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Technical Assistance Consultant’s Report

Project Number: 40375 April 2010

TA 7279-REG: Second Greater Mekong Subregion Regional Communicable Diseases Control Project Final Consultation Report Prepared by: Cardno Emerging Markets (Aust) Pty Ltd For the Ministry of Health, Phnom Penh, Cambodia

Department of Planning and Budgeting, Ministry of Health, Lao PDR Administration of Preventive Medicine, Ministry of Health, Hanoi, Viet Nam

This consultant’s report does not necessarily reflect th e views of ADB or t he Go vernment concerned, and ADB and the Go vernment cannot be held liable for its contents. All the views expressed herein may not be incorporated into the proposed project’s d esign.

Second Greater Mekong Subregion

Regional Communicable Diseases Control Project

ADB TA 7279 - REG

FINAL CONSULTANT REPORT April 2010

Managed on Behalf of the

Asian Development Bank

by

Cardno Emerging Markets (Aust) Pty Ltd

ADB TA 7279 – REG: Second GMS Regional Communicable Diseases Control Project

Final Consultant Report – April 2010 Page i

CURRENCY EQUIVALENTS

(as of 1st November 2009)

Cambodia Currency Unit – riel (KR)

$1.00 = KR4,200

Lao People‘s Democratic Republic Currency Unit – kip (KN)

$1.00 = KN8,500

Viet Nam Currency Unit – dong (D)

$1.00 = D17,002

NOTES

(i) The fiscal years (FY) of the Governments of Cambodia and Viet Nam ends on 31 December, and for Lao People‘s Democratic Republic, on the 30th September each year.

(ii) In this report, ―$‖ refers to US dollars.


Final Consultant Report – April 2010 Page ii

ABBREVIATIONS

ADB Asian Development Bank. AI AFD

Avian Influenza. Agence Francaise de Development.

AHI Avian and Human Influenza. AIDS AOP APSED

Acquired Immunodeficiency Syndrome. Annual Operating Plan. Asia Pacific Strategy for Emerging Diseases.

ARI Acute Respiratory Infection. ASEAN AusAID

Association of Southeast Asian Nations. Australian Agency for International Development.

BCC Behaviour Change Communication. BTC Belgian Technical Cooperation. CD Communicable Disease. CDC Communicable Diseases Control. CDC1 CDC2 CDCD CDHS

First Communicable Diseases Control Project. Second Communicable Diseases Control Project. Communicable Diseases Control Department, Cambodia. Cambodia Demographic Health Survey.

CMPE CPR CHS

Centre for Malaria, Malariology, Parisitology and Entomology, (Lao PDR). Contraceptive Prevalence Rate Commune Health Station.

CHW Community Health Worker. CLV Cambodia, Lao PDR and Viet Nam. COP COPE

Community of Practice. (related to KM) Client Oriented Provider Efficient. (Quality of Care).

DALY Disability Adjusted Life Years. DD Diarrheal Diseases. DF Dengue Fever. DFID United Kingdom Department for International Development. DHF Dengue Hemorrhagic Fever. DHP Department of Hygiene and Prevention, (Lao PDR). DOH DPF DTWG EA EID EIRR EMDP

Department of Health. (Vietnam). Department of Planning and Finance. (Vietnam and Lao PDR). District Training Working Group. Executing Agency. Emerging Infectious Disease. Economic Internal Rate of Return. Ethnic Minority Development Plan.

EMG Ethnic Minority Group. EPI Expanded Program of Immunization. FAO FETP

Food and Agriculture Organisation. Field Epidemiology Training Program.

GDP Gross Domestic Product. GDPMEH General Department of Preventive Medicine and Environmental Health. (VN) GMS Greater Mekong Subregion. GoL GoV HC

Government of Lao Peoples Democratic Republic. Government of Vietnam. Health Centre.


Final Consultant Report – April 2010 Page iii

HCFP Health Care Funds for the Poor. HCMC Ho Chi Minh City. HEF Health Equity Funds. HRD HSSP

Human Resource Development. Health Systems Support Program, Cambodia.

IA IDDP IEC

Implementing Agency. Indigenous Peoples Development Plan. Information, Education and Communication.

IMC IHR

Inter-Ministerial Committee International Health Regulations.

IMCI Integrated Management of Childhood Illnesses. IMR Infant Mortality Rate. (number of deaths of children < 1/ 1000 live births) INGO International Non-governmental Organization. IOM IVM

International Organisation for Migration. Integrated Vector Management.

JFPR Japanese Fund for Poverty Reduction. KM L2280 M&E

Knowledge Management. ADB funded Preventative Health System Support Project. Monitoring and Evaluation.

M&EF MEF MBDS

Monitoring and Evaluation Framework. Ministry of Economy and Finance. (Cambodia). Mekong Basin Disease Surveillance Program.

MCH Maternal and Child Health. MDG Millennium Development Goal. MfDR MMR

Managing for Development Results. Maternal Mortality Ratio. (number of maternal deaths/ 100,000 live births)

MOF MOH

Ministry of Finance. Ministry of Health.

MPI Ministry of Planning and Investment. MRD NCHDSC

Ministry for Rural Development. National Centre for HIV/AIDS, Dermatology, and Sexually Transmitted Diseases Control.

NCLE National Centre for Laboratory and Epidemiology, (Lao PDR). NCPEMC National Centre for Parasitology, Entomology and Malaria Control, Cambodia NIMPE National Institute for Malaria, Parasitology, and Entomology, (Vietnam). NIPH National Institute of Public Health, (Cambodia and Lao PDR). NIHE NSEDP6

National Institute for Hygiene and Epidemiology. 6th National Socio-economic Development Plan.

NSC NTD

National Steering Committee Neglected Tropical Diseases.

O&M ODA OECD PCR PPIU PHC

Operation and Maintenance. Office of Development Assistance. Organisation for Economic Cooperation and Development. Project Completion Report.. Provincial Project Implementation Unit. Primary Health Care.

PHD Provincial Health Department. PHSSP PMO

Preventative Health System Support Project. Project Management Office.

PMU Project Management Unit. PMC Preventative Medicine Centre. (in provinces of Viet Nam)


Final Consultant Report – April 2010 Page iv

PPC Provincial People‘s Committee. PPMC Provincial Preventive Medicine Centre. PRC PSC

People‘s Republic of China. Provincial Steering Committee.

PTWG Provincial Training Working Group. QOC Quality of Care. RBM RCAPE

Results Based Management. Regional Country Assistance Program Evaluation.

RCSP Regional Cooperation Strategy and Program. RCU Regional Coordination Unit. RETA Regional Technical Assistance. RGoC RPG

Royal Government of Cambodia. Regional Public Goods.

RPPTA Regional Project Preparation Technical Assistance. RRP Report and Recommendation of the President. SARS Severe Acute Respiratory Syndrome. SBT Skills Based Training. SC SEDP

Steering Committee. Socio-economic Development Plan.

SGIA SMS

Second Generation Imprest Account. Secondary Medical School.

SoE ST STA

Statement of Expenditure. State Treasury. Short Term Technical Assistance.

STH Soil Transmitted Helminths. STI Sexually Transmitted Infections. SWAp Sector-wide Approach. TA Technical Assistance. TB Tuberculosis. TOT TWG

Training of Trainers Training Working Group.

UNICEF United Nations Children‘s Fund. VAS VAAC

Vietnam Accounting Standards. Viet Nam Administration of HIV/AIDS Control.

VHW Village Health Worker. WB World Bank. WHO World Health Organization. WPRO WU

Western Pacific Regional Office, World Health Organisation. Women‘s Union.

YU Youth Union.


Final Consultant Report – April 2010 Page v

Map 1. Economic Corridors in the Greater Mekong Subregion.


Final Consultant Report – April 2010 Page vi

Map 2. Second GMS Regional Communicable Disease Control Project

NOTE: Since this report was written Preah Vihear Province in Cambodia has been withdrawn from CDC2.


Final Consultant Report – April 2010 Page vii

Map 3. National Map of Cambodia with Project Districts

NOTE: Since this report was written Preah Vihear Province in Cambodia has been withdrawn from CDC2.


Final Consultant Report – April 2010 Page viii

Map 4. National Map of Lao PDR with Project Districts


Final Consultant Report – April 2010 Page ix

Map 5. National Map of Viet Nam with Project Districts


Final Consultant Report April 2010 Page x

TABLE OF CONTENTS

I. THE PROPOSAL ................................................................................................................. 1

II. RATIONALE: SECTOR PERFORMANCE, PROBLEMS, AND OPPORTUNITIES ............. 1

A. Rationale for a Regional Approach....................................................................................... 1 A.1. Experience from CDC 1 .................................................................................................. 1 A.2. Scope of CDC2 Project ................................................................................................... 2 A.2.1. Impact and Outcomes ..................................................................................................... 2 A.2.2. Components ................................................................................................................... 3 A.3. Geographic and Development Focus of CDC2................................................................ 3 A.4. Project Benefits and Beneficiaries ................................................................................... 5 A.4.1. Direct and Indirect Beneficiaries ...................................................................................... 5 A.4.2. Justification for CDC2 ..................................................................................................... 6 A.4.3. Regional Security ............................................................................................................ 6 A.4.4. Economic Corridors – Economic and Social Issues ........................................................ 7 A.5. Regional Perspective ...................................................................................................... 9 A.6. ADB Investment in CDC2 .............................................................................................. 13 A.7. Social and Poverty Impact............................................................................................. 13 A.8. Economic Viability ......................................................................................................... 14

B. Performance Indicators and Analysis ................................................................................ 15

C. Analysis of Key Problems and Opportunities .................................................................... 18 C.1. Communicable Disease Priorities.................................................................................. 18 C.2. Regional Framework for CDC ....................................................................................... 19 C.2.1. Regional Challenges and Opportunities ........................................................................ 20 C.3. Challenges in National CLV Programs for CDC ............................................................ 21 C.3.1. HRD and Skills Training ................................................................................................ 24 C.3.2. Vulnerable Populations ................................................................................................. 26 C.3.3. Improved CDC along Borders and Economic Corridors ................................................ 26 C.4. Shortage of Regional Public Goods .............................................................................. 28

D. External Assistance ............................................................................................................. 29 D.1. Cambodia ..................................................................................................................... 29 D.2. Lao PDR ....................................................................................................................... 30 D.3. Viet Nam ....................................................................................................................... 30 D.4. World Health Organization ............................................................................................ 31 D.5. Mekong Basin Disease Surveillance Program ............................................................... 32

E. Lessons Learned ................................................................................................................. 33 E.1. Regional and Cross-Border Collaboration in Health ...................................................... 33

III. THE PROPOSED PROJECT ............................................................................................. 38

A. Impact and Outcomes ......................................................................................................... 38 A.1. Impact Statement .......................................................................................................... 38 A.2. Outcomes ..................................................................................................................... 38 A.3. Components ................................................................................................................. 39 A.3.1. Component 1: Strengthening Regional Cooperation in CDC ......................................... 39 A.3.2. Component 2: Strengthening National Surveillance, Response and Health Systems .... 41

B. Special Features .................................................................................................................. 49

C. Cost Estimates ..................................................................................................................... 49

D. Financing Plans ................................................................................................................... 50

E. Implementation Arrangements ........................................................................................... 52 E.1. Project Management ..................................................................................................... 52 E.2. Implementation Period .................................................................................................. 53 E.3. Outline of Implementation Responsibilities .................................................................... 53


Final Consultant Report April 2010 Page xi

E.4. Procurement ................................................................................................................. 54 E.5. Consulting Services ...................................................................................................... 54 E.6. Contracting Research and Training Institutions ............................................................. 55 E.7. Accounts and Audit ....................................................................................................... 55 E.8. Disbursement Arrangements ......................................................................................... 56 E.9. Reporting ...................................................................................................................... 56 E.10. Project Review .............................................................................................................. 56 E.11. Project Performance Monitoring and Evaluation ............................................................ 57 E.12. Good Governance ......................................................................................................... 57 E.13. Capacity of Executing and Implementing Agencies ....................................................... 57

IV. PROJECT BENEFITS, IMPACTS, ASSUMPTIONS AND RISKS ...................................... 58

V. ASSURANCES .................................................................................................................. 62

A. Special Assurances ............................................................................................................. 62

B. Conditions for Grant Effectiveness .................................................................................... 62

TABLES: Table 1: Project Provinces Populations in proposed Clusters for CDC2. ......................................... 4 Table 2: Ethnic Minority Population in proposed Clusters for CDC2. ............................................... 4 Table 3: Summary of Cost Estimates: Lao PDR ............................................................................ 50 Table 4: Summary of Cost Estimates: Cambodia .......................................................................... 50 Table 5: Summary of Cost Estimates: Viet Nam/a ......................................................................... 50 Table 6: Project Financing Plan: CLV countries ............................................................................ 51 Table 7: Project Financing Plan: Cambodia .................................................................................. 51 Table 8: Project Financing Plan: Lao PDR .................................................................................... 51 Table 9: Project Financing Plan: Viet Nam .................................................................................... 52 Table 10: Population of Project Provinces proposed for CDC2. .................................................... 59

MAPS: Map 1. Economic Corridors in the Greater Mekong Subregion. ...................................................... v Map 2. Second GMS Regional Communicable Disease Control Project ........................................ vi Map 3. National Map of Cambodia with Project Districts ............................................................... vii Map 4. National Map of Lao PDR with Project Districts ................................................................ viii Map 5. National Map of Viet Nam with Project Districts .................................................................. ix Map 6. Hydro Power Development in the CLV Region ................................................................. 10 APPENDICES: 1. Design and Monitoring Framework.

2. Project Scope.

3. Project Rationale.

4. Situation Analysis.

5. Lessons learned.

6. Cost Estimate and Financing Plans.

7 Implementation Schedule.

8. Implementation Arrangements.

9. Procurement Plans

10. Training Systems Development Framework. 11. Economic and Financial Analysis.


Final Consultant Report April 2010 Page xii

12. Fiduciary Financial Assessment. 13. Social Analysis. 14. Ethnic Minority Development Plan. 15. Gender Action Plan. 16. Results Framework

17. Project Provincial Profiles.

18 External Assistance to the Sector (Prepared in January 2010).

19. Performance Based Management

20. Regional Coordinating Unit


Final Consultant Report – April 2010 Page 1

I. THE PROPOSAL

II. RATIONALE: SECTOR PERFORMANCE, PROBLEMS, AND OPPORTUNITIES

A. Rationale for a Regional Approach

1. Since 1992, the Asian Development Bank (ADB) has supported the Greater Mekong Sub-region (GMS) Economic Cooperation Program to enhance cooperation between Cambodia, Lao People‘s Democratic Republic (Lao PDR), Myanmar, Thailand, Viet Nam, and the People‘s Republic of China (PRC), specifically Yunnan Province. Areas of focus include: strengthening infrastructure linkages; facilitating cross-border trade, investment and tourism; enhancing private sector participation and competitiveness; developing human resources and skills competencies; protecting the environment; and promoting sustainable use of shared natural resources.

2. However, it has become increasingly evident that the benefits of regional economic integration, including increased economic activities and job opportunities across borders, as well as ‗common use‘ of health facilities, are accompanied with undesired side effects, such as: the spread of HIV/AIDS and other communicable diseases; increased drug trafficking; increased illegal labor migration and related issues of human trafficking and child labor; environmental degradation; escalating land prices causing farmers to become landless; and increasing traffic accidents. There is also concern that integration may be worsening the income distribution in these countries as it is leading to an expansion of the formal sector, at the cost of the informal sector where most of the poor are engaged.1 To address these issues, ADB developed the Regional Cooperation and Strategy Program (RCSP) for 2004 – 2008, which supported2 pro-poor, sustainable growth in the GMS including initiatives to: (i) identify issues related to cross-border migration, and related health and other social issues, and to undertake studies to address these issues; and (ii) to implement cooperative arrangements for addressing health and other social issues related to cross-border migration, particularly for HIV/AIDS prevention and control, and improvement of health and other social services delivery to EMGs in the border areas; and (iii) prevention and control of malaria for border areas.3

A.1. Experience from CDC 1

3. The GMS Regional Communicable Diseases Control (CDC) Project (referred to as ‗CDC1‘) was a USD38.75 million project over four years to support CDC in Cambodia, Lao PDR and Viet Nam (CLV). The Project was supported by the Governments of the participating countries, ADB and the World Health Organization (WHO). The project aimed to:

(i) strengthen national surveillance and response systems;

(ii) improve CDC for vulnerable groups; and

(iii) strengthen regional collaboration in CDC.

4. Whilst being part of an integrated regional approach with a common goal and objectives, each country project has been tailored to the country needs and adapted to the country planning process and programmatic timelines. CDC1 concluded in December 2009 and is considered to have made good progress in CDC preparedness and response during the four years, illustrated by a high level of awareness across sectors, within governments, and in communities at large, of the 1 Asian Development Bank, 2001. Moving the Poverty Agenda Forward in Asia and the Pacific: The Long-term Strategic Framework for

the Asian Development Bank (2001-2015) 2 The fifth meeting of the GMS Human Resource Development Working Group, held in June 2004 confirmed that communicable

diseases control (CDC) is a top priority for regional collaboration in view of emerging diseases. 3 Asian Development Bank, 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (2004-2008), p.31



issues relating to communicable diseases and their impacts. The Second GMS Regional Communicable Diseases Control Project (referred to as ‗CDC2‘) will potentially have a greater impact on disadvantaged populations and ethnic minority groups, as CDC2 is more focused on border districts and will be working in less districts that was undertaken in CDC1.

A.2. Scope of CDC2 Project

5. The CDC2 Project will use the experience of CDC1 as a basis on which to develop CDC2 and to contribute to the further development of CDC in the GMS. The Project will focus on cross border cooperation for communicable diseases control and prevention. It will address CDC issues associated with cross border traffic and population movements and impacts on border populations, which have been rapidly accelerating, enabled by the GMS economic corridors and subsidiary road networks. In recent years, globalization has transformed borders from barriers to bridges, and this transformation has shifted attention to cross-border matters that localities have in common. Regional economic developments, catalytic events and their economic impact, and high-level political commitment to attaining Millennium Development Goals (MDGs) have generated strong support for regional cooperation across health sectors. The current GMS setting favors a regional approach to CDC that can significantly improve the health of the poor in CLV.

6. Activities under the CDC2 Project are pro-poor, focusing on rural and remote populations in the project districts of CLV border areas, where many ethnic groups and the poorest reside. Women and children will be the major beneficiaries of the primary health care (PHC) and community-based interventions, including community based CDC surveillance and responses in these border provinces and districts.

A.2.1. Impact and Outcomes

Impact Statement

7. The overall project impact will be improved health for the populations in the project provinces in the border region, which will assist the Ministries of Health in Cambodia, Lao PDR and Vietnam (CLV) to achieve MDGs 4, 5 and 6 and by reducing the spread of emerging and neglected communicable diseases thereby reducing morbidity and mortality, in particular among children, and the economic cost of these diseases.

Outcomes

8. The expected project outcomes will be improved regional security through:

(i) Governments of GMS adopting a harmonized approach in the region, with established long-term multi-sector strategic national policies for prevention and emergency response to communicable diseases;

(ii) Strengthened regional and MOH‘s technical capacity for surveillance and response, following WHO guidelines for implementation of the IHR and APSED with timely responses to epidemics in provinces with common borders that are likely to have a major impact on public health and the economy in the region;

(iii) Increased capacity of national, provincial and district health services in results based management and technical capability with integrated CDC and health services particularly underserved populations who have a high disease burden neglected tropical diseases (NTDs) and are at risk from newly emerging diseases (EIDs); and

(iv) Improved knowledge management and community of practice, policies, strategies, and coordination among the GMS countries to improve CDC, through regional cooperation in cross-border cluster areas.



9. A total of approximately $51 million grant and loan funds will be made available from ADB for CDC activities in the three countries, with a focus on 29 provinces, 102 districts, in the border regions within the economic corridors. In reality, CDC2 cannot cover all of the demands summarized above. The optimal solution is that CDC2 be used as additional investment to supplement other ongoing and pipelined projects of both donors and governments of CLV countries. Under this approach, a number of key areas are selected to be considered for funding and the ―key words‖ for these are: ‗linkage to economic corridor‘; ‗border province and district focus‘; ‗surveillance and response‘; ‗regional cooperation‘; and ‗the poor and EMGs focus‘. These ―key words‖ then become short guiding principles for the Consultant Team to propose project areas (three clusters), project components (2) and sub-components (10), and project activities (various).

10. The Project will be implemented over a period of five years, commencing in July 2010 and will be adjusted yearly on the basis of Annual Operating Plans (AOPs) developed at the provincial level, and approved by the National Steering Committees (NSC).

A.2.2. Components

Component 1: Strengthening Regional Cooperation in CDC

11. The Project will establish and support mechanisms to increase regional cooperation, with a focus on EIDs and NTDs, in selected border and cross-border districts in the economic corridors in the three clusters of border provinces in CLV (see Map 2). The Project will support compatible and coordinated GMS strategies for CDC across borders, including: (i) assessment of regional health threats and plans for implementing a harmonized approach to CDC (EIDs and NTDs) based on WHO IHR, APSED and the MBDS Action Plan; (ii) establishment of regional focal points in the MOH to improve regional cooperation in CDC; (iii) establishment ofa regional Project Steering Committee (RPSC) and national working groups; (iv) formalization of agreements on CDC cross-border cluster activities; (v) enhanced cross border planning, monitoring and evaluation based on a comprehensive baseline survey; and (vi) sustained knowledge management.

Component 2: Strengthening National Surveillance, Response and Health Systems

12. Component 2 will strengthen institutional structures, partnerships, and policies through Project support for the development of: (i) multi-sector long-term strategic national policies for regional collaboration for emergency response and prevention of communicable diseases; (ii) incorporating WHO guidelines for implementing the IHR; (iii) national multi-sector mechanisms to define sector and departmental roles for emergency CDC responses; and (iv) consolidated and expanded provincial and district surveillance and response capacity. Project provinces will be supported to increase the capacity of health workers to provide quality health services, including surveillance, response and preparedness. Following a clearly planned strategy from inter-provincial, to provincial, to district, to community levels, with gender issues an integral part of all activities, the project will support: (i) strengthening human resource planning and management; (ii) building training capacity at provincial and district levels; (iii) training of district and commune / health center staff to improve quality of health services, including for community-based CDC preparedness, (iv) scholarships for up-grading and advanced specialist training; and (vi) improved quality of provincial laboratory services will also be provided.

A.3. Geographic and Development Focus of CDC2

13. The CDC2 Project will be funded by the Asian Development Bank (ADB) and the Governments of Cambodia, Lao PDR, and Viet Nam. The Project will cover three clusters of provinces in CLV with common borders, providing assistance in controlling and preventing cross-border transmission of communicable diseases. It will also support regional arrangements to increase cooperation with People‘s Republic of China (PRC), Myanmar, and Thailand for sharing surveillance and the development of cooperative CDC responses in the GMS. The proposed clusters will comprise of:



Cluster 1: In Lao PDR; Phongsaly, Luangnamtha, Oudomxay, Bokeo and Khammuane (5 provinces) In Viet Nam; Dien Bien, Son La, Thanh Hoa, Nghe An, and Ha Tinh (5 provinces) making a total of 39 districts in 10 provinces. The project will engage with the MOHs and provincial and district health departments of PRC, and Thailand and Myanmar in contiguous border areas. The RPPTA team have requested that Lai Chau and Lao Cai in northern Vietnam also be considered for inclusion in CDC2 as part of the northern cluster, as well as the inclusion of Quang Binh in the central region of Vietnam to join with Khammuane province in Lao PDR. Cluster 2: In Cambodia; Rattanakiri, Stung Treng, and Mondolkiri (3 provinces) In Lao PDR; Saravane, Sekong, Champasak and Attapeu (4 provinces) In Vietnam; Quang Tri, Quang Nam, Dak Lak, Dak Nong and Binh Phouc (5 provinces) making a total of 39 districts in 12 provinces. The project will engage with the MOH and provincial and district health departments of Thailand in contiguous border areas. The RPPTA team have requested that Kon Tum, Gia Lai provinces in Vietnam also be considered for inclusion in CDC2 as part of the central region cluster. Cluster 3: In Cambodia; Kampot, Takeo, (2 provinces) in Viet Nam; Tay Ninh, Long An, Dong Thap, An Giang, Kieng Giang (5 provinces), (24 district in 7 provinces). The RPPTA team have requested that Svay Rieng, Prey Veng, Kampong Cham provinces in Cambodia also be considered for inclusion in CDC2 as part of the southern region cluster.

14. Expansion of CDC2 to include additional GSM Partners. It is proposed that the provincial and district health departments of PRC (Yunnan province), Thailand and Myanmar joined by contiguous border areas be invited to participate in cross border and knowledge management activities including regional technical forums and workshops.

15. The Project will provide grant funding to Cambodia and Lao PDR, and loan funding to Viet Nam. Technical assistance will be supported from the Project pool fund. The Peoples Republic of China (PRC) and Thailand and Myanmar will participate using their own national resources, or additional alternative funding arrangements.

Table 1: Project Provinces Populations in proposed Clusters for CDC2.

Country

Cluster 1 Cluster 2 Cluster 3 TOTAL Border Dist.

Border Population

Border Dist.

Border Population

Border Dist.

Border Population

Border Dist.

Border Population

Cambodia 11 190,716 6 414,848 17 605,564 Laos 18 665,854 15 645,677 33 1,311,531 Vietnam 21 1,809,269 13 863,435 18 2,019,309 52 4,692,013

Total 39 2,475,123 39 1,699,828 24 2,434,157 102 6,609,108 Table 2: Ethnic Minority Population in proposed Clusters for CDC2.

Country

Cluster 1 Cluster 2 Cluster 3 TOTAL As % of B-Pop.

EMG Pop. As % of B-Pop.



EMG Pop.

Cambodia 42.5% 80,998 0.7% 2,754 13.8% 83,752 Laos 38.3% 255,184 19.9% 128,381 29.2% 383,565 Vietnam 54.2% 981,177 32.2% 278,155 6.7% 135,119 29.7% 1,394,451

Total 50.0% 1,236,361 28.7% 487,534 5.7% 137,873 28.2% 1,861,768 Source: Population data gathered for CDC2 project preparation see Appendix 17 - Project Provincial Profiles



A.4. Project Benefits and Beneficiaries

16. The Project will help minimize the social and economic impact of communicable diseases in GMS by helping departments of health in the border provinces of Cambodia, Lao PDR and Vietnam to respond rapidly and effectively to contain the spread of emerging and epidemic diseases. It will strengthen provincial-level, cross border cooperative capacity to contain outbreaks of communicable diseases that can have devastating human and economic impacts, most dramatically illustrated by the Severe Acute Respiratory Syndrome (SARS) pandemic in 2003. WHO points out new diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue noting that national investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border. By strengthening cross-border cooperation on disease surveillance and response systems, the costs associated with outbreaks will be reduced. The strengthening of provincial and district health systems, community level primary health care and activities for disease prevention will lead to improvements in public health, and decrease out-of-pocket health expenditures. These interventions will also reduce the number of sick children, thereby improving school attendance and overall physical and cognitive development.

A.4.1. Direct and Indirect Beneficiaries

17. The Project will focus on surveillance and response and control of selected diseases, which will strengthen CDC and PHC services. It will mainly benefit poor border communities in border provinces and districts of CLV, which comprise a population of 26.4 million, of which approximately 6.6 million live in the 102 targeted districts with border crossings, and of whom more than 50 percent live below or close to the poverty line. Ethnic minorities comprise 28.2 percent of the 6.6 million of the Project beneficiaries, in border districts in provinces currently nominated by governments for inclusion in CDC2. However, in most of the priority border districts in the three countries, ethnic minorities comprise the majority of the population. (see Appendix 17 Project Provincial Profiles).

18. It is estimated that 30 percent of the population in the CLV‘s project areas will directly benefit from the project services through various interventions, as summarized in Box 1. The exact number of beneficiaries will be determined after the Baseline Survey has been conducted and a more detailed assessment can be made of health services coverage, capacity, and community needs.

Box 1. Summary of activities that will directly benefit populations and health staff in CDC2

People from national to commune/village levels will be trained in various subjects related to CDC and project management through formal training courses, workshops, study tours, and fellowships. Villagers will benefit from ‗Healthy Village activities‘ implemented and monitored in selected villages. Health staff at district health centers will benefit from project direct supports such as per diem, fuel and telephone cards, basic supplies. Students and teachers will benefit from the community initiatives that support local schools for S&R and Community CDC. Local people will benefit from community initiatives that support local remote communities for Environmental Cleanup programs (for dengue control). Householder in communes/villages will benefit from community initiatives which support village rainwater jar protection initiatives (for dengue control).

19. In support of Project implementation, there are 34,425 health staff engaged in the health sector in the project border provinces and districts in CLV. Of these, 20,035 are employed at district offices, hospitals or health centers or health posts. It is anticipated that 55 percent of the total staff plus key staff from national level will receive training during the course of the Project. The exact number of staff to be trained will be determined after a Training Needs Assessments (TNA)



is undertaken at all levels in CLV.4 In addition, specific training will be provided to Village Health Volunteers (VHV) and Community Health Workers (CHW), as well as community and village representatives in support of community projects, Healthy Village initiatives, community based surveillance and response, and management of funds provided by the project.

Implementation Responsibilities

20. Whilst the main operational activities of the Project is at the provincial level and below, the national level will continue to have regular surveillance reporting from all provinces as part of the national surveillance system. In addition, the national level will also be able to respond to outbreak investigation and response in other provinces that are not included in CDC2. The provision of emergency outbreak funding and the cost of maintaining the national surveillance program is also included in the budget for national and provincial levels. An outline of the areas of responsibility for the national and provincial levels for the implementation of the CDC2 project is included in Section F, Implementation Arrangements in Part III of this document.

A.4.2. Justification for CDC2

21. CDC1 was intended to facilitate cross-border cooperation in CLV on building compatible responses to potential cross-border disease outbreaks. However, the CLV provinces or districts selected for participation in CDC1 (with a few notable exceptions) were rarely internationally contiguous, and the priority districts in the provinces were not on border areas, and/or lacked a focus on border issues, thus undermining the potential for specific joint CDC surveillance and response activities in CLV.

22. By strengthening CDC response capacity at provincial and district levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the sub-region. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue.5 The sudden and deadly outbreak of SARS early in 2003 provides a lesson. By mid 2003 SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world.6

A.4.3. Regional Security

23. By focusing in cross border cooperation for communicable diseases control and prevention, the Project will address CDC issues associated with cross border traffic and population movements and impacts on border populations which have been rapidly accelerating, enabled by the GMS economic corridors and subsidiary road networks. In recent years, globalization has transformed borders from barriers to bridges, and this transformation has shifted attention to cross-border matters that localities have in common. The current GMS setting favors a regional approach to CDC that can significantly improve the health of the poor in the CLV countries.

24. A regional focus and cooperation is justified if benefits exceed what countries acting on their own can achieve. Specifically for CDC, the rationale and justification for regional cooperation can be broken down into four broad categories:

(i) Nature of communicable disease transmission: Communicable diseases are transmitted by people, vectors, food, and elements throughout a particular geographic region irrespective of national borders.

(ii) Technology transfer: Regional cooperation enables participating countries to

share experiences and knowledge about health policies, system design, and disease control, and apply lessons learned. These technology transfers also

4 See page 43 of Appendix 13, Social Analysis Report for details of health staffing levels, and page 15, Annex 1 of Appendix 10,

Training Systems Development Framework for indicative list of training activities. 5 World Health Organization, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html. 6 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15

http://www.who.int/whr/2003/chapter5/en/index.html



facilitate greater consistency, clarity, and transparency among countries in CDC and other health matters.

(iii) Economies of scale and greater leverage: Regional cooperation helps to achieve

economies of scale for more efficient resource allocation, e.g., sharing design work, testing, expertise, and procurement. Also, participating countries can acquire greater leverage in attracting donor funding by aggregating particular underfunded endemic diseases.

(iv) Regional public goods for health: Programs to prevent HIV/AIDS and other

infectious diseases are regional public goods (RPGs). The weakest link in a chain determines the chain‘s overall strength, and thus coordination in disease prevention programs and the raising of standards across countries will provide greater protection for the populations in the region.

25. The focus of disease control needs to be geographic rather than just being based on national boundaries. Differences in national health policies, such as the cost of treatment and the quality of service may push residents of border areas to seek treatment in a neighboring country. The MOHs in each country realize the need to act in new and different ways. Importantly, countries can learn from one another what works in matters ranging from the health education needs of ethnic minority groups (EMGs) to health sector financing. Working together can also provide important leverage and opportunities to benefit from economies of scale.

A.4.4. Economic Corridors – Economic and Social Issues

26. Over the past decade or more, much of the GMS has experienced a double transition: from subsistence farming to more diversified economies, and from command economies to more open, market-based economies. While greater integration has contributed to the sub-region becoming an internationally recognized growth area, there have also been costs. The construction of new and/or upgrading of existing roads have had impacts on the environment of the sub-region from the uplands to plains to coastal areas affecting people‘s livelihoods, particularly the three-quarters still living in rural areas, where they lead subsistence or semi-subsistence agricultural lifestyles.

