of technicalknowledge and expertise, while fewer members have relevantprogrammatic and financial management experience.• Finally, there is a concern that several CCC and CCC-SC members arealso working for a Sub-Recipient (or National Program) and that thismay represent a potential conflict of interest. Members are aware ofthis, but regard these dual roles as unavoidable and are of the opinionthat conflicts of interest can be avoided by putting in place theappropriate mitigation mechanisms (i.e. clear procedures). A policy onconflict of interest has been developed by the CCC and approved by theGFATM.Several of the issues and constraints raised here are not new to the CCCmembers. For example, the CCC has already decided to recruit a full-timecoordinator with the aim to get the appropriate support necessary toresolve identified issues. Furthermore, selected CCC-SC members nowparticipate in PR-TRT meetings in order to speed up the review of periodicreports and disbursement requests.Page 60

The role of the PR-TRT appears to be clear to all and is limited to assistingthe PR in the technical review of two specific documents:• The periodic progress reports (semi-annual and annual) anddisbursement requests• Annual work plans and budgets prepared by the PR and the Sub-Recipients.The main constraint regarding the PR-TRT, as perceived by its membersas well as by the PR, is the limited time available for the review of semiannualreports and disbursement requests. As mentioned, the PR has tosubmit a consolidated semi-annual report and disbursement requestwithin 45 days after the end of the reporting period, including a 15-dayperiod for the Sub-Recipients to compile and submit their reports to thePR. This leaves little time for PR-TRT members to review these reports andto provide timely feed-back to the PR.In addition, the PR-TRT appears to focus its analysis on planned andactual achievements as reported in the semi-annual reports, not takinginto consideration an analysis of actual expenditure against approvedbudgets. Apart from the fact that the PR-TRT is not instructed to makethis analysis, its membership also appears to lack the necessary financialand programmatic experience.4.2.2. Local Fund Agent (LFA)KPMG has been contracted by the GFATM as the LFA in Cambodia and itsrole is summarised as to oversee and report on progress in programimplementation and to make recommendations for future funding toGFATM.The PR and many of the Sub-Recipients are critical of the LFA, especiallywith regard to its role in reviewing the semi-annual progress reports anddisbursement requests. Most of the criticism appears to focus on the factthat KPMG staff involved in reviewing the consolidated semi-annualreports submitted by the PR are junior staff, without sufficient experiencein health projects (mainly a financial background), and with frequent staffturnovers prohibiting a learning process (building institutional memory).This is believed to have resulted in the LFA frequently asking for furtherclarifications, without sufficient technical basis and justification for suchrequests, and the same questions being asked again by the LFA duringsubsequent reporting rounds. Ultimately, this has resulted in delayedPage 61

decisions by the GFATM regarding disbursement request and hence,delays in the disbursement of funds by the GFATM to the PR.The Review Team feels that although most of this criticism may have beenjustified in the past, the LFA has made progress in addressing identifiedshortcomings. This is most evident from KPMG’s recent recruitment of amedical doctor with experience in national programs as well as in themanagement of GFATM funded programs.During the two most recent rounds of reporting (semi-annual reports thatwere due by the middle of February 2006 and the middle of August 2006)the LFA’s requests for clarification have been more substantial withevidence of a detailed analysis of programmatic progress made incombination with an analysis of program expenditures against budget.Especially during the most recent reporting round this resulted inconsiderable delays and disbursements being received by the Sub-Recipient in late November (almost two months later than expected).At present the relationship between the LFA and the PR is strained withthe PR holding the LFA responsible for delays in reporting and in thedisbursement of funds, while the LFA maintains that the reportssubmitted by the PR are often incomplete. Intervention by the GFATM hasresulted in the following proposed actions:• The proposal to have joint meetings between LFA, PR and Sub-Recipients soon after the PR has submitted its consolidated report tothe LFA and with the aim to clarify outstanding issues as soon aspossible. These meetings are planned to take place for the first timeduring the next round of reporting (January/February 2007).• The proposal that the LFA drafts a protocol that clearly outlines theanalysis it performs and the information it requires. A draft protocolwas presented by the LFA in December 2006 and is expected to befinalised before the next progress reports and disbursement requestsare due.• GFATM informally established a deadline of 15 days for the LFA, bywhich it needs to have finalised its verification of the progress reportsand disbursement requests and needs to submit its findings andrecommendations to GFATM.Page 62

It should be noted, that both the CCC and the CCC-SC appear to haveplayed a very limited role in finding solutions for the strained relationshipbetween the PR and the LFA.The expectation is that the LFA will soon take up an additional role inverification of data that is being reported by the Sub-Recipients and thePR. This will further expand the role and perceived invasiveness of the LFAand may further strain its relationship with the PR and possibly also withthe Sub-Recipients. It is hoped that the LFA will recruit additional andqualified staff before embarking on verification of data through field visitsin order to avoid unnecessary confusion.4.2.3. The Principal Recipient (PR)In summary, the PR is the legally accountable party in Cambodia (signsthe PGA with the GFATM), acts on behalf and under general guidance ofthe CCC, and is responsible on behalf of the MoH for day to dayoperations.As mentioned in section 2.1., the PR was established four years ago andcounted six full-time staff (the manager and five professional staff) withoverall responsibility for one grant with a total value of $11.2 million.Graph 4.3 shows that by the end of 2006, the number of professional staffhas almost quadrupled, while the number of grants has increased to sixwith a total approved value of $66 million. The graph illustrates clearlythat the workload of the PR has increased dramatically and that therecent recruitment of staff was well overdue and necessary.Figure 4.3: Increase in Number of Grants and Value (in millions),Compared with the Number of PR Staff2570# staff/grants2015105605040302010$ in MillionsStaffGrantsValue02003 2004 2005 20060Page 63

It is widely recognised by the Sub-Recipients and other in-country GFATMstructures that the PR has been very successful in starting up andmanaging program implementation in a very challenging and complexenvironment:• GFATM was new with several procedures and requirements beingunclear and/or loosely defined.• GFATM requirements (in reporting, etc.) have changed continuouslyand have become more demanding over time.• The increasing number of grants (see figure 4.3), which meant morefunding, more Sub-Recipients, more responsibility and workload interms of reporting, capacity building, monitoring, procurement, etc.• This environment is mostly outside the control of the PR asrequirements are imposed by GFATM and because the PR is notinvolved in proposal development and the selection of Sub-Recipients.• Multiple relationships between PR and other in-country GFATMstructures (CCC, CCC-SC, PR-TRTs), each with their specific roles andresponsibilities in assisting, overseeing and providing guidance to thePR.This success is also recognised by the GFATM, which often refers to thePR in Cambodia as a model for successful implementation of GFATMfunded programs.In particular, it is being recognised that the PR has been successful infulfilling most of its tasks:(i) Semi-annual and annual reporting and semi-annual disbursementrequests have been compiled and submitted in line with agreedtimeframes, i.e. within 45 days after the end of the reporting period. Thishas not been an easy task given the time constraints as a result offrequent late reporting by a few Sub-Recipients and their frequent needsfor revision and re-submission of reports. In addition, the PR needs toleave sufficient time for the PR-TRT and the CCC-SC to review thesereports.(ii) As far as within its control, the PR has disbursed funds to the Sub-Recipients in a timely manner. The frequent delays in disbursement werethe result of late disbursement of funds by GFATM to the PR. On severaloccasions when Sub-Recipients were running out of funds to supportPage 64

program implementation, the PR has facilitated the application process foremergency disbursements by the GFATM.(iii) The PR has developed and revised comprehensive and appropriateM&E, procurement and financial guidelines, disseminated theseguidelines to the Sub-Recipients, and provided timely and adequatetraining for Sub-Recipients in the use of these guidelines. As a result, thePR has strengthened Sub-Recipients’ capacity to comply with GFATMprocedures and requirements.(iv) The PR’s role in strengthening the procurement capacity of Sub-Recipients and of the National Programs deserves special mentioning.Formal training as well as more informal (hands-on and on-the-job)support provided by the PR has strengthened the procurement capacity ofSub-Recipients and of the National Programs, which are now more able tocomply with international procurement standards. In addition, centralizedprocurement of OIs and ARVs has resulted in considerable savings.(v) More general, the PR facilitated the participation of weaker nationalNGOs, beneficiary groups and government agencies by way of itswillingness to take on responsibility for procurement and financialmanagement. In this way, the PR ensured their compliance with GFATMrequirements and procedures.(vi) The PR facilitates and processes requests from Sub-Recipients andNational Programs for program modification and budget realignment (to beapproved by the National Programs and the CCC-SC).(vii) The quarterly meetings organised by the PR are much appreciated bythe Sub-Recipients as a forum for sharing experiences and for buildinglinks and relationships between the various Sub-Recipients included in aspecific grant.(viii) Finally, regular monitoring visits by the PR often focus on the weakerSub-Recipients and hence, are a means to provide additional supervisionand support. Furthermore, the monitoring visits are considered importantbecause they provide an opportunity for PR staff to familiarise themselveswith the program activities and approaches implemented by the Sub-Recipients.Page 65

More recently, there have been concerns regarding the quality of the lastbatch of semi-annual progress reports and disbursement requestssubmitted by the PR. Reports are believed to be incomplete and incorrectat times, reflect the lack of a systematic financial and programmaticanalyses and show limited adherence to principles of performance basedfunding. These concerns were raised not only by the LFA, but are sharedby GFATM, several key members of CCC and CCC-SC as well as by someof the Sub-Recipients. The Review Team had access to all consolidatedprogress reports that have been submitted by the PR and a thoroughreview of these report confirmed the concerns raised by others.Furthermore the PR has been relatively slow to respond to the moresubstantial analysis of these reports by the LFA and the resultingincreased demand for clarification. As mentioned, this has delayed theLFA’s submission of its recommendations to the GFATM and has delayedthe disbursements of funds.These recent issues have resulted in a growing concern that the PR isbecoming too stretched and that current capacity is not sufficient tosustain continued increases in the number of grants, amount of fundingand number of Sub-Recipients. The recent recruitment of severaladditional staff will provide some relief, but at the same time it is believedthat present capacity requires further strengthening and standardizationof the PR’s systems and procedures to meet the growing work load.It needs to be said that the PR’s procurement unit appears to have beenmore successful in keeping up with growing demands, and more specificconcerns are raised here especially with regard to M&E and financialmanagement:(i) For obvious reasons the focus has been on meeting reporting deadlinesand on responding to frequent ad-hoc requests from GFATM. There hasbeen limited focus on a programmatic and financial analysis of theprograms as part of forward planning and in support of overall grantsmanagement by the PR.(ii) This raises questions regarding who should identify and act onunder/over achievement and under/over-spending by Sub-Recipients,and who should identify the need for program modification and budgetrealignment. From discussions with the PR, it is clear that the PR regardsPage 66

this as the responsibility of the Sub-Recipients and sees its own rolemostly as a coordinator and a facilitator. In other words, the PR does notsee itself as having been given the authority of a grants manager.(iii) Reports that are presently prepared and submitted by the Sub-Recipients in the GFATM format do not provide the PR with all theinformation that is necessary in support of detailed analysis and forwardplanning. While Sub-Recipients provide detailed information on actualexpenditures (information that is hardly used by the PR) and reportprogress made in achieving a relatively large number of indicators, themain shortcoming is in the fact that Sub-Recipients have not been askedto report against the approved work plans.The combined analysis of these three set of information (actualexpenditures against budget, actual activities against approved workplans and actual achievements against intended results) would give thePR detailed insight in progress made in program implementation andfacilitate a level of forward planning that is not possible at the moment.Furthermore, reporting activities against agreed work plans would alsohelp to justify the carrying forward of unspent funds, as it would clearlyindicate which activities were delayed and are planned to be implementedduring the next reporting period.From discussions with PR staff, it is clear that the potential of and needfor a comprehensive analysis is realised. However, in the absence of clearguidance from GFATM and given the resistance from the Sub-Recipientsagainst a PR that is becoming more invasive, the PR feels that thesemeasures are too sensitive and that it has not been given the requiredmandate.(iv) Sub-Recipients report against a large number of indicators, which aremostly output and process indicators, and only a small number of theseindicators are linked to the overall (consolidated) M&E plan for the grantas a whole. For a number of reasons, it is felt that this does not representa strong overall M&E framework for the individual grants:• There is little proof that these additional indicators (i.e. output andprocess indicators that are not included in the overall M&E plan)reported by the Sub-Recipients are actually being used.Page 67