27. One recent trend has been the opening up of remote provinces. For example, recent studies by the International Organization for Migration detail the impacts of opening up remote areas in Cambodia to commercial enterprises. In Ratanakiri (bordered by Viet Nam and Lao PDR), the provincial population grew from 94,243 to 149,997 between 1998 and 2008; the population grew nearly 60 percent in ten years. Similarly, in neighboring Mondulkiri province, there has been an 80 percent population growth in the last five years. In both cases the change is mainly due to the influx of Khmer populations into the province.7

28. Examples of population mobility:8 In Bokeo Province in northern Lao PDR (which is the area known as ‗the golden triangle‘ where Lao PDR, Thailand and Myanmar border join one another on the Mekong River), a large casino has opened, which is funded by private investment from China. An associated hotel, shopping mall and staff quarters have been completed, and work has begun nearby on a big resort complex which will include villas, canals and golf courses. The road between the provincial centre of Bokeo and the development is being upgraded, reportedly with private investment from China. This road connects to the economic corridor through to Luangnamtha Province and Yunnan Province in China. Along this road are hundreds – perhaps thousands 9– of hectares of agricultural land have plantations producing vegetables and maize. The plantations are reportedly leased and operated by Chinese companies.

7 Haynes Sumaylo, K. K., 2009. Mapping Vulnerability to Natural Hazards In Rattanakirii. International Organization for Migration (IOM),

Mission in Cambodia. Thuon T. & Haynes Sumaylo K. K., 2009. Mapping Vulnerability to Natural Hazards In Mondulkiri. International Organization for Migration (IOM), Mission in Cambodia.

8 Details provided by local government provincial officials during RPPTA field visit to Bokeo in October 2009 9 Ibib



29. In Luangnamtha Province, which borders on to Bokeo province by the North South economic corridor, a new border crossing has been opened at Boten (Namtha district). A casino and several hotels have been built on the Lao PDR border and there is a very large market place comprising hundreds of small Chinese-owned shops selling goods from China and Thailand, and accepting only Thai and Chinese currency. On the highway between the provincial centre and this border crossing (there is another in Sing district with similar development), there are hundreds of plantations, mainly rubber. Most of those close to the road are smallholder rubber plantations, which are supplied by a Chinese company, further from the road, there are reportedly thousands of hectares of large-scale rubber plantation under management of Chinese companies.

30. The response to these developments among government officials interviewed was positive: the provinces had been backwaters but are now booming; however one concern they raised was the health impact of labor migration which they thought might be inevitable, given the scale of investments and the potential labor demand. Already it is rumored that labor from Myanmar is being employed on private investments in Bokeo.

31. It seems unlikely these provinces will be able to supply the demand which must grow for construction workers, agricultural laborers and rubber tappers from their own local populations. It seems likely that the cross-border scenario developing in these provinces is one in which labor will be recruited from EMGs within the two adjoining provinces and other provinces in northern Lao PDR, and/or from Myanmar. Skilled workers and business managers will come from China. Tourists will come mainly from China and Thailand, as well as some from within Lao PDR.

32. The risk recognized by local officials was particularly Human Immunodeficiency Virus (HIV) and other sexually transmitted infections (STIs), as the sex industry flourishes under these conditions and that human trafficking could become a greater issue.10 However there would also be significantly increased risks from new and emerging infectious diseases including Dengue, as well as the neglected tropical diseases associated with poverty and poor environmental hygiene.

33. A study of population mobility between Lao PDR, Myanmar, Viet Nam, Thailand and Yunnan Province of PRC11 found that since the late 1990s most migrants crossing borders in the region have been responding to economic incentives. Each country, except Myanmar, has increasing rural to urban population flows. Each country has flows to border sites, as well as to remote construction or mining sites. These internal flows may include seasonal labor, trading, travel to markets and festivals, tourism, and service and transport industry workers, plus uniformed and state officials as well as private sector personnel.

34. Transnational population movements include much the same groups as the internal movements with both emigration and immigration occurring in each country. Thailand receives most of this emigration from Myanmar and in total has almost a million migrant workers in the country, with numbers having marginally decreased since the financial crisis. Viet Nam has many thousands of workers in Cambodia and abroad, with the number of documented workers going abroad projected to rise sharply. Cambodia has had many thousands of workers in Thailand and a few thousand in Malaysia. Even Lao PDR has possibly tens of thousands of workers from China and Viet Nam, mostly documented, but this is more than matched by emigration from Lao PDR to Thailand, with as many as 100,000 undocumented migrants annually.

35. The manufacturing, service, agriculture, fisheries and construction sectors attract many unskilled workers. Other mobile populations include transport workers, traders, businessmen and sales representatives. State and uniformed officials are constantly on the move, and they may also be located at cross borders or travel overseas. Thailand, where the economy has been booming for decades, has attracted many cross-border migrants; its borders are porous, with little difficulty in crossing, from Lao PDR, Myanmar and Cambodia. Once across the border migrants are readily

10 See: Asian Development Bank, 2009. Broken Lives: Trafficking in Human Beings in the Lao PDR. Manila 11 Chantavanich, Supang et. al., 2000. Mobility and HIV/AIDS In The Greater Mekong Subregion. Asian Research Center for Migration

Institute of Asian Studies Chulalongkorn University Bangkok, Thailand in consortium with World Vision Australia and Macfarlane Burnet Centre for Medical Research under TA 5881 REG: Preventing HIV/AIDS Among Mobile Populations in the Greater Mekong Subregion Asian Development Bank (ADB) United Nations Development Program (UNDP)



employed in a range of low-paying jobs, but for many their illegal status, language difficulties, and low awareness of their new surroundings places them in a precarious position.

36. The opening of cross-border trade and tourism has revitalized many border towns and settlements. These border crossing points are meeting places of thousands of mobile and migrant populations, namely, transport workers, traders, tourists and visitors, border police and military personnel, and service and entertainment workers. They are destinations for some, and transit points for others, whether classified as mobile populations or migrant workers.12

A.5. Regional Perspective

37. Greater connectivity has resulted in rapidly accelerating flows of people and goods across borders. New roads have attracted new labor intensive developments (plantations, casinos, resorts, logging, hydropower dams, mines, ecotourism projects) bringing both benefits and CDC consequences. However, there is no reliable systematic data collected on the numbers of people crossing border to work because the borders are so porous and many migrants are undocumented and working in the informal economy. These population movements are driving rapid social change in border provinces, particularly in localities where the populations were previously sparse and isolated, mainly comprising EMGs.

38. Road building is opening up mountainous areas, resulting in intensified competition for land, as well as for forest resources. The traditional domains of many EMGs are shrinking as highland areas are allocated for economic development. As these areas become more accessible with new roads, migrant settlers from the lowlands and across borders are migrating to these areas. Traditionally EMGs held their lands under customary tenure, which has now has limited or no recognition in modern national law. Without legal title to their land they are easily displaced.

39. Rapid integration: Most EMGs in GMS border areas can no longer be thought of simply in terms of being disadvantaged due to isolation; they are becoming increasingly and rapidly integrated into national and regional economic processes and the associated processes of social change. This transformation is largely as a result of new roads opening up previously isolated areas, attracting not only investment but growing numbers of national and international cross-border migrants. In most cases, EMGs are beginning this process of integration from a very disadvantaged position.

40. As an example to illustrate the extent of potential economic development in just one sector in rural and remote areas, one only has to look at hydropower development in Lao PDR and areas adjoining the Mekong River catchment (Map 6), which shows the status of hydropower dams, with eleven existing, nine under construction, and 31 planned. The ever increasing demand for energy is driving the development, but the environmental consideration on the river systems and changing entomological environs of vectors, as well as the environment and social impacts through these large scale developments are not so well documented nor understood. The relevant individual project (as well as other major development) social and environmental impact assessment and resettlement documents should be brought together under CDC2, analyzed, and linked into the CDC2 monitoring and evaluation information, if considered that there are CDC risks locally and regionally.

12 Since this study was undertaken new casinos have opened in Bokeo province of Lao PDR, on the borders of Thailand and Myanmar,

and in Luangnamtha, Lao PDR on the border with PCR.



Map 6. Hydro Power Development in the CLV Region



41. Health Issues. Several recent studies suggest that EMG populations living near regional economic corridors bear a disproportion burden of the health costs of the rapid social and economic changes created by these developments.13 For example, when EMGs whose customary habitat is in high mountain areas move to lower altitudes, they are exposed to malaria, to which they have little acquired resistance, so in the early phase of relocation to lower altitudes there have been high mortality rates from malaria, as well as morbidity resulting from exposure to other water-born and environmentally-related infectious diseases.14 Those who live close to rapidly developing hubs on transport corridor areas are particularly vulnerable to recruitment into the sexual services industry, to cross border human trafficking. Under these circumstances they become vulnerable to infection with HIV and other sexually transmitted diseases.

42. Dengue fever and Dengue Hemorrhagic Fever (DF/DHF) are the most prevalent vector-borne diseases in the GMS, in terms of morbidity and mortality, especially for children less than 15 years of age. In Viet Nam, in the past five years there have been approximately 50,000 to 90,000 new cases per year with a relatively high mortality (0.1 percent). A similarly severe situation has emerged in Cambodia and Lao PDR. Although the diseases were traditionally urban, they have progressively spread to rural villages where breeding of the vector mosquito Aedes agypti has become substantial.15 The mosquitoes can travel from country to country on trucks and other vehicles, while the parasite moves in mobile human hosts, undermining national efforts towards vector control. Outbreaks of mosquito-borne Japanese encephalitis has emerged as a growing threat in several provinces of CLV in the past two years. CDC2 will support activities related dengue outbreaks; it is foreseen that ADB will fund a regional five year dengue program, with the design being undertaken this year or next year.

43. Epidemiological and Social Studies. There is very limited data on the social and associated epidemiological impacts of the border regions of CLV adjacent to the border crossings associated with economic corridor.16 ADB published a brief socioeconomic impact profile of the GMS corridors in 2008.17 Such health research and associated programs focused on border crossing areas that were undertaken to address the spread of HIV, mainly focusing on Lao PDR. The most detailed study to date was in 2004, and examined the social and health impacts of Highway 17 in northern Laos and its border crossings from PRC and Thailand in north-eastern Luangnamtha Province in Lao PDR. This road is linked but not integral to the north-south corridor.18 No comparable research for regional CDC policy and program development purposes has been done for provinces and districts linked by border crossings in CLV. CDC2 will strongly encourage international and regional institutes and donors to fund regional studies that will contribute to a better understanding of range of socioeconomic and health impact issues in the economic corridors.

44. By strengthening CDC response capacity at provincial and district levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the subregion. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue.19 The sudden and deadly outbreak of Severe Acute Respiratory Syndrome (SARS) early in 2003 provides a lesson. By mid

13 Cited in Cornford, Jonathon and Nathaniel Matthews, 2008. Hidden Costs: the Underside of economic transformation in the Greater

Mekong Subregion. Oxfam, Australia. Broken Lives: Trafficking in Human Beings in the Lao PDR. Manila 14 See the evidence for this and the discussion of the impact on Akha people in two border districts of Luangnamtha, Lao PDR in

Lyttleton, C. et. al., 2004 Watermelons, bars and trucks: Dangerous Intersection in Northwest Lao PDR . Institute for Cultural Research of Lao and Macquarie University.

15 Detailed analysis of border crossings in the GMS is being completed. 16 Detailed analysis of border crossings in the GMS is being completed. 17 Asian Development Bank, 2008. Corridor Chronicles: Profiles of Cross Border Activities in the Greater Mekong Subregion. Manila,

Philippines. 18 Lyttleton, Chris et. al. 2004. Watermelons, bars and trucks: dangerous intersections in Northwest Lao PDR: An ethnographic study of

social change and health vulnerability along the road through Muang Sing and Muang Long. Lao Institute for Cultural Research and Macquarie University, Australia.

19 World Health Organization, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html




2003 SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world.20

45. National Focus. An important focus of the GMS RCSP was to have been the systematic building up of national capacities and the strengthening of regional and sub-regional institutions for the purposes of: (i) regional policy formulation and implementation; (ii) research and training on GMS issues; and (iii) regional dialogue and consultation. Harnessing the experience of more developed countries in favor of the poorer ones will be an important way to leverage resources. Equally important for the success of the economic corridors are national programs addressing issues such as access and feeder roads, urban management, health, education and poverty reduction. National development programs will increasingly need to reflect regional dimensions as the corridors are completed, connectivity increases hardships for women and children in terms of risk for illegal trafficking, and of vulnerability to communicable diseases such as HIV/AIDS, particularly in the border areas.21

46. Common Challenges in National Health Systems. There are many common issues in the CLV health systems that affect CDC, including human resource constraints, the management of health services, and the affordability and financing of health services. CDC must also cope with specific challenges including: (i) integration of disease control programs in PHC; (ii) staff constraints for preventive care; (iii) standard setting and regulation; and (iv) regional surveillance and response. A challenge is to decentralize CDC to the provinces and to reduce the overlap of training, laboratory services and supervision. Of critical importance in CLV is the development of competent provincial planning, budgeting, management and monitoring capacity, with the provinces having responsibility and authority for health sector performance.22

47. Surveys confirm that the poor and EMGs receive the lowest coverage because of remoteness, language barriers and the low number of health staff from EMGs. Table 1 of the Situation Analysis Report (Appendix 4) indicates that coverage indicators for access to routine preventive and curative health services in CLV are still low or sub-optimal.

48. Access to and by qualified health workers is a key issue for many border populations. Both public and private sector healthcare provision decreases as population density falls. Surveys show that the poor, in particular women and children, and ethnic minority groups (EMG) typically receive the lowest coverage of prevention and care services due to their remoteness, language barriers and the low number of trained outreach health staff.23

49. Currently, provincial and district health authorities in CLV face a number of challenges in addressing CDC in vulnerable rural border populations mainly comprising EMGs. Typically they cite the constraints of distance and accessibility to the typically mountainous terrain in most border areas. But district health offices (working with the district hospitals and health centers) also lack the resources to provide outreach services. Budgetary allocations are insufficient for fuel and to cover incentive payments or travel allowances to health staff. There may be staff shortages. Often there is no adequate transportation for outreach activities, such as trail bikes that can travel on rough tracks, or in some instances, boats to reach villages without road or track access.

50. Generally, border people are expected to get themselves to health centers when they need services. At district level, health staff experience frustration when they attempt to reach a rural border population and find many of the target population are absent from their villages, or else located in areas that health staff cannot reach.24 In some projects, it has been found that people living in scattered locations can be reached on market days when they come together. But in general, the planning of the limited outreach programs that do exist in border districts is not sufficiently flexible to match the annual activity cycles of minority peoples to ensure that outreach activities occur when they people are in their main village. 20 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15 21 Asian Development Bank, 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (2004-2008) 22 Asian Development Bank, 2005. RRP. GMS Regional Communicable Diseases Control Project 23 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 24 Based on discussions with district health staff in Bokeo, Luang Namtha, Champasak and Attapeu districts in Lao PDR and in Tay

Ninh, Quang Tri, and Nge An provinces, Viet Nam



51. Health Management. With the move toward decentralization, provincial health authorities in CLV countries are assuming increasing responsibility. Managerial roles are changing and uncertain, and managers often lack the financial resources, information, training and experience to carry out their new responsibilities effectively. Managers at the central level are reluctant to give up their authority, or unsure how to do so without abdicating their own obligations. The willingness of provincial health departments to exercise their authority differs between provinces. The assessment of the management skills of key personnel will be undertaken at the start up phase of the project. Provision has been made to provide skills training in: project management; basic epidemiology, IT and data processing and analysis, as well as Managing for Development Results (MfDR) will be a foundation subject for all managers and key personnel and assessment will be conducted annually (see Appendix 19 for details of MfDR).

52. The above constraints have been addressed in the design for CDC2. In addition provincial studies and participatory activities with rural populations in border districts will support development and implementation of gender sensitive strategies and guide engagement and communication with minority linguistic/ethnic groups. Demand and access to quality health services will be increased by: (i) strengthening health care services in remote, underserved border areas; and (ii) improving health behavior through increased knowledge, awareness, and participation in community-based disease surveillance and prevention activities. Experiences from the participatory needs assessments, provincial, district and community workshops, study tours and the learning process will together be analyzed to produce clear strategies for multi-sector, community-based health promotion and CDC that seek to empower people about their choices about health, which in combination compliment Project improvements to the delivery of health services, and thereby encourage greater and more discerning use of those services.

A.6. ADB Investment in CDC2

53. In determining the proposed grant and loan funds for CLV countries in CDC2, the following factors were considered: (i) this is not a leading investment but a supplementary one to support the existing and pipelined investments in health sector in general and in CDC in CLV countries in particular; (ii) even though demand is high, this investment is targeted to be spent for border provinces and districts rather than to be centralized at the national level (three ‗clusters‘ are proposed to be formed under CDC2 along the borders between Viet Nam and Lao and Cambodia from the North to the South (map 2]); and (iii) the poor and vulnerable groups in these investment clusters should have the chance to receive more direct support from the project. Total proposed cost from ADB is $50.5 including $25 million soft loan funds, $2.8 million grant funds for Viet Nam, $10.6 million and $11.6 million grant funds for Cambodia and Lao. In addition to ADB funds, total counterpart fund in cash and in kind contributed by the three CLV countries is $4.3 million equivalent.25

54. The type of inputs of CDC2 emergency response remains the same as in CDC1 except that emergency funds will be available at three levels (national, province and district)26 with the majority of project operational funds allocated at local levels. An important baseline survey is included to build up baseline information on communicable diseases in the project areas together with other relevant information which will help improve the planning, monitoring and evaluation of project activities. In addition, some funds will be provided directly to the commune/village level in the form of block grants to support community initiatives.

A.7. Social and Poverty Impact

55. CDC2 will make three major economic contributions to the GMS sub-region. The project will support national surveillance and response systems and cross border cooperation in CLV countries and assist cooperation with neighboring countries of PCR, Thailand and Myanmar. Its social economic and poverty impacts will be:

25 Details can be seen in Appendix 6. 26 Ibid.



56. Reduction of economic risk of major communicable disease outbreaks. By strengthening CDC response capacity at provincial levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the subregion. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue.27 The sudden and deadly outbreak of SARS early in 2003 provided a good lesson. By mid 2003, SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world. Apart from the direct costs of intensive medical care and control interventions, SARS caused widespread social disruption and economic losses. Schools, hospitals, and some borders were closed and thousands of people were placed in quarantine. International travel to affected areas fell sharply by 50-70 percent. Hotel occupancy dropped by more than 60 percent. Businesses, particularly in tourism-related areas, failed, while some large production facilities were forced to suspend operations when cases appeared among workers.28

57. Increased sustainability of national investment to eradicate endemic infectious diseases. Emerging epidemic diseases such as Dengue and the group of parasitic diseases (such as Filiariasis, Schistosomiasis, and Helminthiasis and food-borne Trematodiasis and Cestodiasis), referred to as neglected tropical diseases (NTDs), pose significant cross-border risks. This issue of NTDs is less well understood as many NTDs are not included among notifiable diseases and tend to be endemic to specific areas, however, NTDs span borders in the GMS. The increasing population mobility arising from increasing economic integration in the GMS means that there are growing risks of parasitic diseases moving into new populations via human contacts. National investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border.29

58. Poverty reduction by improving the health of border populations: NTDs are endemic in most border areas of GMS and are associated with poverty and poor environmental sanitation and poor health services. The effective treatment of these infections is known to increase work capacity and productivity. Without treatment, prevention and eradication programs, these diseases disable and eventually kill unknown thousands of people every year. Hookworm, for example, causes anemia, which endangers the lives of unknown thousands of women in the GMS border regions and contributes to high maternal mortality rates in these areas. The development of unknown thousands of children in these areas is affected by intestinal parasites.30

A.8. Economic Viability

59. The economic analysis of CDC2 is considered economically viable31 and the economic benefits of the Project will come from:

(i) helping prevent major epidemics;

(ii) productivity gains from an increased lifespan and reduced mortality;

(iii) productivity gains from improved achievements in education, especially through less absenteeism and reduced dropout rates; and

(iv) public and private savings in health expenditures, including indirect costs.

60. Economic benefits will accrue from: reduced health care costs; gains in labor productivity and educational achievements as a result of decreased incidence and severity of illness; and reduced population growth as a result of better access to family planning. In addition, gains and investments in women‘s health will have additional positive impacts on reducing the country‘s

27 World Health Organization, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html 28 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15 29 Country Reports presented at the The First GMS-CDC Technical Forum on the Control and Elimination of NTDs in the Mekong Sub-

Region October 21-22, 2009 30 Presentation by the Global Network for Neglected Tropical Diseases The First GMS-CDC Technical Forum on the Control and

Elimination of NTDs in the Mekong Sub-Region October 21-22, 2009 31 See details of economic analysis in RPPTA Appendix 11 - Economic and Financial Analysis Report, 2009




population growth rate; improving the health and welfare of children and families; reducing health costs; and contributing to poverty reduction. The economic benefits, both for direct and indirect beneficiaries and social and poverty impacts are discussed under Section IV to justify that substantial economic benefits are provided by this project to the GMS countries.

61. Based on the rationale and justification as articulated in the preceding sections, CDC2‘s scope and design is well founded to address the national and cross border CDC issues. It provides for a refocusing of CDC to the border regions within the economic corridors, as well including a Training Systems Development Framework for a systematic approach to capacity building of health staff in the Project border provinces and districts, as well as community volunteers and commune or village administration to ensure community based surveillance systems are developed, implemented and maintained. This, together with approximately 70 percent of the project operational budget, is allocated for project provinces, districts and communities, to support improved health service delivery and health outcomes for a large percentage of the border populations in the cluster areas.

B. Performance Indicators and Analysis

62. As reflected in the United Nations Millennium Statement, ―We the Peoples,‖ human development is the crux of poverty reduction and economic growth. Four out of eight MDGs relate directly to health and nutrition — reducing child and maternal mortality and malnutrition, and containing and beginning to reverse the trend of HIV/AIDS32 and other communicable diseases. In the GMS and elsewhere, human development plays a major role in economic growth and poverty reduction. Efforts to achieve MDGs that prioritize intensified control of NTDs will contribute directly to the reduction of the communicable disease burden (MDG 6) and indirectly reduce poverty and hunger (MDG 1).

63. Achievement of the health-related MDGs in CLV requires providing improved coverage of PHC services to remote populations that are suffering from high burdens of infectious and reproductive diseases, and improving the affordability and quality of health care, including mobilization of communities to contain emerging diseases. All three countries have made good progress in improving the health of their populations over the last decades, and are making major efforts to put into place strong policy frameworks and primary health care (PHC) systems.33

64. Communicable disease prevention and control (Goal 6) is one of the four health-related MDGs, which aim to reduce child and maternal mortality and malnutrition, and contain the spread of HIV/AIDS and other communicable diseases, such as malaria, Diarrheal Diseases (DD) and (Neglected Tropical Diseases (NTDs). Illness and disability caused by NTDs have a tremendous social and economic impact. Efforts to reduce the burden of communicable diseases contribute indirectly to reduce poverty and hunger. Table 3 shows CLV progress towards meeting these health-MDGs.

65. Viet Nam has reached most of its MDGs, and the Government has set out a number of its own additional Viet Nam Development Goals (VDG). To continue its many advancements, and to extend their benefits more broadly, the Government of Viet Nam has set out an ambitious plan to address an array of continuing problems in the health sector, including: deteriorating and poorly equipped infrastructure; shortages of skilled health workers; constraints on access to health services, especially for the poor; and limited capacity to govern and manage an increasingly complex health system.34 35

66. Despite considerable progress towards meeting their health-related MDG goals, it is still a major challenge to meet all the targets in Cambodia and Lao PDR, where for example, the bulk of

32 Human immunodeficiency virus/acquired immunodeficiency syndrome. 33 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 34 Asian Development Bank, 2006. Country Strategy and Program: Viet Nam 2007-2010 35 Government of Viet Nam, 2006. Comprehensive Development Design for the Health System in Viet Nam to 2010 and Vision by 2020.



the sick population gets by using traditional medicines without taking up curative services even where there is improved access to health services.36

67. Since 2000, Cambodia has made significant progress in health. It has succeeded in reducing infant and under-five mortality from 95 to 66 and from 124 to 83 deaths per 1,000 live births, respectively.37 This progress has been attributed to the strong performance of the national immunization programme, successful exclusive breastfeeding promotion, the reduction of poverty levels, improved access to education, and better roads. The proportion of children aged 12 to 23 months fully immunized against six preventable diseases increased from 40% in 2000 to 66% in 2005. Feeding practices have improved with an increase in babies being breastfed early and exclusively, from 11% to 35% and from 11% to 60%, respectively. Cambodia has also succeeded in arresting and reversing the growth of the HIV/AIDS epidemic, and has a declining prevalence currently at 0.8%.38

Table 3. Health Sector Achievements, Projections and 2015 MDG Targets Achievements Projected

2010-2015 MDGs 2015

Health Indicator 2001 2005 2008-2009 CAM LAO VN CAM LAO VNa CAM LAO VN

CAM LAO VN CAM LAO VN

Maternal mortality ratio 437 530 95 472 405 85 461d 400 83 140 250 60b 140 185 62

Under-5 mortality rate 124 107 42 83 98 31.5 44d 70 15 65 55 25b 65 55 18

Under-5 malnutrition rate (wt. for age)

45 40 31.9 36 39 26.6 28.4 36.4 20 36 20 20 22 20 22

HIV prevalence rate among pregnant women (%)

3.0c 0.06 0.22c 1.1 0.2 0.37 0.8e 0.3 0.25 0.6 0.76b 0.5b 1.8 <0.1 <1.0

Sources: Lao PDR census, 1995, 2000, Lao RH survey 2000, Lao MDG report, Cambodian MDGs, CDHS 2000, 2005, NSDP 2006/10; tracking the millennium development goals, Cambodia Census 2008; Cambodia National AIDS Administration 2008 Annual Report; Viet Nam MDGs Report 2008; GMS-CDC Project RRP, a=2004, b=2010, c=2000, d=2008

68. In 2003, Cambodia prepared its own set of nine Cambodian Millennium Development Goals (CMDGs), which include an additional goal relating to mine injury risk and victim assistance. A 2006 CMDG progress report noted significant improvements in the situation of women and children, with the exception of the maternal mortality rate which remains high. Achievements also included progress in combating communicable diseases such as HIV/AIDS, malaria and TB.39 Severe malaria case fatality rate decreased to 7.9% (compared with a target of 10.2%), however malaria incidence increased to 7.9%. Dengue case fatality rate reached its target at less than 0.9% in 2005, and reporting time lag has decreased almost 50%40 De-worming activities showed a remarkable increase in which 57% of children aged 12 to 59 months received treatment, against the target of 40%.41

69. In Lao PDR, the child mortality rate was reduced from 170 to 98 per 1,000 live births from 1995 to 2005, but is will need to have inputs to reach the MDG of 55 per 1,000 (a two thirds reduction) by 2015. The maternal mortality rate reduced from 656 to 405 per 100,000 live births 36 World Bank, 2006. Lao PDR Poverty Assessment Report From Valleys to Hilltops – 15 years of Poverty Reduction 37 Cambodia Demographic and Health Survey 2005 38 World Bank, 2006, Cambodia Halving Poverty by 2015? Poverty Assessment 39 UNICEF, 2008, Report of Mid-Term Review of the Country Program 40 World Health Organization, Cambodia.2007. GMS CDC 6th Regional Project Review Workshop, Vientiane. 41 Ministry of Health, Cambodia, 2007. Joint Performance Review (JPR)



from 1995 to 2005, and may reach 250 instead of the goal of 185 per 100,000 (a three fourths reduction) by 2015. Surrounded by countries with higher HIV prevalence, the spread of HIV/AIDS in Lao PDR is unlikely to halt at current levels (about 1% of service women and 0.1% of adults 15 to 45 years).42

70. The death rate in Lao PDR associated with malaria fell due to an improvement in early detection of malaria in risk areas through the provision of impregnated bed-nets, rapid tests at the village health volunteer (VHV) level, indicating correct diagnosis and early treatment. The number of tuberculosis cases detected and treated on direct observation increased.43 Despite remarkable progress on lowering infant and maternal mortality rates, immunization coverage remains unsatisfactory, for example, infant immunization against measles declined from 61.5% in 1999 to 46% in 2000.44 In order to improve these trends, and achieve MDGs, higher investments and human resources are needed.

71. While Viet Nam has made remarkable progress in reducing poverty and improving the health status of its citizens, those who live in rural areas, ethnic minority groups (EMGs) lag behind those populations in the more accessible areas. Studies show that EMGs are much poorer than the ethnic majorities; the poverty headcount ratio was 64.3% in 2002, almost three times larger than that of ethnic majorities (22.3%). Poverty among ethnic minorities has actually risen proportionately in Viet Nam from 20% in 1993 to 30% in 2002 because poverty has declined among ethnic majority groups whereas the economic condition of EMGs has stagnated.45

72. There is no data comparing CDC incidence and prevalence of EMGs with majority populations in CLV but the disparities are highlighted in data showing that provinces with high infant and child mortality rates also have high concentrations of EMGs, and that EMGs have lower education and literacy rates, especially among women, as well as higher poverty rates in the three countries.46

73. Achieving MDGs will require targeting poor and remote populations, women and infants, ethnic minorities, and people living in border areas are the main focus areas of CDC2. These populations are suffering from a high burden of illnesses and common infections such as malaria, diarrhea, typhoid fever, acute respiratory infections, measles, tuberculosis, and parasitic infections. Without appropriate care these diseases result in high mortality, disability, and malnutrition, with the impact of infectious diseases on learning and productivity continuing to impact on peoples‘ lives.

74. DALYs is a summary measure of a population‘s disease burden which combines the number of healthy years of life lost due to premature morbidity and disability.47 Table 4 presents the level of disease burden in each of the CLV countries, measured by the total disability adjusted life years (DALYs) lost per capita for all causes. The table also indicates the proportion of DALYs lost due to the health-related MDG indicators, which include factors related to communicable diseases (CD), nutrition, perinatal, and maternal conditions (CNPM).

75. Notably, more than half of the total DALYs in Cambodia and Lao PDR, and nearly one third the DALYs in Viet Nam, are attributed to CNPM health issues, which include CDs. This considerable proportion of disease burden attributed to CNPM indicates the need for increased investments in CDC, as well as on the related issues of nutrition, maternal and child health. Table 4 also shows DALYs country estimates for selected endemic and neglected diseases.

42 Asian Development Bank, June 2007. Proposed ADB Fund Grant Lao PDR: Health System Development Project 43 World Bank, 2006. Lao PDR Poverty Assessment Report From Valleys to Hilltops – 15 years of Poverty Reduction 44 Ibid 45 E.g.: Imai, Katsushi and Raghav Gaiha, 2007. Poverty, Inequality and Ethnic Minorities in Vietnam. Brooks World Poverty Institute

WPI Working Paper 10, University of Manchester. Asian Development Bank (2002) Indigenous Peoples / Ethnic Minorities and Poverty Reduction - Viet Nam. Manila, Philippines: ADB..van de Walle, D. and Gunewardena, D. (2001) Sources of ethnic inequality in Viet Nam, Journal of Development Economics, 65, 177-207 A detailed analysis is also provided in the forthcoming Word Bank background paper for the 2008-09 Vietnam Poverty Update.

46 ADB, 2001. Health and Education Needs of Ethnic Minorities in the Greater Mekong Subregion. Manila, Philippines. 47 WHO, 2003. Assessing the Environmental Burden of Disease at National and Local levels . Geneva.



Table 4. Disease Burden in CLV (Estimated DALYs per 100,000 population by cause)

Country Total DALYs lost per

100,000 pop

Percent DALYs lost to CNPM per 100,000

pop

DALYs lost to Malaria per

100,000 pop

DALYs lost to Dengue per 100,000 pop

DALYs lost to ARI per 100,000

population

DALYs lost to Intestinal Nematode Infections

Cambodia 36.464 21.153 (58%) 143 44 4,659 354

Lao PDR 29.205 14.897 (51%) 46 93 2,560 300

Viet Nam 15.327 4.598 (29%) 8 16 480 228

Source: WHO DALY Country Estimates 2004, WHO February 2009

C. Analysis of Key Problems and Opportunities

C.1. Communicable Disease Priorities

76. Emerging Diseases. Outbreaks of newly emerging diseases such as SARS in 2003 and AHI in 2004 and 2005 have so far had little impact on health in the region, but could have vastly more devastating effects. The case fatality rate for SARS is around 10% and for human AHI had about 50%. As of May 2008, Viet Nam had the second highest number of human cases and deaths in the world48 with 52 deaths out of 106 cases (case fatality rate of 48%). As of the end of 2009, 56 people in Viet Nam had died from AHI, or 86% of all deaths in the region. Cambodia has had seven deaths, with two deaths in Lao PDR.49 However, scientists indicate that the AHI virus may mutate or reassert into another virus that spreads in humans like an ordinary flu virus. This could cause a global pandemic with potentially high levels of deaths in the region.

77. These emerging diseases, even with limited health impact, have major economic consequences. SARS slowed economic growth by reducing tourism and communication. GDP in the region could have declined by 0.2–1.8 percentage points if SARS had persisted for one economic quarter, and, GDP in the individual countries could have fallen by 0.5–4.0 percentage points if it had gone on for two quarters.50 While the CLV countries do not have a major poultry export industry like Thailand, AHI has probably reduced GDP by about 0.5% in Viet Nam.51 More importantly, it has had a major impact at the local level on poor backyard farmers and wet markets. Viet Nam has culled almost a quarter of its national poultry stock. A human pandemic has the potential to cause an economic meltdown.

78. The fast spread of these diseases and their potential consequences highlight the need for regional collaboration in CDC. Such a strategy must entail the strengthening of surveillance and response systems from community-level workers detecting outbreaks to laboratory facilities and provincial and national response centers. Cooperation across the health and agriculture sectors is important for AI. AI requires better poultry biosecurity and vaccination, improved preparedness and response of public and private services including quarantine arrangements and medicines, and risk profiling and monitoring the spread and genotype of the virus in hosts. The ministries of agriculture in the region are performing animal surveillance with assistance from the FAO. Laboratory conditions for the cultivation of the AHI virus in the national animal health laboratories are substandard and pose a biohazard.

48 According to WHO, as if May 2008, Indonesia had the highest number of human cases and deaths in the world at 108 deaths out of

133 cases, or a case fatality rate of 81% 49 ADB. REG: Prevention and Control of Avian Influenza in Asia and the Pacific and activities related to Avian Influenza. Progress

Report 6. October 2007- May 2008 50 ADB. 2003. Economic Research Department Policy Brief No. 15. Manila. 51 McLeod, R. 2005. The Socio-Economic Impacts of Emerging Infectious Diseases in Asia, with a Focus on the Greater Mekong Sub-

Region. Asian Development Bank. Manila. Unpublished Mimio



79. Early and accurate detection is also a vital element in preventing the spread of other infectious diseases like measles, dengue, typhoid, and cholera. Beyond the rise of emerging diseases, the capacities of the CLV countries‘ health systems are further challenged by WHO‘s introduction of new International Health Regulations (IHR), mandating that governments report any outbreak of infectious diseases (starting in June 2006, as discussed below. The health surveillance and monitoring systems in the CLV countries already required long-term assistance to strengthen the capacity to generate reliable, timely, routine data before SARS and AHI, and thus the emergence of new, complicated communicable diseases is compounding the pressures placed on the surveillance systems. While most diseases require basic laboratory procedures, some of them, such as AHI, require more complicated laboratory procedures for confirmation done in bio-safety level-3 laboratories. It is acknowledged that CLV countries would have difficulty in coping with a major outbreak of emerging diseases. At present there are limited human vaccines available for the types of newly emerging diseases that are threatening the region. Experience with AHI cases in Viet Nam suggests that currently available treatment is of limited benefit. Only few hospitals can manage a limited number of AHI cases and are not prepared for any major epidemic. Even if vaccines and drugs were available, production capacity would not be able to cope with the demand.

80. Neglected Endemic Diseases. Intensive efforts are under way to control and prevent communicable diseases such as dengue, HIV/AIDS, tuberculosis, and malaria in the CLV countries. However, acute respiratory infections, infectious diarrhea, typhoid, cholera, food-borne diseases, dengue, and parasitic diseases are significant causes of morbidity and mortality. These diseases, increasingly being referred to as neglected tropical diseases (NTDs), are often concentrated in poor and ethnic minorities living in remote rural areas (or urban slums in the case of dengue). Thus, NTDs primarily affect poor and vulnerable communities, and they disproportionately affect women and children. The high morbidity from neglected diseases affects school attendance, cognitive development, physical growth, and overall productivity. Worm infestations like helminthiasis, filariasis, and schistosomiasis, which receive very little donor attention, make up a special group of neglected diseases. Controlling these infections would result in major health and education benefits to children. Highly cost-effective interventions are available to manage most common infections, but budget shortages and selective donor priorities have hampered provincial and local health staff in tackling these common problems.

81. In addition to the comparatively low funding for NTDs, the prevention and treatment of these diseases is hampered by the absence of an integrated approach to dealing with them at the district and community levels. Integrated local planning for managing these diseases is insufficient (or absent). Local health planning and services usually take a selective approach to prioritized diseases. The CLV countries have implemented the IMCI Program, which manages acute childhood illnesses in an integrated manner, but the program has not shown to be well implemented or understood. It has been acknowledged that IMCI as a protocol/algorithm has limited application in remote areas as is not suitable for suitable for the provision of village health care. In CDC2, health care intervention programs will be implemented through an integrated PHC mechanism which should also link directly to the surveillance and response system (evidence based), whereby health workers providing treatment for NTDs also feed into the HMIS reporting system.

C.2. Regional Framework for CDC

82. A number of programs, strategies and legal frameworks now exist as a basis for GMS regional CDC cooperation. With the support of the Mekong Basin Disease Surveillance (MBDS) program funded by the Rockefeller Foundation, a major landmark was achieved in 2001 when the six GMS Ministers of Health signed an agreement to share disease information and cooperate to control diseases across borders. MBDS has now developed a regional CDC surveillance action plan (2008-2013) to improve pandemic influenza preparedness in the region. Its seven core strategies are to:

(i) maintain and expand cross-border cooperation;

(ii) improve human-animal interface and strengthen community-based surveillance;



(iii) strengthen epidemiology capacity;

(iv) strengthen ICT capacity;

(v) strengthen laboratory capacity;

(vi) strengthen risk communications; and

(vii) conduct and apply policy research.

83. WHO‘s IHR, approved in May 2005, serve as the new legal framework for actions to prevent the spread of disease internationally.52 The Asia-Pacific Strategy for Emerging Diseases (APSED), approved by WHO in 2005, provides a strategic framework to help guide national capacity building programs and productive partnerships to reduce the threat of emerging diseases in the Asia-Pacific region. It is an important stepping stone towards effective implementation of the broader IHR, which calls for the development of a bi-regional strategy for strengthening capacity for CDC surveillance and response. APSED is organized under five objectives to reduce the threat of emerging diseases:

(i) reduce the risk;

(ii) strengthen detection of outbreaks;

(iii) strengthen early response;

(iv) strengthen preparedness; and

(v) develop sustainable technical collaboration within the region.

84. APSED also offers a potential framework for training initiatives that can be adapted to each country context depending on levels of competence. APSED concludes in 2010, and is to be assessed . Recommendations are that it will be revised and extended to build upon specific country experience. The design for CDC2 has been built around the current strategy.

C.2.1. Regional Challenges and Opportunities

85. Despite the strong rationale and growing international support for regional cooperation in CDC and broader health systems development, regional initiatives in the GMS health sector have been limited to agreements in principle, with few cross-border CDC activities being implemented so far. The political will for regional CDC cooperation seems to be in place, but the appropriate mechanisms to achieve it are still not clear. ADB support to local and national CDC programs builds on existing systems for preparedness, surveillance and response capacities at all levels, including greater reach to community level. CDC2 has provided funding and support to MOHs to ensure that these regional initiatives can be realized and strengthened.

86. Developing the regional linkages and international capacity for CDC programs has proved to be much more challenging, for reasons including:

(i) the lack of an existing model, system or funding mechanism for regional development cooperation for health or social sector assistance;

(ii) continued institutional and legal constraints that hamper international and cross-border sector cooperation; and

(iii) lack of country ownership of a regional mechanism.

However, benefits of regional approaches being piloted are beginning to emerge, in terms of technology transfer for strategic planning and generating a healthy climate of professional cooperation, competition, and commitment.53

52 The revised international health regulations were endorsed by the World Health Assembly in May 2005 with a proposed

implementation date of June 2006. 53 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater Mekong Subregion:

Maturing and Moving Forward.



87. CDC1 undertook a series of cross border activities including CDC surveillance and outbreak response simulation to build cooperation and develop compatible responses for potential cross-border disease outbreaks in CLV. In particular component 3 of CDC1 aimed to build the necessary trust and confidence through:

(i) frequent and focused dialogue and exchange;

(ii) developing professional networks and relationships across the ministries of health, health institutes, and other stakeholders;

(iii) learning from one another‘s experiences; and

(iv) embarking on joint research on critical regional health issues.

As the trust and networks develop, importantly the personal relationships, the GMS countries are expected to move on to more challenging regional cooperation on health initiatives such as sharing of data systems, standardization of health policies and regulatory frameworks, and coordination of responses to outbreaks of disease.54

88. There are a number of areas where sub-regional cooperation in HRD is logical and urgently needed to address:

(i) health and social problems associated with mobile populations, including CDC;

(ii) the rights of migrant and guest workers; and

(iii) the trafficking of women and children.

For example, the AHI crisis and more recently, the H1N1 pandemic highlighted how national and regional approaches complement each other. In CLV, public health loans have financed the purchase and installation of badly needed equipment for culling and quarantine. These activities are essential at the national level but will only be effective to the extent that regional or international monitoring and surveillance mechanisms are also put in place.55

89. Greater province-to-province response across borders is needed not only for coordinated rapid response to outbreaks, but also for harmonization of disease prevention strategies, plans and activities. One major achievement of CDC1 in many Project provinces has been the development of provincial plans of action based on multi-sectoral cooperation for rapid CDC response. Regional surveillance and response has been shown to need further strengthening.

90. At present, no complete inventory exists of national institutional arrangements for CDC surveillance and response on the twenty six international crossings on economic corridors through CLV or the 40 or more other GMS road and river border crossings. The CDC1 Regional Coordination Unit (RCU) has endeavored to collect information on cross-border quarantine activities but the results are not comprehensive nor includes information from PRC, Thailand and Myanmar.

91. For reasons discussed in the following section, most successful regional initiatives Cross-border cooperation have had a ‗one disease‘ focus. The AusAID-funded ASEAN +3 Emerging Infectious Diseases program has conducted collaborative studies between member state on social aspects of AI, DF/DHF and Rabies. There have also been small border-focused programs of cooperation for Schistosomiasis between Cambodia and Lao PDR; on Dengue vector control between Lao PDR and Thailand, and on Japanese Encephalitis surveillance between PCR and Lao PDR. CDC2 will act as a catalyst for promoting further studies or interventions to compliment baseline information and disease surveillance and response activities.

C.3. Challenges in National CLV Programs for CDC

92. There are many common issues in the CLV national health systems that affect CDC outcomes, including human resource constraints, the management of health services, and the

54 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 55 Ibid.



affordability and financing of health services. CDC must also cope with specific challenges including:

(i) integration of disease control programs with national commitments to PHC;

(ii) constraints on staffing for preventive activities; and

(iii) standard setting and regulation in design and implementation.

93. Surveillance is particularly complicated by the use of several separate systems for prioritized diseases that receive financial and technical support from international organizations.

94. Although the extensive national surveillance networks cover all levels down to the commune health centers, the coverage and functioning of the surveillance and response systems need strengthening. Surveillance is further complicated by the use of several separate systems for prioritized diseases that receive financial and technical support from international organizations. As many people use private health-care providers, a significant amount of information regarding communicable diseases is missing as it is not part of the current surveillance and response system. The village level appears the weakest link because of the geographical and social barriers, and the low priority given to prevention and limited capacity to gather and report on disease surveillance.

95. National CDC programs in CLV Ministries of Health are centrally managed and organized into vertical, weakly integrated programs focused on malaria, HIV, TB, Dengue, and other communicable diseases, or on other prevention programs such as EPI, IEC/BCC, and water and sanitation. To some extent this is related to the availability of donor funding and the associated priorities and requirements. Projects are often implemented in isolation, and interventions are often not sustained.

96. Provincial, district and village level health outreach activities are usually tightly scheduled, organized and budgeted around centrally directed programs activities and special campaigns. These are often difficult to integrate at the district and commune or village service delivery level because they are often inflexibly planned, budgeted and timed, although there are some excellent examples of provinces where integration of health programs within district services has been achieved. CDC1 effectively supported a number of these programs in Project provinces, particularly those for HIV, Dengue, and Helminthisasis.56

97. Although the Ministries of Health in CLV have policies to decentralize CDC to the provinces and to reduce the overlap of training, laboratory services and supervision, there is very uneven capacity at provincial levels for planning, budgeting, management and monitoring. Health sector planning, financing, and aid coordination remain major challenges with limited accountability and authority at the local level. Provincial authorities have limited capacity in health system development and improving services to reach the poor.

98. Observations suggest that provincial plans often fall short of targeted interventions to reach underserved rural communities. Managerial roles are changing and uncertain, and managers often lack the financial resources, information, training and experience to carry out their new responsibilities effectively. Managers at the central level are reluctant to give up their authority, or unsure how to do so without abdicating their own obligations. The willingness of provincial health departments to exercise their authority reflects their continuing dependence on national subsidies. The need to make informed decisions at provincial levels will increase the need for more comprehensive data collection and analysis. In CDC2 provision has been made to give provinces more flexibility to be able to respond to local situations.

99. The foundational concepts of PHC and district-based health systems toward achieving ‗health for all‘ remain highly relevant in all three CLV countries, and form the central approach within their national health policies. However, as support for PHC has been increasingly replaced

56 For example in Sayaboury Province in Lao PDR and Takeo Province in Cambodia.



by a more selective approach focusing on diseases and sub-sectors, and increasingly organized through vertical programs for swifter impact, integrated PHC at community level is weak in most provinces of CLV. In many provinces, unless there is specific project support, insufficient efforts and resources are devoted to the promotion environmental sanitation and provision of associated infrastructure, community mobilization and health IEC through local level government and community based organizations.57

100. Despite the multi-sector nature of CDC (with links to a number of other sectors including education, animal health, water and sanitation, public works, rural and community development), CDC tends to be viewed as a health sector issue focused narrowly on the MOH programs. Many sectors have roles in CDC, for example services, government agencies responsible for quarantine, water and sanitation, food safety, animal health and education, and local governments - all needing to be coordinated to achieve good public health and disease prevention outcomes.

101. Integrating CDC programs within the national health systems are complex, and with some exceptions, proceeding at a slower pace. However, lessons are emerging on the integration of CDC, for example, from the RETA Roll-back Malaria (RBM) initiative (2000-2005) and include: (i) efficiency could be improved by integrating other diseases (e.g. DD) into malaria control activities; and (ii) the information generated from the project argues for an expansion of the TA scope into non-endemic areas and other EMGs, to take advantage of economies of scale.58 To begin to address the integration of CDC and other provincial services, support will be provided for the establishment of a provincial technical management committee to ensure that planning and finance and other technical departments are engaged in the project.

102. Support to the decentralized arrangements of health systems require strong planning and management participation at provincial as well as district levels for enhanced ownership by local authorities, and to clearly define roles and responsibilities, User-friendly guidelines and standard operating procedures (SOPs) are also needed for work within and external to the health system. For example, border quarantine check-point stations for agriculture and health observed in RPPTA team field visits were established side by side at international border crossings, but operational guidelines for joint operations or collaboration of any sort between health and agriculture stations were not in place, and therefore very little collaboration.

103. Sustainable approaches to CDC: Experience has also shown when outbreaks occur, communities tend to passively participate in what, from the community standpoint, is often seen as the responsibility of the health authorities. Chemical vector eradication must be accompanied by community and household level participation in vector control. For example, the widespread project provision of abate for dengue control at the community level is expensive and may also become less effective in the long term due to resistance.59 Complementary, multi-sector approaches are needed to promote environmental health, personal hygiene, food safety, and safe drinking water and proper sanitation. Further support is also needed for improved health services capacity and reach to remote areas, as well as for community preparedness and prevention including for CDC forecasting, risk mitigation, and reinforcing of public health fundamentals to contain transmission and exposure to pathogens.60 Provision has been made in CDC2 to provide outreach to underserved populations. Support will be given to districts to plan integrated village-based primary health care program based on national ‗healthy village‘ criteria for environmental sanitation and coordination of government services to support achievement of these criteria, including health care funds for the poor. Existing maternal and child health (MCH) services in rural areas will be strengthened to increase communicable disease prevention capacity, by increasing outreach services to border communities. The focus of activities and priorities will be determined by the district‘s comprehensive baseline study and will be tailored accordingly, with gender and cultural sensitivity, to the specific needs of each district. National women‘s organizations will be provided

57 AusAID, 2003. Primary Health Care for Women and Children Project Evaluation, Viet Nam. 58 Asian Development Bank. TA Assessment: RCAPE on GMS. RETA 5958: Rollback Malaria Initiative in the GMS 59 Discussion with the WHO Regional Dengue TA for CDC1 60 Asian Development Bank, 2008. Aide Memoire: Fact Finding Mission for the PPTA for the Second GMS Regional Communicable

Disease Control Project (CDC2) Cambodia, October 2008.



with support to promote women‘s participation (which is currently weak), MCH activities, immunization, healthy village concepts and associated CDC project activities at community level.

104. Participatory, multi-sector approaches among government departments and within the community have been shown to strengthen the outcomes and impacts of health and social development interventions. For example, schools were observed to be active, effective partners in CDC, including for: (i) integration of CDC information into school health education curricula, (ii) are key venues for regular de-worming and EPI campaigns; and (iii) to mobilize students as ―cost effective‖ community mobilization workers, whereby students conduct regular hygiene and environmental sanitation surveys in and around their homes as part of their health education homework assignments. This model has proved to be highly successful in pilot communities in Viet Nam and Cambodia, especially for promoting vector control initiatives, such as fish breeding, and for modeling healthy behaviors and reinforcing health information in the home.

105. Experience from CDC1 has also demonstrated that community mobilization, IEC/ BCC and health education, if systematically implemented through local structures, such as multi-sector health committees, mass organizations, CHWs and other community volunteers (such as school children who carry out routine environmental sanitation surveillance at home as health education homework assignments) and with the support of the local political authority, can improve preventive actions, health seeking behavior and overall population health. The CDC2 Project will continue to support this approach, but with a stronger focus on BCC.

106. Integrated CDC plans. Under CDC2 each province will have an inter-departmental provincial steering committees (PSC). Each province will be assisted to prepare a multi-sectoral plan of action for community-based preparedness and CDC using a participatory approach. This will include the development and implementation of gender sensitive strategies for engagement and communication with minority linguistic/ethnic groups, for increased demand and access to quality health services for the poor, women and children and EMGs living in underserved border areas. Each province will go through a number of planning and field sessions with targeted districts and communities. The provinces will include cross-border activities and seek to mainstream community and cross-border activities in provincial health plans and budgets with support of provincial governments. The provinces will endeavor integration among all community health development programs, and consider incorporation of community-based PHC/MCH services, the model healthy village, and the integrated health panning approach. The Project will support provincial workshops and field visits, and technical support from the advisory team.

C.3.1. HRD and Skills Training

107. Experience from CDC1 demonstrates that capacity building at all levels of the health system can lead to significant health benefits, including increased utilization of services (due to public trust and confidence in the skills that have been built up); improved outcomes (e.g. better preparedness and a more rapid response to disease outbreaks); and improved service quality. In many provinces and districts reviewed, CDC1 capacity building inputs were found to have helped to up-grade the existing health systems, and provided a good model for quick response to common serious endemic diseases like dengue, including better clinical diagnosis, and greater reach to the community level, enabling better management of dengue by local health departments. Prior to CDC1 support in project provinces, surveillance and response capacity extended to district level only, with training only available at district level. CDC1 extended training and capacity-building to the health center staff and village health volunteers, effectively extending the surveillance system to the village level. This includes reporting capability, depending on phone networks, and availability of phone cards.61

108. Increased Staff Capacity in CDC. To build on CDC1 experience it is recognized that there needs to be a more sustainable approach which builds capacity by developing training systems for planning and management of human resources, particularly at provincial and sub-provincial levels, and in keeping with national policies for the decentralization of health systems. Under CDC2 a

61 Asian Development Bank. TA Assessment: RCAPE on GMS.



major capacity building effort in the health sectors is proposed for CLV based on a Training Systems Development Framework (TSDF) to develop a sustainable training system to improve staff skills and quality of services through (i) improved provincial human resource management; (ii) organized provincial training system; (iii) improved staff performance, and (iv) reduced staff gaps.

109. The TSDF approach includes the development of master trainer teams, and improving training materials in each project province, and harmonizing the approach in CLV. While such training and capacity-building activities and structures have the potential to significantly improve knowledge and practice, the training processes need closely monitored support at implementation and supervisory levels to ensure quality, and at central and senior levels to ensure sustainability and continuing relevance. Frequent and careful monitoring of project implementation is essential to ensure that the newly established operational processes and procedures for CDC are clearly understood and activities carried out correctly and completely by the responsible parties at all levels. CDC2 will continue to support the approach that the staff at the provincial and district level have the supplementary resources that will enable them to provide the training facility based and outreach services at all levels. Experience from CDC1 and other ADB projects also indicate that attention should be given to build capacity for project management and implementation prior to project launch.62 Based on APSED and the lessons learned, Details of the training programs to support the CDC2 capacity building is included in Appendix 10 Training Systems Development Framework. The level of institutional capacity building for provincial systems should also be addressed and these is a need for greater emphasis on gender and ethnic minority needs.

110. The governments of CLV have all set goals to train increased numbers of health personnel, and to improve the quality of their training, training curricula and training materials, and to strengthen the capacity of trainers, in order to bridge the gap between the quantity of students and the quality of their education. While health workers are widely distributed throughout every level of the health care system, mal-distributions and chronic shortages exist. Practical needs for gender equity in staffing is not given adequate consideration in many provinces, for example, to ensure that both male and female staff are appointed to each health centre, and that both male and female community health workers are appointed in every village (as in Cambodia). The staff that are available are often inadequately trained to provide the quality of health care needed and female health staff are usually less qualified than male staff. A comprehensive analysis of the status of gender issues in the health systems in CLV is detailed in Appendix 13 Social Analysis Report.

111. Project Management Competence. CDC1 management experienced several challenges due to complex procurement procedures and limited staff capacity. To ensure sustainability of investments, the Project will support the development of an integrated project management structure and capacity to ensure mainstreaming of project activities in the the MOH and the Project provinces. Output 5 will assist to achieve (i) improved provincial capacity in CDC planning, management, and monitoring skilled managers in results-based management, (ii) integrated and sustained project activities in provincial plans, (iii) improved procurement, financial management, and technical support.

112. The Project will support mainstreaming of project activities in the provincial and district five year and annual plans. These plans will address surveillance and response, CDC in border areas and along economic corridors, gender and EMG issues, training capacity, and results-monitoring. The Managing for Development Results (MfDR) will be introduced in the project and senior management at all levels will receive training and support to move towards a performance or results based approach. National or cluster meetings will be arranged on a quarterly basis to discuss and address project implementation issues. Special attention will be given to sustaining project investments, in terms of national policies and guidelines, financing, capacity, and mainstreaming developments. These aspects will be included in the mid-term and end-of-project evaluations. Project managers and experts will track conditions for sustainability of all project activities.

62 ibid



113. Whilst capacity in project management, procurement and financial management has been built up during CDC1, this capacity is still limited and largely restricted to project staff. With support of technical experts and other programs, these skills will be improved further and mainstreamed in the provincial health administration. The recruitment of international consultants through the ADB managed pooled fund on behalf of the concerned ministries, and using local organizations and institutions for national consulting services will provide a good range of technical expertise at the start-up phase of the CDC2 project.

C.3.2. Vulnerable Populations

114. Mobile Populations. A priority in the GMS has been facilitating connectivity among the member countries through the provision of transport infrastructure. Greater connectivity had resulted in rapidly accelerating flows of people and goods across borders. New roads have attracted new labor intensive developments (plantations, casinos, logging, dams, mines) bringing both benefits and CDC consequences. These population movements are driving rapid social change in border provinces, in localities where the populations were previously sparse and isolated and mainly comprising EMGs. So far there is very limited data on the social and associated epidemiological impacts in CLV districts adjacent to 26 international and 40 national border crossings that are directly or indirectly associated with the GMS economic corridors.63

115. Remote Populations. Populations residing in remote border areas, mainly EMGs, are often very poor and lack physical access to health-care providers. Both public and private sector healthcare provision decreases as population density falls. In parts of the Mekong Region, people may have to travel more than 5 to 10 kilometers on foot to a health post. Outreach teams find it difficult to reach remote villages, resulting in lower coverage of immunization and other preventive services in these communities.64 Access to and by qualified health workers is a key issue for many border populations. Surveys show that the poor, in particular women and children and EMGs, typically receive the lowest coverage of prevention and care services due to their remoteness, language barriers and the low number of trained outreach health staff.65

116. Poor Women and Children. Gender equity considerations run through all the MDGs, including the health-related MDGs. Goal 3, to promote gender equality and empower women, has targets and indicators related to gender equality in education and literacy, improvements in women‘s income, poverty related to the share of women‘s wage employment, as well as women‘s representation issues, all of which are important to improving women and children‘s health and the health standards of society overall. Gender issues are now fairly well understood in relation to HIV and other sexually transmitted diseases, but less well understood in relation to other CDCs. Recent research on gender and CDC in the CLV region shows that gender is a significant variable in understanding vulnerability and for planning response to communicable diseases and that insufficient attention is given to women.66

C.3.3. Improved CDC along Borders and Economic Corridors

117. CDC2 will target about 100 districts in 30 provinces grouped in 3 clusters along borders and economic corridors, and will support (i) detailed community assessments baseline survey, (ii) cross-border collaboration, (iii) accelerated model healthy village development, (v) greater community engagement promoting behavioral change communication, (vi) better skilled village health workers, and (vii) targeted disease control through integrated CDC plans.

63 The most detailed study to date was in 2004, and examined the social and health impacts of Highway 17 and its border crossings

from PRC and Thailand in north-eastern Luangnamtha Province in Lao PDR. This road is linked but not integral to the north-south corridor Lyttleton, Chris et. al. 2004. Watermelons, bars and trucks: dangerous intersections in Northwest Lao PDR: An ethnographic study of social change and health vulnerability along the road through Muang Sing and Muang Long. Lao Institute for Cultural Research and Macquarie University, Australia.

64 Country Data from CLV presented at the first GMS-CDC Technical Forum on Control and Elimination of Parasitic Diseases in the Mekong Subregion. Lao PDR, 21-22 October, 2009

65 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 66 ASEAN + 3 disseminated the findings of the studies at a regional workshop on gender and social issues related to emerging inf ection

diseases on 13-14 October 2009 under the auspices of the Lao PDR Ministry of Health. Publication is forthcoming.



118. Baseline Survey. The Project will support baseline and evaluation surveys in all targeted districts to provide a means to inform district and provincial staff about community issues, plan interventions, introduce a results-based approach, and improve monitoring systems in each province.

119. Baseline data for M&E: Of considerable concern is the lack of the establishment of baseline information and the level of project M&E and quality assurance at national and provincial levels, which appears to remain weak overall, making it difficult to attribute improvement in key indicators to specific project strategies and interventions, before and after project implementation. National M&E frameworks need to include collection of health coverage appropriate performance indicators at the lowest implementation level from the start of project activities. Experience from the Community Action for Preventing HIV/AIDS project (JFPR 9006), and later CDC1, demonstrated the importance of building a strong research component in pilot projects right from the start, to be able to measure outcome and impact from project interventions.67 The lack of good baseline in CDC1 is well recognized. A key feature of Component 1 of CDC2 is a comprehensive baseline survey designed to guide the provincial and district CDC strategies for cross-border cooperation and initiatives. This will identify EMG communities in border districts and their needs in more detail, and will assist to plan harmonized cross-border activities to improve CDC in these communities, based on the priority disease or service constraints in the border areas, such as the control of AI, malaria, dengue or cholera including vector control in border areas.

120. Baseline information can be compiled from existing data, small, periodic targeted surveys and behavioral studies at the community level to identify the most effective and sustainable means of promoting the desired changes are also cost efficient options, appropriate to local capacities, and can more easily fit into the routine health M&E systems. The baseline will be the bench mark for monitoring and evaluation for the life of the project, outputs outcomes and impact will determine the performance of the project which will include the reduction of CDCs among EMG populations in project provinces and districts.

121. An international consultant Social Anthropologist with relevant GMS experience will advise on specific research activities on EMGs for the baseline and on the development of more appropriate ethnic and gender sensitive strategies for engagement and communication with linguistic/ethnic groups in the participating districts. It is foreseen that the consultant will lead a team, working with national institutes for social and cultural research, during the period of the Baseline Survey

122. The interventions, depending on the needs assessments derived from baseline data, may include:

(i) mobile clinics, with provision of vehicles, trail bikes, boats and equipment for conducting outreach programs for vaccination, checkups of children under five years old, antenatal care, family planning and HIV and STI awareness, hookworm treatment, vitamin supplements, tetanus immunization, malaria treatment and bed nets, dengue vector eradication and other measures relevant to local CDC situations;

(ii) IEC training package to retrain health volunteers and health workers using participatory, culturally and gender sensitive methods to raise community awareness on prevention of communicable diseases and environmental sanitation;

(iii) provision of water and sanitation facilities where needs and additional donor funding is available.

123. Model Healthy Village Approach. The Project will strengthen CDC prevention and treatment services to vulnerable populations in targeted districts along borders and economic corridors through a model healthy village approach based on PHC with a major emphasis on prevention of communicable diseases and mother and child care. The Project will support case by 67 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater Mekong Subregion:

Maturing and Moving Forward



case needs assessment including for health promotion, health care, water and sanitation, vector control (including animals), cultural practices, and care for women, children and the poor in particular. The community engagement strategy68 will include; effective community-based health promotion and risk mitigation for CDC with specialist support to assess staff and community BCC skills, materials and activities, including the mass organizations. At the community level, village development committees, community volunteers and local staff will be mobilized to deal with specific CDC issued identified, such as recognition and prevention of emerging and other infectious diseases, basic health care and referral, HIV/AIDS prevention, community preparedness, and timely reporting and control measures in case of a disease outbreak.

124. Strengthening Communities and Village Health Workers. The Project will also support government policies in CLV for expanding and strengthening the grass-roots network of village health workers (VHWs), and other volunteers, particularly in remote and disadvantaged areas in the Project border districts. In addition to training all volunteers and community representatives in BCC, the VHWs and community representatives will also be trained to recognize emerging and endemic diseases, and in remote areas and the VHWs will be provided with a basic medical supplies. The clinical and preventive health trainer teams will collaboratively produce appropriate materials for the training of VHWs and community. The Project will provide specific support to provinces for the training of CHS and HC heads in the monitoring and supervision of VHWs and community activities, with practical guidelines and allowances for outreach and follow-up supervision. All training will emphasize the Project‘s SBT approach, using substantial field practice to reinforce techniques. The TOT package for district trainers will have at least half the trainers as women, Project HRD TA, NGOs, and local health promotion and PHC specialists will play a key role in the community initiatives and training. Where possible existing materials will be tested and improved. Based on an assessment of local needs and resources, the Project will support the purchase of boats, motorbikes and bicycles for use by CHS and HC staff, VHWs and other volunteers providing outreach services.

125. Incentive payments are widely perceived to be a key element to successful implementation of community-based interventions, particularly in remote areas. However, recurrent costs for community health workers (CHWs) require careful consideration. Experience from CDC1 and other ADB health projects (e.g. JFPR HIV/AIDS and RETA malaria) highlight the trade-off between effectiveness and sustainability, where incentive payments for CHWs in some cases have jumped to four to five times of the usual government CHW payments under project funding, with no evidence of government capacity or commitment to sustain this level of payment after project completion, or how CHW participation would be affected with post-project reinstatement of lower government incentive payments.

C.4. Shortage of Regional Public Goods

126. Regional public goods (RPG) receive less attention than global public goods and national public goods, despite the fact that RPGs can help attain global and national public goods. In particular, rates of return on regional investments are often higher than individual country investments and reduce high costs for smaller economies. This applies equally to RPGs in the health sector.

127. Clear gaps in RPGs related to health exist within the Association of Southeast Asian Nations (ASEAN) and the GMS countries. First, there is no comprehensive regional health information system. Several attempts at regional data and information sharing have been made (such as ASEAN Disease Surveillance.net, MBDSP, Asian Collaborative Training Network for Malaria Web site, ADB, and WPRO); none of these has so far achieved a satisfactory information database. Sharing of health information will require capacity building and also confidence building among the governments. Research with a regional perspective is minimal. Research related to mobility across borders is particularly important for HIV/AIDS, but only limited studies have been undertaken to date.

68 Community Engagement strategy will be developed after the analysis of the Baseline Survey.



128. Aid agencies often prefer to invest in country-focused programs because of the need to establish ownership and the relative ease of arranging lending and grants with a single country. Broader-scale health initiatives by the key multilateral institutions tend to be global in scope instead of responding to particular regional needs and solutions. These global initiatives prevail over regional ones despite the complexities involved in implementing them worldwide, and they tend to lose focus on the ―weak links‖ (i.e., countries with limited capacities) that reduce the overall effectiveness of global health initiatives.

129. The current setting appears in need of regional collaboration in CDC. Common standards and legal frameworks for actions to prevent the international spread of disease regionally and globally, such as the IHR and APSED, make it easier for countries to coordinate and exchange staff, information, services and goods, and provide member countries with a common reference point to prevent global health threats and to coordinate international responses to those threats. Under APSED in the Asia-Pacific region and the IHR globally, countries are expected to report any (potential) epidemic or other public health threat. They must establish and maintain minimum core surveillance and response capacities to successfully implement regional and global health security, epidemic alert and response strategy. An important element will be regional capacity building. The recent epidemics have created more political will to exchange information, harmonize quality standards, and learn key lessons from one another. CDC2 plans to build on this experience and build better communications and knowledge management.