• Several indicators appear to lack clear definitions and what appear tobe similar indicators have been formulated differently by different Sub-Recipients.• As a result, was not always obvious for the Review Team how indicatorsreported by the Sub-Recipients are linked to the indicators included inthe PR’s consolidated M&E Plan.It should be noted that the quality of the M&E plans and of the indicatorshas improved over time, but also that M&E plans for the two Malariagrants appear to be much stronger than for the HIV/AIDS grants:• This is believed to be a reflection of the quality of the underlyingproposals, which has improved over time.• The quality of Malaria proposals is believed to be a reflection of a morecomprehensive and better coordinated proposal development process.• M&E plans for the HIV/AIDS programs are believed the be moreproblematic as a result of the complexity of this disease area, the largernumber of Sub-Recipients involved and the fact that the sub-sector isstill in the process of developing an overall HIV/AIDS M&E framework..At the same time, however, the Review Team feels that possibly morecould have been done at the time of negotiating the PGA and MoAs interms of clarification of indicator definitions and in streamlining andrestructuring the large numbers of indicators used by the various Sub-Recipients. At the start of Round 1 this was not done, largely due to thefact that GFATM funding was new and everybody was learning their newroles and responsibilities. However, 2 years on (i.e. at the beginning ofRound 1 Phase 2) most improvements can be attributed to the changedGFATM M&E plan formats and it is felt that more could have been done toimprove M&E plans.It is recognised by the Review Team, however, that M&E plans need to beapproved by other in-country GFATM structures such as the PR-TRT andthe CCC-SC as well as by the GFATM. Furthermore, any changes toalready approved M&E plans need to go through a long approval process.Given the PR’s already heavy work load, it does not come as a surprise theapproval process has discouraged the PR to propose significant changes toexisting M&E plans.(v) Another concern raised here is regarding coordination between thethree technical units (finance, M&e and procurement) in the PR. InitiallyPage 68

there was limited need for this as there was a limited number of staff, whowere dealing with only 1 program (Round 1). However, with the steepincrease in the number of programs managed by the PR as well as in thenumber of PR staff, there is clearly a need for more formal coordinationbetween the units.The recent appointment of chiefs for each of the units in the PR and of anassistant manager provides an opportunity to enforce better coordinationbetween the units.(vi) Finally, it needs to be noted here that some of stakeholdersinterviewed by the Review Team expressed concerns regarding thesustainability of the PR. Although part of the MoH, the PR was establishedas a new and separate unit with the sole purpose to manage GFATMfunding. Furthermore, due to lack of qualified staff several of the new staffhave been seconded from other MoH departments or have been recruitedfrom outside the government sector (non-government staff). This raisesquestion regarding the PR’s contribution to strengthening institutionalcapacity of the MoH and what will be left of the PR’s current capacitywhen GFATM funding would come to an end.The PR and the MoH take a more practical view on this issue and statethat the current approach was necessary in order to get the work done inan environment characterised by a lack of qualified and experienced staff.This view is supported by the success of the PR in implementing currentGFATM funded programs.4.3. Findings - Financial ManagementThe program review examined the areas of budgeting, budget realignment,compliance, reporting, disbursement requests, disbursement of funds,procurement, and risk management in order to examine the efficiency ofthe management of GFATM funds and assess the capacity of relevantentities to meet GFATM requirements with a focus on the future.Review Objective:Examine the efficiency of the management of GFATM funds inCambodia by the relevant entities (SRs and the PR) and assess howwell they can currently meet GFATM requirements, with a particularfocus on the future (of potential additional funding Rounds)Page 69

BudgetingThe quality of the proposals submitted by Cambodia has improvedthrough time and along with the quality of the proposals. However, somedetail is lost in the budgeting process, when individual Sub-Recipientproposals are combined into the Country Coordinated Proposal. Thiscomplicated the negotiation of the PGA and the MoAs after the grant hasbeen approved and when Sub-Recipients’ budgets need to reconstructed.It is recommended to carefully document how the consolidated budget wasdeveloped in the form of detailed budget notes. This could be achieved byinstructing the consultant hired by the CCC to facilitate proposaldevelopment or through increased involvement of the PR at the proposaldevelopment stage.Budget Re-AlignmentThe budget re-alignment process has been successful. Sub-Recipients aregiven the opportunity to realign their respective budgets once a year. Sub-Recipients also realign their budgets during the Phase Two proposalprocess. Key to successful budget realignment is the careful monitoring ofbudgets verses actual expenditures (BVA) variance and the ability toaccurately forecast the expected amounts of unspent funds to berealigned.Some challenges remain concerning budget realignment. Although budgetrevisions have been approved following the appropriate process (involvingthe National Programs and the CCC-SC), on occasion the LFA has notbeen aware of budget realignments approved by the PR and the CCC-SC.This has caused confusion and hence, has delayed in the LFA reviewprocess.The PR is not clear whether or not it has the authority to propose thetransfer of budget between Sub-Recipients within one grant. Budgetrealignments within a grant and between Sub-Recipients are notconsidered and could only happen when initiated by the Sub-Recipientsthemselves.ComplianceFinancial and procurement reporting procedures are adequately explainedby the PR to Sub-Recipients in the PR’s guidelines. The PR is doing a goodjob in disseminating these guidelines and ensuring that Sub-Recipientsand National Programs are aware of reporting requirements andPage 70

esponsibilities. GF has frequently changed reporting and otherrequirements since the start of Round 1. The PR and most of the Sub-Recipients have been able to adapt to these changes. When changesoccurred the PR has been quick to up-date guidelines, to disseminaterevised guidelines and to train Sub-Recipients in the use of revisedguidelines. It is expected that this will continue to be an important part ofthe PR’s work in the near future.The Global Fund initially intended for each country to rely on existingstructures (including financial and procurement systems) to ensure grantscompliance. However, GFATM has steadily increased its requirements andhas become more demanding and more prescriptive. GFATM enforcescompliance to its increasing requirements through the LFA.Capacity AssessmentThe PR assesses the financial and procurement capacity of Sub-Recipientsat the start of the program and before releasing funds. Initial concerns areaddressed through capacity building activities by the PR itself andthrough outsourcing. Capacity is also observed and strengthened on aroutine basis as part of the regular field (monitoring) visits.The main distinction among Sub-Recipients was the determination to givea working advance to those institutions more familiar with that fundingmechanism and who lacked capacity to manage large amounts of funding.In Round 4 this includes NCMCH, and the PR’s finance team spends a fairamount of time accounting for the cash advances given to these Sub-Recipients.ReportingReports from the PR are submitted on time, while Sub-Recipients arereporting in a timely manner, but with some exceptions.In general, the PR, Sub-Recipients and National Programs are spendingfunds according to plan. Several Sub-Recipients have experiencedepisodes of under-spending, while no proof was found of overspending ofbudgets. Given the absence of activity reports, is it difficult to assess howexpenditures support program activities, while the link betweenexpenditures and performance indicators is more indirect and hence, lessuseful.Page 71

The PR and the Sub-Recipients are able to track and report on variousrounds separately, and Sub-Recipients are able to segregate funds fromGFATM and other donors through their existing accounting systems,which allow them to avoid duplication.Annual audits are conducted by Sub-Recipients with the aim to judgewhether their financial statements are free from material miss-statement.This should allow the detection of any material duplication. Annual Auditsshould also evaluate compliance with GFATM requirements and PRFinancial guidelines. The suggestion to have the PR pool procurement ofaudit services for all Sub-Recipients has three advantages. Pooling willyield a better price, will eliminate the current compliance issue wheresome SRs are very late submitting the audit reports, and ensure that thePR is aware of any internal control issues raised in any accompanyingmanagement letter.The main concerns regarding financial reporting are errors made whilecompleting the forms and the reporting format does not require enoughinformation. In particular, several Sub-Recipients fail to provide adequateexplanation for variances between the budget and actual expenditures forthe period. Reports do not explain why amounts are not spent, becauseactivities are a) delayed, b) changed, c) implemented but not paid for, or d)implement and paid for with other funds (due to late or insufficientdisbursement of GFATM funds). They do not explain sufficiently howactivities carried forward will be conducted in addition to already plannedactivities. The LFA has raised these issues with the PR. The PR discussesthese issues with the Sub-Recipient. However some errors remain in theSR financial reports the PR forwards to the LFA.Furthermore, it is felt that the PR’s approach of reviewing and discussingprogram expenditures of Sub-Recipients does not always lead to correctiveaction when there is significant variance; the burden rests mainly with theSRs to take action. The PR is not required to report budgeted verses actualexpenditures to GFATM and hence, the PR limits its role to preparation ofthe consolidated financial report and disbursement request, withoutsufficient comprehensive analysis of the detailed financial reports providedby the Sub-Recipients. The timeframe for reporting this analysis iscurrently the same as the timeframe for the disbursement request.Page 72

Disbursement RequestsThere are similar concerns regarding the disbursement request, which aresubmitted to the GFATM through the LFA along with the semi-annualreports. Based on the reporting format, the amounts requested for eachSub-Recipient are not listed separately in the disbursement request. Inorder to validate the requested disbursement one must refer to a separatespreadsheet prepared by the PR that collates the information provided bythe Sub-Recipients information.Financial Guidelines state that Sub-Recipients should only bring forwardamounts from previous periods that are legally committed or firmlyplanned. In practice, it appears that many Sub-Recipients simply copyand paste the amounts in the column “funds remaining from currentperiod” to the column “unspent funds to be spent in the next quarter”. ThePR does not correct this practice because SRs believe they can use allthese funds in the next period. The PR does not change these amounts inthe SR report, even if there is a question of whether or not the funds canbe spent in the next period. The LFA has recently asked for additionaldocuments that have not been routinely given by Sub-recipients, such asbank statements, budget modifications, and contracts for committedamounts that are not part of the GFATM requirements. It is not clear tothe review team why explanations of variances and amounts carried to thenext period were not required from the beginning of the grant.Furthermore, the disbursement request prepared by the PR often showsthe same amounts for both the forecasted cash expenditures in theoriginal budget and the forecast for the next two quarters. These numbersshould not be the same if unspent funds from the previous period arecarried over to the next period.Another concern is that the PR is not clearly informed by the GFATM howthe actual amount of the approved disbursement is calculated. Thismakes it very difficult for the PR to calculate disbursements to be made tothe various Sub-Recipients in case GFATM approved a lower amount thanrequested by the PR.Other Reporting IssuesSeveral other reporting issues are raised here.• Although separate bank accounts are required, neither the GFATM northe PR appears to require any bank reconciliation reports of Sub-Page 73