D. External Assistance

D.1. Cambodia

130. In Cambodia public spending in the health sector has doubled and aid funding grew by 50% between 2003 and 2007, however, donor spending continues to exceed the Government‘s spending, and out-of-pocket expenses still account for 65% of total health expenditure. This means that many households face excessive healthcare costs, and with fewer health outcome achievements due to inefficiency in Cambodia‘s health sector, including:

(i) fragmentation of donor support;

(ii) skewed allocation towards HIV/AIDS, TB and malaria;

(iii) delayed execution of the government budget, resulting in low public sector service quality and reliance on user fees that impedes access for the poor;

(iv) low allocation to salaries, and low budget share reaching primary health centers at the sub-national level; and

(v) the very low availability of health professionals.69 131. Cambodia‘s MOH has a policy of harmonizing and integrating projects into regular services to avoid creating separate PMUs. Formal agreements with the seven major health sector partners70 specify the arrangements and commitments between partners and the MOH in support of the Second Health Sector Support Project (HSSP2), around which all partners have agreed to align their support. Within the HSSP2 there is already pooling of funds as Cambodia moves closer to a full sector-wide approach. HSSP2 is supported by strong commitment within the Good Governance Framework, the Financial Management Guidelines, and (in December 2008) the signing of a Joint Partnership Arrangement between the Government and the seven HSSP2 partners. HSSP2 also defines sector support within the existing pooled funding which allows for donor support to pooled funding for activities under the HSSP2, as well as for direct support to defined groups of activities. This allows donors to retain a range of options including for the pool itself.

69 Ibid. 70 Donors supporting Pooled Funds. BTC, AusAID, DIFD, WB, UNFPA, UNICEF, AFD (2nd Health Sector Support Project)



132. GMS-Regional Technical Assistance (RETA)71 support for CDC among EMGs in Cambodia includes support by:

(i) Health Unlimited (HU), an INGO working in Ratanakiri, to train Kreung CHWs;

(ii) BBC Trust, which was involved in the TV soap series on HIV/AIDS in Khmer language;

(iii) Equal Access, a local NGO that sets up digital satellite radio receivers; and

(iv) UNAIDS, Cambodia.

Ongoing funding from the Global Fund (GF), particularly for malaria control, has been provided to Rattanakiri, Stung Treng and Mondulkiri, with support from HU and another NGO, Partnership for Development, which has also piloted successful models for child to child school-based surveillance for CDC at community levels. From 2004 to 2008, MOH and PHD contracted another INGO (HealthNet International) to manage health center services and operate the provincial referral hospital to agreed targets, including malaria control, supported under an ADB loan.72

D.2. Lao PDR

133. Over the past five years, there has been a substantial shift in donor assistance to Lao PDR, with several bilateral donors phasing out their assistance as global funds moved in. External assistance in the health sector is fragmented and typically supports a specific sub-sector or geographic area. Since 1992 ADB has provided significant support to the sector principally in PHC and more lately CDC. The latest ADB funded support has focused on health sector development projects and program funding. This will be an asset for CDC2, as it will also support the strengthening of the health system. Assistance for HRD is mostly for in-service training under various projects. For CDC, the Global Fund for AIDS, TB and Malaria (GF) has significantly increased funding for malaria, tuberculosis and more recently for HIV/AIDS.73 The increased funding in the country, especially for HIV/AIDS, supports the justification to redirect ADB funding support away from HIV/AIDS to other priorities in CDC2.

D.3. Viet Nam

134. MOH and its partners recognize that the health sector in Viet Nam is fragmented and that foreign aid has contributed to, and resulted in, multiple reporting systems at commune level, high transaction costs and imbalanced investments. The health sector has been selected as a pilot sector for aid harmonization. The Health Partnership Group (HPG), chaired by the MOH (and including ADB, EU working group on health, UN agencies, WB and other agencies), was established in 2004 to increase the coordination and efficiency of development assistance. Its terms of reference have recently been broadened to enable it to contribute more effectively to health policy and strategy development, and to guide the Joint Annual Health Review (JAHR). JAHR is expected to help ensure that MOH and donors share the same understanding of the health situation, and work collectively toward improving it. A series of joint performance indicators will be used both internally by MOH and externally by donor agencies.74

135. At present, ADB supports provincial health systems development through four projects:

(i) the 2005 Preventive Health Systems Support Project (PHSSP), which is helping to finance the upgrading of preventive medicine centers and providing computers, surveillance software and training for 46 provincial and four national institutes for more efficient and streamlined surveillance and data management systems at provincial levels, and at sub-provincial levels in 17 priority provinces;

71 E.g.; RETA 5958; Roll Back Malaria Initiative in GMS, and RETA 6247: HIV/AIDS vulnerability and risk reduction among EMG through

communication strategies (in partnership with UNESCO) 72 Ibid. 73 National Committee for the Control of AIDS. 2006. National Strategic and Action Plan on HIV/AIDS/STI 2006-2010. Vientiane. 74 Asian Development Bank, 2007. PPTA Report: South Central Coastal Region Project



(ii) Health Care in the South Central Coastal Region Project, which began implementation in January 2009, supports eight provinces with equipment, facilities upgrading and HRD;

(iii) the 2004 Health Care in the Central Highlands Project now nearing completion; and

(iv) CDC1, supporting surveillance and response systems, control of neglected endemic diseases, and regional cooperation in 15 provinces, but not all of these border provinces in Cambodia and Lao PDR.

136. The World Bank (WB) is supporting similar projects in Northern Mountains, North Central Coastal and Mekong Delta regions. WB is also supporting a pilot for establishing computerized CDC surveillance software for ease of data analysis and management at commune level. Both Banks have been asked by the Government to support similar projects along Viet Nam‘s central coast – an area lagging in health status indicators (women and children and EMG populations), and that has persistently poor access to health services.75

137. The Government is planning to establish a computerized surveillance system and software on a national scale, based on the model currently being tested by PHSSP. Consideration should be given to building on from the surveillance software model being piloted under the PHSSP, which supports improved disease notification by improving data management and the ease of analysis.76

138. Training modules developed and tested for BCC and surveillance system operations in PHSSP are currently undergoing approval by the MOH Department of Science and Training. Action-oriented training methods used for training of trainers (TOT) for provincial master trainers were developed and supported by international TA, and provided provincial trainers with a set of training methodology skills for BCC training at local levels on community mobilization for CDC, and on the use of the surveillance software. The PHSSP has also benefited from having a national TA based in each project province, and a team of international country-based TA to support and monitor implementation. Overlap provinces would benefit if CDC2 were to pick up the continuing support when PHSSP finishes in December 2011. The PHSSP mid-term review is scheduled for 2010.

D.4. World Health Organization

139. Under CDC1, WHO and ADB entered into a partnership agreement,77 with WHO to provide technical support through engagement and management of consulting services for CDC nationally and regionally, including for surveillance and response, outbreak preparedness, virology, dengue control, and control of endemic diseases. Some of the WHO experts (e.g. the dengue control expert in Cambodia, and NTD expert in Laos) also served in a regional capacity. The implementation agreement between ADB and WHO, and agreed to by MOH in CLV specifies among others:

(i) the type of experts to be provided by WHO;

(ii) the manner in which these experts will operate in close coordination with MOH; and

(iii) implementation arrangements for the selection of experts, reporting, disbursement and performance review.78

140. Whilst the agreement between the parties is clear and well documented, and the technical support seems to have worked well, the RPPTA team recommends that there is a closer engagement by the experts in the day to day activities of the project with the MOHs, particularly in the establishment of the baseline, quarterly and annual reviews, as well as in the areas of the specialist technical expertise. It would seem that the cost of recruiting and maintaining WHO 75 Asian Development Bank, 2006. Country Strategy and Program: Viet Nam 2007-2010 76 Discussions with PMU for the PHSSP Project 77 Project Implementation Agreement, 7th February 2006 for 2 years to provide TA experts to the MOH in CLV. 78 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project



experts in each country is quite high compared to what could be achieved in the market place. It is therefore proposed that the specialist consultants for CDC2 be recruited through ADB. This also instills a greater sense of accountability and performance to their specific outputs within the project. The original agreement was that the WHO consultant should be based in the MOH or specialized national institute. It is expected that this practice would continue. This approach will require further higher level discussions between ADB and WPRO as the international engagement with WHO on CDC and other health related matters is technically and strategically, very important to CDC2.

D.5. Mekong Basin Disease Surveillance Program

141. The Mekong Basin Disease Surveillance (MBDS) Program has been operating for 10 years based out of the Ministry of Public Health in Thailand and as such is not an independent institution. Its Mission Statement is: Strengthen national and sub-regional capabilities in infectious disease surveillance and outbreak response, especially for priority diseases, to rapidly and effectively control them. This mandate is to continue, with the Ministers of the six participating countries signing a new MOU agreement in Geneva in 2007. The six GMS participating countries include Cambodia, China, Lao PDR, Myanmar, Thailand and Vietnam. Its current operations are based on the MBDS Action Plan 2008 to 2013 which is structured around seven inter-related core strategies:

(i) maintain and expand cross-border cooperation;

(ii) improve human-animal sector interface and strengthen community-based surveillance;

(iii) strengthen epidemiology capacity;

(iv) strengthen Information and Communications Technologies (ICT) capacity;

(v) strengthen laboratory capacity;

(vi) strengthen risk communications; and

(vii) conduct and apply policy research.

142. As MBDS‘s brief is similar to some of the key operations aspects of CDC2, it is recommended that ADB enter into a partnership or contract agreement with MBDS to participate in CDC2 for the following reasons:

(i) in most of the participating countries, MBDS is working with the same senior MOHs officials who have had similar responsibilities under CDC1 and it is anticipated that they will continue in the same positions in CDC2;

(ii) MBDS already has a valuable network of donors and institutions who are active or specialist agencies in CDC;

(iii) the CDC2 design is based on the key elements of the MBDS Action Plan and seven inter-related core strategies, as well as the Asia Pacific Strategy for Emerging Diseases (APSED) strategies;

(iv) MBDS is already undertaking border crossing activities through its MOH partners and efficiencies can be gained, from drawing on their experience, not duplication or overlapping, and more border crossing will therefore have greater coverage between CDC2 and MBDS;

(v) the MBDS cross border training manuals, guidelines, and reporting formats, can be used in CDC2 as the respective MOH staff are already using these documents.

(vi) CDC2 could combine with MBDS and utilize the same IT surveillance data base, and perhaps further develop the system to provide real time reporting on a regional basis;



(vii) cooperation between all partners engaged in CDC activities nationally or regionally could see the Knowledge Management and Community of Practice ―Clearing House‖ concept developed (see Appendix 20.2 for details); and

(viii) the MBDS Program Coordinator can make a valuable contribution to CDC2 by participating in the Technical Group for the design of the Baseline Survey, and quarterly and annual reviews, as well as discussions on cross border activities.

E. Lessons Learned

E.1. Regional and Cross-Border Collaboration in Health

143. The lessons learned from CDC1 and other related programs have been quite valuable. They are summarized below and detailed in Appendix 5.

144. Regional and cross-border collaboration in health is not intended to replace national disease control efforts and health services. Instead, it is meant to supplement or reinforce these national and local efforts by addressing common gaps or pockets of infection that the national programs and services have missed.79 Despite the many advantages of regional health cooperation, collaboration has been difficult to achieve due to a number of barriers, which include:

(i) political barriers;

(ii) legal barriers;

(iii) administrative barriers;

(iv) cultural barriers; and

(v) professional barriers. 80

145. A key lesson that can be derived from these barriers is that cross–border collaboration in health must involve the central, state/provincial, and local levels, and public and private sectors, as well as community-focused interventions that support locally owned initiatives that enable communities to improve their own health. 81 This experience here has helped determine the project geographic areas with a distinct re-focusing to a cross border orientation within the context of the GMS economic corridors.

146. A SWOT analysis conducted by the RCU team identified CDC1 strengths and weaknesses.

Strengths included:

(i) Project officials are key ministry officials;

(ii) CDC1 placed within the broader context of the ADB-GMS Program;

(iii) significant project funding ($39M); and

(iv) strong linkages developed among scientists in the CLV countries.

Weaknesses included:

(i) lack of high level coordination with established regional organizations like ASEAN and MBDS;

(ii) RCU seen as a separate ‗project office‘ rather than an institutionalized structure;

79 Lemma Merid, 2003. ―A Regional Perspective Towards Managing HIV/AIDS in Northeast Africa,‖ Journal of Health and Population in

Developing Countries. 80 Homedes, Nuria and Antonio Ugalde. 2003. ―Globalization and Health at the US-Mexico Border‖ 81 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. Nov 2009. Phnom Penh



(iii) CDC1 limited to only three countries within the 6-country GMS; and

(iv) insufficient multi-sector focus, including poor links to animal health.

Opportunities included:

(i) existing political will;

(ii) senior health networks;

(iii) a growing trust;

(iv) development and use of ICT;

(v) the APSED framework; and

(vi) lessons learned from recent pandemics.

Threats included:

(i) a lack of momentum;

(ii) donor fatigue

(iii) abandoning initiatives before doing serious trials;

(iv) lack of regionally focused staff; and

(v) unsustainable funding.82

147. A suggested definition of what is meant by ‗regional‘ is that regional programming should concentrate on elements that are regional, and fill the gaps that are left by the national programs, such as addressing language barriers and clarifying the role of provincial offices for improved cross-border collaboration, mobilizing skills and resources from across the region, including from China and Thailand, clarifying the role of MDGs in Project M&E, and addressing the need for additional training and research, especially for dengue and NTDs in border areas.83

148. GMS cooperation for CDC. Agreements and frameworks for regional cooperation have been developed, and benefits of regional approaches being piloted are beginning to emerge, in terms of technology transfer for strategic planning and generating a healthy climate of professional cooperation, competition, and commitment.84 However, activities have been limited and have tended to follow vertical planning approaches, and progress on regional reporting needs strengthening. The basis for joint disease control activities has not been laid down, and networking among these professionals has not taken root outside of forums and workshops. Only one sub-regional project country achieved substantial policy and regulatory reform in enabling and sustaining surveillance and response systems (the foremost of which is funding) compared to the other two countries, and the knowledge generated from the projects may not have been used effectively. 85

149. Within a regional context, a balance between quality and coverage is needed, including for inter-provincial and cross-border approaches to ensure impact. Financial sustainability must also be addressed. Partnerships with WHO-SEARO and WPRO will help to improve national and regional strategies. Coordination with ASEAN, MBDS and others should be explored as well. The

82 Asian Development Bank. 2009. A Concise S.W.O.T. Analysis of the “Regionality” of the ADB GMS CDC. Discussion Paper. Regional

Coordination Unit, Hanoi 83 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. Nov 2009. Phnom Penh 84 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater Mekong Subregion:

Maturing and Moving Forward 85 Asian Development Bank, GMS-RCAPE, 2008.



activities of the Global Network for NTDs should be built on to leverage additional funds. There remains a question whether dengue should be harmonized across the three countries.86 CDC2 will continue to support funding support for dengue activities in the event of an emergency outbreak. It is foreseen that ADB will in 2010 begin the preparation of a five year regional dengue program.

150. The WHO-SEARO APSED bi-regional strategy provides a good framework to review and assess regional capacity for CDC. However, APSED is still largely overlooked in national program plans and strategies, and there is a lack systematic assessment of country progress on APSED, particularly relating to such areas as preparedness and capacity. The new IHR (2005) has provided a stronger international framework for cooperation in infectious diseases and other serious public health threats. It has also imposed strong legally binding obligations, whereby attention becomes focused on IHR-bound international check-points, for example, and may neglect the ‗unofficial‘ border crossings where the risk of disease spread may sometimes be higher, given possible unchecked, illegal activities taking place (e.g. livestock smuggling, illegal immigrants, trafficking of counterfeit medicines, etc).87 APSED has helped shape the approach and components of the CDC2, and it is recommended that it should form the basic framework for guiding CDC2.

151. Although (ground) cross-border cooperation is considered a critical element of regional CDC and pandemic preparedness, few donors and partners have actively supported cross-border activities. Consultative workshops on cross-border collaboration supported under CDC1 have led to a three year plan for 5 cross-border sites, which will be followed up under CDC2 to develop and agree on specific operational guidelines and procedures for cross-border cooperation.88 Effective donor coordination in Lao PDR, for example, is reported to have resulted from an annual project planning process that is based on province level or ―bottom-up‖ planning and which is also well harmonized with GF planning, and the key link for success according to the project management team in Lao PDR has been the placement of the EA and PMU for the CDC1 Project in the Budget and Planning Department of the MOH, which provides for greater overall management leverage for more effective implementation.89

152. Quarantine services in CLV received CDC1 project support mainly for equipment, such as computers, and some capacity building in selected ports and border points. However, much more is needed to meet the requirements according to government plans, including for:

(i) civil works;

(ii) equipment and supplies provision;

(iii) increase staff levels and a range of capacity building needs; and

(iv) recurrent costs for these inputs.

153. Given the magnitude of investment required to expand and strengthen quarantine services is beyond the scope of the available funding under CDC2, plans to further expand and strengthen quarantine in CLV should be addressed in a separate project outside CDC2, specifically tailored to meet these needs.

154. Addressing HIV: One of the most extensively researched90 negative impacts of population mobility facilitated by the GMS economic corridors is the spread of HIV. ―Hot spots‖ are mainly

86 Asian Development Bank. *the GMS Regional CDC Review Workshop Report. November 2009. Phnom Penh 87 Asian Development Bank. February 2009. Lessons Learned In Regional Cooperation in CDC.RCU, Hanoi 88 Asian Development Bank. 2009.. A Concise S.W.O.T. Analysis of the “Regionality” of the ADB GMS CDC. Discussion Paper.

Regional Coordination Unit, Hanoi 89 Asian Development Bank, 2009. TA RCAPE Assessment Report. 90 The most detailed study to date was supported by Rockefeller Foundation in 2003 to examine the social and health impacts of

Highway 17 and its border crossings from PRC and Thailand in north-eastern Luangnamtha Province in Lao PDR. This road is linked but not integral to the north-south corridor Lyttleton, Chris et. al.. 2004. Watermelons, bars and trucks: dangerous intersections in Northwest Lao PDR: An ethnographic study of social change and health vulnerability along the road through Muang Sing and Muang Long. Lao Institute for Cultural Research, and Macquarie University, Australia. Another ADB –sponsored study is highly informative but does not capture the rapid economic growth on GMS corridors since it was written in 2000: Chantavanich, Supang et. al. 2000. Mobility And HIV/Aids In The Greater Mekong Subregion. Asian Research Center for Migration Institute of Asian Studies Chulalongkorn University Bangkok, Thailand in consortium with World Vision Australia and Macfarlane Burnet Centre for Medical



border towns. Because these towns are close to border checkpoints they are logical rest points for trucks and buses transiting from one country to another. Many are close to casinos and big markets, attracting cross border trade. Concerns were raised by government health officials in Bokeo and Luangnamtha Provinces in Lao PRD, where HIV prevention activities are said to be insufficiently funded and risk factors are growing rapidly with road traffic through these provinces and construction of casinos. This should be a matter for ADB policy dialogue with Lao PDR, where reservations were expressed by MOH about working in INGOs. However, many INGOs have extensive relevant experience and expertise in HIV work, and access to the Global Fund. There is considerable scope for increasing partnership between MOH/INGOs on the Economic Corridors and associated ‗Hotspots‖.

155. Data presented by the Global Network for Neglected Tropical Diseases91 shows that ODA for HIV/AIDS accounted for 21% of spending 2003-2007, (Malaria got 2.20 percent and TB 1.40%, while neglected tropical diseases (NTDs) - a large group of mainly parasitic diseases - got 0.35%). Average annual growth rate in ODA expenditure on these infectious diseases was about 29% for Malaria, 30% for TB and 18% for TB and 10% for NTDs. NTDs affect 56.6 million people around the world; most NTDs are diseases of poverty, and many slowly disable and kill those infected.

156. As the representative from PRC noted in her presentation at the Second GMS Regional Health Forum (Guilin, 23-24 February 2009), the GMS Economic Corridors are conduits, not just for HIV but for many other potentially fatal or incapacitating diseases, such dengue, cholera, malaria, measles, TB, encephalitis, hepatitis, filiariasis, and helminthiasis and many others. She noted the common regional impacts of the increasing interface between local people with mobile populations, and the neglect of CDC in isolated border areas. She commented that lack of coordination was a major concern, concluding that ―the health of neighbors is our own immunity‖

157. The Project will support HIV surveillance activities within its program to improve the quality of overall epidemiological analysis for CDC in the Project border provinces but will not support programs for prevention of HIV/AIDS transmission and treatment, as these are well funded by other donors in the region.

158. Strengthening and rationalization of laboratory services is needed but should be a component in national health systems development assistance. Laboratory capacity in project provinces and districts has improved as a result of CDC1 support, although shortage of consumable reagents is reported to be a chronic problem. CDC2 will provide limited capacity-building assistance focused on border districts in the context of strengthening cross-border surveillance, and encourage adequate government budget support to essential laboratory recurrent costs. The Project will also provide short term TA Laboratory Specialist to undertake an assessment of the national support systems and the basic laboratory services at provincial and district levels to ensure that prompt and quality diagnosis is available to confirm or not suspected infectious communicable diseases.

159. Participatory and multi-sector approaches at local government and community levels will strengthen the outcomes and impacts of health and social development interventions. Support to the decentralized arrangements of health systems require strong planning and management participation at provincial as well as district levels for enhanced ownership by local authorities, and to define clear roles and responsibilities. Experience from CDC1 has also demonstrated that community mobilization, IEC and health education, if systematically implemented through local structures, such as multi-sector health committees, mass organizations, commune health workers and other community volunteers - such as school children who in some communities carry out routine environmental sanitation surveillance as part of their health education home work assignments - and with the support of the local administration authority, can improve preventive actions, health seeking behavior and for overall population health.

Research under TA 5881 REG: Preventing HIV/AIDS Among Mobile Populations in the Greater Mekong Subregion Asian Development Bank (ADB) and United Nations Development Program (UNDP)

91 Presentation by the representative of the Global Network for Neglected Tropical Diseases presented to the First GMS-CDC Technical Forum on the Control and Elimination of NTDs in the Mekong Sub-region. October 22, 2009



160. Importantly, for the capacity building outcomes to remain effective and sustained, refresher training for health staff and community health workers will be required, as well as support for recurrent costs to implement activities. For disease surveillance, response and preparedness systems to be effective, sufficient cash support (on hand) is also required to respond to disease outbreaks, as a supplement to the existing government health budgets that are insufficient for rapid response.92

161. Training of village health volunteers‘ remains of vital importance. Involving and training the community, especially community health workers and ensuring a system of community surveillance is established as it is important in limiting the spread of disease in regionally. The role of communities in disease prevention and containment needs to be prioritized to ensure that services are delivered at the highest possible standards. Innovative incentives for sustained community involvement such as salaries, stipends, preferential access to medicine and health care, training opportunities or public recognition will also be important to ensure buy-in from community health workers and local administration.93

92 Ibid. 93 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. Nov 2009. Phnom Penh



III. THE PROPOSED PROJECT

162. The proposed CDC2 project will be built around the three strategic pillars94:

(i) Pillar 1: Regional strategy , policy and mechanisms for regional cooperation in CDC;

(ii) Pillar 2: Regional Knowledge Management and human resource development; and

(iii) Pillar 3: Cross border (ground) collaborations and health services.

163. Activities under the Project are pro-poor, focusing on rural and remote populations in the project districts of CLV border areas where many ethnic groups and the poorest reside. Women and children will be the major beneficiaries of the PHC and community-based interventions, including community based CDC surveillance and response in these border districts.

164. The Project has two components:

(i) strengthening regional cooperation in communicable disease control, and

(ii) strengthening national surveillance, response and health systems.

A. Impact and Outcomes

A.1. Impact Statement

165. The overall project impact will be improved health for the populations in the project provinces in the border region, which will assist the Ministries of Health in Cambodia, Laos and Vietnam (CLV) to achieve MDGs 4, 5 and 6 by reducing the spread of emerging and neglected communicable diseases thereby reducing morbidity and mortality, in particular among children, and the economic cost of these diseases.

A.2. Outcomes

166. The expected project outcomes will be improved regional security through:


(ii) Strengthened regional and MOH‘s technical capacity for surveillance and response, following WHO guidelines for implementation of the IHR and APSED with timely responses to epidemics in provinces with common borders that are likely to have a major impact on public health and the economy in the region;

(iii) Increased capacity of national, provincial and district health services in results based management and technical capability with integrated CDC and health services particularly underserved populations who have a high disease burden neglected tropical diseases(NTDs) and are at risk from newly emerging diseases (EIDs); and


94 The Three Pillars concept was developed by ADB under the CDC1 Project.



167. The Project will be implemented over a period of 5 years, commencing in July 2010 and will be adjusted yearly on the basis of Annual Operating Plans (AOPs) developed at the provincial level, and approved by the national steering committees (NSC).

168. CDC2 design is based on the core capacities and basic public health infrastructure for an effective response to existing and emerging diseases and other public health emergencies95 are well illustrated in figure 2 and articulated in APSED. Which is recommended as one of the foundation project management documents to be utilized by all project managers in the implementation of the Project.

A.3. Components

A.3.1. Component 1: Strengthening Regional Cooperation in CDC

169. Component 1 will establish and support mechanisms to increase regional cooperation with a focus on EIDs and NTDs in selected border and cross-border corridor districts, in three clusters of border provinces in CLV (see Map 2). The sub-components are:

170. The first subcomponent (1.1: Compatible and coordinated strategies for CDC across borders) will support compatible and coordinated GMS strategies for CDC across borders. Outputs will include:

(i) plans for implementing a harmonized approach to CDC (EIDs and NTDs) based on WHO IHR, the MBDS Action Plan, and APSED;

(ii) establishment of a regional focal point in the MOH at national and provincial departments of health for regional cooperation;

(iii) GMS meeting to establish a regional Project Steering Committee and national working groups; and

(iv) formalization of agreements on CDC cross-border activities.

171. The second subcomponent (1.2: Cross border planning, monitoring and evaluation for CDC) will support development of cross-border planning monitoring and evaluation for CDC. Outputs will include:

95 WHO APSED, 2005, page 21.



(i) Comprehensive baseline surveys in the border districts of the three project clusters to guide provincial and district CDC strategies and cross-border cooperation;

(ii) appointment of technical advisory teams to prepare a draft design of the baseline survey including an analysis of;

(i) CLV border provinces demographics; (ii) district health service; (iii) cross border traffic and population movement, (iv) border quarantine service; (v) village water and sanitation coverage; (vi) animal health services; (vii) diagnostic capacity in district health centers; and (viii) gender, social and poverty analysis, including human trafficking issues.

Much of this data already exists, but has not been collated for provincial and district level analysis, some special follow-up surveys are likely to be required. Although not all the above issues will be addressed in project activities, information will be referred to the appropriate national and provincial authorities for further detailed studies or investigation. Invitations will be extended to the MOHs of PRC (Yunnan province), Thailand (Ubon Ratchathani and Chang Rai provinces) and Myanmar to also participate in cross border activities in CLV adjoining districts.

(iii) National and provincial workshops are planned to design the review, finalize and approve the survey design including defined objectives for evidence-based gender planning. A regional workshop to agree on common criteria for baseline survey of contiguous districts will be endorsed by CLV MOHs.

(iv) Design of software for collating the baseline data will be shared in the provinces and districts. A common CDC software database for recording, analysis and M&E will be shared among the project provinces. Training will be provided on the use of the software and on research methodologies using existing data.

(v) National and Provincial workshops to plan the implementation of the baseline survey (with guidance from the technical team), and shared with the participating border districts through dissemination workshops for district level planning and implementation.

(vi) Comprehensive baseline surveys in all border districts in the cross-border cluster provinces, supported by provision of computers, software and peripheral equipment for compiling and analyzing baseline data for each province.

(vii) Provincial and district multi-sector, long-term strategic plan of action on CDC based on baseline data that address specific needs and issues and identify sentinel surveillance locations, with support from the Baseline Survey technical team.

(viii) Provincial workshops to harmonize their border district CDC priorities, plans and activities including integration with other donor programs, and consider incorporation of relevant aspects of the WHO strategy and planning framework for integrated package of MCH services developed for Lao PDR, the ―healthy village‖ criteria, and Cambodia‘s PHC strategy and plan will be used as the basis for district level interventions .

(ix) Detailed monitoring and evaluation frameworks enabling comparable information from each border district to be monitored in each cluster. This will include establishing sentinel surveillance locations and review of annual data updates of epidemiological information, health services utilization data, and progress on sector coordination.



(x) Quarterly and annual consultations and reviews of activities in each GMS CDC province.

172. The third subcomponent (1.3: Regional Knowledge management) will refocus the current activities of the RCU towards CDC project implementation, and knowledge management for the GMS. The RCU will operate for the duration of the Project but it is possible that the knowledge management program of Project will be transferred to MBDS or another regional organization as soon as institutional arrangements permit. Detailed of the TORs for the RCU and proposed ‗clearing house‘ program are included in Appendix 20. In brief it is proposed that the ‗clearing house‘ program will be established to:

(i) compile information on CDC donor activities in GMS with an associated matrix of donor activities and GIS mapping of CDC programs in GMS, and continuously update these;

(ii) collect and disseminate all relevant information on CDC, particularly dissemination of CDC best practices;

(iii) maintain a directory of CDC professionals;

(iv) maintain a GMS website and list serve to disseminate this information;

(v) provide GIS mapping services;

(vi) management of the transition of the RCU ―clearing house‖ activities to MBDS; and

(vii) support technical forums that will be organized by the MOHs of CLV, addressing CDC issues in the GMS and Project border and cross-border areas.

173. The fourth Subcomponent (1.4: Support for regional GMS CDC implementation and coordination) will support project implementation to achieve efficient and effective management of GMS CDC Project activities, and other GMS CDC regional Project activities. Outputs will include:

(i) technical support for regional GMS CDC implementation and coordination;

(ii) design of a detailed M&E framework for GMS CDC cluster project activities;

(iii) establishment of regional focal points in MOHs;

(iv) coordination of regional TA inputs and by specialized technical agencies and health INGOS;

(v) coordination and planning of linkages with national and regional health sector programs and projects.

A.3.2. Component 2: Strengthening National Surveillance, Response and Health Systems

174. The first subcomponent (2.1: strengthening institutional structures, partnerships and policies) will strengthen institutional structures, partnerships, and policies. Outputs will include:

(i) national multi-sector long-term strategic national policies for regionally collaborative emergency CDC response and prevention of communicable diseases; incorporating WHO guidelines for implementing the IHR; and

(ii) national multi-sector mechanisms to define sector and departmental roles for emergency CDC response.

175. The second subcomponent (2.2: Strengthening systems for Human Resource Development) supports a Training Systems Development approach to HRD to strengthen surveillance, response, and preparedness and health services delivery as required. Provinces will



be supported to increase their training capacity using ―training of trainers‖ (TOT) approach to improve the quality of health workers skills and quality health services and coverage, including for surveillance, response and preparedness in the 29 project provinces. Increasingly, the responsibility for recruiting, training, and managing human resources in health is a local concern, and a demanding obligation of provincial health authorities. The Project will support:

(i) strengthening human resources planning and management;

(ii) building training capacity at provincial and district levels;

(iii) training of district and commune HC staff to improve quality of health services, including community-based CDC; and

(iv) training of VHV/CHW and village and commune administration.

176. Outputs will include:

(i) MOHs acceptance and support for the ―Training Systems Framework‖ for HRD;

(ii) National Institutes participate in the development of the TSF and detailed program including curriculum development and are contracted to undertake TOT training of master trainers;

(iii) provincial human resource staffing and training plans of action including analysis and training needs in provincial health services;

(iv) plans of action to increase gender and ethnic minority equity in provincial and district health services;

(v) review of existing training curricula and materials and adopt or develop new materials;

(vi) identification of IEC and training materials that can be translated and shared in regional clusters, including IEC materials produced or planned by ASEAN+3, national institutes, provinces in CDC1, donors, WHO, UNICEF, and INGOs;

(vii) training equipment needs are assessed and provided based on needs assessment;

(viii) training plans, materials and activities approval by national authorities;

(ix) provincial technical management group to oversee provincial training programs, advise on priorities and approve training funds;

(x) provincial training groups for implementing the provincial plans and for master training systems and training of master trainers in skills based training;

(xi) harmonized master training approaches in the Project provinces strengthening, provincial, district and commune/village level capacity for surveillance and reporting;

(xii) inter-provincial training working groups to share experiences and development of strategies according to local priorities.

177. As government policies in CLV currently mandate increased decentralization of their national health systems, MOHs need to devolve these responsibilities and maintain close links with provincial, district, commune and local health center levels. This is particularly important in regard to human resources development (HRD), to ensure that:

(i) the training, distribution and management of health workers is consistent with national policy directions;



(ii) the local levels are able to influence future policy making based on their implementation experience; and

(iii) the MOHs have the capacity and information needed not only to develop their long-term national health sector HRD plans for CDC, but also to fulfill their broader regional and global obligations within the APSED and the IHR.

178. The Project will support the MOHs, and relevant departments and institutions responsible for HRD in implementing national HRD policies and building HRD planning and capacity at all levels by strengthening mechanisms of coordination and collaboration, and were required, funding of operational research. This will include provision of assistance to each province to annually update and maintain its human resources (HR) Plan. The annual HR Plans will take into account national policy initiatives and staff management issues; and the annual HR plans will consider the training needs of health providers, especially in underserved districts, and the availability of training resources in terms of trainers, training courses, equipment, facilities and funds. Special attention will be given to ensure proper linkages between the different training programs, ensure participation of ethnic groups and women, facilitate appropriate scheduling, and avoid overlaps. The plans will also include targeted strategies to increase the leadership roles of qualified female personnel in the management of health services. The plans will provide for monitoring and evaluation of the quantity and quality of staff training programs and work place activities especially in border areas.