Recipients. The LFA requests this information, but it should be part ofthe reporting format.• Audit reports are reviewed and findings recorded in an audit log toensure compliance. The PR and Sub-recipients discuss what progresshas been made in resolving outstanding issues raised in the PR or SRaudit reports. However, this information is not captured in thereporting format.• Budget reprogramming is discussed in the “Implications for futureprogram design” section of the annual narrative report but noinformation on actual budget modifications is given in the reportingformat.• Confusion remains on who should report expenditures for the ARV andOI drugs procured by the PR but included in Sub-Recipients’ budgets.This issue has been discussed and it has been reported to the ReviewTeam that ARV and OI drugs are budgeted on the SR report butexpenses are recorded on the PR report.Disbursement of FundsDisbursement of funds from the PR to Sub-Recipients and the NationalPrograms has been timely once funds were received from GFATM.However, disbursements have been delayed frequently, resulting in Sub-Recipients running out of funds and hence, seriously disrupting programimplementation.It needs to be noted that several Sub-Recipients have been able to preventserious disruption and continued implementation by using (borrowing)other funds, either their own or from other donor funded projects. Thishas allowed Sub-Recipients to stay on track despite the frequent delays indisbursements of GFATM funds. There are no clear guidelines on how toaccount for expenditures that are made with other funds while awaitingdisbursement of GFATM funds. Some Sub-Recipients book theseexpenditures and hence, report negative cash balances, while othersrequest to carry forward the balance unspent from the last reportingperiod in order to get reimbursed for expenditures made using othersources of funds.The process of cash advances and reimbursements to PHDs and OD variesamong National Programs. CNM transfers money into provincial bankaccounts to be used for the implementation of provincial level activitiesthat have been agreed as part of the PHD AOP. CENAT on the other hand,Page 74

provides small amounts of money to PHDs on the basis of individualactivities. Other expenditures in support of HC DOTS are paid directly byCENAT staff during the quarterly OD level meetings.ProcurementThe PR procurement team developed and regularly updated ProcurementGuidelines that outline rules and regulations and help to ensurecompliance with the Global Fund requirements. The PR must submitprocurement plans once a proposal is approved. These have been reviewedby the LFA and approved the GFATM. There have been few significantissues between the PR and the LFA concerning procurement.Procurement has been an issue for most Sub-Recipients as they struggledto familiarize themselves with the GFATM procedures. Most Sub-Recipients feel that the PR has done a good job in strengthening theirprocurement capacity. Several Sub-Recipients and in particular theNational Programs mentioned having to comply with internationalprocurement standards and the hands-on support they received from thePR has improved their procurement systems. The learning process delayedinitial procurement efforts, but Sub-Recipients now better understand theprocedures are more able to comply.Some Sub-Recipients report that they find it difficult to plan theirprocurement needs far in advance due to the changing environment. Longlead time reduces the ability to respond quickly to environmental changes.It was also raised that procurement far in advance is risky because ofpossible changes in treatment protocols, especially in HIV/AIDs, leavingthem with a surplus of un-useable drugs. Timely procurement requiresgood forward planning. While planning in a changing environment issometimes difficult, it is also a process not given enough attention bysome implementers.Centralized procurement of OIs by the PR began in June 2005 adding tothe already existing centralized procurement of ARVs. While centralizedprocurement has resulted in considerable savings, efforts to move towardsmore centralized procurement may be a cause of concern for some Sub-Recipients as it reduces their flexibility. Sub-Recipients with experience ininternational procurement of drugs mentioned that they would not be ableto do procurement any faster/better themselves than the PR.Page 75

The PR faces constraints in procurement, in particular in finding suppliersto respond to relatively small bids. The PR invites SR’s to join bidevaluation committees for reasons of transparency, but ensuring SRattendance is a challenge, as are repeated requests from a few SubRecipients to amend their earlier procurement requests.Procurement related expenses are reported as delayed because they arebudgeted at the beginning of the grant, but recorded only when invoicesare paid.The PR procures goods and services for some Sub-Recipients that requesttheir help, which drains PR staff time. However, this assistance helpsensure representation of local organizations that may have stronger grassrootsimplementation than administrative skills. All need to balance thecost of providing capacity building and supplementary services with thebenefit of including a wide range of partners, including affectedcommunities.Risk ManagementVarious risk management issues have been addressed by the PR,including insurance coverage, off site storage of data, secure physicalassess to computers through password protection, and compliance withrelevant tax issues. These concerns have also been passed on anddiscussed with Sub-Recipients and the National Programs.4.4. Findings - GFATM AdditionalityGFATM only finances programs when it is assured that its assistance doesnot replace or reduce other sources of funding. Furthermore, GFATMseeks to complement the finances of other donors and to use its owngrants to catalyze additional investments by donors and by recipientsthemselves 8 .These two funding principles are usually referred to as additionality andtranslate in practical terms into GFATM’s aim to avoid overlap withexisting donor funding and to provide the resources that will help to scaleupexisting programs, to expand proven interventions, and to initiate newprograms where none existed due to a shortage of funds.8 GFATM WebsitePage 76

The TOR of the program review includes two Review Objectives, which arediscussed below. In addition, the Review Team was asked to proposeeffective ways to capture additionality, which is addressed in section 6 ofthis report.Review Objective:Assess whether GFATM funds in Cambodia are efficiently utilized inaddition to other existing donor funding sources and appropriatelyprogrammed to fill existing funding gaps.There is little evidence that Sub-Recipients regard GFATM as “just anotherdonor.” Most Sub-Recipients were already working in HIV/AIDS orproviding certain HIV/AIDS services. In addition, some Sub-Recipientsused GFATM funding to address identified health needs in facilities orgeographical areas they were already supporting.A few examples of additionality at Sub-Recipient level:• The Sihanouk Hospital Centre of Hope use GFATM funding to providecare and treatment to the growing number of HIV/AIDS patients usingthe services of the hospital.• KHANA was already implementing home based care services withUSAID funding. GFATM funding has allowed KHANA to support anincreased number of home based care teams and hence, support largernumbers of PLWHA and OVCs.• Health Unlimited (HU) and Partners for Development (PFD) have a longhistory of working in provinces where Malaria is a main health problem(endemic areas) and use GFATM funding to take to scale malariacontrol efforts in these provinces.A good example of additionality at work is provided by the fact that severalSub-Recipients have been able to continue implementation of projectactivities despite frequently delayed disbursement of GFATM funds byusing (borrowing) either their own funds or funding from other donors.Another aspect that is felt to be closely linked with additionality is the factthe GFATM funding has established and further strengthened linkagesand collaboration between Sub-Recipients and with the National Program.It is more difficult to judge whether additionality is being achieved atdonor level. The gap analysis that is now part of the proposal developmentensures that GFATM funds are requested in line with existing prioritiesPage 77

and gaps and that duplication is avoided. At the same time, however,some of the stakeholders interviewed by the Review Team expressed fearsthat other donors may decide not to continue or to reduce funding for the3 disease programs as a result of the Cambodia’s success in obtainingGFATM funding.Review ObjectiveAssess whether GFATM funds are making a substantial contributionin the existing programs to fight the 3 diseases, a difference in thefield and is effectively used to strengthen/magnify the effects ofother foreign assistance funding for the 3 major diseases inCambodia.There is ample evidence that GFATM has made possible a scaling-up andexpansion of services in all three disease areas. Not only services providedby the NPs itself, but also through national and international NGOs,community based volunteers, and the private sector (social marketing).For example:• GFATM funding has been an important factor in the dramatic increasein the number of patients on ARVs during the last three to four years.• GFATM funding has supported increased access to TB treatmentthrough expansion of both Health Centre DOTs and Community DOTS.• GFATM funding resulted in Malaria diagnostics and treatment nowbeing made available at community level in the 300 most endemicvillages in the country.The objectives as included in the Rounds 1, 2 and 4 proposals submittedto GFATM and in the PGAs between GFATM and the PR are conformdisease specific national policies and have been formulated with the aimto contribute to achievement of goals and objectives as stated in diseasespecific national strategies. This is a direct result of the fact that the threeNPs have a key coordination and technical role during proposaldevelopment, which allows them to act as gatekeepers and to make surethat national policies and strategies are adhered to. The NPs play a similarrole during program implementation as all requests for programmodification and budget alignment require their approval.Recent calls for proposals required that a gap analysis was conducted aspart of the proposal development process in order to demonstrate theavoidance of overlap with other donor funding and the planning of GFATMPage 78

inputs in combination with existing programs and existing funding. Mainstakeholders welcome this requirement and believe it has facilitated amore strategic positioning of GFATM funded programs in relation to otherdonors and overall efforts in the three (disease specific) sub-sectors.Page 79

5. ConclusionsThis section discusses the main conclusions regarding Round 2 and 4program implementation and the three cross-cutting issues. Theseconclusions are drawn based on the findings presented in the previoussection.Mid-Term Results – Round 2Half-way through the programs’ lifetime (after two-and-a-half years),progress in terms of achievement of intended results is largely on track.Especially, the HIV/AIDS component has been successful, with only 2 (outof 20) indicators included in the consolidated report behind target andreporting results for most of the remaining indicators that are well overtarget.These programmatic results are in contrast with the relatively lowexpenditure reported by the end of June 2006. Sub-Recipient included inthe HIV/AIDS component reported having spent only 47% of the availablebudget, while the Malaria and TB components reported 72% and 84%respectively.Preliminary Results – Round 4After only ten months of implementation almost all indicators (18 out of21) included in the consolidated M&E plan of the HIV/AIDS componentare on target, with a smaller number of indicators reporting progress wellabove intended results. For the Malaria component, progress to date ismore modest with only 1 indicator reported to be on target and withmalaria health education activities and the procurement of LLIMNs wellbelow intended results.Both programs have been slow in spending the available budget. Acomparison of actual expenditures (including procurement commitments)versus budgets shows that 33% of the budget of the HIV/AIDS componenthad been spent after ten months of program implementation. The Sub-Recipients in the Malaria component had spent or obligated 55% of thebudget available to them.Constraints and ChallengesGiven the fact that Round 2 implementation started only 4 months afterRound 1, both programs have faced more or less the same constraints andPage 80

challenges, which were mostly related to the fact that GFATM funding wasnew.A specific constraint for Round 2 programmes has been the approvalprocess of Phase 2. The late signing of the PGA for Phase 2 resulted indelayed procurement and disbursement of funds, which seriouslydisrupted planned implementation for most of the Sub-Recipients.During the Phase 2 approval process, GFATM earmarked expected savingsby the end of Phase 1 to contribute to funding the proposed Phase 2budgets. It appears that most of the Sub-Recipients were not clear abouttheir expected end of Phase 1 savings and failed to increase the availablePhase 2 budget with the amount of expected savings. In this way,$850,000 in end of Phase 1 savings was lost, with the highest losses inthe TB component ($470,000).The nine months delay in signing of the PGA continues to be a majorchallenge for the Round 4 Sub-Recipients. In particular for those involvedin the Malaria component as malaria school health activities missed thebeginning of the new school year and there was not enough time tocomplete procurement of LLIMNs in advance of the 2006 rainy season.GFATM Structures: CCC, CCC-SC and PR-TRTThe CCC has been especially active during proposal development, but hasplayed a more modest role in overseeing program implementation. CCCmembers recognised that there has been limited supervision of the PR andthat it has made little progress in developing a vision for futuremanagement of GFATM grants in Cambodia.Given the large number of CCC members, their limited availability and thefact that the committee meets only once every quarter, the practicaldecision was made to delegate some tasks and to establish the CCC-SC.Members of the CCC-SC noted that the level of authority that has beendelegated to them by the CCC needs further clarification.Both the CCC-SC and the PR-TRT have largely fulfilled their roles insupporting program implementation. The main constraint has been thelimited time available for CCC-SC and PR-TRT to review and comment onprogress reports and requests for program modification and budgetrealignment.Page 81