179. To help increase the number of women and ethnic minority health workers in targeted communities, the Project will provide assistance to each province to develop ethnic minority development plans, and ensure that gender is mainstreamed across the project activities including focused interventions designed to ensure they reach targets for women and EMGs in training courses at all levels. Where appropriate, training courses offered through the Project will be provided in local languages of EMGs. Language preparatory courses will be offered to EMG staff who are selected to participate in courses that are only available in the national language. Health workers serving EMG communities will be given priority for training, and training programs will include topics that disproportionately affect EMG

180. An initial inventory and review of IEC/BCC materials will identify deficits in existing resources and suitable materials. Using a range of methods, these materials will be pre-tested as part of the project training in audience analysis and the testing of these materials will continue as an ongoing consultative process, resulting in a package of targeted materials distributed to all Project districts and communes. The Project will foster a needs-based and participatory approach to the development of innovative, creative and culturally appropriate IEC/ BCC materials through audience analysis, and substantial community involvement in style and content.

181. The Project will strengthen the relevance, accessibility, quality, and effectiveness of training in the target provinces of CLV. Provincial in-service training systems will be strengthened to support the introduction and/or expansion of skills-based training – an approach which has been proven to be very successful in several localities in the region. Skills-based training (SBT) is a simple, flexible approach based on the principle that training is complete only when the learner can demonstrate skilled performance. The SBT model involves several elements, including:

(i) development of a skills checklist, based on MOH standards, and adapted to the needs of each province; and

(ii) training of trainers (TOT) on adult learning principles, inter-active learning, how to teach skills, and how to conduct workplace assessment; and

(iii) on-the-job follow-up to assess the application of learned skills and knowledge, and to provide further coaching as required to gain proficiency.

182. To assist provincial health authorities to implement SBT programs, the Project will support existing Provincial Training Working Groups (PTWG) and encourage the formation of similar groups where they do not exist or are inactive. PTWGs include senior clinical and preventive health



trainers and supervisors from provincial and district hospitals, preventive medicine, health education, reproductive and child health centers, and secondary medical schools. The PTWGs play a key role in planning, developing, delivering, managing, and evaluating training activities. PTWG members will be trained as ―Master Trainers‖ by senior training specialists who are experienced in SBT and interactive teaching methodologies. At the district level, the Project will support the strengthening of District Training Working Groups (DTWG) who will take the responsibility for planning and mobilizing training programs in their districts and local communities. In each province, a group of eight Master Trainers trained in SBT methodologies, along with four trainers from each district will be trained as trainers. Capacity building will be further enhanced by the sharing of experiences between Project provinces in each CLV country.

183. A package of in-service training materials will be developed and compiled for use by the provincial and district trainers including an in-service Training Procedures Manual and a range of SBT training modules addressing important topics related to CDC, and based on training needs analysis (TNA). The project will also draw upon other Health Sector Project (Past and present) with TOT approach and where possible use existing curriculum, materials, and trainers. Trainers will be oriented on these topics, and taught the skills necessary for conducting regular training needs analysis (TNA), management and implementation of SBT, and evaluation of training outcomes. The Project will also support the purchase of equipment needed to enhance in-service training activities or otherwise strengthen training capacity. Equipment may include computers, software, projectors, screens, flip-charts, training aids, and other training materials and supplies. Provincial Project Steering Committees (PPSC) will oversee training plans and programs and are responsible for advising the Project on provincial training priorities and approving training funds. The MOH in each CLV country is responsible for approving all training curricula used by the Project to ensure consistency with other training nationwide.

184. This approach is founded on the understanding that in-service training needs are best determined at the local level. Relevance and efficiency of training is improved where provinces and districts have the discretion to plan in-service training based on their training needs analysis (TNA), and to coordinate the implementation of training with service delivery needs.

185. The third subcomponent (2.3: Strengthening systems of surveillance, response and preparedness) will support the strengthening national systems of surveillance, response, and preparedness and will be based on the APSED, the MBDS Action Plans, and WHOs IHR. Outputs will include:

(i) national health policies that incorporate the WHO ICD, IHR, the MBDS Action Plan for Mekong Regional Cooperation and APSED;

(ii) review of national health surveillance strategies and plans to incorporate WHO ICD, IHR, MBDS Action Plan and APSED;

(iii) harmonizing CDC policy in the GMS;

(iv) strengthening and harmonization of provincial rapid response capacity in project provinces.;

(v) needs assessment of provincial rapid response capacity;

(vi) provision of vehicles and equipment provided based on the needs assessments; and,

(vii) harmonized surveillance plans and activities based on existing surveillance criteria and draw upon the MBDS Action Plan ‗seven core strategies‘

186. The fourth subcomponent (2.4 Capacity building of provincial and district staff for CDC and health services) will strengthen provincial and district diagnostic capability, CDC systems response and reporting, health facilities and health services delivery. Outputs will include:



(i) Training of trainers (TOT) by master trainers in each province on field epidemiology, clinical diagnosis and treatment, data management, analysis and reporting, communications skills for effective IEC and BCC, and other priority topics identified in the training needs analysis (TNA);

(ii) assessment of laboratory services in project cluster provinces and districts;

(iii) laboratory strengthened services at provincial and district levels by provision of equipment and supplies and laboratory technical training, based on the assessed needs; and

(iv) improved quality, timeliness and accuracy of reporting and analysis by data management using ICT wherever feasible, including design of surveillance reporting software, provision of computers, software and peripheral equipment, and training on use of surveillance reporting software, and use of IT for communication.

187. The Project will support training to improve the quality of health services provided by clinical and preventive health personnel and laboratory technicians working in commune health stations (CHS), health centers (HC), provincial and district hospitals, preventive medicine, health education, and reproductive / mother and child health centers. Based on HR Plans developed by Provincial Health Departments (PHD), the Project will support the mobilization of Master and District Trainers to train doctors, nurses, midwives, laboratory technicians and preventive health outreach workers based on TNA in each project province. Training programs will be for a short duration(typically 5 to 10 days with on-the-job follow-up), and will emphasize SBT in priority topics identified in TNA. Supervisors will be trained to ensure they have the skills necessary to support trainees in applying the new skills on the job. A list of training activities, and the estimated numbers of participants, is attached in Appendix 10. Support will also be provided for PTWGs and DTWGs to undertake workplace assessments of the impact in-service training has on the performance of health workers, as a mechanism of quality improvement.

188. The Project will specifically address the quality of health services in remote, underserved border districts, CHSs and HCs, where lack of staff is a problem. Recruiting staff from other areas has not been successful in addressing staff shortages, due to the challenging living and working conditions, and the cultural and social differences between ethnic groups. The Project will therefore provide scholarships for local school leavers from these border communities to attend health worker training at secondary medical schools or local colleges. These scholarships will cover living expenses such as food and accommodation, uniforms, books, travel between home and school for holidays, extra tuition and preparatory courses if needed, and will supplement current government subsidies that may be available

189. To assist provinces in achieving MOH personnel standards for health facilities, the Project will also support scholarships for prioritized specialized training, upgrading training or other advanced education for health professionals, based on Provincial HR Plans. National scholarships will be provided for study within each country, at the closest academic or technical institution with capacity to provide such training. A limited number of international scholarships will be supported for relevant advanced education in neighbor countries within the GMS. Funding will be provided for tuition, accommodation, meals, travel, and other costs associated with completing the course. Preparation courses will also be covered if necessary. The Provincial Departments of Health will work with the Provincial Steering Committee and the Provincial Project Implementation Unit (PPIU) to select candidates, who must then be approved by the Project Management Unit (PMU) at the MOH. Criteria will be developed to ensure that the selection of candidates for scholarships is consistent with Project goals to increase the representation of ethnic minorities and women in senior positions within the health sector.

190. The fifth subcomponent (2.5: Targeted communicable disease control and training activities for rural populations in border districts) will provide CDC prevention and treatment services to vulnerable populations in the rural areas of border districts in border provinces of CLV through an integrated PHC/MCH and ‗healthy village‘ approach. The Project will support targeted



communicable disease control services and training activities for rural populations in border districts based on the data and analysis of the comprehensive baseline survey. These activities will include the development and implementation of gender sensitive strategies for engagement and communication with minority linguistic/ethnic groups, for increased demand and access to quality health services for the poor, women and children and EMGs living in underserved border areas.

191. Activities and Outputs will include:

(i) provincial planning meetings to identify underserved border villages;

(ii) CDC workshop to harmonize healthy village criteria based on district baseline data and plans of action to provide outreach to underserved populations;

(iii) formation of inter-departmental provincial steering committees (PSC) within provincial and district level health departments, and chaired by the local political authority responsible for CDC, to integrate vertical health programs;

(iv) provincial and district needs assessment for strengthened MCH/PHC;

(v) district teams established in all border districts of project provinces that work with a network of health centers, dispensaries and VHWs;

(vi) provincial and district needs assessment for transportation and equipment to establish mobile clinics and provision based on the needs assessment;

(vii) mobile clinics to provide CDC and MCH/PHC services to remote and underserved communes and villages;

(viii) strengthening health care services in remote, underserved border areas and ethnic minority group (EMG) communities;

(ix) improving health behavior through increased knowledge, awareness, and participation in community-based disease surveillance and prevention and PHC activities;

(x) provincial studies designed to guide engagement and communication with minority linguistic/ethnic groups on CDC;

(xi) CDC cluster workshops to harmonize approaches and strategies for gender sensitive engagement and communication with minority linguistic/ethnic groups; and

(xii) provincial and district plans and actions for engagement and communication with minority linguistic/ethnic groups.

192. Strategy workshops in each province will review draft guidelines drawn for research, study tours, and consultation with counterparts to finalize the operational guidelines for the community activities in each province. Local and international study tours of relevant models of community-based surveillance and risk mitigation, rapid response and prevention of EID and NTD. The Project will encourage the continuation of links and networks developed during these study tours. Experiences from the community workshops, study tours, and the learning process will together be analyzed to produce clear strategies for community-based BCC activities, and practical guidelines which are tailored to fit local conditions in the project areas.

193. A wide range of training programs, developmental workshops, baseline research, needs assessments and consultative community activities involving health sector personnel and community members will contribute to the development of provincial strategies and capacities for implementation of community-based health promotion, personal hygiene and environmental sanitation activities for CDC, such as the design, implementation and maintenance of healthy



village models, VHW networks, community-based transportation schemes, and other local initiatives addressing locally defined health promotion and disease prevention priorities.

194. Effective community-based health promotion and risk mitigation for CDC requires collaboration between a range of service sectors and community groups so that health is seen as an issue of communal concern and not simply a technical issue for workers inside the health system. In the health system, this will be promoted by developing skills in community needs assessment, and improving outreach activities. At the community level, activities involve mass organizations, government officers from various community-level departments, commune and village development committees, community volunteers and staff from commune health stations (CHS) and health centers (HC). Strengthening health services therefore focuses on district, commune and village levels96, and includes the strengthening of disease recognition and prevention, first aid, clinical care, communication and supervisory skills.

195. Selected members of PTWGs and DTWGs from preventive medicine, health education and reproductive and child health centers will identify and mobilize appropriate trainers who will conduct TNA, plan, design, develop, deliver and evaluate SBT materials and courses for health workers at commune and village levels, including VHWs working in remote, border communities. Training activities will be based on TNA, and will address priority topics related to behavior changes needed for disease prevention and risk mitigation, surveillance and rapid response.

196. The provincial and district trainers will provide training in teams for health workers in their districts and communes to help minimize the dilution of skills and knowledge as the training evolves down the levels from provincial, to district and then commune and village. Based on the TNA conducted in each target district, and with sufficient time allocated for the training courses, topics may include:

(i) field epidemiology (short courses);

(ii) data management, analysis and reporting;

(iii) clinical diagnosis and treatment;

(iv) laboratory hygiene and rapid testing;

(v) audience analysis for IEC/ BCC media testing and development;

(vi) communication techniques for community-based health promotion, disease surveillance and prevention;

(vii) health services administration and management;

(viii) monitoring and evaluation;

(ix) project management; and

(x) skills training to build capacity will take many forms; training of trainers, training workshops, on-the-job training, staff exchanges, study tours and field practice. Details of the range of training to be undertaken is detailed in Appendix 10, Training Systems Development Framework.

197. The Project will also support government policies in CLV for expanding and strengthening the grass-roots network of commune and health center personnel, village health workers (VHWs), and other volunteers, particularly in remote and disadvantaged areas (among the 29 project provinces and 102 Project districts which share a contiguous border with a neighboring country). VHWs will be trained or retrained based on existing MOH VHW curricula, and modified according to local conditions and capacities. Topics will include BCC and effective use of culturally

96 Communes are administrative entities in Cambodia and Vietnam but do not exist in Lao PDR.



appropriate IEC material and messages for community-based health promotion, disease surveillance and prevention.

198. Volunteers nominated by their communities will be provided training based on MOH VHW training curricula, and adapted to the needs, ethnic groups, literacy levels, and situations in each targeted district. VHWs play a key role in facilitating community involvement in health issues since they live in the same village and share common culture and language. Retired health personnel, members of mass organizations, national program collaborators and other community volunteers can become VHWs – with training, monitoring and supervision from district and commune health personnel – and can serve as an effective link between the health system and the community. Village health workers will be trained to recognize common endemic diseases, promote behaviors to prevent transmission of common infections and mitigate the risk of spread of disease at community level using preventative environmental approaches. In remote, EMG areas, CHS and HC staff can receive training in the local languages of their communities.

199. The clinical and preventive health trainer teams will collaboratively produce appropriate materials for the training of VHWs, modifying existing materials and producing new, locally appropriate materials as necessary. Project activities will provide specific support to provinces for the training of CHS and HC heads in the monitoring and supervision of VHWs, and practical guidelines for outreach and follow-up supervision. All training will emphasize the Project‘s SBT approach, using substantial field practice to reinforce techniques. The TOT package will be developed with support from the PTWGs, Project HRD TA, NGOs, and local health promotion and PHC specialists. PTWGs will conduct TOT for the district trainers, at least half of whom will be women. The techniques used and much of the content will be new and unfamiliar to most, if not all participants. Project staff will therefore need to ensure that training is thorough and that regular and intensive refresher courses are conducted to help sustain and advance the new skills learned.

200. Wherever possible existing materials will be tested and improved. But where audience analysis identifies deficiencies, new messages or materials will be developed using a participatory approach. All materials developed will be submitted to the MOH for approval in order to ensure consistency with existing policy, and to make them available to a wider context where applicable. To maximize the value of the IEC/BCC materials produced, training will be provided to health workers and volunteers to use then effectively. Health workers, VHWs and members of mass organizations will be trained together so that they develop a close working relationship and a common understanding of the methods used. Innovative and effective IEC media will be developed as a ―parallel‖ process to the training activities, whereby the training strategy integrates the development and production of IEC/BCC materials into the content of the community-based health promotion training. Therefore, the process is not conducted as a discrete activity, but rather, as a part of the training, and includes the use of all the materials effectively. It will also be important to allow sufficient time for printing and distribution of materials.

201. Experiences from participatory needs appraisal activities, community workshops, study tours and the learning process will together be analyzed to produce clear strategies for community-based health promotion activities, including for CDC, that seek to empower people in their choice about health, which in combination, compliment Project improvements to the delivery of health services, and thereby encourage greater and more discerning use of those services.

202. The Project will support a number of research grants for provincial studies related to CDC in cross-border settings, and to guide engagement and communication with linguistic/ ethnic groups on CDC, and related issues. Research and study proposals will be processed by the PMU, upon recommendation of provincial project implementation units (PPIU), and review by a national review committee composed of representatives of provincial and national health authorities, and relevant institutes. National, provincial and regional meetings will be supported for sharing of research findings.97

203. Lack of transport can be a significant impediment to successful outreach efforts. Based on an assessment of local needs and resources, the Project will support the purchase of boats, 97 This activity is for small scale provincial studies



motorbikes and bicycles for use by CHS and HC staff, VHWs and other volunteers providing outreach services.

204. The sixth subcomponent (2.6: Support for national project implementation) will provide support for efficient and effective management and implementation of national project activities. Outputs will include:

(i) design of a detailed M&E framework from the comprehensive baseline survey;

(ii) management support for national and provincial project activities;

(iii) coordination of TA inputs to national and provincial project activities;

(iv) procurement of vehicles, motor bikes, boats and motors, office equipment;

(v) provision of operating and maintenance costs for PMUs and PPIUs; and

(vi) funding support for pool funds for Regional activities, International TA and operational costs for RCU.

205. ADB has developed the Managing for Development Results (MfDR) Action Plan (2009-2011) which provides a roadmap for advancing the implementation of MfDR in ADB funded projects. and to mainstream the MfDR approach within ADB's operations and country programs. Managing for Development Results (MfDR) is a management approach that focuses on using results information; specifically outputs, outcomes and impact, for projects to achieve clearly defined project goals. This approach will be introduced in to the project and senior management at all levels who will receive training and support to move towards a performance or results based approach to project management within the context of an M&E Framework and the PMF. Details of the approach and the framework in which it could be implemented is included in Appendix 19 Performance Based Management.

B. Special Features

206. The Project builds on achievements and lessons learned from CDC1, and introduces an innovative GMS cross border cluster approach that will translate regional agreements into actions for CDC. The approach is based on the consultations and consensuses of the 8 th GMS region CDC review workshop and the 4th GMS regional steering committee meeting held in Phnom Penh, Cambodia on the 1 – 12 November, 2009.

C. Cost Estimates

207. Project cost estimates were prepared separately for each country and integrated in a set of cost tables. The constant prices of November 2009 were used for compute the costs. Cost estimate summaries for each project country is presented in Tables 5, 6 and 7 below. Detailed cost tables for CLV are included in Annex 1 to 4 of Appendix 6

208. ADB has a plan to finance grant funds to Lao PDR and the Kingdom of Cambodia and a loan fund from Asian Development Fund (ADF) for Viet Nam. Two grant funds amounts to Lao PDR and Cambodia are nonrefundable while the lending terms for ADF loans applied for this project of Viet Nam are the following: 32-year maturity, including an 8-year grace period, 1% interest charge during the grace period and 1.5% during the amortization period.



Table 3: Summary of Cost Estimates: Lao PDR Total Cost (US$ '000)

ADB GoL Total Percent A. Base Costs 9,570 671 10,241 82.2% B. Taxes and Duties 122 121 1% C. Contingencies 629 65 694 5.6% D. Pool Fund 1,400 1,400 11.2% TOTAL (A) + (B) + (C ) + (D) 11,600 858 12,456 100%

Table 4: Summary of Cost Estimates: Cambodia Total Cost (US$ '000)

ADB RGoC Total Percent A. Base Costs 8,762 562 9, 323 82.4% B. Taxes and Duties 0 101 101 0.9% C. Contingencies 438 43 482 4.3% D. Pool Fund 1,400 0 1,400 12.4% TOTAL (A) + (B) + (C) +(D) 10,600 706 11,306 100%

Table 5: Summary of Cost Estimates: Viet Nam/a Total Cost (US$ '000)

ADB GoV Total Percent A. Base Costs/b 23,551 2,063 25,614 92.5% B. Taxes and Duties 0 506 506 1.8% C. Contingencies 1,450 135 1,585 5.7% TOTAL (A) + (B) + (C) 25,000 2,704 27,704 100%

a/ The proposed Grant fund for Viet Nam is under disussion and not included and presented in this Table. b/ Base costs include an unallocated amount of $4.716 million under SubComponent 2.5

209. Cost estimates for Technical Assistance and operation of the Regional Coordination Unit (RCU) include relevant costs for consulting services to be based in Viet Nam in an RCU office. The total cost for this TA/RCU is $ 5.6 million for a 5-year implementation with a detailed breakdown of costs in Annex 4 of Appendix 6. Lao PDR and Cambodia will contribute to this pool fund $ 1.4 million each and Viet Nam will contribute a sum of $2.8 million from ADB‘s grant fund.

D. Financing Plans

210. The proposed CDC2 does not involve any cofinancing from other donors. There are also no local contributions either in kind or in cash from community beneficiaries. The financing plans for both Project Loan / Grants have been verified, and the ADB loan/ grant funds and counterpart funds from three Governments will be made available in a timely fashion.



211. The Royal Government of Cambodia (RGoC) has requested a Grant from ADB in SDR equivalent to $ 10.6 million from ADB‘s Special Fund resources to help finance the Project (Table 9). The grant fund will have a 5-year term. The RGoC will contribute $ 0.706 million in kind and in cash of which $0.562 million is for recurrent costs (operation and maintenance supplies) and $ 0.101 million is for local taxes. The total project investment cost and recurrent cost is estimated at $ 11.306 million, including physical and price contingencies, taxes and duties.

212. The Government of Lao PDR (GoL) has requested a Grant from ADB in SDR equivalent to $ 11.6 million to help finance the Project (Table 10). The nonrefundable grant fund will have a 5-year term. The GoL will contribute US$ 0.856 million equivalent including $ 0.671 million in kind for recurrent costs (operation and maintenance, supplies) and $ 0.121 million in cash for local taxes purpose. The total project investment cost and recurrent cost is estimated at $ 12.456 million, covering also physical and price contingencies, taxes and duties. Since this report was written ADB have advised that an additional 1 million grant funds would be available for Lao PDR.

213. The Government of Viet Nam (GoV) has requested a Loan from ADB in SDR equivalent to $ 25 million from Asian Development Fund resources to help finance the Project (Table 11). The loan will have a 32-year term, including a grace period of 8 years, and an interest rate of 1% during the grace period and 1.5% per annum thereafter. The GoV will contribute $ 2.704 million in kind and in cash of which $ 0.506 million and $ 1.422 million will be paid for local taxes, duties and the recurrent costs respectively. The total project investment cost and recurrent cost is estimated at US$ 27.704 million, including physical and price contingencies, taxes and duties and other charges during implementation, unallocated amount ($4.716 million)98. As to support project implementation, ADB is considering to finance a grant fund for technical assistance for Viet Nam valued at approximately $ 2.8 million and this is under discussion between ADB and GoV. This grant fund amount is planned to be administered by ADB and placed under the Project Pool Fund for consulting services and other regional cooperation activities. Since this report was written ADB have advised that an additional 8 million of loan funds would be available for civil works for Preventative medicine Centers in the Project Provinces.

Table 6: Project Financing Plan: CLV countries (US$ million)

Source Total % Asian Development Bank (Loan) 25.00 49.7 Asian Development Bank (Grant)99 Government of RGoC; GoL; GoV

22.20 4.27 41.4

8.9 Total 51.47 100.00

Note: Number may not sum precisely because of rounding Table 7: Project Financing Plan: Cambodia

(US$ million)

Source Total % Asian Development Bank 10.600 93.4

Government of RGoC 0.706 6.6

Total 11.306 100.00

Table 8: Project Financing Plan: Lao PDR

(US$ million)

Sources Total % Asian Development Bank 11.60 92.80

Government of Lao PDR 0.856 7.20

Total 12.456 100.00

98 GoV will use other sources of fund to pay interest for this loan funds (see further information in Appendix 11) 99 Does not include $2.8 million for VIE.



Table 9: Project Financing Plan100: Viet Nam

(US$ million)

Source Total % Asian Development Bank (Loan) 25.000 90.1

Government of Viet Nam 2.704 9.9

Total 27.704 100.00

E. Implementation Arrangements

E.1. Project Management

214. In Cambodia, the MOH is the Executing Agency (EA) and, CDC2, as with CDC1, will be implemented through the Second Health Sector Support Program (HSSP2) for national health sector development. This HSSP2 will be the project administrator for the EA. The Communicable Disease Control Department (CDCD) through the Project Management Office (PMO) will be the implementing agency (IA) together with the 6 project provinces as PIAs.

215. In Lao PDR, the Department of Planning and Budgeting (DPB) under MOH will administer CDC2. The Department of Hygiene and Prevention (DHP) will be the coordinating National Implementing Agency (NIA). There are 9 project provinces participating in this project in the role as Provincial Implementing Agencies (PIA). Some of the national institutes will also participate as contractors to provide technical supports to the Project.

216. In Viet Nam, MOH will be responsible for overall project management and guidance as the EA. The General Department of Preventive Medicine and Environment Health (GDPMEH) will be the coordinating IA and PMU, and the MOH‘s Department of Planning and Finance (DPF) will be involved in this project with regards to financial management.

217. Because CDC2 follows on from CDC1, it is proposed that three Project Management Units (PMUs) in the three CLV countries for CDC2 will be the same as those of the CDC1, and will also be located in Phnom Penh, Vientiane and Hanoi. Each PMU to be headed by a Project Director and be responsible for the overall project management. It is noted that in Cambodia, the HSSP2 and CDC Department are serving as the PMU.

218. Regional. The regional CDC Steering Committee (SC) proposed under the project preparatory TA will meet every six months, with the hosting rotated among the three countries. The regional CDC SC is advisory in nature and will give guidance in project implementation, policy dialogue, and the building of regional capacity and cooperation for CDC, and will facilitate country decisions on the use of pooled funds for regional activities. It will be chaired by the minister or vice-minister of the host country and will consist of leading representatives from the national SCs, project directors, and ADB and WHO representatives. The RCU will act as the secretariat for regional coordination activities and the management of regional funds, and will include a Chief Technical Adviser, an accountant, a program officer, and a receptionist / administrative assistant.

219. To facilitate the flow of funds for regional activities, $5.6 million, will be administered by ADB as a regional CDC fund for regional collaboration, managed by the Regional Coordination Unit (RCU). This fund will cover expenditure for the Project‘s regional SC, technical forums, international consulting services, cross-border activities, and the RCU itself. ADB‘s administration of the pooled regional funds is considered necessary for the efficient release of funds. The regional CDC fund will be financed from ADB‘s share of the grant, on the basis of a ratio of 25:25:50 for Cambodia, Lao PDR, and Viet Nam, respectively. The contribution to the RCU and regional activities will follow this ratio, subject to CLV approval. 100 Excluding proposed Grant funds for technical assistance of approximately $ 2.8 million



E.2. Implementation Period

220. CLV countries will implement CDC2 over five years from July 2010 to the end of June 2015. The completion date is proposed as 30 June 2015, on which all physical project activities should be completed. ADB will not be responsible to finance any activities occurring after the completion date as agreed in the loan/grant agreements. The loan/grant closing date is proposed to be three months from the project completion date, as of 30 September 2015.

E.3. Outline of Implementation Responsibilities

221. Whilst the main operational aspect of the project is at the provincial level and below, the national level will continue to have regular surveillance reporting from all provinces as part of the national surveillance system. In addition, the national level will also be able to respond to outbreak investigation and response in other provinces that are not included in CDC2. The provision of emergency out break funding and the cost of maintaining the nation surveillance program is also included in the budget for national level. The following outlines the general areas of responsibility for the implementation of the CDC2 project.

National Level

(i) regional dialogue, development of regional cooperation agreements;

(ii) high level consultation in the event of disease outbreaks;

(iii) facilitation of donor and inter-sectoral meetings and cooperation (including ADB);

(iv) conduct of National Steering Committee and participation in Regional CDC Steering Committee activities;

(v) operation of Project Management Unit (PMU) – Project management, contract management, financial management and liaison with ADB;

(vi) coordinate of National Technical Committee activities;

(vii) manage National and International Technical Assistance inputs and their performance;

(viii) coordinate National Institutes contracted contribution and support to the project provinces and districts;

(ix) coordinate the National Technical Committee for the design and conduct of the Baseline Survey and annual reviews;

(x) coordinate national CDC surveillance and instigate national response to disease outbreaks, and provide technical support to the provinces;

(xi) provide Technical CDC and specialist support to the project provinces;

(xii) ensure that the project provinces and district comply with MOH policies, strategies and guidelines; and

(xiii) provide specialist advice and oversight of provincial research initiatives.

Provincial Level

(i) Conduct of the Provincial Steering Committee;

(ii) coordinate Provincial Technical Management Committee activities;

(iii) coordinate Provincial Training Working Group activities;



(iv) operation of Provincial Project Implementation Unit (PPIU) – Project management, contract management, financial management to ensure the efficient implementation of project activities, and liaison and reporting to the national PMU;

(v) facilitation of donor, NGO, and inter-sectoral meetings and cooperation relating to CDC;

(vi) participate in local cross border meetings relating to CDC;

(vii) coordinate National and International Technical Assistance inputs;

(viii) work with National Institutes on local research initiatives;

(ix) coordinate the provincial, district and community contributions to the design and conduct of the Baseline Survey

(x) coordinate quarterly cross border reviews, and participate in annual regional reviews;

(xi) coordinate local surveillance and response to disease outbreaks, engage with national level technical specialist support (as required);

(xii) provide technical CDC and specialist support to the district staff;

(xiii) ensure that the provincial and district staff comply with MOH policies, strategies and guidelines; and

(xiv) support district health service delivery and staff in their outreach programs and commune or village community initiatives.

E.4. Procurement

222. All ADB partly or fully financed procurement under CDC2 will be done according to ADB‘s Procurement Guidelines (2007, as amended from time to time). The procurement plans for CLV countries, with indicative contract packages are provided in Appendix 9. International Competitive Bidding procedures will be applied for any packages valuing equal or more than $ 0.5 million in case of Goods, and equal or more than $1 million in case of Civil works. Any bid packages of Goods and Civil works valuing less than $ 0.5 million and less than $1 million respectively will be procured through National Competitive Bidding. In addition, project vehicles for Lao and Cambodia will be procured through the United Nations system when the procurement procedures are acceptable to ADB.

223. Smaller goods and civil works packages costing less than $0.1 million may be procured through shopping procedures. In CDC2, as partly built capacity for the provincial level, small contracts of goods may be directly procured by PPIUs rather than PMUs including but not limited to medical supplies, office equipment and consumables.

E.5. Consulting Services

224. Technical assistance for international consulting services and national consultants for short term consultancies relating to the baseline survey for CLV countries and operations of the RCU will be financed by the grant funds under a budget line of the pooled fund. There will be 8 international long term consultants (if 3 WHO consultants are included) and 4 short term international consultants and 3 national consultants engaged as individual consultants. ADB will directly recruit and pay these individual consultants. The Guidelines on the Use of Consultants by Asian Development Bank and Its Borrowers 2/2007 (ADB Consultant Guidelines) will be applied as amended from time to time. (See Annex 2 of Appendix 8 Implementation Arrangements for listing of consultants and TORs in Annex 3).



225. In the PMUs of Cambodia and Viet Nam, there will be a number of national staff consultants be recruited by PMUs following ADB Consultant Guidelines as mentioned above . These positions are: (i) one project accountant and two accounting assistants (in Cambodia); and (ii) a Chief Accountant and two Accountants and one Accounting Assistant (in Viet Nam). In Lao PDR, an accounting firm will be recruited by PMU using CQS procedures to undertake all accounting works from project commencement. TORs for staff consultants and finance staff in PMUs are provided in Annex 1 of Appendix 8. More details of the consulting packages (individual and firm engagements) and assigned recruitment procedures are outlined in Appendix 9 - Procurement Plan.

226. In the PMUs of Cambodia and Viet Nam, there will be a number of national staff consultants be recruited by PMUs following ADB Consultant Guidelines as mentioned above . These positions are: (i) one project accountant and two accounting assistants (in Cambodia); and (ii) a Chief Accountant and two Accountants and one Accounting Assistant (in Viet Nam). In Lao PDR, an accounting firm will be recruited by PMU using CQS procedures to undertake all accounting works from project commencement. TORs for staff consultants and finance staff in PMUs are provided in Annex 1 of Appendix 8. More details of the consulting packages (individual and firm engagements) and assigned recruitment procedures are outlined in Appendix 9 - Procurement Plan.

227. In addition, NGOs / consulting firms experienced with baseline survey will be contracted through CQS procedures to undertake a comprehensive baselines survey for CDC2 as one key activity of Component 1. Institutes at central level will also be contracted by PMUs using CQS procedures to provide specific technical support to the provincial and district levels as defined during annual project planning.

E.6. Contracting Research and Training Institutions

228. National research institutions may also be contracted to undertake a study of provincial level CDC issues and strengthen linkages among health institutions by conducting joint research with project provinces. Projects will be selected following a competitive process, with a set of clear criteria and guidelines issued as part of the study selection process (see Appendix 8). Training may also be implemented by government institutions. A list of indicative training packages are included in Appendix 10.

E.7. Accounts and Audit

229. After grant / loan effectiveness, three First Generation Imprest Accounts (FGIAs) will be opened in CLV. In Cambodia and Lao PDR, the MEF and MOF will respectively manage this account directly while in Viet Nam, the MOH will be assigned to manage the FGIA. The initial amount to be deposited by ADB in the imprest account of each country will be based on the estimated expenditure for the first 6 months of project implementation or $900,000 for Cambodia, $1,000,000 for Lao PDR, and $2,500,000 for Viet Nam. The imprest account will be established, managed, replenished, and liquidated according to ADB‘s Loan Disbursement Handbook of 2007, (as amended from time to time), and detailed arrangements agreed upon between the MOH of each country and ADB. The mentioned above, ceilings are tentative; ADB and CLV governments will discuss and decide during loan/grant negotiations.

230. External audit is mandatory in CDC2. The audit101 coverage will include a special audit of project imprest account, including separate opinions on;

(i) utilization of the primary and secondary imprest accounts;

(ii) the statement of expenditures, including whether the amount claimed is duly supported and verified;

101 CDC2‘s PMUs will need to prepare Terms of reference acceptable to ADB for the annual project audit. The auditing company should

review and substantiate the accuracy and sustainability of accounting documents, figures and other accounting liquidation reports kept by PMU and PPIUs.



(iii) whether the PMU is operating the imprest account in accordance with ADB procedures; and

(iv) compliance with financial covenants specified in the loan/ grant agreements. The annual project accounts should contain detailed descriptions of the fund sources and expenditures. The annual financial project statements should consist of a balance sheet, cash flow statement, and related notes to financial statements.

231. The audit reports, management letter, and related financial statements will be submitted to ADB not later than 6 months after the end of the fiscal year (31 December for Cambodia and Viet Nam and 30 September for Lao PDR) to which they relate, or the project closing date. The annual financial statements will be a consolidation of all project operations. ADB will review the implementation and operation of the Project Loan/ Grants based on these reports and other relevant reports and meet with MOH, PMU and other relevant Government agencies annually to discuss project progress. It is also noted that ADB has informed three EAs of its policy on submission of audited accounts, which covers failure of submitting audited accounts and financial statements by the due date. A formal warning will be issued for accounts more than 6 months overdue, and disbursements will be suspended for accounts that are 6 months overdue.

E.8. Disbursement Arrangements

232. The SOE procedures may be used to reimburse expenditures and liquidate the FGIA for all individual payments not exceeding $ 50,000 for Cambodia and Lao PDR and $100,000 for Viet Nam. The FGIA will be flexibly replenished on a monthly or quarterly basis to ensure liquidity of funds or when the accounts are drawn down to 20% of the initial deposit. For consulting services through firms (such as auditing services, accounting services in Lao, surveys) and large goods contracts, PMUs should use direct payment and commitment letter procedures as guided by the ADB‘s Loan Disbursement Handbook 2007, amended from time to time.

233. PIUs in three countries will be reimbursed funds spent from their designated accounts up to 2 times per month at the middle and at the end of the month, depending on disbursement progress in each PIU. This will help speed up disbursement and ensure that PIUs always have sufficient funds to use. The District Heath Center/Office or Commune/ Village authority will be authorized by PPIU to spend a number of budget lines for the planned project activities at these levels as designed by the project and they may open a bank account102 at any convenient local bank for them to receive and pay out the eligible project funds provided that the ADB fund will not be held in such bank account more than 48 hours from the time the funds are deposited. Detailed disbursement arrangements in CLV can be seen in Appendix 8.

E.9. Reporting

234. The CLV Governments will submit annual, semiannual, and quarterly progress reports,. In addition the Government of Cambodia will also submit biannual reports based on the agreed format with the HSSP development partners. The project director will consolidate the reports and address necessary improvements for CDC indicators and the institutional development aspects of the Project. The progress reports will have information on the physical progress of activities, compliance with grant covenants, organizational and financial issues, gender and ethnic minority activities, the proposed program of activities, and expected progress in the next planning period.

E.10. Project Review

235. ADB, WHO, and the Governments will carry out project supervisory missions every six months. Before each visit, an updated progress report will be prepared. Reviewers will examine records of monitoring and evaluation activities and meet with central and local governments,

102 This procedures is designed to avoid the complication in opening and managing any kind of imprest account as the ‗son‘ of PPIU‘s

imprest account.



community leaders, and project beneficiaries. Within 2 years after project effectiveness, the parties will undertake a comprehensive midterm review to:

(i) examine the scope, design, implementation arrangements, and other relevant issues in light of the Governments‘ development of CDC strategies and policies;

(ii) assess the Project‘s progress and achievement of the objectives;

(iii) identify problems and constraints; and

(iv) recommend any required modifications, restructuring, and reallocations.

E.11. Project Performance Monitoring and Evaluation

236. Data collection will be undertaken to monitor progress in achieving the project objectives. Specifically, the system will provide the Governments, ADB and WHO with the data and indicators to monitor project inputs, processes, and outputs as provided in the project framework and in key performance indicators to assess the technical, social, and economic impacts of the Project. The Project will conduct baseline and evaluation surveys, drawing upon existing data wherever possible, and collecting new field data only where necessary. Annual reports will be submitted to ADB and WHO throughout project implementation; these reports will include indicators of project completion, delivery, and benefits. The indicative project benefits and monitoring and evaluation framework and arrangements are included in Appendix 19 - Results Based Management.

E.12. Good Governance

237. The Governments promote good governance, and executing and implementing agencies are informed about ADB anti-corruption policy, particularly the section on fraud and corruption, as stated in ADB‘s Guidelines for Procurement and Guidelines on the Use of Consultants.

E.13. Capacity of Executing and Implementing Agencies

238. Generally, the CDCD in Cambodia, the DPB in Lao PDR and the GDPMEH in Viet Nam are the lead departments of this Project and will be responsible to the respective Ministers of the Ministries of Health in the CLVs for the quality, effectiveness, efficiency of Project implementation within the funds allocated. Findings from previous studies and the CDC1 confirm that three MOHs in the CLVs with their assigned coordinating departments have acceptable experience with donor funded projects including ADB and WB even though there is room for improvement.

239. In three project countries, the Provincial Health Departments (PHDs) will work as the IAs to implement the project in their provinces. Each PHD will set up and maintain a small PPIU including three key positions as Project Manager, Technical Coordinator and Accountant. In all CLV countries, lack of understanding and experience of ADB procedures, noncompetitive salaries, allowances, and workload have been the constraints for CDC2 implementation. In Viet Nam, in addition, long bureaucratic delays caused in provincial departments are an emerging issue that need to be addressed not only in CDC2. These require a comprehensive capacity building on project management and CDC technical aspects for both central and local project related staff.



IV. PROJECT BENEFITS, IMPACTS, ASSUMPTIONS AND RISKS

240. The Greater Mekong Subregion (GMS) Second Regional Communicable Diseases Control Project (CDC2) will make three major economic contributions to the GMS. The project will support cross border cooperation in 30 provinces of Cambodia, Lao PDR and Vietnam, and assist cooperation with neighboring countries of PRC, Thailand and Myanmar and economic impacts are expected to be:

(i) Reduction of economic risk of major communicable disease outbreaks. By strengthening CDC response capacity at provincial levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the subregion. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue.103 The sudden and deadly outbreak of SARS early in 2003 provides a lesson. By mid 2003 SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world. Apart from the direct costs of intensive medical care and control interventions, SARS caused widespread social disruption and economic losses. Schools, hospitals, and some borders were closed and thousands of people were placed in quarantine. International travel to affected areas fell sharply by 50-70%. Hotel occupancy dropped by more than 60%. Businesses, particularly in tourism-related areas, failed, while some large production facilities were forced to suspend operations when cases appeared among workers.104

(ii) Increased sustainability of national investment to eradicate endemic infectious diseases. Emerging epidemic diseases such as Dengue and the group of parasitic diseases (such as Filiariasis, Schistosomiasis, and Helminthiasis and food-borne Trematodiasis and Cestodiasis) referred to as neglected tropical diseases (NTDs) pose significant cross-border risks. This issue of NTDs is less well understood as many NTDS are not included among notifiable diseases and tend to be endemic to specific areas. However, NTDs span borders in the GMS. The increasing population mobility arising from increasing economic integration in the GMR means that there are growing risks of parasitic diseases moving into new populations via human contacts. National investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border.105

(iii) Poverty reduction by improving the health of border populations. NTDs are endemic in most border areas of GMS and are associated with poverty and poor environmental sanitation and poor health services. The effective treatment of these infections is known to increase work capacity and productivity. Without treatment, prevention and eradication programs, these diseases disable and eventually kill unknown thousands of people every year. Hookworm, for example, causes anemia, which endangers the lives of unknown thousands of women in the GMS border regions and contributes to high maternal mortality rates in these areas. The development of unknown thousands of children in these areas is affected by intestinal parasites.106

241. Project Benefits and Beneficiaries. The Project will help minimize the social and economic impact of communicable diseases in GMS by helping departments of health in the border provinces of Cambodia, Lao PDR and Vietnam to respond rapidly and effectively to contain the spread of emerging and epidemic diseases. It will strengthen provincial-level, cross border cooperative capacity to contain outbreaks of communicable diseases that can have devastating 103 World Health Organization, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html. 104 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15 105 Country Reports presented at the First GMS-CDC Technical Forum on the Control and Elimination of NTDs in the Mekong Sub-

Region October 21-22, 2009 106 Presentation by the Global Network for Neglected Tropical Diseases The First GMS-CDC Technical Forum on the Control and

Elimination of NTDs in the Mekong Sub-Region October 21-22, 2009




human and economic impacts, most dramatically illustrated by the SARS pandemic in 2003. WHO points out new diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue, noting that national investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border. By strengthening cross-border cooperation on disease surveillance and response systems, the costs associated with outbreaks will be reduced.

242. National investments to eradicate endemic infectious diseases will also become more sustainable. Diseases spread via increasing population mobility arising from increasing economic integration, spanning international borders in the GMS. Targeted surveillance and response, along with capacity building activities for targeted control of endemic diseases, will reduce the burden of communicable diseases and generate economic benefits. For example, strengthening of provincial and district health systems, community level primary health care and activities for disease prevention will lead to improvements in public health, and decrease out-of-pocket health expenditures. These interventions will also reduce the number of sick children, thereby improving school attendance and overall physical and cognitive development.

Table 10: Population of Project Provinces proposed for CDC2.

Population

CAMBODIA LAO PDR VIET NAM TOTAL # Population # Population # Population # Population

Project provinces

5 1,797,419 9 2,187,716 15 22,420,579 29 26,405,714

Border districts

17 605,564 33 1,311,531 52 4,692,013 102 6,609,108

Ethnic Minority Groups, % of border district population

13.8% 83,752 29.2% 383,565 29.7% 1,394,451 28.2% 1,861,768

Source: Population data gathered for CDC2 project preparation see Appendix 17 Project Provincial Profiles. 243. The Project will focus on surveillance and response and control of selected diseases, which will strengthen CDC and PHC services which will mainly benefit poor border communities in border districts of the three countries. The project will operated in 29 provinces which have a collective population of more than 26.4 million of whom at least 6.6 million live in the GMS 102 targeted districts with border crossings, and of whom more than 50% live below or close to the poverty line. Ethnic minorities comprise a significant proportion of the total number of Project beneficiaries, comprising a total 28.2% of the population of all border districts in provinces currently nominated by governments for inclusion in CDC2 (some of which have no minority populations). However, in most of the priority border districts in the three countries, ethnic minorities comprise the majority of the population (see Appendix 17 - Project Provincial Profiles). The poor and vulnerable will benefit from the Project's focus on border areas and its commitment to train local health workers and community volunteers.

244. Analysis of Economic and Financial Sustainability. The economic benefits of the Project will come from:





245. The Project‘s recurrent costs include integrated service delivery staff costs, procurement of medical supplies, and ongoing institutional strengthening costs, which together will account for



about $1.7 million in 2009, the year of project completion. It is envisaged that recurrent costs would be scaled back to about $1.1 million in 2012 as the Project demonstrates the benefits of preventive measures introduced at community level, and community adopt these basis minimum cost benefits. The summary economic and financial analysis is in Appendix 11.

246. Environment: The Project will not have any significant adverse environmental effects. In general, it will finance preventive health services, which leave limited by-products, and will help safeguard the environment by putting in place an early warning and response system. This will help reduce the environmental costs of disease control, in particular insecticide spraying. Project ensure that the issue of disposal of medical wastes is part of the biomedical plan.

247. Social Analysis: The Border provinces and districts in the three countries that are recommended as priority Project locations have been opened up over the past decade by new road construction, encouraging greatly increased population movements. These changes are accelerating social and economic changes, creating new and more widespread forms of inequality and driving the transmission of communicable diseases. A detailed social analysis detailing these issues and the changing demographics in the region are detailed in Appendix 13 Social Analysis.

248. Poverty: The Project will promote poverty reduction by improving the health of border populations where many communicable diseases are associated with poverty and poor environmental sanitation and inadequate health services. It will increase work capacity and productivity of targeted vulnerable populations. It will also help the countries progress toward their health-related Millennium Development Goals (MDGs) for 2015 of reducing maternal and under-5 mortality rates. The summary poverty reduction and social strategy is in Appendix 13.

249. Gender: The project has a strategic focus on supporting gender sensitive health policy and services, CDC surveillance and epidemiological information systems. These will be strengthened to identify and respond appropriately to the differences in the health needs of men and women, who have different degrees of vulnerability to infectious diseases, depending on how they are exposed and what access they have to information. By establishing gender disaggregated baseline databases, the gender objectives relevant to district situations will be established and monitored. Gender equity will be improved by mainstreaming evidence-based and results-oriented gender training on primary health capacity building activities for district health staff and village health workers. The project will support targeting the health and information needs of women and men by strengthening maternal and child health and care outreach services to vulnerable populations in border regions. A detailed Gender Action Plan is included in Appendix 15.

250. Ethnic minorities: A regional project to address CDC in the border regions of the GMS must necessarily focus on ethnic minorities. In the past these ethnic minority populations depended on subsistence farming, hunting and gathering for their livelihoods. Now, with opening up of border areas for transportation, plantations, hydroelectric dams, mining, and logging, the trend is towards rapid displacement of previously isolated minority populations, pushing them into markets for unskilled labor. These changes have increased the vulnerability of minority groups to contracting and to spreading communicable diseases. The Project is specifically targeting ethnic groups in the selection of priority districts, types of interventions, and planning and monitoring arrangements. The ethnic minority development plan is included in Appendix 14.

251. Risks. The Project has some technical risks in the effectiveness of control measures. Technical risks will be mitigated by partnering with WHO, hiring national consultants for local capacity building, and strengthening provincial and community involvement. Institutional networking and regional collaboration will also help in strengthening community engagement in the border districts.

252. Previous ADB projects showed project management to be critical to achieving results. Each coordinating IA will have a project management unit, which will be supported by existing project administrative capacity in MOH in areas like planning, procurement, financial management, monitoring, and reporting. The CDC2 Project has recognized to need to strengthen project management and capacity building and have addressed these issues with the provision of



additional international and national TA. A particular challenge will be the moved to performance or results based management.

253. Regional forums and workshops are considered one of the successes of CDC1. CDC2 plans to build on that experience but recognize that will be challenging especially with the addition of China, Thailand and perhaps Myanmar. If done well, there are significant benefits from regional disease control, technology transfer and strengthened national commitment for health sector development, all of which will have long-term value across the region. ADB will need to ensure that the RCU is increased significantly, so that this potential regional cooperation and growth can materialize, and at the same time the knowledge management and the clearing house aspects of the RCU becomes fully institutionalized in terms of budget, staff, responsibility, and with authority from the CDC2, MOHs engaged in the project.

254. In order to strengthen training content and outputs as part of a broader capacity building approach, CDC2 proposes that a Training System Framework be adopted by each MOH as part of their overall HRD plan. Failure to adopt the approach both in principle and practice will considerably jeopardize the investment and results of capacity building endeavors in the project.

255. CDC2 is intended to provide supplementary budget support, particularly at the provincial and district and community levels to ensure increased health care coverage, in addition to having active community based surveillance and response established. It must be clear that CDC2 budget is just that, ―supplementary‖ and not used as a substitute for government recurrent operational budgets. In addition the additional support is to be utilized in the rural remote populations in the designated border district.



V. ASSURANCES

A. Special Assurances

256. The CVs of chief accountant and accountants for Lao and Cambodia and the CV of the Procurement Consultant for Viet Nam to be forwarded to ADB for review and no objection as a condition for loan/grant negotiations.

257. Cost norms for staff consultants for Lao and Cambodia to be agreed during grant negotiation and attached as a Key Appendix of RRP. This will help PMUs to recruit good consultants based on market prices (in Viet Nam, since GoV has changed cost norms for ODA projects there is no major concern on this).

B. Conditions for Grant Effectiveness

258. The MOH adopt the Training Systems Framework Approach as the basis of training and capacity building within CDC2.

259. The MOH in each country endorse the selection of the border districts which will then form the major part of the CDC2 activities during the duration of the Project.

260. The Director and Deputy Director of the PMUs are to be recruited from within the respective MOH staff and appropriately experienced and qualified as described in Annex 3 of Appendix 7. It is acknowledged that the Director may be part-time but the Deputy Director must be full time in the position (Capacity building approach). A National Consultant may assist the Director and Deputy in their tasks BUT should not be recruited for either of these positions as was the case with the Assistant PMO Manager in Cambodia in CDC1.

261. As discussed after finalization of the Consultants Report, the following provinces be added: Cluster 1: The RPPTA team requested that Lai Chau and Lao Cai in northern Vietnam also be considered for inclusion in CDC2 as part of the northern cluster, as well as the inclusion of Quang Binh in the central region of Vietnam to join with Khammuane province in Lao PDR.

262. Cluster 2: The RPPTA team requested that Kon Tum, Gia Lai provinces in Vietnam also be considered for inclusion in CDC2 as part of the central region cluster.

263. Cluster 3: The RPPTA team requested that Svay Rieng, Prey Veng, Kampong Cham provinces in Cambodia also be considered for inclusion in CDC2 as part of the southern region cluster.

264. Expansion of CDC2 to include additional GSM Partners. Further discussions by ADB with the provincial and district health departments of PRC (Yunnan province), Thailand and Myanmar regarding contiguous border areas adjoining CDC2 provinces are invited to participate in cross border and knowledge management activities including regional technical forums and workshops. Such activities are funded from their own resources or other sources.



APPENDICES 1. Design and Monitoring Framework.

2. Project Scope.

3. Project Rationale.

4. Situation Analysis.

5. Lessons learned.

6. Cost Estimate and Financing Plans.

7 Implementation Schedule.

8. Implementation Arrangements.

9. Procurement Plans

10. Training Systems Development Framework. 11. Economic and Financial Analysis. 12. Fiduciary Financial Assessment. 13. Social Analysis. 14. Ethnic Minority Development Plan. 15. Gender Action Plan. 16. Results Framework

17. Project Provincial Profiles.

18 External Assistance to the Sector

19. Performance Based Management

20. Regional Coordination Unit

APPENDIX 1: DESIGN AND MONITORING FRAMEWORK

ADB TA: 7279 – REG: Second GMS Regional Communicable Diseases Control Project

Appendix 1: Design and Monitoring Framework – Final Consultant Report April 2010 Page 1

APPENDIX 1 - DESIGN AND MONITORING FRAMEWORK

Design Summary Performance Targets/ Indicators

Data Sources/Reporting

Mechanisms

Assumptions and Risks

Impact: Improved Health in populations in GMS border areas. The overall project impact will be improved health for the populations in the project provinces in the border region, which will assist the Ministries of Health in Cambodia, Laos and Vietnam (CLV) to achieve MDGs 4, 5 and 6 by reducing the spread of emerging and neglected communicable diseases thereby reducing morbidity and mortality, in particular among children, and the economic cost of these diseases.

Cambodia targets by 2015: U5MR: reduced from 83/1,000

to 65/1,000 live births MMR: reduced from

472/100,000 to 120/100,000

Lao PDR targets by 2015: U5MR reduced from 98/1,000


405/100,000 to 185/100,000 Viet Nam targets by 2015: U5MR reduced from 32/1,000


85/100,000 to 62/100,000

All countries Burden of communicable

diseases decreased by 15% of current DALYs in targeted population.

Annual health statistics

reports Statistical and

qualitative surveys National demographic

and health surveys Communicable

diseases surveillance systems

MDG update reports Final project evaluation

measured against baseline data.

Assumptions No major social or

economic disruptions to allow time to set up and test the system

Disease control interventions are effective (this is a particular issue for dengue control)

Behavioral change is effective in improving awareness and practices for reducing selected diseases.

Outcomes Improved Regional Security through: (i) Governments of GMS

adopting a harmonized approach in the region, with established long-term multi-sector strategic national policies for prevention and emergency response to communicable diseases.

Regional Cooperation Strategy Regional coordination focal points established in each MOH.

Regional and national steering committees roles and responsibilities reviewed and expanded to encourage greater engagement with cross border partners leading to long term regional cooperation agreements.

Common criteria for baseline studies of contiguous provinces and districts endorsed by MOHs

Comprehensive baseline survey provides details of CDC risks through an analysis of (i) demographics; (ii) district health services, including diagnostic capacity in district health centers; (iii) cross border traffic; (iv) border quarantine services; (v) water and sanitation coverage; and (vi) animal health services.

Regional Cooperation Strategy Document.

National policies Ministerial decrees and supportive legislation.

Partnership agreements or MOUs signed.

Meeting reports, and signed MOUs.

Baseline Implementation Plan

Baseline data analysis

reports Baseline Database,

Quarterly reports Monitoring and

Evaluation reports. Provincial and District

operational plans.

Active political support

for the introduction of Regional Strategy and National policies and Ministerial decrees and supportive legislation.

Common empathy for CDC across borders.

Senior management in

the CDC project understand and support the conduct of the baseline and it use and measuring performance over time.

Communities and community and village administration are supportive and participate in the baseline survey and community based surveillance program.





Mechanisms


(ii) Strengthened r egional and MOH’s technical capacity for surveillance and response, following WHO guidelines f or implementation of t he IHR a nd APSED w ith timely r esponses to epidemics i n pr ovinces with c ommon bor ders that are l ikely to have a major impact on p ublic health and the economy in the region.

Timely and adequate control of epidemics that are likely to have a major impact on the region’s public health and economy.

Proportion of targeted districts that provided timely reporting and appropriate response to disease outbreaks.

Disease surveillance and response reporting systems, including WHO IHR monitoring reports, disease outbreak reports, and APSED Strategy.

Evaluation study. Sentinel surveillance data.

Surveillance system can identify diseases in a timely manner.

Funding for surveillance and response system is adequate.

Necessary work can be carried out in border and isolated areas.

(iii)Increased capacity of national provincial a nd district h ealth s ervices in results b ased management an d technical c apability with integrated C DC a nd health s ervices for t he underserved populations who have a high d isease bur den from Neglected Tropical Diseases ( NTD) and are at r isk f rom n ewly emerging di seases (EIDs).

The National Project Steering

Committee (NSC) and is responsible for overall strategic coordination of the project, review of policies and progress

Provincial Steering Committees (PSCs) chaired by the local political authority for provincial/ district decision-makers.

Inter-departmental Provincial Technical Management Committees (PTMCs) follow-up on the management of the detailed implementation schedules and methods, plans and progress, review of financial reports, monitoring and reporting on Project activities

Efficient and effective management of project activities at central and provincial levels

Efficient and effective multi-sector coordination and management of project activities at provincial and District levels.

Project managers skilled in use of IT/GIS for information and communication in project management and information sharing.

Minutes of national Steering Committee including list of participants.

Minutes of provincial steering committee meetings.

List of key policy decisions

Minutes of Inter-departmental Provincial Technical management committee meetings.

Committee reports. Participation List.

Performance Reports detailing effective and timely management of national project implementation at national, provincial and District levels.

Results Based Management (RBM) approach for Project Management Training Curriculum.

Results based management Reports

IT/GIS Training Curriculum and list of persons trained.

The National Steering

committee members understand their roles and responsibilities and are proactive in their tasks

Lack of provincial or individual commitment to the committee or the project.

Individuals unable to regularly participate because of heavy workloads.

Little interest in having their performance measured.

Individuals TORs are not followed.

Project managers and other staff have an interest to improve their management skills.

Reporting, M onitoring and Evaluation does not adequately r eflect change, and no t linked to performance.





Mechanisms


Policy reforms carried out to improve CDC, including integration of CDC into provincial and district health systems for improved health services particularly in remote communities, cross-border and bilateral coordination, and for improved migrant and mobile populations access to quality health services.

Improved coverage of appropriate prevention, diagnosis and treatment of communicable diseases in vulnerable populations, in particular poor women and children living in border areas.

Improved community knowledge of pro- poor policies, standards, and coordination through a culturally sensitive community engagement strategy implemented among CLV countries to improve CDC and health services delivery.

Proportion of targeted men, women, children, and ethnic minorities that received proper prevention information and care for common infections.

Innovative models to

operationalise effective and sustainable cross-border CDC activities, including for: (i) reducing the risk of EID; (ii) strengthening early warning systems for outbreaks; and (iii) addresses programmatic issues and gaps in NTD prevention, control and elimination, especially among underserved populations in remote and rural border areas.

HR Plans and Master Trainer System established. Project Training Procedures Manual produced using skills based training as the basis of all training programs, and with gender and EMG training guidelines incorporated in national languages.

Policy and Strategy Documents

Ethnic Minority Development Plan and Gender Action Plan

User satisfaction report as a result of work place assessment.

Community health surveys, measured against baseline.

Behavioral change survey measured against the baseline

HIS/ Sentinel Data.

Special evaluation of project support for local populations, migrants and mobile people in border areas

Routine HIS reports on health services

Innovation Strategy for Community Engagement Document and guidelines.

Applied research conducted to operationalise effective, sustainable cross-border CDC activities, and findings disseminated.

Policies and community engagement strategies are effectively implemented.

Current funding for CDC and health services is sustained

There are available staff to expand services

Behavioral change communication is effective.

Remote communities, migrants and mobile populations routinely have access to quality health services.

Finding from Baseline

Survey not acted upon with regards to the development and implementation of Community Engagement Strategy.

Specialist training workshops not supported.

MOHs commitment to improved quality and retention of staff at health facilities in the most disadvantaged areas, with priority given to women and EMG candidates to increase the proportion of women and members of EMGs with high level qualifications and employment opportunities.





Mechanisms


(iv)Improved k nowledge management a nd community of pr actice, policies, s trategies, a nd coordination among t he GMS c ountries t o improve CDC, t hrough regional cooperation i n cross-border c luster areas.

Regional Evaluation workshops conducted annually and well supported by CDC GMS MOHs and member organizations.

Technical forums address CDC issues, including gender and EMG dimensions in CDC2 project areas.

“Clearing house” database of donor activities for CDC in GMS established.

RCU website incorporates register, which includes gender studies and projects

Wider understanding of KM within the CDC project participants.

Annual Evaluation Reports and Annual Workshop Reports.

Project reports and KM assessments.

Satisfaction workshop reports.

RCU Websites actively utilized and recorded on Website user information report.

In-house evaluation study.

Workshop or forums don’t realize its objectives.

Finding from technical forums not disseminated because of lack of funding which mean the findings cannot be implemented .

CDC Partners do not utilize web site.

Knowledge

management not well articulated or understood.

Activities with Milestones 1.0 Strengthening Regional Cooperation in CDC 1.1 Conduct annual regional w orkshops o f s ix M OHs and pa rtners t o r eview p roject

performance and discuss regional CDC issues. 1.2 Bi-Annual Regional S teering Committee meetings i n support of bi lateral and r egional

cooperation in CDC and public health and regional agreements signed. 1.3 Conduct policy dialogue and pe er review on he alth laws and regulations according to

regional agenda. 1.4 Develop joint implementation criteria for the revised IHR. 1.6 Expanded legislative framework for CDC developed. 1.6 Development of multi-sector, long-term strategic plans of action for CDC cross border

activities in provinces and districts supported by the GSM countries. 1.7 Regional cooperation and agreements formalised. 1.8 Develop and document guidelines and SOPs for cross-border collaboration. 1.9 Comprehensive Baseline Survey conducted in CLV in the border districts. 1.10 GMS countries participate in at least three technical Regional Forums per year. 1.11 GSM countries conduct at least 4 cross-border events annually. 1.12 MoH’s conduct annual forums for local and regional donors. 1.13 CLV MoH’s initiate and conduct national intersectoral CDC related forums. 1.14 CDC data base developed based in baseline survey data and M&E requirements. 1.15 Maintain a database of existing regional initiatives in “Clearing House” of CDC2.

2.0 Strengthening National Surveillance and Response Systems 2.1 Support mechanisms for intra- and inter-sectoral collaboration to implement the IHR. 2.2 Support stepwise planning and development of a national surveillance and response

system. 2.3 Develop in-service capacity building programs and implement training courses for

surveillance and response at different levels of the health system. 2.4 Develop and implement community and hospital preparedness plans, including

simulation exercises. 2.5 School teachers trained and students mobilized for community-based surveillance and

prevention activities 2.6 Emergency response preparedness plans formulated and implemented in all target

areas and national and multinational outbreak simulation exercises conducted. 2.7 Measurable contributions made to comprehensive national surveillance and response

Inputs ADB $50.00 million Cambodia $0.71 million Lao PDR $0.86 million Viet Nam $2.70 million Total: $54.27 million Summary of Base Costs Procurement - Vehicles $4.03 - Lab & Office $1.73 Systems Development $2.30 Training/W-shops/F-Ships $7.66 Community Mobilisation $21,23 Consulting Services $2.39 Project management $1.51 Recurrent Cost $4.33 Total $45.18





Mechanisms


systems, including institutional structures; preparedness; surveillance and response; laboratory services; and HRD in all three countries in the project provinces.

2.8 HRD training Systems Development approach adopted by MOHs in CLV. 2.9 Master TOT Trainer System Procedures Manual produced and staff trained as Master

trainers. 2.10 Reference manuals/guidelines, equipment, and training modules to implement

prepared for the HRD planning and management systems for capacity building at all levels, including for surveillance and response systems in selected provinces and districts.

2.11 Develop and implement undergraduate- and graduate-level training models for surveillance and response. Develop a national system of quality assurance and bio-safety.

2.13 Women and ethnic minority students from remote, border areas with skills needed to join in Project Pre-service training to become health workers

2.14 Training curricula, with supporting training, learning and reference materials and aids for district and commune health workers in priority areas

2.15 Develop GIS-based inventory of health facilities and resources as tool for planning outbreak response.

2.16 Provide equipment and user support for provincial and reference laboratories for emerging diseases in border and remote regions.

2.17 IEC/ BCC and relevant training materials produced by MOH, ASEAN+3, National Institutes, donors, WHO, UNICEF, and INGOs, and are used effectively in project districts.

2.18 IEC/BCC materials held and used effectively by health staff and VHWs in selected border communities. Strengthened provincial capacity for CDC and PHC services.

2.19 Plans for integrated CDC, including ARI and DD prepared and implemented by districts.

2.20 Carry out preventive and curative disease control training and participatory community-based activities for endemic and emerging diseases.

2.21 Expanded and integrated CDC and PHC services for vulnerable groups in 29 provinces (five in Cambodia, nine in Lao PDR, and fifteen in Viet Nam).

2.22 Community engagement strategy and operational guidelines developed for implementation of community-based health promotion activities, such as healthy village model.

2.23 Established a functioning healthy village models in target villages in remote, border areas.

2.24 Support village and commune committees, local schools to establish and support community surveillance and response initiatives.

2.25 Provincial and District trained and support programs for provincial planning and budgeting implemented.

2.26 Results based performance management implemented and used to monitor project implementation performance.

2.27 Develop methods of enhancing the capacity of MOHs to use national data generated by the surveillance systems.

2.28 Mid Term Review undertaken.

ADB = Asian Development Bank, CDC = communicable disease control, CLV = Cambodia, Lao PDR, and Viet Nam, DALY = disability-adjusted life year, IHR = International Health Regulations, IMR = infant mortality rate, Lao PDR = Lao People’s Democratic Republic, MDG = Millennium Development Goal, MOH = Ministry of Health, U5MR = under-5 child mortality rate, WHO = World Health Organization.

APPENDIX 2:

PROJECT SCOPE


Appendix 2 – Project Scope – Final Consultant Report April 2010 Page 1

APPENDIX 2 – PROJECT SCOPE

TABLE OF CONTENTS

I. DEVELOPMENT AND FOCUS OF CDC2 ............................................................................... 2

A The Scope of Project ....................................................................................................... 2

B. Project Components: ...................................................................................................... 3 B.1 Component 1: Strengthening Regional Cooperation in CDC ............................................. 3 B.2 Component 2: Strengthening National Surveillance, Response and Health Systems ........ 4

C. Project Benefits and Beneficiaries ................................................................................. 5

D. Financing Plans ............................................................................................................... 6

E. Implementation Arrangements ....................................................................................... 6

ANNEX 1 - PROJECT CLUSTERS ................................................................................................ 8 ANNEX 2 - SUMMARY OF BASE COST ESTIMATES BY EXPENDITURE CATEOGRY

AND COUNTRY 9 Table 1: Population of Project Provinces proposed for CDC2. ....................................................... 5 Table 2: Project Provinces Populations in proposed Clusters for CDC2. ......................................... 8 Table 3: Ethnic Minority Population in proposed Clusters for CDC2. ............................................... 8



APPENDIX 2 - PROJECT SCOPE

I. DEVELOPMENT AND FOCUS OF CDC2

A The Scope of Project

1. The CDC2 Project will use the experience of CDC1 as a basis on which to develop CDC2 and to contribute to the further development of communicable diseases control (CDC) in the GMS. The Project will focus on cross border cooperation for communicable diseases control and prevention, and will address CDC issues associated with cross border traffic and population movements and impacts on border populations, which have been rapidly accelerating, enabled by the GMS economic corridors and subsidiary road networks. In recent years, globalization has transformed borders from barriers to bridges, and this transformation has shifted attention to cross-border matters that localities have in common. Regional economic developments, catalytic events and their economic impact, and high-level political commitment to attaining Millennium Development Goals (MDGs) have generated strong support for regional cooperation across health sectors. The current GMS setting favours a regional approach to CDC that can significantly improve the health of the poor in Cambodia, Lao PDR and Viet Nam (the CLV countries). 2. Activities under the project are pro-poor, focusing on rural and remote populations in the project districts of CLV border areas, where many ethnic groups and the poorest reside. Women and children will be the major beneficiaries of the primary health care (PHC) and community-based interventions, including community based CDC surveillance and responses in these border districts. 3. The project will be built around the three strategic pillars that were developed by ADB in CDC1:



(iii) Pillar 3: Cross border (ground) collaborations and health services. (i) Components The Project has two components:

(i) strengthening regional cooperation in communicable disease control, and (ii) strengthening national surveillance, response and health systems.