GFATM Structures: LFAThe LFA has been criticised for the fact that it lacks the qualified andexperienced staff to fulfil its role, which is widely regarded as the reasonfor frequent and unsubstantial questions and requests for furtherclarification on the semi-annual reports. This criticism appears to bejustified and there is ample evidence that this has delayed the reportingprocess and the subsequent disbursement of funds. This has disruptedprogram implementation by the Sub-Recipients on several occasions.However, the LFA has responded to this criticism by appointing a medicaldoctor with relevant program experience. This has resulted in a moredetailed analysis of the semi-annual reports and disbursement requestsand more substantial requests for further clarifications from the LFA. ThePR has been slow to respond to the more substantial questions andcomments coming from the LFA, which has delayed the reporting processand subsequent disbursement of funds.The relationship between the PR and the LFA is best described as“strained”. Intervention by GFATM resulted in several suggestions tofurther standardise/formalise the interactions between the LFA and thePR. These suggestions are believed to be appropriate and are in theprocess of being implemented by both the PR and the LFA.GFATM Structures: Principal RecipientThe PR’s success in starting up and managing implementation of theprograms in a very complex environment is widely recognised. Particularsuccesses include timely reporting, timely disbursement of funds, havingbuilt capacity the comply with international procurement standards,centralised procurement of OI/ARV drugs resulting in considerablesavings, capacity building and hands on support which allowsparticipation of potentially weaker Sub-Recipients, quarterly meetingsresulting in sharing and building linkages between Sub-Recipients, andregular monitoring visits.On the other hand, there are concerns that the PR is becoming toostretched and that its current capacity is insufficient to sustain thecontinued increases in the number of grants. This is reflected in thequality of the most recent semi-annual reports. As a result, the LFArequired many clarifications, which delayed the reporting process andhence, the disbursement of funds by GFATM. The recent recruitment ofPage 82

additional staff is expected to provide some relief, but at the same timethere is a need for revised and improved systems, procedures and workarrangements within the PR.The PR does only partially fulfil the role of grants manager. To some extentthis is the result of time constraints and the sizeable workload of having tomeet reporting deadlines, implementing routine tasks such as monitoring,organization of quarterly meetings, and dealing with frequent and ad-hocrequest from GFATM. But more importantly, the PR perceives itself as acoordinator and facilitator, with neither the responsibility nor theauthority to conduct regular financial and programmatic analysis insupport of forward planning. As a result, it is left to the Sub-Recipients toidentify and act on under/over achievement against intended results andunder-spending against agreed budgets.Financial ManagementAlthough the budgeting process was not observed, the results showadequate ability to develop budgets. The budget re-alignment process hasbeen a work in progress, with significant improvements as each structurelearned its role. Budget realignment can only be done well if Sub-Recipients are comparing their budgets with their expenditures. The PRfeels that Sub-Recipients must take the lead on this. The large amount offunding left un-spent at the end of Round 1 and the considerable losses inbudget that occurred at the end of Round 2 Phase 1 were the result ofrealignment not happening in a timely manner.Reporting has generally been timely. Concerns remain about the quality ofexisting reports and whether the reporting format provides enoughinformation and/or whether available information is used adequately tomanage the grants effectively. A specific concern is the lack of adequatewritten explanation of budget variances and of how unspent funds will beused in next period.Various Sub-Recipients complete the same financial forms differently andoften include errors. Most financial data collected from the Sub-Recipientsis not included in the consolidated financial report, but Sub-Recipients’reports are forwarded to the LFA (for information). Forwarding Sub-Recipients’ incomplete or inaccurate financial reports to the LFA hascaused confusion and has delayed the reporting process. It should benoted that there are no such issues between the LFA and PR concerningPage 83

procurement in spite of the large amounts of funds used for procurementof goods and supplies.The PR disburses funds to the Sub-Recipients and the National Programson time. While there are no issues on the Sub-Recipient side aboutdistribution of funds from Phnom Penh to the field, some issues remainbetween the National Programs and field operations. This is oftenidentified as on of the main causes for slow spending by the NationalPrograms.AdditionalityThere is ample evidence that the majority of the Sub-Recipients applied forGFATM funding as an opportunity to scale-up existing HIV/AIDS activitiesor to address previously identified needs in the geographical area orfacility supported by them.It is more difficult, however, to assess whether additionality is beingachieved at donor level. The gap analysis, that is part of the proposaldevelopment, surely helps to avoid duplication and replacement of existingdonor support. Nonetheless, some of the health partners expressedconcerns that existing donors may interpret Cambodia’s success inobtaining GFATM funding as a reduced need for other donor support.There is ample evidence that GFATM has made it possible to scale-up andexpand service delivery, while the role of the National Program in proposaldevelopment and program implementation has ensured that nationalHIV/AIDS policies and strategies have been adhered to.Page 84

6. RecommendationsThe following are the main recommendations for ongoing and futureGFATM program.Program ImplementationFollowing the return to GFATM of a relatively large amount of funds at theend of Round 1, it is recommended that Sub-Recipients in ongoing andfuture Rounds are encouraged to closely monitor expenditures againstbudget in order to assure timely budget realignments that guarantee thatavailable funds are well spent and used to produce maximum programresults.Following the budget losses that occurred during the Round 2 Phase 2approval process and given the considerable under-spending for bothRound 4 programs to date, it is recommended that Round 4 Sub-Recipients make realistic projections of expenditures until the end ofPhase 1. This will allow Sub-Recipients to estimate Phase 1 savings and toinclude these savings in the budget for the Phase 2 proposal.The M&E plans of the Round 2 programs include several indicators withactual result to date that are much higher than the intended results. It isrecommended to modify (increase) the intended results for theseindicators in order guarantee that maximum possible results will berealised and to maintain the principles of performance based funding.GFATM Structures: CCC, CCC-SC and PR-TRTThe decision by the CCC to delegate certain tasks and responsibilities tothe CCC-SC has helped program implementation. In order to furtherstrengthen the role of the CCC-SC in overseeing program implementationand in supporting the PR, it is necessary to clarify the level of decisionmaking authority of the CCC-SC.At the same time, it is recommended that the CCC should have moreoversight of program implementation, which is necessary for it to play aprominent role in overall decision making. It is hoped that the plannedappointment of a full-time coordinator will contribute to this.The time constraints faced by most of the CCC-SC members is animportant concern and will be a determining factor in the future relevanceof the CCC-SC. This concern has already been acted upon in the form ofPage 85

CCC-SC members attending the PR-TRT meetings. It is recommended thatCCC-SC members also mobilise support within their own organizationswhen and where appropriate. For example, organizations’ technicaladvisors working in any of the three disease areas could assist in thereview of semi-annual reports and other documents.GFATM Structures: LFAIt is recommended that both the LFA and the PR continue to implementthe course of action proposed by the GFATM.The LFA could further increase its credibility and the quality of its workthrough the appointment of staff with sufficient experience in theimplementation of health projects.The PR on the other hand, could do more in terms of analysing financialand programmatic information that is provided by the Sub-Recipients.This analysis would help to improve the quality of the consolidated reportsand provide the PR with the information required to address in a timelymanner most of the LFA’s requests for clarification.It appears that the CCC played only a very limited role in finding ways toovercome the strained relationship between PR and the LFA. It isrecommended that the CCC closely monitors this issue in the future andwill consider appropriate action in case current issues are not resolved.GFATM Structures: Principal RecipientGiven the level of investment in the current PR, the review team is of theopinion that there are considerable advantages in the continued use ofthis PR for the management of future GFATM grants. However, presentconcerns regarding the PR’s capacity and its self-perceived role as acoordinator rather than the grants manager need to be addressed.The challenge of an ever increasing workload has been addressed recentlyin the form of recruitment of additional staff. The number of PR staff hasalmost quadrupled during the last 4 years and further growth in thenumber of staff is believed to be only a partial solution for presentcapacity constraints. In order to maximise the effectiveness and efficiencyof the staff the following measures are recommended:(a) All staff members have job descriptions, but the Review Team didnot see any proof of systematic management of staff performance. ItPage 86

is recommended that the PR considers the introduction of the staffperformance management system that has been developed by theMinistry of Health.(b) The performance management system would help PR managementto identify the capacity development needs of individual staffmembers and provide the information it needs to develop a relevantand timely staff development plan.In addition, it is recommended that the PR considers other measures thatcan help to cope with the considerable workload, such as a review andprioritization of current tasks, further strengthening of existing systemsand procedures, and out-sourcing of certain routine and ad-hoc tasks:(a) A systematic review of existing systems and procedures may identifyways to work more efficiently and to save time. It should be notedhere that there are high expectations that the introduction of thenewly developed database will speed up the reporting process andresult in considerable time-savings.(b) A review of current tasks may result in better prioritization of thesetasks (Are all current tasks necessary or do all current tasks need tobe implemented by PR staff?).(c) Several routine and ad-hoc tasks could be out-sourced, somethingthat is already done by the PR (e.g. customs clearance of importedgood and supplies, and the contracting of SCA to provide technicalassistance to MoSVY). It is recommended that the PR considers theoutsourcing of additional tasks, such as the assessment of Sub-Recipients’ capacity at the start of a new program and building thecapacity of weaker Sub-Recipients during implementation.It is also recommended that the CCC clarifies the roles and responsibilityof the PR and provides it with the clear mandate and authority to act asthe grants manager. This role would require the PR to put more emphasison regular and systematic analysis of on-going programs, including ananalysis of actual expenditures versus budgets:(a) In the short-term, this will help the PR to meet the growingdemands of the LFA and help to avoid delays in reporting.(b) A more analytical approach will also allow the PR to have a betterunderstanding of program implementation and will facilitate its rolein promoting more and better forward planning.(c) More emphasis on forward planning will help to timely identifyunder-spending and under-/over-achievement of program resultsPage 87

and will facilitate timely and appropriate action by the Sub-Recipients in the form of program modification and budgetrealignment. In the long-run these actions will help to avoid a repeatof the end of Round 1 situation with program results largelyachieved despite a relatively large amount of funding remaining unspent.The recommended analysis of ongoing programs requires the PR to makebetter use of data that is already available and to collect additional data:(a) The PR already collects detailed financial information from theSub-Recipients, which is sufficient for the recommended analysis ofactual expenditures against budget(b) It is recommended that Sub-Recipients report against existingwork plans and up-date the work plans for the following period (sixmonths). This would not only facilitate a more realistic planning ofactivities by the Sub-Recipients, but also provide sufficientjustification for un-spent funds to be carried, and facilitate closermonitoring of the Sub-Recipients by the PR.(c) It is recommended to use every opportunity to further strengthenM&E plans, not only as part of the PGA and MoA negotiations, butalso as part the proposal development for Phase 2.Regular (weekly or bi-weekly) team meetings and senior staff(management) meetings could play an important role in promoting andstandardising coordination between the different teams in the PR. Therecent appointment of chiefs for each of the teams provides an excellentopportunity to further strengthen coordination between the teams.Grants management would benefit from the appointment of grantcoordinators, i.e. staff members that are responsible for thecommunication with all Sub-Recipients and with the different PR teamsconcerning a particular grant. Grants managers would also be responsiblefor mentioned analysis of program implementation and would help tostreamline communication with Sub-Recipients. The newly appointedAssistant Manager is envisaged to play a similar role as described above. Itis doubtful, however, that one person will be able to deal with theworkload of having to manage all eight ongoing programs in addition toother management responsibilities.Page 88