(ii) Impact and Outcomes Impact Statement

4. The overall project impact will be improved health for the populations in the project provinces in the border region, which will assist the Ministries of Health in Cambodia, Laos and Vietnam (CLV) to achieve MDGs 4, 5 and 6 and by reducing the spread of emerging and neglected communicable diseases thereby reducing morbidity and mortality, in particular among children, and the economic cost of these diseases.

Outcomes

The expected project outcomes will be improved regional security through:


(ii) Strengthened regional and MOH’s technical capacity for surveillance and response, following WHO guidelines for implementation of the IHR and APSED with timely responses



to epidemics in provinces with common borders that are likely to have a major impact on public health and the economy in the region;

(iii) Increased capacity of national, provincial and district health services in results based management and technical capability with integrated CDC and health services particularly underserved populations who have a high disease burden neglected tropical diseases(NTDs) and are at risk from newly emerging diseases(EIDs;


5. The Project will be implemented over a period of 5 years, commencing in July 2010 and will be adjusted yearly on the basis of Annual Operating Plans (AOPs) developed at the provincial level, and approved by the national steering committees (NSC). 6. The CDC2 Project will be managed and implemented under the same structure as CDC1 within each Ministry of Health (MOH), integrated with existing national and provincial structures, with implementation delegated as far as possible to the provinces. Collaboration with WHO and other regional organisations (such as MBDS) will be integrated into the project for coordination and strengthening of technical and cross-border activities. The Project will be implemented over a period of five years and will have two components as detailed below. 7. The Project will provide grant funding to Cambodia and Lao PDR, and loan funding to Viet Nam. Technical assistance will be supported from the Project pool fund. The Peoples Republic of China and Thailand and Myanmar will be invited to participate in CDC2, and is anticipated that they will be using their own national resources, or seeking additional alternative funding arrangements. B. Project Components:

The Project has two components as outlined in the following pages:

B.1 Component 1: Strengthening Regional Cooperation in CDC

8. The Project will establish and support mechanisms to increase regional cooperation with a focus on EIDs and NTDs in selected border and cross-border corridor districts, in three clusters of border provinces in CLV (See annex 1). The Project will support compatible and coordinated GMS strategies for CDC across borders, including: (i) plans for implementing a harmonized approach to CDC (EIDs and NTDs) based on WHO IHR, APSED and the MBDS Action Plan; (ii) establishment of regional focal points in the MOH; (iii) GMS meetings to establish a regional Project steering committee and national working groups; and (iv) formalization of agreements on CDC cross-border cluster activities. 9. Comprehensive baseline information will be collected and established for cross-border planning, monitoring and evaluation of CDC, including: (i) comprehensive baseline surveys in the border districts of the three Project clusters to guide provincial and district CDC strategies and cross-border cooperation; (ii) appointment of technical advisory teams to prepare a draft design of the baseline survey using existing data, and covering: (a) demographic analysis; (b) district health service analysis; (c) cross-border traffic and population movement analysis; (d) border quarantine service analysis; (e) village water and sanitation coverage analysis; (e) animal health services analysis; (f) analysis of diagnostic capacity in district health centers; and (h) gender, social and poverty analysis, including human trafficking issues.

10. The current activities of the Regional Coordination Unit (RCU) will support Project Implementation to achieve efficient and effective management of Project cluster activities, and other regional activities including CDC knowledge management for the GMS. In particular RCU activities will include: (i) technical support for regional cluster implementation and coordination; (ii) assistance in the design of a detailed M&E framework for Project activities; (iii) establishment of



regional focal points in the MOHs; (iv) coordination of regional TA inputs, and inputs by specialized technical agencies and health INGOs; (v) management of the RCU and linkages with MBDS; and (vi) coordination and planning of linkages with national and regional health sector programs and projects.

B.2 Component 2: Strengthening National Surveillance, Response and Health Systems

11. Component 2 will strengthen institutional structures, partnerships, and policies through Project support for the development of: (i) multi-sector long-term strategic national policies for regional collaboration for emergency response and prevention of communicable diseases; (ii) incorporating WHO guidelines for implementing the IHR; and (iii) national multi-sector mechanisms to define sector and departmental roles for emergency CDC response. Project provinces will be supported to increase the capacity of health workers to provide quality health services, including surveillance, response and preparedness. Following a clearly planned strategy from inter-provincial, to provincial, to district, to community levels, with gender issues an integral part of all activities, the project will support: (i) strengthening human resource planning and management; (ii) building training capacity at provincial and district levels; and (iii) training of district and commune/ health center staff to improve quality of health services, including for community-based CDC and scholarships for up-grading and advanced specialist training will also be provided. 12. National surveillance, response, and preparedness systems will be supported through: (i) national health policies, strategies and plans that incorporate the IHR; the MBDS Action Plan for Mekong regional cooperation and APSED; (ii) harmonized CDC policy in GMS; (iii) assessment of needs, and support for strengthened and harmonized provincial rapid response capacity; (iv) vehicles and equipment provided based on the needs assessments; and (v) harmonized surveillance plans and activities based on the MBDS Action plan ‘seven core strategies’. 13. Provincial human resource staffing and training plans will include: (i) analysis of training needs in provincial health services; (ii) plans of action to increase gender and ethnic minority equity in provincial health services; (iii) review of existing training curricula and materials and adopting or developing new materials; and (iv) identification of IEC and training materials that can be translated and shared among project provinces, including IEC materials produced or planned by ASEAN+3, national institutes, provinces in CDC1, donors, WHO, UNICEF, and INGOs. Training equipment needs will be assessed and provided based on needs assessment. Training plans, materials and activities will be approved by national authorities and then reviewed by provincial steering committees that oversee provincial training programs, advise on priorities and approve training funds. Provincial training groups consisting of senior trainers will implement provincial plans, including for training systems development and training of trainers in skills based training. Provincial HR planning and training system approaches will be harmonized in Project provinces to further strengthen provincial, district and commune and village level capacity for surveillance and reporting. Inter-provincial training groups will advise on overall strategies and priories. 14. Based on provincial HR Plans, Project training will improve the quality of diagnostic, reporting and health services provided by clinical and preventive health staff and laboratory technicians working in commune health stations, health centers, provincial and district hospitals, preventive medicine, health education, and reproductive / mother and child health centers. Provincial and district trainers will participate in training of trainers (TOT) courses according to their training and supervision role in the province. They will develop their skills to conduct training needs analyses (TNA) and plan, design, develop, deliver and evaluate skills based training (SBT) materials and courses for health workers at district and commune levels and for village health workers in underserved border areas. Sustainability will be enhanced by working within existing national programs, institutes and departments, and in compliance with established government policies, guidelines and prioritized health agendas for effective CDC and quality primary health care. Topics for the training will be identified from project baseline information and ongoing TNA, and may include: (i) field epidemiology; (ii) information and communication technology; (iii) clinical diagnosis and treatment; (iv) laboratory management and haematology; (v) BCC for community-



based surveillance and prevention; (vi) audience analysis for IEC testing and development; (vii) project management, monitoring and evaluation; and (viii) training of trainers. Training will take place as training workshops, on-site training, exchanges, study tours and field practice.

15. Provincial studies and participatory activities with rural populations in border districts will support development and implementation of gender sensitive strategies and guide engagement and communication with minority linguistic/ethnic groups. Demand and access to quality health services will be increased by: (i) strengthening health care services in remote, underserved border areas; and (ii) improving health behavior through increased knowledge, awareness, and participation in community-based disease surveillance and prevention activities. Experiences from the participatory needs assessments, provincial, district and community workshops, study tours and the learning process will together be analyzed to produce clear strategies for multi-sector, community-based health promotion and CDC that seek to empower people about their choices about health, which in combination compliment Project improvements to the delivery of health services, and thereby encourage greater and more discerning use of those services. C. Project Benefits and Beneficiaries

16. The Project will help minimize the social and economic impact of communicable diseases in GMS by helping departments of health in the border provinces of Cambodia, Lao PDR and Vietnam to respond rapidly and effectively to contain the spread of emerging and epidemic diseases. It will strengthen provincial-level, cross border cooperative capacity to contain outbreaks of communicable diseases that can have devastating human and economic impacts, most dramatically illustrated by the SARS pandemic in 2003. WHO points out new diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue noting that national investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border. By strengthening cross-border cooperation on disease surveillance and response systems the costs associated with outbreaks will be reduced. The strengthening of provincial and district health systems, community level primary health care and activities for disease prevention will lead to improvements in public health, and decrease out-of-pocket health expenditures. These interventions will also reduce the number of sick children, thereby improving school attendance and overall physical and cognitive development 17. The Project will focus on surveillance and response and control of selected diseases, which will strengthen CDC and PHC services which will mainly benefit poor border communities in border districts of CLV. The project will operate in 29 provinces which have a collective population of more than 26.4 million of whom at least 6.6 million live in GMS 102 targeted districts with border crossings, and of whom more than 50 percent live below or close to the poverty line. Ethnic minorities comprise 28.2% proportion of the 6.6 million of the Project beneficiaries, in border districts in provinces currently nominated by governments for inclusion in CDC2. However, in most of the priority border districts in the three countries, ethnic minorities comprise the majority of the population. (see Appendix 17 Project Provincial Profiles). The poor and vulnerable will benefit from the Project's focus on border areas and its commitment to train local health workers and community volunteers. Table 1: Population of Project Provinces proposed for CDC2. Population


Project provinces

5 1,797,419 9 2,187,716 15 22,420,579 29 26,405,714

Border districts

17 650,564 33 1,311,531 52 4,692,013 102 6,609,108


13.8% 83,752 29.2% 383,565 29.7% 1,394,451 28.2% 1,861,768



Source: Population data gathered for CDC2 project preparation see Appendix 17 Project Provincial Profiles. 18. The Project is considered economically viable and the economic benefits of the Project will come from:





D. Financing Plans

19. The Project will provide grant funding to Cambodia and Lao PDR, and loan funding to Viet Nam. Technical assistance will be supported from the Project pool fund. The Peoples Republic of China (PRC)(especially Yunnan Province), Thailand and Myanmar will participate using their own national resources, or additional alternative funding arrangements. 20. The proposed CDC2 Project does not involve any cofinancing from other donors. There are also no local contributions either in kind or in cash from community beneficiaries. The financing plans for both Project Loan / Grants have been verified, and the ADB loan / grant funds and counterpart funds from three Governments will be made available in a timely fashion. 21. The RGoC has requested a Grant from ADB in SDR equivalent to $ 10.6 million from ADB’s Special Fund resources to help finance the Project. The total project investment cost and recurrent cost is estimated at $ 11.306 million. The GoL has requested a Grant from ADB in SDR equivalent to $ 11.6 million to help finance the Project The total project investment cost and recurrent cost is estimated at $ 12.456 million. The GoV has requested a Loan from ADB in SDR equivalent to $ 25 million to help finance the Project The loan will have a 32-year term, including a grace period of 8 years, and an interest rate of 1 percent. The total project investment cost and recurrent cost is estimated at US$ 27.704 million. In addition, and in support of project implementation, ADB is considering to finance a grant fund for technical assistance for Viet Nam valued at approximately $ 2.8 million and this is under discussion between ADB and GoV. This grant fund amount is planned to be administered by ADB and placed under the Project Pool Fund for consulting services and other regional coorperation activities.

22. Since this report was written ADB have advised that an additional 1 million grant funds would be available for Lao PDR, plus an additional 8 million of loan funds would be available for civil works for Preventative Medicine Centres in the Project Provinces.

23. The cost estimates for Technical Assistance and operation of the Regional Coordination Unit (RCU) include relevant costs for consulting services to be based in Viet Nam in an RCU office. The total cost for this TA/RCU is $ 5.6 million for a 5-year implementation with a detailed breakdown of costs in Annex 4 of Appendix 6. Lao PDR and Cambodia will contribute to this pool fund $ 1.4 million each and Viet Nam will contribute a sum of $2.8 million from ADB’s grant fund.

E. Implementation Arrangements

24. The Project will be implemented over a period of five years, commencing in July 2010 and will be adjusted yearly on the basis of Annual Operating Plans (AOPs) developed at the provincial level, and approved by the national steering committees (SC). The following implementation arrangements are proposed. 25. In Cambodia, MOH will be the Executing Agency (EA) and will be implemented through the Second Health Sector Support Program (HSSP2) as the project administrator for the EA. The



Communicable Disease Control Department (CDCD) through the Project Management Office (PMO) will be the implementing agency (IA) together with six provinces as PIAs. 26. In Lao PDR, the Department of Planning and Budgeting (DPB) under MOH will administer CDC2. The Department of Hygiene and Prevention (DHP) will be the coordinating National Implementing Agency (NIA). There are nine project provinces participating as Provincial Implementing Agencies (PIA). 27. In Viet Nam, MOH will be responsible for overall project management and guidance as the EA. The General Department of Preventive Medicine and Environment Health (GDPMEH) will be the coordinating IA and PMU, and the MOH’s Department of Planning and Finance (DPF) will be involved in this project with regards to financial management. 28. Because CDC2 follows on from the CDC1, it is proposed that the three Project Management Units (PMUs) in the the CLV countries will be the same as those for CDC1. Each PMU to be headed by a Project Director and be responsible for the overall project management.


Appendix 2 – Project Scope – Final Consultant Report February 2010 Page 8

ANNEX 1 - PROJECT CLUSTERS

Component 1 will establish and support mechanisms to increase regional cooperation with a focus on EIDs and NTDs in selected border and cross-border corridor districts, in three clusters of border provinces in CLV (see map 2 in main report). These proposed clusters are likely to be: Cluster 1: In Lao PDR; Phongsaly, Luangnamtha, Oudomxay, Bokeo and Khammuane (5 provinces) In Viet Nam; Dien Bien, Son La, Thanh Hoa, Nghe An, and Ha Tinh (5 provinces) making a total of 39 districts in 10 provinces. The project will engage with the MOHs and provincial and district health departments of PRC, and Thailand and Myanmar in contiguous border areas. The RPPTA team have requested that Lai Chau and Lao Cai, also be considered for inclusion in CDC2 as part of the northern cluster, as well as the inclusion of Quang Binh to join with Khammuane province in Lao PDR. Cluster 2: In Cambodia; Rattanakiri, Stung Treng, and Mondolkiri (3 provinces) In Lao PDR; Saravane, Sekong, Champasak and Attapeu (4 provinces) In Vietnam; Quang Tri, Quang Nam, Dak Lak, Dak Nong and Binh Phouc (5 provinces) making a total of 39 districts in 12 provinces. The project will engage with the MOH and provincial and district health departments of Thailand in contiguous border areas. The RPPTA team have requested that Kon Tum, Gia Lai provinces also be considered for inclusion in CDC2 as part of the central region cluster. Cluster 3: In Cambodia; Kampot, Takeo, (2 provinces) in Viet Nam; Tay Ninh, Long An, Dong Thap, An Giang, Kieng Giang (5 provinces), (24 district in 7 provinces). The RPPTA team have requested that Svay Rieng, Prey Veng, Kampong Cham provinces also be considered for inclusion in CDC2 as part of the southern region cluster. Expansion of CDC2 to include additional GSM Partners. As mentioned above, CDC2 will also invite the provincial and district health departments of PRC (Yunnan province), Thailand and Myanmar in contiguous border areas to participate in cross border activities and knowledge management activities including technical forums and workshops.

Table 2: Project Provinces Populations in proposed Clusters for CDC2.

Country

Cluster 1 Cluster 2 Cluster 3 TOTAL Border Dist.

Border Population

Border Dist.

Border Population

Border Dist.

Border Population

Border Dist.

Border Population

Cambodia 11 190,716 6 414,848 17 605,564 Laos 18 665,854 15 645,677 33 1,311,531 Vietnam 21 1,809,269 13 863,435 18 2,019,309 52 4,692,013

Total 39 2,475,123 39 1,699,828 24 2,434,157 102 6,609,108 Table 3: Ethnic Minority Population in proposed Clusters for CDC2.

Country

Cluster 1 Cluster 2 Cluster 3 TOTAL As % of B-Pop.

EMG Population in Border Districts

As % of B-Pop.


As % of B-Pop.


As % of B-Pop.


Cambodia 42.5% 80,998 0.7% 2,754 13.8% 83,752 Laos 38.3% 255,184 19.9% 128,381 29.2% 383,565 Vietnam 54.2% 981,177 32.2% 278,155 6.7% 135,119 29.7% 1,394,451

Total 50.0% 1,236,361 28.7% 487,534 5.7% 137,873 28.2% 1,861,768 Source: Population data gathered for CDC2 project preparation see Appendix 17 - Project Provincial Profiles


Appendix 2 – Project Scope – Final Consultant Report February 2010 Page 9

ANNEX 2 – SUMMARY OF BASE COST ESTIMATES BY EXPENDITURE CATEOGRY AND COUNTRY

Second GMS Regional Communicable Diseases Control Project: Summary of Cambodia, Lao PDR and Viet Nam Summary of Base Cost Estimates by Expenditure Category and Country ($Thousand)

Expenditure Category TOTAL - CLV

Base Cost %

$('1000) %

1 Civil Works

2 Laboratory and Office Equipment 312 3.3% 472 5% 945 3.7% 1,729 3.8% 3 Vehicles 700 7.5% 829 8% 2,503 9.8% 4,032 8.9% 4 System Development 697 7.5% 672 7% 928 3.6% 2,297 5.1% 5 Training, workshop, fellowships 2,146 23.0% 2,136 21% 3,382 13.2% 7,664 17.0% 6 Community Mobilization 3,463 37.1% 3,959 39% 13,803 53.9% 21,225 47.0% 7 Consulting services 723 7.8% 667 7% 1,000 3.9% 2,390 5.3% 8 Project Management 389 4.2% 423 4% 702 2.7% 1,514 3.4%

9 Recurrent Costs 893 9.6% 1,083 11% 2,350 9.2% 4,326 9.6%

Total 9,323 100% 10,241 100% 25,613 100% 45,177 100%

Summary of Base Cost Estimates by Expenditure by Component/Subcomponent and Country ($Thousand)

COMPONENT ONE

1.1 Compatible and coordinated strategies for

CDC across borders 101.0 1.1% 66.8 0.7% 141.0 0.6% 308.8 0.7%

1.2 Cross-border planning, monitoring and

evaluation for CDC 709.5 7.6% 803.3 7.8% 1,554.5 6.1% 3,067.3 6.8% 1.3 Regional knowledge management 152.0 1.6% 163.0 1.6% 174.0 0.7% 489.0 1.1%

1.4 Support for regional GMS CDC cluster

implementation and coordination. 49.0 0.5% 52.0 0.5% 120.0 0.5% 221.0 0.5%

Total Component One 1,011.5 10.9% 1,085.1 10.6% 1,989.5 7.8% 4,086.1 9.0%

COMPONENT TWO

2.1 Strengthening institutional structures,

partnerships, and policies. 30.0 0.3% 19.3 0.2% 19.0 0.1% 68.3 0.2% 2.2 Strengthening Systems for HRD 476.0 5.1% 602.4 5.9% 952.0 3.7% 2,030.4 4.5%

2.3 Strengthening systems of surveillance,

response, and preparedness 1,559.0 16.7% 1,718.3 16.8% 3,151.0 12.3% 6,428.3 14.2%

2.4 Capacity Building of Provincial and District staff

for CDC 1,786.0 19.2% 1,805.5 17.6% 3,046.0 11.9% 6,637.5 14.7%

2.5 Targeted CDC and training activities for rural

populations in border districts 1,501.0 16.1% 1,829.2 17.9% 9,388.0 36.7% 12,718.2 28.2% 2.6 Support for national project implementation 2,959.0 31.7% 3,181.2 31.1% 7,068.0 27.6% 13,208.2 29.2%

Total Component One 8,311.0 89.1% 9,155.9 89.4% 23,624.0 92.2% 41,090.9 91.0%

TOTAL COMPONENTS 1 & 2 9,323 100% 10,241 100% 25,614 100% 45,177.0 100%

APPENDIX 3:

PROJECT RATIONALE


Appendix 3: Project Rationale – Final Consultant Report April 2010 Page 1

APPENDIX 3 – PROJECT RATIONALE

I. RATIONALE FOR THE 2ND GMS REGIONAL COMMUNICABLE DISEASE CONTROL PROJECT

1. Since 1992, the Asian Development Bank (ADB) has supported the Greater Mekong Subregion (GMS) Economic Cooperation Program to enhance cooperation between Cambodia, Lao People’s Democratic Republic (Lao PDR), Myanmar, Thailand, Viet Nam, and the People’s Republic of China (PRC), specifically Yunnan Province. Areas of focus include: strengthening infrastructure linkages; facilitating cross-border trade, investment and tourism; enhancing private sector participation and competitiveness; developing human resources and skills competencies; protecting the environment; and promoting sustainable use of shared natural resources.

2. Since the 1990s a network of roads has been upgraded or constructed as part of the Greater Mekong Sub-region (GMS) strategy for regional integration which began in 1992 with the development of six major regional corridors of GMS (see map 1)). The GMS strategy has promoted closer economic ties and economic cooperation among the six countries that share the Mekong River. The Asian Development Bank (ADB) has been the lead agency in both initiating inter-country consultations and financing transportation and energy infrastructure.

3. Greater connectivity has resulted in rapidly accelerating flows of people and goods across borders. New roads have attracted new labour intensive developments (plantations, casinos, resorts, logging, dams, mines, ecotourism projects) bringing both benefits and communicable disease control (CDC) consequences. There is no reliable data on the numbers of people crossing border to work because the borders are so porous and many migrants are undocumented and working in the informal economy. These population movements are driving rapid social change in border provinces, particularly in localities where the populations were previously sparse and isolated, mainly comprising ethnic minority groups (EMGs).

4. The expansion of transport networks exposes those in previously remote and isolated communities to a world where their life skills do not easily transfer and where few support mechanisms are available for coping with emerging socio-economic shocks, potentially placing them into conditions of landless poverty and pushing many of them to move in search of better opportunities. Construction and other development projects have led to large scale displacement and resettlement of local communities, especially ethnic minority populations, leading to the migration of those who have lost their land and other sources of livelihood, or who are relocated to land where they cannot make a living, or where they experience psychosocial dislocation.

5. The benefits of regional economic integration in the region, have been accompanied with undesired side effects, such as: the spread of HIV/AIDS and other communicable diseases; increased drug trafficking; increased illegal labour migration and related issues of human trafficking and child labour; environmental degradation; escalating land prices causing farmers to become landless; and a worsening the income distribution in these To address these issues, ADB developed the Regional Cooperation and Strategy Program (RCSP) for 2004 – 2008 which supported1:

pro-poor, sustainable growth by addressing human development through health and other social, economic and capacity-building measures, in particular, development of human resources and skills competencies in the GMS, to: (i) identify issues related to cross-border migration, including related health and other social issues, and undertake studies to address these issues; and (ii) to implement cooperative arrangements for addressing health and other social issues related to cross-border migration, particularly for HIV/AIDS prevention and control, and improvement of health and other social

1 The fifth meeting of the GMS Human Resource Development Working Group, held in June 2004 confirmed that communicable diseases control (CDC) is a top priority for regional collaboration in view of emerging diseases.



services delivery to ethnic minority groups (EMGs) in the border areas; and (iii) prevention and control of malaria for border areas.2

6. Outbreaks of newly emerging diseases such as SARS in 2003 and AI in 2004 and 2005 have so far had little impact on health in the region, but could have had more devastating effects. The case fatality rate for SARS is around 10% and for human AI about 50%. However, scientists indicate that the AI virus may mutate or reassert into another virus that spreads in humans like an ordinary flu virus. This could cause a global pandemic with millions of deaths in the region.

7. These emerging diseases, even with limited health impact, have major economic consequences. SARS slowed economic growth by reducing tourism and communication. GDP in the region could have declined by 0.2–1.8 percentage points if SARS had persisted for one economic quarter, and, GDP in the individual countries could have fallen by 0.5–4.0 percentage points if it had gone on for two quarters.3 While the CLV countries do not have a major poultry export industry like Thailand, AI has probably reduced GDP by about 0.5% in Viet Nam.4 More importantly, it has had a major impact at the local level on poor backyard farmers and wet markets. As Viet Nam had culled almost a quarter of its national poultry stock. A human pandemic could cause an economic meltdown. The fast spread of these diseases and their potential consequences highlight the need for regional collaboration in CDC. Such a strategy must entail the strengthening of surveillance and response systems from community-level workers detecting outbreaks to laboratory facilities and provincial and national CDC response centres. Cooperation across the health and agriculture sectors is important for AI.

8. The fast spread of these diseases and their potential consequences highlight the need for regional collaboration in CDC. Such a strategy must entail the strengthening of surveillance and response systems from community-level workers detecting outbreaks to laboratory facilities and provincial and national response centres. Cooperation across the health and agriculture sectors is important for AI. AI requires better poultry bio-security and vaccination, improved preparedness and response of public and private services including quarantine arrangements and medicines, and risk profiling and monitoring the spread and genotype of the virus in hosts. The ministries of agriculture in the region are performing animal surveillance with assistance from the Food and Agriculture Organization. Laboratory conditions for the cultivation of the AI virus in the national animal health laboratories are substandard and pose a biohazard.

9. Significant cross-border risks arise from emerging epidemic diseases such as Dengue but also the group of parasitic diseases referred to as neglected tropical diseases (NTDs). The issue of NTDs is less well understood as a cross-border CDC issue because many NTDS are not included among notifiable diseases and tend to be endemic to specific areas. However, NTDs span borders in the GMS. The increasing population mobility arising from increasing economic integration in the GMS means that there are growing risks of parasitic diseases moving into new populations via human contacts. National investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border. 5

Regional Security 10. By focusing in cross border cooperation for communicable diseases control and prevention. The Project will address CDC issues associated with cross border traffic and population movements and impacts on border populations which have been rapidly accelerating, enabled by the GMS economic corridors and subsidiary road networks. In recent years, globalization has transformed borders from barriers to bridges, and this transformation has shifted attention to cross-border matters that localities have in common. The current GMS setting favors a regional approach to CDC that can significantly improve the health of the poor in the CLV countries. A regional focus and cooperation is justified if benefits exceed what countries acting on their own can achieve. 2 Asian Development Bank, 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (2004-2008), p.31 2 Asian Development Bank, 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (2004-2008). 3 ADB. 2003. Economic Research Department Policy Brief No. 15. Manila. 4 An initial economic impact assessment is available as a separate report (and has already been circulated within ADB). 5 Country Reports presented at the First GMS-CDC Technical Forum on the Control and Elimination of NTDs in the Mekong Sub-Region October 21-22, 2009



Specifically for CDC, the rationale and justification for regional cooperation has to be seen in economic as well as health and social context.

11. The group of parasitic diseases (such as Filiariasis, Schistosomiasis, and Helminthiasis and food-borne Trematodiasis and Cestodiasis) referred to as neglected tropical diseases (NTDs) also pose significant cross-border risks. This issue is less well understood as many NTDS are not included among notifiable diseases and tend to be endemic to specific areas. However, many of these areas span borders in CLV. Parasites spread by contact with infected soil are endemic in most border areas of GMR and are associated with poverty and poor environmental sanitation. Hookworm causes anaemia, which endangers the lives of unknown thousands of women in the GMR border regions, while the development of unknown thousands of children in these areas is affected by intestinal parasites. The increasing population mobility arising from increasing economic integration in the GMS means that there are growing risks of parasitic diseases moving into new populations via human contacts. The effective treatment of these infections is known to increase work capacity and productivity.

12. In collaboration with ADB and other partners, the GMS countries have made significant national progress in the control of many of these diseases. However, when governments take initiatives to eradicate NTDs via vector eradication programs, mass drug administration (MDA), and environmental sanitation on one side of a border and there is no corresponding measures taken on the other side, the parasites and vectors become rapidly re-established and re-infection of the population follows. 6

13. A key factor in the rationale is that the focus of disease control needs to be geographic rather than being based on national boundaries. Differences in national health policies, such as the cost of treatment and the quality of service may push residents of border areas to seek treatment in a neighbouring country. The MOH’s in each country realize the need to act in new and different ways. Importantly, countries can learn from one another what works in matters ranging from the health education needs of ethnic minority groups (EMGs) to health sector financing. Working together can also provide important leverage and opportunities to benefit from economies of scale.

14. Regional cooperation is justified if benefits exceed what countries acting on their own can achieve. Specifically for CDC, the rationale for regional cooperation can be broken down into four broad categories:

(i) Nature of communicable disease transmission (ii) Technology transfer (iii) Economies of scale and greater leverage (iv) Regional public goods for health

15. CDC1 was intended to facilitate cross-border cooperation in CLV on building compatible responses to potential cross-border disease outbreaks. However the CLV provinces or districts selected for participation in CDC1 (with a few notable exceptions) were rarely internationally contiguous, and the priority districts in the provinces were not on border areas, and/or lacked a focus on border issues, thus undermining the potential for specific joint CDC surveillance and response activities in CLV. These issues and concerns will be addressed in the recommendations for CDC2.

16. By strengthening CDC response capacity at provincial and district levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the sub-region. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue. 7 The sudden and deadly 6 Asian Development Bank, 2009. Background Information, First GMS-CDC Technical Forum on Control and Elimination

of Parasitic Diseases in the Mekong Sub-region. Forum 7 World Health Organisation, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html.




outbreak of Severe Acute Respiratory Syndrome (SARS) early in 2003 provides a lesson. By mid 2003 SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world.8

Economic Corridors 17. Over the past decade or more, much of the GMS has experienced a double transition: from subsistence farming to more diversified economies, and from command economies to more open, market-based economies. Whilst greater integration has contributed to the sub-region becoming an internationally recognised growth area, there have also been costs. The construction of new and/or upgrading of existing roads have had impacts on the environment of the sub-region from the uplands to plains to coastal areas affecting people’s livelihoods, particularly the three-quarters still living in rural areas, where they lead subsistence or semi-subsistence agricultural lifestyles.

18. The focus of disease control needs to be geographic rather than just being based on national boundaries. Differences in national health policies, such as the cost of treatment and the quality of service may push residents of border areas to seek treatment in a neighboring country. The MOHs in each country realize the need to act in new and different ways. Importantly, countries can learn from one another what works in matters ranging from the health education needs of ethnic minority groups (EMGs) to health sector financing. Working together can also provide important leverage and opportunities to benefit from economies of scale.

19. CDC tends to be fragmented and donor-driven, causing projects to be implemented in isolation, resulting in further fragmentation, repetition, and lack of sustainability of interventions. Surveillance is particularly complicated by the use of several separate systems for prioritized diseases that receive financial and technical support from international organizations. Many people, especially in remote regions, use private healthcare providers, and therefore a significant amount of CDC information is not recorded in the existing surveillance systems. Furthermore, health services often lack minimum standards against which performance can be measured. Health sector planning, financing, and aid coordination remain major challenges with limited accountability and authority at the local level.

20. Human Resources Development - GMS countries also face different challenges in human resource development (HRD). Because of these, as well as diverse languages and cultures, the normal tendency is to favor national education, training and health programs. Regional initiatives in health, for example, do not fit easily and seamlessly across borders due to the vertical structures that separate disease programs in national health systems. There are a number of areas where sub-regional cooperation in HRD is logical and urgently needed to address: (i) health and social problems associated with mobile populations, including CDC; (ii) the rights of migrant and guest workers; and (iii) the trafficking of women and children.

21. By strengthening CDC response capacity at provincial and district levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the subregion. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue. 9 The sudden and deadly outbreak of Severe Acute Respiratory Syndrome (SARS) early in 2003 provides a lesson. By mid 2003 SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world.10

8 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15 9 World Health Organisation, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html. 10 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15




22. Experience in CDC1 indicates that training efforts are often shallow, and have limited means to assess skills development. Training needs to be more practical and less theoretical, more hands-on and experiential, using adult learning methodologies and materials. Training processes also need to be closely monitored at implementation and supervisory levels to ensure quality, and at central and senior levels to ensure sustainability and continuing relevance.11

23. While health workers are widely distributed throughout every level of the health care system, mal-distributions and chronic shortages exist, and the staff that are available are often inadequately trained to provide the quality of health care needed. The governments of CLV have all set goals to train increased numbers of health personnel, and to improve the quality of their training, training curricula and training materials, and to strengthen the capacity of trainers, in order to bridge the gap between the quantity of students and the quality of their education.

24. Currently, provincial and district health authorities in CLV face a number of challenges in addressing CDC in vulnerable rural border populations mainly comprising EMGs. Typically they cite the constraints of distance and accessibility to the typically mountainous terrain in most border areas. But district health offices (working with the district hospitals and health centres) also lack the resources to provide outreach services. Budgetary allocations are insufficient for fuel and to cover incentive payments or travel allowances to health staff. There may be staff shortages. Often there is no adequate transportation for outreach activities, such as trail bikes that can travel on rough tracks, or in some instances, boats to reach villages without road or track access.