The advice and assistance of an organisational development andmanagement expert may be useful in this respect. It is advised that the PRfurther discusses this with the CCC as a possible next step in findingways of dealing with present and future workloads and in furtherstrengthening the management of the PR.National ProgramsIn line with recommendations made by both the CCC and senior MoHmanagement 9 , it is recommended to work towards increased collaborationbetween the National Programs and the PR, especially in areas such astechnical monitoring, analytical review of progress made and forwardplanning of program implementation. The National Programs have therequired disease specific technical skills, while this would also allow thePR to delegate certain tasks and to reduce its workload.There is a need to further build the management and implementationcapacity of the three National Programs. GFATM and the PR could play arole in helping the National Programs to identify training needs and indeveloping strategies to address identified needs. Implementation ofcapacity building strategies could be funded through future proposalssubmitted to GFATM.Financial ManagementIt is recommended that the PR assumes a wider role in financialmanagement of the grants:(a) The PR must not only ensure that Sub-Recipients report correctlyand consistently but also that Sub-Recipients explain variancesbetween budget and actual expenditures. Since the PR receivesinformal financial reports on a monthly basis, this analysis need notwait for the end of the semi-annual reporting period. The otherquarterly meeting with Sub-Recipients is a good opportunity todiscuss and explain variance analysis and plan for activityreprogramming and budget realignment.(b) Although Sub-Recipients are responsible for managing their budgetsand to request for realignment when appropriate, the PR mustensure Sub-Recipients consider budget realignment whenappropriate (i.e. in case of considerable under-expenditure).(c) In case a Sub-Recipient fails to adequately realign their budget andhence, will not be able to fully use the available budget, the PR9 Guidance on Strengthening of Integration of GFATM Grants into the National Programs;14 December 2005.Page 89

should consider the possibility of asking the CCC-SC to move fundsfrom one Sub-Recipient to another.In line with requests from the LFA, Sub-Recipients must provide moreinformation in support of their request to carry unspent funds to the nextperiod. Simply passing on unsupported Sub-Recipient requests isconsidered inadequate and has resulted in considerable delays in thesemi-annual reporting process. The LFA, PR, and Sub-Recipients mustdecide together on what information is needed and prepare appropriatereporting formats. These formats should then become a reportingrequirement. Semi-annual reporting against work plans and up-dating ofthese work plans is one possible tool that is recommended here.Better information sharing between PR, LFA and GFATM is necessary inorder to make sure that all parties involved have sufficient and up-to-dateinformation:(a) Decisions about reprogramming and budget realignment need to bemore systematically reported to the LFA.(b) The GFATM Fund Portfolio Manager should provide to the PR a clearjustification for adjustments made to semi-annual disbursementrequests and identify how much has been adjusted from each SR.(c) In a similar way, GFATM should discuss the funding of approvedPhase 2 proposals with the PR, before making a final decisionconcerning the required incremental funding. This is order to makesure that estimated Phase 1 savings are correct and in line with upto-datefinancial information.It is recommended to review financial procedures and when necessary toclarify/standardize these procedures. Clear guidance from GFATMregarding their expectations about grant management would facilitateproposed review.(a) Details needed for evaluating disbursement requests should beprovided in writing preferably in a report format to ensurestandardized reporting.(b) Clear procedures are needed on how Sub-recipient should reportexpenditures when spending their own (“borrowed”) funds, e.g. whilewaiting for delayed disbursement of GFATM funds.(c) Preparation of consolidated financial reports for each of the grantsfor internal management would facilitate the analysis ofPage 90

programmatic performance against expenditures. Such reportswould facilitate the work of the proposed grant coordinators.National Programs may wish to review their internal financial procedures,in particular the disbursement and clearance of working advances toPHDs and/or ODs. The use of banking facilities is now common practicein Cambodia and should be encouraged.ProcurementThe planned centralized procurement of vehicles should be expanded toinclude all international procurement. This will save time in the import taxexemption process and may save money where tax exemption is notcurrently sought for small value purchases such as motorcycles andcomputers.Although more pooled procurement is welcomed, it is important that Sub-Recipients’ needs for items and goods with specific specifications will betaken into consideration when these are programmatically justified. Forexample, packaging may require items of a particular shape and size andprevious investments in training of health staff may require theprocurement of items with exactly the same specifications as previoussupplies.AdditionalityAdditionality can be captured by encouraging Sub-Recipients to reportoverall results and to specify how much of this can be attributed toGFATM funding. However, this is realistic only for key (impact and somecoverage) indicators, and the experience to date demonstrates how difficultthis is.Additionality is already demonstrated by way of the gap analysis duringthe proposal development process, and it is recommended that the PR willinclude a brief report on the actual situation in its annual reports to theGFATM. Furthermore, the gap analysis could be repeated (up-dated) aspart of the process of developing the proposal for Phase 2 of a grant.Especially for entities that are part of the public health system (e.g. theNational Programs), additionality can be easily captured anddemonstrated through their Annual Operational Plans (AOPs). The AOPsfacilitate comprehensive plans, joint planning, and transparency byencouraging all partners to join in a common annual planning process.Page 91

Annex 1: Terms of ReferenceGFATM in Cambodia - Program Review for GFATM GrantsEnd-of-Project for Round 1 and Mid-Term for Rounds 2 and 4)Terms of ReferenceAugust 2006I. Program Background:1. What is the Global Fund? The Global Fund to Fight AIDS,Tuberculosis and Malaria (GFATM), a non-profit foundation, wasestablished under the laws of Switzerland (referred to as the “GlobalFund”) in January 2002 to attract, manage and disburse large amounts ofadditional financing to support locally-driven strategies to combat thethree pandemics. AIDS, TB and malaria – which are both preventable andtreatable – kill more than six million people every year.The Global Fund allocates funding through proposal rounds. The mostrecent round of proposals (the 5th such round) was approved inSeptember 2005. The Round 6 call for proposals was announced on 3rdMay, 2006, with applications due on 3rd August, 2006.2. GFATM Globally: As of 31 March 2006, the Global Fund hasapproved a total of US $ 5.2 billion to over 350 grants in 131 countriesthrough five rounds of proposals and including the latest grants to receiveapproval for Phase 2 ( years 3 to 5 of the grant lifespan).Of the US $ 5.2 billion approved, US $ 2.1 billion has been disbursed topublic and private recipients in 127 countries. Through 2008, a total ofUS $ 8.8 billion has been pledged and/or contributed to the Global Fund.3. GFATM in Cambodia: In Cambodia, GFATM has approved proposalssubmitted during the first, second, fourth and fifth Rounds 10 . Theexecuting body of GFATM programs is called the Principal Recipient (PR),which, in Cambodia, is based within the Department of CommunicableDisease Control (CDC), Ministry of Health (MOH). Thus, under Rounds 1,2 and 4, six Program Grant Agreements (PGAs) between the GFATM andthe PR were signed, or approved, as follows:10 The 3rd Round GFATM submission was not successful in Cambodia.Page 92

• Round 1: 1 PGA for HIV/AIDS component for US $ 15.7 million/3years 11 .• Round 2: 3 PGAs for HIV/AIDS, Malaria and Tuberculosis for thefollowing US $ amounts: 1) HIV/AIDS for $14.7 million, 2) Malaria for$9.9 million, and 3) TB for $ 6.3 million, or a total of US $ 31 million/ 5 years 12 .• Round 4: 2 PGAs for HIV/AIDS and Malaria were signed for thefollowing US $ amounts: 1) HIV/AIDS for $ 8.8 million and 2) Malariafor $ 5.2 million, or a total of US $ 14 million /2 years.• Round 5: In January 2006, 3 Program Components were approvedunder Round 5, including 1) HIV/AIDS, 2) Tuberculosis and 3) HealthSystems Strengthening for a total of US $ 21.2 million / 2 years.Grant negotiations and signing of 3 PGAs are anticipated for June2006, with an expected start date of July 2006.II. This Program Review has dual Purpose/Objectives:1. End of Program Review for Round 1 HIV/AIDS grant. Purpose ofthis End Program Review is to assess the overall outputs and outcomes ofthe grant and evaluate its effectiveness after 3 years of programimplementation. The Objectives of this Review are specifically to:a. Assess to what extent program’s original and revised plans and goalshave been implemented by the Sub-Recipients (SRs) and NationalPrograms (NPs), were the anticipated results delivered according tothe plans? Discuss any significant program changes made in thecourse of the implementation.b. Assess any constraints and challenges that the program hasencountered and how these have been resolved by the implementingpartners (SRs/NPs) and/or PR? What challenges continue to persist?c. Review to what extent the existing GF structures (SRs, NPs, PR, CCC-SC, CCC, LFA) have been fulfilling their roles, either in direct programimplementation or in supporting it. Have any adjustments beenmade in the course of program implementation?11 Round 1 proposal was approved for a total of 3 years, therefore Phase 2 is only 1 year.12 These amounts include Phase 1 and Phase 2 funds.Page 93

d. Assess to what extend have the recommendations of the Mid-TermProgram Review (for Round 1) been acted upon? What are theremaining constraints?e. Have any specific lessons learned from the Round 1 experience beenidentified and incorporated into the existing and future GFATMgrants in Cambodia?f. Assess GFATM’s contribution to strengthening the national programimplementation structures and systems, particularly the M&Esystem.2. Mid-Term Program Review for Round 2 and 4 grants(HIV/AIDS,Malaria, TB). Purpose of this Mid-Term Review is to assessinputs, processes, accomplishments of the five (5) on-going Round 2 andRound 4 grants (often implemented by the same agencies under bothrounds). Identify lessons learned and make recommendations to the PRand CCC for the next stages of program implementation 13 . To generatethis information, the Mid-Term Review should address the followingObjectives:a. Assess whether program activities under Rounds 2 (3 grants) andRound 4 (2 grants) are being implemented according to the agreedplans (as specified in the PGAs and MOAs); assess programeffectiveness in terms of working towards achieving its stated outputsand objectives;b. Assess the main challenges and constraints faced by the GFATMgrants in Cambodia, and recommend specific solutions to addressthem;c. Examine the coordinating and monitoring role of the PR; assess itseffectiveness in managing the GFATM portfolio in Cambodian contextand propose any improvements, as needed;d. Assess the relationships among different in-country GFATMstructures (SRs – PR –CCM - LFA), and in turn, their relationship withGFATM-Geneva, and how all of those affect implementation of theGFATM grants in Cambodia.e. Assess GFATM program’s fit into the MOH’s National Health SectorStrategic Plan 2003-07 and other national programs and policies. Arethe GFATM grants consistent with the relevant national strategicplans?13 Ideally, findings of this review will be incorporated into Round 4 Phase 2 Request (dueat GF in February 2007).Page 94

f. Assess the degree to which the GFATM grants have impacted theprograms adversely, in duplication of systems, processes, etc.g. Identify lessons learned and make recommendations to the PR andCCC for the next stages of the GFATM grants’ implementation.III. Common Concerns Relevant to both Parts of the assignment (inPoint II): Throughout the course of this assignment, the Review Team willconsider the following issues for all the existing GFATM Rounds inCambodia (1, 2, 4):1. Financial Management; Examine the efficiency of the management ofGFATM funds in Cambodia by the relevant entities (SRs and PR) andassess how well they can currently meet GFATM requirements, with aparticular focus on the future (of potential additional funding Rounds).Specifically assess the following issues:a. whether the funds have been used according to the approved budgets(expenditures, timeframes), supporting relevant program activities;b. demonstrated degree of professionalism in efficient financialmanagement, which at a minimum, should include the ability to:develop various budgets, track program expenditures, and producecomplete reports in a timely manner;c. whether the SRs and PR have appropriate systems in place to ensurethat all financial transactions and operations are handled in fullcompliance with the PR’s Financial Guidelines and GFATM’srequirements;d. to what extent, those Sub-Recipients and National Programs withmultiple GFATM funding Rounds, are able to track their grantsseparately;e. to what extent, those Sub-Recipients and National Programs withmultiple donor funding (in addition to GFATM), are able to track thesefunds separately and avoid any duplication;f. identify any constraints and challenges that need to be addressed andformulate relevant recommendations.2. GFATM Structures; To what extent are the existing GFATMstructures fulfilling their existing Terms of Reference while supportingprogram implementation; especially the PR, CCC-SC and LFA? Assesswhether the existing PR guidelines (M&E, Financial and Procurement) arePage 95

adhered to by the relevant GFATM structures. Provide recommendationson how to strengthen these functions to ensure:a. timely disbursement of funds and processing the requests for thesubsequent disbursements from the SRs;b. timely processing of procurement contracts to ensure timely deliveryof goods in support of the program implementation; while adhering tothe PR-GFATM guidelines;c. program monitoring and evaluation, including data collection,analysis, synthesis and effective monitoring to verify that results areachieved as stated;d. as more GFATM funding has been approved for Cambodia (Round 5),it is deemed valuable to demonstrate that all the necessary systemsare in place, and functioning well, or to propose mid-courseadjustments and corrections.3. GFATM Additionality; Examine utilization of GFATM funds inaddition to other funding sources in Cambodia, through assessing:a. whether GFATM funds in Cambodia are efficiently utilized in additionto other existing donor funding sources and appropriatelyprogrammed to fill the existing funding gaps (ensuring theiradditional contribution and avoiding any potential duplication);b. whether GFATM funds are making substantial contribution in theexisting programs to fight 3 major diseases, a difference in the fieldand is effectively used to strengthen/magnify the effects of otherforeign assistance funding for the 3 major diseases in Cambodia.c. Propose a simple yet effective way to capture this “additionality”effect, while maximizing utilization of the existing reports andsystems, and minimizing the additional burden on the SRs, NPs andPR.IV. Program Review Methodology:Program Review will use the combination of quantitative and qualitativemethods, including the desk reviews of multiple backgrounddocumentation (Proposals, Reports, PR Terms of Reference, etc.),interviews with project staff (SRs, NPs and PR) and relevant stakeholders(CCC, WHO, UNAIDS, MOH, etc.), and field visits to select projectactivities, as appropriate.Page 96

1. Program Review Team; It is envisioned that the review team willconsist of 5 individuals: two expatriate consultants (1 of whom will be ateam leader), 1 local consultants, a representative of the Department ofPlanning, within the Ministry of Health (MOH), and a representative of theNational AIDS Authority (NAA). This team is expected to divide the tasksof this Program Review into two sub-teams, one concentrating on End ofProgram Review for Round 1 and another focusing on Mid-Term ProgramReview for Rounds 2 and 4, or based on the specific technical strengths ofthe individual team-members.2. Expertise Required: The Program Review team will includeprofessionals with the following fields of expertise and extensiveexperience in:a. Primary Health Care, including community-based programs aimingto maximize program coverage among hard-to-reach target groups;b. HIV/AIDS programming including prevention, care and communitysupport;c. Program design and strategic planning in health, preferably withlarge scale, national projects (experience in Cambodia a strongasset);d. Extensive grants management and oversight; familiarity withfinancial functions;e. Expertise in financial management of complex health programs indeveloping countries;f. International procurement procedures and systems and monitoringtheir effective implementation;g. Monitoring and Evaluation systems; development of sound M&Eplans, work plans and oversight in their implementation;h. Capacity building in resource-poor, complex environments, linkingboth government and non-government sources;i. Functioning of health system and health services in Cambodia;j. Excellent communication skills in English (both spoken andwritten);k. Prior experience with GFATM processes and/or programsconsidered a strong asset.3. Illustrative Timeline for the Program Review: The assignment isenvisioned to last 6 weeks, between October-November 2006, with theproposed utilization of time as follows:Page 97

a. Week 1-2: Desk reviews of the relevant documentation anddiscussions with key stakeholders (list to be provided by PR) inPhnom Penh, with an initial meeting to discuss the TOR and reachconsensus on division of specific tasks.b. Week 3-4: Further in-depth assessment of the GFATM grants,through field visits to a sample of implementing partners (SRs/NPs)to see select program activities.c. Week 4-5: Synthesis of information; clarification of issues,formulation of preliminary findings and recommendations, with aPower Point presentation thereof by the end of the Week 4 at theCCC-SC meeting.d. Week 6: Writing of the draft Report, with a clear set ofrecommendations for the subsequent years of the GFATM grantsimplementation. Draft report is to be submitted to the PR by theend of Week 6 (or 30 November 2006) for review. After PR providesspecific feedback, the consultants are expected to finalize the reportwithin 1 week.NOTE: Throughout the course of this assignment, and in the final reportsthe Program Review team will consider the following issues:• Priorities; the health needs the project has to address,• Strategy; the strategy or approach the project should apply in orderto address identified needs, the best practices methodology to obtainthe best results.• Project framework: possible changes in project’s objectives, outputsand activities.• Project area: the geographical areas to be included in the projectduring the remaining two years.• Counterparts; the organizations/groups the project should workwith.• Resources; human resources needs for effective implementation ofthe projects, and the associated resources required by the project.• Decentralized contracts procurement on health and non-healthproducts to strengthen program implementation in timely manner.4. Anticipated Specific Outputs of the Program Review: It isenvisioned that this Program Review team will produce the followingoutputs:a. Detailed work plan for conducting this Program Review (1 st week);Page 98

. Power Point presentation of preliminary findings andrecommendations (4th week);c. Draft Report form the Program Review (5 th week);d. Final Report from the Mid-term Review. (6 th week)Each of the above outputs should be presented in two clear parts:Part 1: End-of Program Review for Round 1, andPart 2: Mid-Term Program Review for Rounds 2 and 4.Page 99

Annex 2: Work Plan for Program Review of GFATM Grants1. MethodologyEnd of Program Review for Round 1: Assessment of overall outputs,and the effectiveness of three years of implementationIn order to assess to what extent the program’s goals and objectives havebeen achieved and plans have been implemented by the SRs and the NP,the review team will focus on:→ Review of available documents and reports, such as the originalproposals, Program Grant Agreements (PGA), Memoranda of Agreement(MoA) with SRs, implementation letters (amendments of PGAs andMoAs) periodic progress reports, PR’s monitoring reports (field visitreports), minutes of quarterly meetings, Mid-Term Review Report, scorecards, relevant correspondence, and possibly documents that could beprovided by the LFA.Note: Progress reports for July-August 2006 and End-of-ProgramReports have not yet been submitted by SRs.→ Meetings/interviews with all Round 1 SRs, selected SSRs, with selectedbeneficiaries (e.g. existing support groups), and with PR managementand relevant technical staffThe review of documents/reports and the planned meetings/interviewswith the SRs will also focus on an assessment of constraints andchallenges, whether recommendations from the mid-term review havebeen acted upon.The review team also plans to conduct in-depth interviews with NCHADSmanagement and key program staff in order to assess the GFATM’scontribution to strengthening the NP’s implementation structures andsystems (in particular the M&E system).In-depth interviews and discussions with selected members of CCC andCCC-SC, LFA, SRs and the NP, PR management and relevant staff will beheld to assess whether GFATM structures have been fulfilling their roles.Mid-Term Review for Rounds 2 and 4: Assessment of inputs,processes, and accomplishments, as well as lessons learned andrecommendation for next stagesIn order to assess whether program activities are being implementedaccording to agreed plans, and to assess the effectiveness in workingPage 100

towards achieving stated outputs and objectives, the review team willfocus on:→ Review of available documents and reports, such as the originalproposals, Program Grant Agreements (PGA), Memoranda of Agreement(MoA) with SRs, implementation letters (amendments of PGAs andMoAs), periodic progress reports, PR’s monitoring reports (field visitreports), minutes of quarterly meetings, Mid-Term Review Report, scorecards, relevant correspondence, and possibly documents that could beprovided by the LFA.→ Meetings/interviews with 10 SRs (4 SRs involved in Round 2 and 4malaria component, 1 SR involved in Round TB component, and 5 SRsinvolved in Round 2 and/or 4 HIV/AIDS component that were alsoinvolved in Round 1), and with selected SSRs, with selectedbeneficiaries (e.g. existing support groups), and with PR managementand relevant technical staffThe review of documents/reports and the planned meetings/interviewswith the SRs will also focus on an assessment of constraints andchallenges. The review team will make sure not to make recommendationsthat have already been taken care of in subsequent Rounds (Rounds 5and 6).The review team will conduct in-depth interviews with the different incountryGFATM structures in order to assess the relationships betweenthese structures and to assess the PR’s effectiveness in managing theGFATM grants in Cambodia.The review of strategic plans for the sector as a whole as well as for thecontrol of the three diseases, and in-depth interviews with keystakeholders is expected to provide the relevant information that will allowthe review team to assess whether GFATM program are consistent withsector and sub-sector strategies. The review team will also focus onpossible adverse impacts of GFATM grants on overall efforts to fightHIV/AIDS, Malaria and TB in Cambodia.Financial Management: Assessment of the efficiency of managementof GFATM funds by the PR and the SRs, and of how well they meetcurrent GFATM requirements, with a particular focus on the futureThe team will review relevant financial and audit reports submitted by theSRs as well as those compiled by the PR in order to assess whether fundsPage 101

have been used according to approved budgets and whether appropriateprocesses and procedures have been followed.Furthermore the team will visit selected SRs (including all three NationalProgrammes) as well as a limited number of SSRs in order to assess theirprofessionalism in financial management, whether appropriate financialsystems are in place and in compliance with PR’s guidelines and GFATMrequirements, and to what extent SRs are able to track funds fromdifferent donors and/or from different GFATM funding rounds.GFATM Structures:The team will review all relevant documents, including TORs of theGFATM structures and existing PR guidelines, and interview members andrepresentatives of the various GFATM structures in Cambodia in order toassess to what extent GFATM are fulfilling their roles and to what extentPR guidelines are adhered to.The review of documents and interviews with key members andrepresentatives of all GFATM structures will especially focus on the PR’sfunction to ensure timely disbursement of funds, processing ofprocurement contracts, program M&E, with the aim to providerecommendation on how these functions can be further strengthened.The analysis of the present situation will focus on the question whethersystems are in place and functioning well, resulting in possiblerecommendations adjustments and corrections and meet demands ofcurrent and future funding.Additionality:The review team will assess additionality at the level of the three diseasespecific programs as well as at the level of individual SRs. Activities willinclude:→ In-depth interviews with key stakeholders in each of the threeprograms (National Programs and their technical advisors and maindonors, Ministry of Health senior management, and key CCCmembers).→ Review of existing reporting (not only to the PR/GFATM, but also toother donors) Analysis will focus on the design of possible (simple)ways to capture the additionality effect by making maximum use ofexisting reports and systemsPage 102

2. Detailed Work PlanThe work plan presented below is a preliminary work plan as most of thelisted meetings still have to be arranged. It follows that the actual timingof the meetings will depend of the availability of the person(s) to be met.Weeks 30/10 - 05/11 & 06/11 - 12/11:• Initial meeting with PR Management and TA to discuss TOR• Meetings/Discussions with PR teams (M&E, Procurement, andFinance)• Review of key documents and reports (PGAs, MoA, Periodic Reports, PRGuidelines)• Drafting Work PlanWeek 13/11 – 19/11:• Meetings:→ LFA→ NP Directors and key program staff: NCHADS, CNM, CENAT→ PR Management and TAs (review work plan)→ Round 1 SRs: CRC, DSF, KHANA, MDM, MoND, MoSALVY, PSF,PSI, SHCH, YCC→ Selected Round SSRs and Beneficiaries• Continue identification and review of key documents and reports,including strategic plans for health sector and for the three diseasespecific programs• Identify relevant SSRs and beneficiaries and plan visits, including visitto provinces (all Rounds)Week 20/11 – 26/11:• Meetings:→ Round 1 SRs - Continued→ Round 2 and 4 SRs for Malaria : HU, PFD, PSI→ Selected SSRs and beneficiaries - Continued→ PR Management and TAs• Continue identification and review of key documents and reports• Field Trip to Kg Cham and Kratie Provinces: 23-25/11→ Visit SR field offices: PFD in Kratie→ Visit SSR in Kg Cham: PHD (HIV/AIDS, Malaria, TB); SCA (SSR ofCENAT); DSF (HIV/AIDS in Kg Cham Hospital); CPN+ (SSR ofKHANA), Kasikor Thmey (SSR of KHANA); NAS (SSR of KHANA)→ Visit SSR in Kratie: PHD (Malaria and TB); PFHAD (SSR of CENAT)Page 103

Week 27/11 – 03/12:• Meetings:→ Attend CCC –SC monthly meeting (29/11)→ HE Prof. Dr. Eng Huot (as CCC member and as MoH SeniorManagement)→ Selected key CCC members- Government: Dr. Sok Touch, Representative NAA (HE Dr. HongSon Huot or Prof. Dr. Ly Po)- UN: Dr. O’Leary (WHO) and Mr. Tony Lisle (UNAIDS)- Multi/Bi-laterals: Ms. Elisabeth Smith (DFID), Jonathan Ross(USAID, Dr. Toomas Palu (WB)- NGOs : Dr. Sin Somuny (MEDICAM) , Mr. Scott Simmons (IFRC)- Civil Society/Academics – to be decided→ TAs to National Programmes:- NCHADS: WHO, DFID, UNAIDS,- CNM: WHO- CENAT: WHO (Dr. Jay), JICA→ Technical Review Teams (Will these meet during the period 13/11 to17/12?)• Continue identification and review of key documents and reportsWeek 04/12 – 10/12:• Meetings (spill-over from previous weeks)• Synthesis• Further clarification and possible follow-up meetings• Analysis and preliminary findings (Resulting in output 2: Presentation)• Start writing draft reportsWeek 11/12 – 17/12:• Finalise writing of Draft ReportsWeeks 18/12 – 24/12 & 25/12 – 31/12:• Presentation to PR and CCC-SC• Awaiting feedbackWeek 01/01-07/01:• Drafting of Final Report (based on feedback from PR and others)Page 104

Annex 3: List of People MetName Job Title Organization1 Ms. Kim Sovann Manager – Risk Advisory KPMGYadanyServices2 Mr. Taing Hongchhay Assistant Audit Manager KPMG3 Ms Khuot Thavary Deputy Director – Department MOHof Finance4 Dr. Philippe Guyant Malaria Program Manager PFD5 Dr. Kiv Sokha Malaria Program Coordinator PFD6 Lonh Sok Heng Admin-Finance Officer – Kratie PFD7 Mr. Sam Ussophea Malaria Program Coordinator HU8 Dr. Mao Tan Eang Director CENAT9 Mr. Mark Jerome Executive Director KPMG10 Ms. Heng Seida Audit Manager KPMG11 Ms. Auk Phany Program Coordinator DSF12 Dr. Cécile Bernard Medical Coordinator DSF13 Mr. Mikaël Giret Admin & Finance Advisor DSF14 Mr. Anthony Vautier Country Coordinator PSF15 Dr. Kong Sopheap Team Leader Integrated Care KHANAand Prevention16 Dr. Tran Chheng Kruy Chief of Technical Bureau PHD Kg Cham17 Dr. Keo Chandara TB Supervisor PHD Kg Cham18 Dr. Thoeu Sophana Malaria Supervisor PHD Kg Cham19 Dr. Chhun Ly Pich Chief Provincial AIDS Office PHD Kg Cham20 Mr. Chan Phalin Staff of Finance Department PHD Kg Cham21 Mr. Bun Than TB Program Officer SCA22 Dr. Un Sok Run OD Manager Memut SCA23 Mr. In Mardy TB Chief OD Memut24 Mr. Hun Vannak HC Chief Memut HC25 Mr. Men Sovann Director Kasikor Thmey26 Ms. Chap Chantha Provincial Coordinator CPN+ Kg Cham27 Dr. Chea Saem Director PHD Kratie28 Dr. Chuong Sengly Deputy Director PHD Kratie29 Mr. Leng Naren Malaria Supervisor PHD Kratie30 Mr. Chou Maneth Malaria Staff PHD Kratie31 Mr. Hong Phalla TB Supervisor PHD Kratie32 Ms. Neb Sopomka Staff of Finance Department PHD Kratie33 Dr. Phong Choun Executive Director PFHAD34 Mr. Savun Sam Ol Executive Director NAS35 Sopheak Va Manager, HIV/AIDS Program CRC36 Dr. Sok Long Director, Health Department CRC37 Mr. Om Vutharo Head of Administration & CRCFinance38 Andrea Fearneyhough Administration & Finance PSIAdvisor39 Dr. Ek Bopha Malaria Services Coordinator PSI40 Uth Sophal Field Operations Dept.PSIManager41 Taing Sotheara Procurement, Logistic and PSIAdmin Manager42 Dan Borapich Marketing andPSICommunications Manager43 Samol Mean Product Manager PSI44 Dr. Gerlinda Lucas Project Manager SHCHPage 105

45 Mr. Chim Dararith Finance Manager SHCH46 Mr. Ian Lennard Chief Development Officer SHCH47 Mr. Heng Sokrithy Country Coordinator CPN+48 Dr. Ly Penh Sun Deputy Director NCHADS49 Dr. Michael O’Leary Representative WHO50 Ms. Elizabeth Smith Health and Population Advisor DFID51 Mr. Tony Lisle Country Coordinator UNAIDS52 Dr. Toomas Palu Senior Health Specialist WB53 Mr. Jonathan Ross Deputy Director Office of USAIDPublic Health54 Ms. Kate Crawford Director Office of Public Health USAID55 Mr. Andrew Boner Country Representative PSI56 Mr. Scott TindRepresentativeIFRCSimmons57 Dr. Sin Sumony Executive Director MEDICAM58 Mr. Keo Chen Program Manager CPN+59 Dr. Sok Touch Director CDC Department & MoHChairman of PR60 HE Dr. Eng Huot Secretary of State MoH61 Dr. Keng Sim Deputy Director CNM62 Dr. Srey Sophanaroth M&E Officer CNM63 Ms. Khan Kalyan Finance Manager CNM64 Dr. Md Abdur Rashid Medical Officer WHO65 Ms. Junko Yasuoka Scientist (Malaria) WHO66 Dr. Pratap Jayavanth Medical Officer (TB) WHO67 Dr. Nicole Seguy Medical Officer (HIV/AIDS) WHO68 Dr. Pierre-Régis Project CoordinatorMDMMartin69 Dr. Var Chivorn Associate Executive Director RHAC70 Marie-Hélène Meaux Chief of MissionFRCBoko71 Mr. Thibaud Sournia Administrator FRC72 Dr. Olivier Marcy HIV/AIDS Medical Advisor FRC73 Mr. Oren Ginsberg Fund Portfolio Manager East GFATMAsia and Pacific74 Dr. Or Vandine Manager PR/MoH75 Dr. Chea Sovann Assistant Manager PR/MoH76 Ms. Hok Chantheasy Chief of Procurement PR/MoH77 Ms. Hen Sokun Chief of FinancePR/MoHKolroth78 Ms. Inga Oleksy M&E Advisor PR/MoH79 Mr. Gunatilaka Procurement AdvisorPR/MoHKodituwakku80 Dr. Hay La In Senior M&E Officer PR/MoH81 Dr. Sina Ou Sophea M&E Officer PR/MoH82 Dr. Phan Charun M&E Officer PR/MoH83 Ms. Sok Khim Senior Procurement Officer PR/MoH84 Mr. Pol Kiri Sambath Senior Finance Officer PR/MoH85 Mr. Oeun Vireak Senior Finance Officer PR/MoH86 Dr. Tan Sokhey Chief of HIV/AIDS,MoNDDepartment of Health87 Mr. Mak Sarath Program Manager YCC88 Dr. Sok Y Procurement Manager SHCH89 Mr. Chas Taplin Chief Administration Officer SHCHPage 106

Annex 4: List of Documents / ReferencesAuthor Title DateRound 1 Program Grant January 2003Agreement (Phase 1 & 2) August 2005GFATM / Office of thePrincipal Recipient, Ministryof HealthOffice of the PrincipalRecipient, Ministry ofHealth/Sub-RecipientsGFATM / Office of thePrincipal Recipient, Ministryof HealthOffice of the PrincipalRecipient, Ministry ofHealth/Sub-RecipientsGFATM / Office of thePrincipal Recipient, Ministryof HealthOffice of the PrincipalRecipient, Ministry ofHealth/Sub-RecipientsGFATM / Office of thePrincipal Recipient, Ministryof HealthOffice of the PrincipalRecipient, Ministry ofHealth/Sub-RecipientsOffice of the PrincipalRecipient, Ministry ofHealth/Sub-RecipientsOffice of the PrincipalRecipient, Ministry ofHealth/Sub-RecipientsGFATMGFATMCCC-SCCCC-SCCCC/CCC-SC/MOHOffice of the PrincipalRecipient, Ministry of HealthOffice of the PrincipalRecipient, Ministry of HealthRound 1 Memoranda ofAgreement (Phase 1 & 2)Round 2 Program GrantAgreements (Phase 1 & 2)Round 2 Memoranda ofAgreement (Phase 1 & 2)Round 4 Program GrantAgreements (Phase 1 & 2)Round 4 Memoranda ofAgreement (Phase 1 & 2)Round 5 Program GrantAgreements (Phase 1 & 2)Round 1 Periodic Reports:Q1-Q5 Quarterly Reports;Q6/7-Q10/11 Semi-AnnualReports2004 & 2005 Annual ReportsRound 2 Periodic Reports:Q1-Q4 Quarterly ReportsQ5/6-Q8/9 Semi-AnnualReports2004 & 2005 Annual ReportsRound 4 Periodic ReportsQ1/2 & Q4/5 Semi-AnnualReportsGrant ScorecardCAM-102-G01-H-00Grant ScorecardsCAM-202-G02-H-00CAM-202-G03-M-00CAM-202-G04-T-00GFATM: Terms of Reference forthe Management Processes,Structure and Membership inCambodia (Version 4)CCC Sub CommitteeStructure, Revised VersionGuidance on Strengthening theIntegration of the GFATMGrants into National ProgramsMonitoring and EvaluationGuidelines, Versions 1-3Financial Guidelines, Versions1-4August 2003June 2005October 2003March 2006December 2003March 2006June 2005August 2005VariousVariousVariousJune 2005October 2005December 2003November 200514 December2005Version 3: August2006Version 4: August2006Page 107

Office of the PrincipalRecipient, Ministry of HealthOffice of the PrincipalRecipient, Ministry of HealthOffice of the PrincipalRecipient, Ministry of HealthOffice of the PrincipalRecipient, Ministry of HealthOffice of the PrincipalRecipient, Ministry of HealthOffice of the PrincipalRecipient, Ministry of HealthOffice of the PrincipalRecipientOffice of the PrincipalRecipientPricewaterhouseCoopersPricewaterhouseCoopersPricewaterhouseCoopersMid-Term Review TeamMinistry of HealthNational TuberculosisControl Program – Ministryof HealthNational TuberculosisControl Program – Ministryof HealthNational Centre forTuberculosis and LeprosyControl (CENAT) – Ministryof HealthNational Centre forTuberculosis and LeprosyControl (CENAT) – Ministryof HealthNational Centre forTuberculosis and LeprosyControl (CENAT) – Ministryof HealthNational Centre forTuberculosis and LeprosyControl (CENAT) – Ministryof HealthProcurement Guidelines,Versions 1-8Bulletin, Issues 1-3Assessment of the Capacitiesand Requirements of the FirstRound Sub-RecipientsAssessment Report of theCapacities and Requirementsof the Sub-Recipients of Round2Assessment Report of theCapacities and Requirementsof the Sub-Recipients of Round4Final Report: The Assessmentof the Capacities andRequirements of the Round 5Sub-RecipientsMinutes of Quarterly MeetingsField Visit ReportsAudited Financial Statement2005 for Round 1Audited Financial Statement2005 for Round 2Internal Control ReportReport: Mid-Term ReviewRounds One and TwoHealth Sector Strategic Plan2003-07 – Volume 1Guidelines on Supervision forNational Tuberculosis ControlProgramGuidelines on CommunityDOTS ImplementationNational Health Policies andStrategies for TuberculosisControl in the Kingdom ofCambodia 2001-2005National Health Policies andStrategies for TuberculosisControl in the Kingdom ofCambodia 2006-2010National Health Strategic Planfor Tuberculosis Control 2001-2005National Health Strategic Planfor Tuberculosis Control 2006-2010Version 8: August2006Issue 3: March2006?January 2004May 2005June 2006VariousVariousDecember 2004 –January 2005August 2002March 2003December 2004July 2001March 2006November 2001May 2006Page 108

National AIDS Authority(NAA)National Centre forTuberculosis and LeprosyControl (CENAT) – Ministryof HealthNational Centre forTuberculosis and LeprosyControl (CENAT) – Ministryof HealthNational Malaria Centre(CNM) – Ministry of HealthNational Institute of PublicHealth & MalariaConsortiumNational Centre ofParasitology, Entomology,and Malaria ControlNational Centre ofParasitology, Entomology,and Malaria ControlNational Strategic Plan for aComprehensive and Multi-Sectoral Response toHIV/AIDS 2001-2005Report – National HIVSeroprevalence SurveyAmongst TB Patients inCambodia, 2003Report – National HIVSeroprevalence SurveyAmongst TB Patients inCambodia, 2003Strategic and OperationalMaster Plan for National VectorBorne and Parasitic ControlProgramsCambodia National MalariaBaseline Survey 2004 ReportAnnual Progress Report of theNational Centre forParasitology, Entomology andMalaria Control Program 2004Annual Progress Report of theNational Centre forParasitology, Entomology andMalaria Control Program 2005December 2001March 2005March 2006July 2001August 2005??Page 109

Annex 5: List of Indicators Included in Consolidated M&E PlansRound 2 – HIV/AIDS Indicators1.1 Number of peer educators, HDTs received initial and refreshertraining in HIV/AIDS, sexual health and inter-personalcommunication1.2 Number of people (including fishermen, workers, IDSWs, youngpeople aged 10-24 years and rural people) received education onHIV/AIDS and sexual health1.3 Number of clients referred to RH, HIV/AIDS, and STI services bypeer educators and health development teams1.4 Number of clients (all types) receiving VCCT at RHAC urban clinicsand health posts1.5 Number of pregnant women who received VCCT (these figures areincluded in the indicator above)1.6 Number of clients receiving HIV counselling and testing (nationalfigures for public health facilities – this excludes figures of RHACabove)1.7 Number of STI cases among military men treated for STIs1.8 Number of STI cases treated in RHAC clinics and health posts1.9 Number of condoms sold and distributed2.10 Number of doctors, nurses trained/retrained on HAART2.11 Number of patients on ARV Therapy2.12 Number of people living with advanced HIV infection receiving ARVaccording to the national guidelines (national figure)2.13 Number of children living with HIV/AIDS receiving ARV treatment2.14 Number of PLWHA/peer educators trained on ART adherence2.15 Number of patients provided treatment for OIs during the reportingperiod (non-cumulative)2.16 Number of home based care teams established2.17 Number of self support groups established2.18 Number of PLHAs reached /supported by the project3.19 Percentage of ARV drug distribution made correctly and on timeaccording to national program requirements3.20 Number and percentage of sites (ODs, PHDs, and hospitalsnationwide) that are provided required drugs and supplies on timePage 110

Round 2 – Malaria Indicators1.1 Number of health staff trained / retrained on Malaria BCC/ MalariaHealth Education1.2 Number of VHVs trained on Malaria BCC / Malaria HealthEducation1.3 Number of people reached by Malaria Health Education1.4 Proportion of severe malaria cases among the total confirmedmalaria cases reported in the country from the public healthfacilities2.5 Number of IBNs procured and distributed to the target villages2.6 Number of service providers (health staff & VHVs) trained intreatment of nets2.7 Percentage of families living in endemic areas that have sufficienttreated bed nets2.8 Percentage of population at risk sleeping under insecticide treatednets the previous night, measured during peak malariatransmission season3.9 Number of RDT used (based on 300 hyper-endemic villages)3.10 Number of treatments used (based on 300 hyper-endemic villages)3.11 Number of RDTs Sold3.12 Number of Malarine® Sold3.13 Number of private providers trained in providing correct counsellingon EDAT3.14 Percentage increase of those living in endemic areas who reportusing Malacheck last time they (confirmed or suspected) hadmalaria3.15 Percentage increase of those living in endemic areas who reportusing Malarine last time they (confirmed or suspected) had malaria3.16 Percentage of patients with malaria in public health facilitiesprescribed correctly according to national guidelines3.17 Percentage of public health facilities which maintain stocks of antimalarialsand rapid tests with no out-of-date stocks3.18 Mean percentage of target population (with a 95% confident interval)specifying VMW teams as the first choice for diagnosis andtreatment in the event of developing a fever4.19 Percentage of supervised public health facilities correctly recordingand reporting malaria data4.20 Percentage of provinces and operational districts with appropriateand realistic decentralized operational plansPage 111

4.21 Number of supervision visits made to the provinces and peripheralfacilities by CNM staff4.22 Number of supervision visits made to the ODs facilities by PHD staff4.23 Number of supervision visits made to the HC facilities by OD staffRound 2 – TB IndicatorsA Case detection rateB Cure rate1.1 Number of community DOTS supporters trained in TB awarenessactivities in 24 provinces1.2 Number of population covered with community DOTS supporters1.3 Number of new smear positive TB cases detected in areasimplementing the DOTS program1.4 Number of new smear positive TB cases registered under DOTS (in aspecific period)2.5 Number of health staff from TB unit to be retrained in TB controland DOTS2.6 Number of health staff from HCs trained/retrained in basic TBcontrol and DOTS3.7 Number of adult population who received community based-healtheducation on TB and DOTS3.8 Number of high school students who received basic information onTB and DOTS4.9 Proportion of the TB patients who have a general understanding ofTB and DOTS4.10 Proportion of indigenous people who understand what is TB out ofthose who have been exposed is specially developed audio-visualIEC materials4.11 Proportion of government health staff who have thoroughunderstanding of NTP guidelines and protocols for treatment andfollow-up4.12 Number of surveys/studies conducted by CENAT5.13 Number of community DOTS watchers trained/retrained in sputumcollection, treatment observation /support in two provinces5.14 Number of TB suspects referred to health facilities for smearexaminationPage 112

Round 4 – HIV/AIDS Indicators1.1 Number of provincial ODs with at least 1 site providing ARVs1.2 Number of ARV sites with sufficient ARV drug supplies1.3 Number of national and referral hospitals providing ART for HIVinfected children1.4 Number of health staff trained on HAART adherence and counselling/OI management1.5 Number of medical consultations for patients on HAART duringreporting period (non-cumulative)1.6 Number of people with advanced HIV infection receiving ARVsaccording to national guidelines1.7 Number of people with advanced HIV infection receiving ARVsaccording to national guidelines (national figure)1.8 Number of health staff trained on palliative care1.9 Number of medical consultations for OIs during reporting period(non-cumulative)2.10 Number of PLHAs who received OI treatment/prophylaxis during thereporting period (non-cumulative)2.11 Number of patients receiving palliative care and treatment2.12 Number of provincial ODs with at least 1 MMM2.13 Number of PLHAs participating in support group activities duringthe reporting period (non-cumulative)2.14 Number of PLHAs receiving psycho-social care and support2.15 Number of OVCs receiving psycho-social care and support3.16 Number of provincial ODs that have at least 1 facility offering fullpackage of PMTCT3.17 Number of ODs with IEC/BCC activities related to PMTCT3.18 Number of service delivery points with sufficient ARV drugs and HIVtest kits supplies3.19 Number of health care workers, counsellors, and PLWHAstrained/retrained in PMTCT (able to demonstrate competency intheir areas of delivering PMYCY services within ANC services3.20 Number of ANC clients in target health facilities who received VCCT,including testing and pre- and post-test counselling3.21 Number of HIV-infected pregnant women who received completecourse of ARV prophylaxis to reduce the risk of MTCT of HIVPage 113

Round 4 - Malaria Indicators1.1 Number of VHVs/key women agent health educators trained inMalaria1.2 Number of people reached by Malaria education discussion session1.3 Number of trainers trained (TOT training)/ school teachers trainedin Malaria School Health Education1.4 Number of pupils/ students reached by Malaria School HealthEducation1.5 Proportion of severe malaria cases among the total confirmedmalaria cases reported in the country from the public health1.6 Case fatality rate among severe malaria cases reported in thecountry from the public health facilities2.7 Number of Long Lasting Insecticide Mosquito Net (LLIMN) procured(Public and Private Sector)2.8 Number of free Long Lasting Insecticide Mosquito Net (LLIMN)distributed to beneficiaries through public sector / private sectorsby SMCC2.9 Number of LLIMNs sold to the beneficiaries through socialmarketing (private sector)2.10 Number of Insecticide Treatment Kit (ITK) sold to the beneficiariesthrough social marketing (private sector)2.11 Number of targeted villages in remote areas covered with freedistribution of LLIMN2.12 Percentage of people at risk sleeping under an Insecticide TreatedNet the previous night (includes both types of nets)2.13 Number of population at risk owning Long Lasting InsecticideMosquito Net (LLIMN)Page 114

Annex 6: List of Sub-Recipient by Round and by GrantSub Recipient Round 1 Round 2 Round 4 Round 5Name Acronym H/A H/A TB M H/A M H/A TB HS1 Cambodian Red Cross CRC X X2 CARE CARE X X3 Central Medical Store CMS X4 National Centre for Tuberculosis and Leprosy Control CENAT X X5 National Centre for Malaria CNM X X6 Cambodian PLWH Network CPN+ X7 Douleur Sans Frontieres DSF X X8 French Red Cross FRC X X9 Health Unlimited HU X X10 Khmer HIV/AIDS NGO Alliance KHANA X X11 Medicins du Monde MDM X X X12 Ministry of National Defence (MND) MND X13 Min. of Social Affairs, Veterans & Youth Rehabilitation MOSVY X14 National Centre for HIV/AIDS, Dermatology and STDs NCHADS X X X X15 National Centre for Maternal and Child Health NCMCH X16 National Paediatric Hospital/World Vision International NPH/WVI X17 Partners for Development PFD X X18 Pharmacien Sans Frontieres PSF X X X X19 Population Services International PSI X X X X20 Reproductive Health Association of Cambodia RHAC X X21 Sihanouk Hospital Centre of Hope SHCH X X X X X22 Youth Council for Cambodia YCC X23 National Blood Transfusion Centre NBTC X24 National Institute of Public Health NIPH X25 BBC World Service Trust BBC X26 Family Health International FHI X27 Save the Children Australia SCA X X28 Cambodia Health Committee CHC X29 Partners for Health and Development PFHAD X30 MoH Department of Planning and Health Information DPHI X31 MoH Department of Drugs and Food DDF X32 Medicam MEDICAM XTotal Number of Sub Recipients Rounds 1-5: 11 6 1 4 9 4 15 5 3Round 1, 2, 4 Sub-RecipientsPage 115