25. Generally, border people are expected to get themselves to health centres when they need services. At district level, health staff experience frustration when they attempt to reach a rural border population and find many of the target population are absent from their villages, or else located in areas that health staff cannot reach.12 In some projects, it has been found that people living in scattered locations can be reached on market days when they come together. But in general, the planning of the limited outreach programs that do exist in border districts is not sufficiently flexible to match the annual activity cycles of minority peoples to ensure that outreach activities occur when they people are in their main village.

26. Border populations in many provinces often speak different languages from the majority of the population. Those who have attended school may speak the majority language, but adults (particularly women) do not, and are unlikely to read and write in the national language. They have different customs and beliefs to the mainstream populations of the country, which is likely to influence their perceptions of illness and health. Few health workers are from minority groups because of their generally lower levels of education. Accordingly, there are challenges in communicating information on CDC effectively, especially to women who are key targets for CDC information; therefore the Project has to have an inclusive Gender Strategy and Ethnic Minority Development Plan.

27. Complementing any interventions to address the issues as outlined above, the rationale dictates that the approach should be a systematic building up of national capacities and the strengthening of regional and sub-regional institutions for the purposes of:

(i) Regional dialogue and consultation supported by regional policy formulation, strategy development and implementation with a focus on intersectoral cooperation;

(ii) Drawing upon the experience of other GMS more developed countries and focusing on vulnerable populations most at risk, to better leverage resources and achieve significant impacts.

11 AusAID, 2003. Primary Health Care for Women and Children Project Evaluation, Viet Nam 12 Based on discussions with district health staff in Bokeo, Luang Namtha, Champasak and Attapeu districts in Lao PDR and in Tay Ninh, Quang Tri, and Nge An provinces, Viet Nam



(iii) Research and training on newly emerging diseases, NTD, and GMS cross border issues; and

(iv) Focusing on the economic corridors in the border regions, and the inclusion of the other GMS countries, China (Yunnan province) Thailand, and Myanmar.

28. Equally important for the success of the economic corridors are national programs addressing issues such as access and feeder roads, urban management, health, education and poverty reduction. National development programs will increasingly need to reflect regional dimensions as the corridors are completed, as connectivity increases hardships for women and children in terms of risk for illegal trafficking, and of vulnerability to communicable diseases such as HIV/AIDS, particularly in the border areas.13

29. Economic benefits will accrue from: reduced health care costs; gains in labor productivity and educational achievements as a result of decreased incidence and severity of illness; and reduced population growth as a result of better access to family planning. In addition, gains and investments in women’s health will have additional positive impacts on reducing the country’s population growth rate; improving the health and welfare of children and families; reducing health costs; and contributing to poverty reduction.

30. Based on the rationale and justification as articulated in the preceding sections, CDC2 scope and design is well founded to address the national and cross border CDC issues. It provides for a refocusing of CDC to the border regions within the economic corridors as well including a Training Systems Development Framework for a systematic approach to capacity building of health staff in the Project border provinces and districts, as well as community volunteers and commune or village administration to ensure a community based surveillance system are developed, implemented, and maintained. This together with approximately 70% of the project operational budget allocated for project provinces, districts and communities, to support improved health service delivery and health outcomes for a large percentages of the border populations in the cluster areas.

13 Asian Development Bank, 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (2004-2008)

APPENDIX 4:

SITUATION

ANALYSIS


Appendix 4: Situation Analysis – Final Consultant Report April 2010 i

ABBREVIATIONS

ADB Asian Development Bank

AHI Avian and Human Influenza

AFD Agence Francaise de Developpment

AOP Annual Operating Plan

APSED Asia Pacific Strategy for Emerging Diseases

ARI Acute Respiratory Infection

ASEAN Association of Southeast Asian Nations

AusAID Australian Agency for International Development

BCC Behavior Change Communication

BTC Belgian Technical Cooperation

CD Communicable Disease

CDC Communicable Diseases Control

CDC1 Regional Communicable Diseases Control Project

CDC2 Second GMS Regional Communicable Diseases Control Project

CDHS Cambodia Demographic Health Survey

CHAS Center for HIV/AIDS/STI

CHS Commune Health Station

CHW Community Health Worker

CLV Cambodia, Lao PDR and Viet Nam

CMDG Cambodian Millennium Development Goals

CNPM Communicable Diseases, Nutrition, Perinatal, and Maternal

COMBI Communication for Behavior Impact

DALY Disability Adjusted Life Years

DD Diarrheal Diseases

DF Dengue Fever

DHF Dengue Hemorrhagic Fever

DHP Department of Hygiene and Prevention

DFID United Kingdom Department for International Development

EA Executing Agency

EMDP Ethnic Minority Development Plan

EMG Ethnic Minority Group

EPI Expanded Program on Immunization


Appendix 4: Situation Analysis – Final Consultant Report April 2010 ii

GAP Gender Action Plan

GDPM General Department of Preventive Medicine

GF Global Fund for AIDS, TB and Malaria

GMS Greater Mekong Sub-region

HC Health Center

HCP Health Centers and Posts

HCFP Health Care Funds for the Poor

HCMC Ho Chi Minh City

HEF Health Equity Funds

HIV/AIDS Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome

HPG Health Partnership Group

HRD Human Resource Development

HSP1 Health Sector Plan

HSP2 Second Health (Sector) Strategic Plan

HSSP Health Systems Support Program

HU Health Unlimited

IA Implementing Agency

IEC Information, Education and Communication

IHR International Health Regulations

IMCI Integrated Management of Childhood Illnesses

IMR Infant Mortality Rate (number of deaths of children < 1/ 1000 live births)

INGO International Non-governmental Organization

IVM Integrated Vector Management

JFPR Japanese Fund for Poverty Reduction

MBDS Mekong Basin Disease Surveillance

MCH Maternal and Child Health

MDA Mass Drug Administrations

MDG Millennium Development Goal

M&E Monitoring and Evaluation

MMR Maternal Mortality Ratio (number of maternal deaths / 100,000 live births)

MOEF Ministry of Economy and Finance

MOEYS Ministry of Education, Youth and Sport

MOH Ministry of Health

MPI Ministry of Planning and Investment

NCHP National Center for Health Promotion


Appendix 4: Situation Analysis – Final Consultant Report April 2010 iii

NCLE National Center for Laboratory and Epidemiology

NCMPE National Center for Malariology, Parsitology and Entomology

NCPEMC National Center for Parasitology, entomology and Malaria Control

NCHDSC National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Diseases Control

NGO Non-governmental Organization

NIPH National Institute of Public Health

NIHE National Institute for Hygiene and Epidemiology

NIMPE National Institute for Malaria, Parasitology, and Entomology

NSDP National Strategic Development Plan

NSEDP6 6th National Socio-economic Development Plan

NTD Neglected Tropical Diseases

OD Operational District

PCT Preventive Chemotherapy

PHC Primary Health Care

PHD Provincial Health Department

PHSSP Preventive Health Systems Support Project

PI Pasteur Institute

PMO Project Management Office

PMU Project Management Unit

PPC Provincial People‘s Committee

PPMC Provincial Preventive Medicine Center

PRC People‘s Republic of China

PSC Provincial Steering Committee

PTWG Provincial Training Working Group

RBM Roll-Back Malaria

RCAPE Regional Country Assistance Program Evaluation

RCSP Regional Cooperation Strategy and Program

RCU Regional Coordination Unit

RETA Regional Technical Assistance

RH Referral Hospital

RPG Regional Public Goods

RPPTA Regional Project Preparation Technical Assistance

RRP Report and Recommendation of the President

RRT Rapid Response Team


Appendix 4: Situation Analysis – Final Consultant Report April 2010 iv

SARS Severe Acute Respiratory Syndrome

SBT Skills Based Training

SEDP Socio-Economic Development Plan

SOA Special Operating Agreement

SOP Standard Operating Procedure

STA Short Term Technical Assistance

STH Soil Transmitted Helminthe

STI Sexually Transmitted Infections

SWAp Sector-wide Approach

TA Technical Assistance

TB Tuberculosis

TOT Training of Trainer

TWG Training Working Group

UNICEF United Nations Children‘s Fund

VAAC Viet Nam Administration of HIV/AIDS Control

VAPM Viet Nam Administration of Preventive Medicine

VDG Viet Nam Development Goals

VHW Village Health Worker

VHV Village Health Volunteer

WB World Bank

WU Women‘s Union

WHO World Health Organization

WPRO Western Pacific Regional Office

YU Youth Union


Appendix 4: Situation Analysis – Final Consultant Report April 2010 v

CONTENTS

ABBREVIATIONS ...................................................................................................................... i CONTENTS .......................................................................................................................... v

1. INTRODUCTION ........................................................................................................... 1

2. REGIONAL CONTEXTS IN CDC .................................................................................. 3 2.1 Common CDC Concerns 3 2.2 CDC and GMS Regional Economic Corridors and Cross Border Roads 8 2.3 Common CDC Socioeconomic Issues 10 2.4 Progress Towards Health Millennium Development Goals 14

3. REGIONAL COOPERATION ON CDC ...................................................................... 18 3.1 Current Regional Cooperative Initiatives in CDC 18 3.2 Regional Organizations and Institutions Supporting CDC 18 3.3 Achievements and Challenges in Regional CDC Cooperation 20 3.4 Achievements and Challenges in CDC1 20

REFERENCES ....................................................................................................................... 26

ANNEX 1: Project Structure .............................................................................................. 30

ANNEX 2: Communicable Diseases Morbidity and Mortality Profile in Cambodia, Lao PDR and Viet Nam ................................................................. 31

ANNEX 3 CDC in Cambodia, Lao PDR, and Viet Nam .................................................... 34

TABLES: Table 1: Coverage of Health Services 6

Table 2: Estimated Numbers of adults living with HIV in Thailand, Cambodia and Viet Nam 11 Table 3: Reducing Poverty and Hunger in Cambodia, Lao PDR and Viet Nam 12

Table 4: Population Indicators for Cambodia, Lao PDR and Viet Nam 13

Table 5: Health Sector Achievements, Projections and 2015 MDG Targets 15

Table 6: Disease Burden in CLV 17


Appendix 4: Situation Analysis – Final Consultant Report April 2010 1

1. INTRODUCTION

1. The context of this situation analysis is to provide an understanding of the current situation on communicable diseases control (CDC) in the countries of Cambodia, Lao PDR and Viet Nam (CLV), as well as regional CDC issues, to inform the project design of the Asian Development Bank (ADB) funded Second Regional Greater Mekong Sub-region (GMS) Communicable Diseases Control Project (hereinafter referred to as CDC2). The context of the situation analysis is as follows: Section 1 briefly outlines the rationale for ADB‘s Regional Communicable Diseases Control Project (‗CDC1‘) based on the Report and Recommendation of the President (RRP) and ADB regional strategy; Section 2 covers the regional contexts for CDC, including common CDC concerns, regional economic corridors and cross border roads, and common socio economic issues and Millennium Development Goals (MDGs); Sections 3, 4 and 5 provide an overview of CDC1 programs in CLV; and Section 6 covers current regional cooperative initiatives in CDC, including regional organization and institutions supporting CDC, and achievements and challenges in regional CDC cooperation.

2. The common health sector challenges and opportunities facing countries of the GMS give rise to opportunities (and demand) for new forms of regional cooperation. The cross border nature of many diseases, the need for more efficient allocation of limited resources through economies of scale, and the necessity for joint action to establish preparedness and response to prevent and contain disease outbreaks are the underpinning rationale for ADB‘s CDC initiatives for greater regional health cooperation among the countries. Programs for the prevention and control of communicable disease outbreaks are therefore regional public goods (RPGs), and not merely national pubic goods.1

3. The focus of disease control, therefore, needs to be geographic rather than being based on formal boundaries. Differences in national health policies, such as the cost of treatment and the quality of service may push residents of border areas to seek treatment in a neighboring country. The health officials in each country must act in new and different ways. Importantly, countries can learn from one another what works in matters ranging from the health education needs of ethnic minority groups (EMGs) to health sector financing. Working together can also provide important leverage and opportunities to benefit from economies of scale.

4. Common standards and legal frameworks for actions to prevent the international spread of disease regionally and globally, such as the revised International Health Regulations (IHR), approved by the World Health Organization (WHO) in 2007, and the Asia-Pacific Strategy for Emerging Diseases (APSED) make it easier for countries to coordinate and exchange staff, information, services and goods. Under APSED in the Asia-Pacific region and the IHR globally, countries are expected to report any (potential) epidemic or other public health threat. They must establish and maintain minimum core surveillance and response capacities to successfully implement regional and global health security, epidemic alert and response strategy.

5. Technical assistance provided within the ADB-GMS Regional Cooperation and Strategy Program (RCSP) seeks to contribute to a common framework within which to address these common issues from a regional perspective. An important focus of the GMS RCSP is the systematic building up of national capacities and strengthening of regional and sub-regional institutions for the purposes of: (i) regional policy formulation and implementation; (ii) research and training on GMS issues; and (iii) regional dialogue and consultation. Harnessing the experience of more developed countries in favor of the poorer ones will be an important way to leverage resources.2 . Nevertheless, developing regional 1 Asian Development Bank, 2005. RRP GMS Regional Communicable Diseases Control Project 2 ADB, 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (2004-2008)



linkages and international capacity for CDC have proved to be much more challenging, partly because of the lack of an established regional institution or mechanism to build upon specifically for coordination of CDC in the GMS.3 6. ADB, together with other donors support this effort by providing substantial regional technical assistance and support to local and national CDC efforts that build on existing systems for preparedness, surveillance and response capacities at all levels, including for greater reach to the community level. In 2006, the ADB in partnership with the WHO‘s Western Pacific Regional Office (WPRO) and the governments of the Kingdom of Cambodia, the Lao People‘s Democratic Republic and the Socialist Republic of Viet Nam (CLV) launched the four-year, $38.78 million GMS Regional Communicable Diseases Control Project (2006-2009). About 11 percent of the project funds are pooled regionally for regional activities. 7. CDC1 aimed to: (i) strengthen national surveillance and response systems for timely and adequate control of epidemics; (ii) improve prevention and care of communicable diseases for vulnerable groups; and (iii) strengthen regional collaboration in CDC through improved polices, standards and coordination, and efficient project management.

8. The first component of CDC1 aimed to: (i) strengthen institutional structures, partnerships and policies for comprehensive national surveillance and response systems in the three countries including those related to border quarantine; and (ii) develop community-based models within the health sector and with other sectors for controlling outbreaks of diseases in 26 provinces (five in Cambodia, six in Lao PDR, 15 in Viet Nam). Comprehensive preparedness, surveillance and response systems were to be developed and strengthened, district laboratory services improved and human resources for surveillance and response strengthened.

9. The second component aimed to expand and integrate CDC for vulnerable groups in 26 priority provinces by: (i) strengthening provincial capacity for CDC; (ii) supporting comprehensive CDC for vulnerable groups, including control of neglected communicable diseases like dengue and parasitic infections; and (iii) improving the continuum of care for the control of human immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS) in high risk populations.

10. The third component focused on enhancing regional cooperation in CDC among CLV through regional coordination, policy and technical dialogue and operations research by: (i) strengthening the capacity of Ministries of Health (MOH) for regional cooperation and project management; (ii) promoting learning, operations research and information exchange on HIV/AIDS and other CDC fields through national and regional institutions; and (iii) supporting cross-border cooperation in disease prevention and control. The People‘s Republic of China (PRC), Myanmar and Thailand, which are currently not part of operational and implementation aspects of CDC1, were also invited to participate in regional forums and workshops with the hope that a second phase would include these additional GMS countries.4 A key CDC1 objective was to strengthen regional initiatives in CDC, including supporting CLV countries to fulfill their obligations under the newly revised WHO international health regulations (IHR), and to support improved coordination and collaboration for a comprehensive, sustainable system for CDC in the GMS, and eventually in the Association of Southeast Asian Nations (ASEAN)5 11. CDC1 was implemented through the three Ministries of Health in the three CLV countries: in Cambodia through the Department of CDC and the administrative structure of the Health Sector 3 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater Mekong Subregion: Maturing and Moving Forward 4 Asian Development Bank, 2005. RRP. GMS Regional Communicable Disease Control Project 5 ibid



Support Project (HSSP); in Lao PDR, through the Department of Planning and Budgeting, and in Viet Nam, through the Viet Nam Administration of Preventive Medicine (VAPM). CDC1 closure date is December 2009. The Project Structure is provided in Annex 1.

12. In August 2009, ADB engaged Cardno Acil Pty Ltd, through a Regional Project Preparation Technical Assistance (RPPTA) consultancy, to design a five-year Second GMS regional Communicable Diseases Control Project (CDC2) planned for 2010 to 2015, which aims to build on the achievements of CDC1 to contain the spread of communicable diseases locally and regionally, and to reduce the burden of endemic diseases common to the these three countries, and the additional GMS countries, if agreed.

2. REGIONAL CONTEXTS IN CDC

2.1 Common CDC Concerns

13. Communicable diseases do not stop at borders. Emerging and re-emerging diseases such as Dengue Fever (DF), Dengue Hemorrhagic Fever (DHF), Severe Acute Respiratory Syndrome (SARS), Avian and Human Influenza (AHI), H1N1 Pandemic Influenza (H1N1), and other zoonoses are increasingly becoming priority public health concerns, highlighting the importance of regional cooperation in CDC.

14. Although these newly emerging diseases have not caused major fatalities compared to malaria, tuberculosis (TB), acute respiratory infections (ARI) diarrhea diseases (DD), and other more common infectious diseases, the evident economic impact and the potential for a regional or global pandemic are making AHI, H1N1, HIV/AIDS (and previously SARS) high priorities among national and global health systems and international health institutions. This is particularly so because early recognition and referral at the community level is required to avert these emerging diseases that have high cases of fatality and potential for a rapid epidemic. In areas with targeted support, surveillance, preparedness and response have been expanded to the community level, although sustaining effective community participation is an on-going challenge.

15. Nonetheless, it is ordinary endemic diseases such as ARI, DD and parasitic infections that continue to exact a heavy toll on the population, in particular children. The poor tend to suffer most from common endemic infections that cause high levels of child mortality and malnutrition. Public funding for primary health care (PHC) and child survival programs is inadequate, and local public health systems have limited capacity to reach remote populations. Even where sufficient coverage is achieved, it does not imply good quality of care is available.

16. According to the WHO, ARI, DD, dengue and malaria are the most common causes of morbidity in Cambodia, while malaria, ARI and road accidents cause the most deaths. HIV/AIDS is not in the top five, but may be masked by ARI, TB or even road accidents. In Lao PDR, malaria, pneumonia, and gastrointestinal problems cause the most morbidity and mortality. In Viet Nam, which has better overall health indicators, pneumonia, acute pharangitis, and ARI are the common causes of morbidity and mortality, while intracranial injury, road transport accidents, and pneumonia are common causes of mortality. While increasingly prevalent diseases like HIV/AIDS still require strategic priority, there is potential that these new diseases will absorb limited resources at the expense of addressing the neglected tropical diseases (NTDS).6 Perhaps because they are relatively easy to prevent and treat with low-cost interventions, the common infections receive less priority than diseases such as

6 www.wpro.who.int Country Health Profiles, Cambodia Heath Information System (2007-2008)

http://www.wpro.who.int/



HIV/AIDS, AHI and H1N1. There is a potential danger that new diseases will absorb a considerable level of commitment, staff time, and funding at the cost of addressing common illnesses and NTDs.7 17. DF and DHF are the most important vector-borne diseases in the GMS, in terms of morbidity and mortality, especially for children less than 15 years of age. In Viet Nam, in the past five years there have been approximately 50,000 to 90,000 new cases per year and relatively high mortality (0.1 percent). A similarly severe situation has emerged in Cambodia and Lao PDR. Although the disease is traditionally urban, it has progressively spread to rural villages where breeding of the vector mosquito Aedes agypti has become substantial.8 18. There is currently no vaccine available to prevent dengue infection, with vector control the only preventive measure for lowering transmission risk. There is a general lack of resources and tools to effectively control the vector, and the severity of outbreaks is increasing. The major contributing factors to these outbreaks are: (i) increased mobility of people; (ii) the co-circulation of four dengue sero-types; (iii) insufficient piped water supplies; (iv) poor basic environmental sanitation; and (v) inadequate community participation in vector reduction activities.9 19. WHO‘s Global Dengue Control Strategy emphasizes five main strategies for dengue control, which are: (i) dengue diagnoses and case management; (ii) comprehensive disease and vector surveillance; (iii) selective vector control; (iv) social mobilization and communication toward behavioral change; and (v) operational research. Vector control is the primary focus for dengue transmission control and it should be applied using key principles of integrated vector management (IVM). These include: (i) advocacy; (ii) social mobilization and legislation; (iii) healthy public policies to promote basic sanitation and hygiene and a safe environment for the household and the community; (iv) collaboration within the health sector and other sectors; (v) an integrated approach; and (vi) evidence-based decision-making and capacity building. 20. Although there is no specific treatment for dengue, experience has shown that mortality can be considerably reduced by standard case management, which depends on access to care, especially during an epidemic. Early recognition and prompt control of dengue outbreaks or epidemics is important for control of dengue. This requires effective surveillance, including early warning, good data management, regular information exchange and epidemic preparedness plans that can be operationalized. For control to be effective, programs should organize their work with a focus on inter-epidemic periods as well as on epidemics. Appropriate linkages are needed with integrated disease surveillance programs at national and sub-national levels.10 21. Schistosomiasis, mainly soil-transmitted Helmithiasis, Lymphatic Filariasis, food-borne Trematodiasis and Cestodiasis are among the important Neglected Tropical Diseases (NTDs) affecting primarily the poor and marginalized populations in the GMS. The effective treatment of these infections is known to increase work capacity and productivity and is important to maintain good nutritional status, especially in women of child bearing age, resulting in higher birth weights and lower infant morality rates. 22. Regular treatment of children can prevent malnutrition caused by worms, and thereby reduce under-five morbidity and mortality rates. Many of these diseases can be controlled using low cost technologies that are safe, rapidly effective and easy to administer in resource poor settings. When applied on a large scale, control strategies can interrupt transmission, helping to reduce the risk of 7 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 8 Asian Development Bank, 2008. CDC1 Regional Dengue Technical Forum Report, Viet Nam 9 ibid 10ibid



onward infection for a limited time. Population-wide interventions (such as vector control and mass drug administration) do not discriminate between poor and non-poor, reducing the risk that excluded groups area further marginalized. 23. In collaboration with ADB and other partners, the GMS countries have made significant progress in the control of many of these diseases, particularly in the administration of Preventive Chemotherapy (PCT) in the form of Mass Drug Administrations (MDA). However, there is still a need for improving coverage, and effectively monitoring the coverage and impact of interventions. It is also important to synchronize elimination efforts in the GMS countries and monitor cross border transmission of infection.11 24. A draft strategic plan for control and elimination of NTD in the region was developed by WHO, together with ADB and other partners in March 2009. The draft plan identifies gaps in program implementation, needs for resource mobilization and rationale for partner collaboration to support the endemic countries. A CDC regional technical forum, held in October 2009 in Vientiane, Lao PDR, provided an opportunity for helminth program managers to present their data, share experiences on the control programmes, and come up with plans for regional collaboration to address current priorities, and identify strategies for increasing coverage, data and resource gaps affecting effective monitoring and implementation of the programs.12 25. Access to and by qualified health workers is a key issue for many border populations. Both public and private sector healthcare provision decreases as population density falls. Surveys show that the poor, in particular women and children and EMGs typically receive the lowest coverage of prevention and care services due to their remoteness, language barriers and the low number of trained outreach health staff.13 26. Despite the considerable advances in road construction across the GMS borders, many border communities and other remote areas in these countries are still beyond the reach of conventional health facilities and rely on networks of community health workers, volunteers, and village drug stores for primary care. Community-based activities are typically more challenging, but represent the only long term solution to controlling common endemic diseases, such as dengue. Reaching these populations require innovative strategies which build on lessons learned in the region, such as multipurpose outreach workers and community-based programs that can be adapted and tested locally.14

27. Surveys confirm that the poor and EMGs receive the lowest coverage because of remoteness, language barriers and the low number of health staff from EMGs. As Table 1 indicates coverage indicators for access to routine preventive and curative health services in CLV are still low or sub-optimal:

11 Asian Development Bank, 2009. Background Information, First GMS-CDC Technical Forum on Control and Elimination of Parasitic Diseases in the Mekong Sub-region. Forum 12 ibid 13 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 14 Asian Development Bank, 2007. Proposed Asian Development Fund Grant: Lao People’s Democratic Republic: Health

System Development Project



Table 1: Coverage of Health Services

Indicator Cambodia % Year % Year

Lao PDR % Year % Y ear

Viet Nam % Year % Y ear

Measles vaccination coverage in children 12-23 months of age

65 2003 91 2008 42 2003 60 2009 87 2006 83 2007

2nd Tetanus Vaccination for pregnant women 43 2003 50 2007 36 2003 20 2009 77 2006 94.5 2009

Use of modern contraceptives among married couples

19 2003 40 2009 29 2003 32 2009 60 2006 79 2009

Access to safe water 30 2000 47 2008 50 2002 60 2009 56 2002 92 2009

Access to sanitation 21 2000 34 2008 51 2003 48 2009 73 2000 65 2009

Access to essential drugs 50 2003 -- -- 80 2004 98 2009 85 2004 -- --

Birth attended by skilled personnel (%) 32 2000 58 2008 42 2001 65 2009 85 2002 88 2009

Sources: ADB country reports; ADB Key Indicators, 2009 www.unicefusa.org; Cambodia HIS Report (2007/2008); Cambodia Census 2008; Statistical Yearbook Asia/ Pacific 2007; WHO Health Statistics 2009, Lao EPI Report 2009. 28. Achievement o f sufficient c overage do es not n ecessarily imply that go od q uality care is available. Human resources are the key to good health services. Health facilities, drugs, supplies and equipment are also important, but they can achieve nothing without effective health workers to staff the facilities a nd d eliver s ervices t o t hose w ho need them. H uman r esource, financial a nd s upply constraints, and the general lack of consumer understanding of what constitutes good health care are continuing c hallenges, particularly i n t he r emote areas. The r ise of the private sector, w hile greatly helping to improve coverage, further raises the risk of reduced quality of care, over-prescription with possible medical consequences, and financial burden. Reliable data on the quality of heath service, public or private, is also difficult to track.

29. Common Challenges in National Health Systems - There are many common issues in the CLV health systems that affect CDC, including human resource constraints, the management of health services, a nd t he affordability and financing of health s ervices. C DC m ust al so c ope w ith s pecific challenges i ncluding: ( i) i ntegration o f disease control pr ograms i n PHC; ( ii) s taff c onstraints for preventive care; ( iii) s tandard setting and regulation; and ( iv) regional surveillance and response. A challenge is t o decentralize CDC to the provinces and to reduce the overlap o f t raining, laboratory services and supervision. Of c ritical importance in CLV is the development o f competent provincial planning, budgeting, m anagement and m onitoring c apacity, w ith the pr ovinces having r esponsibility and authority for health sector performance.15 30. The foundational concepts of PHC and the district health system toward achieving health for all remain highly relevant in all three CLV countries, and form the central approach to their national health policies today. However, support for PHC for a variety of reasons, has been increasingly replaced by a

15 Asian Development Bank, 2005. RRP. GMS Regional Communicable Diseases Control Project

http://www.unicefusa.org/



more selective approach focusing on diseases and sub-sectors, and increasingly organized through vertical programs for swifter impact.

31. Vertical programs are established for malaria, tuberculosis, HIV/AIDS, and the expanded program on immunization (EPI). There were also prominent programs for child survival focusing on ARI and DD control, followed by the introduction of tools for the Integrated Management of Childhood Illnesses (IMCI), and recently, a new regional strategy for child survival. Interestingly, the vertical programs are likely to be integrated more so at provincial and district levels, which has emerged in part from the managers themselves, who realize that it is very difficult to improve coverage without pooling resources at the local level and allowing for decentralized management. However, vertical systems continue to pose challenges to integrating CDC into national health systems that are fragmented by these separate, top-down structures.16

32. CDC tends to be fragmented and donor-driven, causing projects to be implemented in isolation, resulting in further fragmentation, repetition, and lack of sustainability of interventions. Surveillance is particularly complicated by the use of several separate systems for prioritized diseases that receive financial and technical support from international organizations. Many people, especially in remote regions, use private healthcare providers, and therefore a significant amount of CDC information is not recorded in the existing surveillance systems.17 Furthermore, health services often lack minimum standards against which performance can be measured. Health sector planning, financing, and aid coordination remain major challenges with limited accountability and authority at the local level.18 33. Despite the multi-sector nature of CDC, with links to a number of other sectors including education, animal health, water and sanitation, public works, rural and community development, CDC tends to be viewed as a health sector issue focused narrowly on the MOH programs.

34. Human Resources Development - GMS countries also face different challenges in human resource development (HRD). Because of these, as well as diverse languages and cultures, the normal tendency is to favor national education, training and health programs. Regional initiatives in health for example, do not fit easily and seamlessly across borders due to the vertical structures that separate disease programs in national health systems.

35. There are a number of areas where sub-regional cooperation in HRD is logical and urgently needed to address: (i) health and social problems associated with mobile populations, including CDC; (ii) the rights of migrant and guest workers; and (iii) the trafficking of women and children. For example, the AHI crisis and more recently, the H1N1 pandemic highlight how national and regional approaches complement each other: in CLV, public health loans have financed the purchase and installation of badly needed equipment for culling and quarantine. These activities are essential at the national level but will only be effective to the extent that regional or international monitoring and surveillance mechanisms are also put in place.19 36. Experience in CDC1 indicates that training efforts are often shallow, and have limited means to assess skills development. Training needs to be more practical and less theoretical, more hands-on and experiential, using adult learning methodologies and materials. Training processes also need to

16 ibid 17 ibid 18 ibid 19 ibid



be closely monitored at implementation and supervisory levels to ensure quality, and at central and senior levels to ensure sustainability and continuing relevance.

37. Frequent and careful monitoring of project implementation is essential to ensure that the newly established operational processes and procedures are clearly understood and activities carried out correctly and completely by the responsible parties at all levels. The combination of technical training and systematic approaches that emphasize follow-up supervision, workplace assessment, and on-the-job training, have demonstrated greatly increased retention of the training content. Experience also suggests that community mobilization, IEC, and health education, if systematically implemented through local structures, such as Provincial People‘s Committees (PPCs), CHWs and village volunteers can improve health seeking behavior and overall population health.20 38. While health workers are widely distributed throughout every level of the health care system, mal-distributions and chronic shortages exist, and the staff that are available are often inadequately trained to provide the quality of health care needed. The governments of CLV have all set goals to train increased numbers of health personnel, and to improve the quality of their training, training curricula and training materials, and to strengthen the capacity of trainers, in order to bridge the gap between the quantity of students and the quality of their education.

39. Health Management - Given the growing complexity of health system technology and finance, further improvements in health status will be more challenging, requiring increased management sophistication in planning and executing targeted programs designed to reach entrenched populations of the poor and underserved. With the move toward decentralization, provincial health authorities are assuming increasing responsibility. Managerial roles are changing and uncertain, and managers often lack the financial resources, information, training and experience to carry out their new responsibilities effectively. Managers at the central level are reluctant to give up their authority, or unsure how to do so without abdicating their own obligations. The willingness of provincial health departments to exercise their authority reflects their continuing dependence on national subsidies. The need to make informed decisions at provincial levels will increase the need for more sophisticated data processing and analysis. 40. Provincial authorities have limited capacity in health system development and improving services to reach the poor. Experience suggests that provincial plans often fall short of targeted interventions to reach underserved rural communities. A number of initiatives may be considered including: introducing the technology, hardware and training needed for modern management information systems, training in institutional and health systems planning, finance, and decision-making; and the introduction of performance monitoring methodologies.

2.2 CDC and GMS Regional Economic Corridors and Cross Border Roads

41. The countries of the GMS have been pursuing a program of regional cooperation since 1992 to jointly promote their economic and social development. A key investment component of this program is the GMS north-south, east-west and southern economic corridors. The development of this system of improved cross-border roads and associated infrastructure is supported by ADB and other donors and the six countries linked by the corridors: Cambodia, Lao PDR, Myanmar, Thailand, Viet Nam, and PRC‘s Yunnan Province and Guangxi Zhuang Autonomous Region.

42. Regional economic integration is supported by agreements between the member states that facilitate trade, investment, employment and other economic activities and opportunities across

20 AusAID, 2003. Primary Health Care for Women and Children Project Evaluation, Viet Nam



borders. This has produced agreements to cooperate in exchange of CDC information and permitted ―common use‖ of border health facilities, which for the GMS, is being encouraged under CDC1.

43. ADB‘s Regional Cooperation and Strategy Program (RCSP) for 2004-2008 supported pro-poor, sustainable growth in the GMS including initiatives to: (i) identify issues related to cross-border migration, and related health and other social issues, and to undertake studies to address these issues; and (ii) to implement cooperative arrangements for addressing health and other social issues related to cross-border migration, particularly for HIV/AIDS prevention and control, and improvement of health and other social services delivery to EMGs in the border areas; and (iii) prevention and control of malaria for border areas.21 44. In contrast, ADB‘s Strategy 2020 does not prioritize the health sector, and assistance is to be realigned mainly through infrastructure projects such as water and sanitation and on governance work that focuses on public expenditure management for cost-effective delivery of health services to all populations. On all other health related issues, ADB will be selective and focused, emphasizing partnerships with other specialized organizations in its operations.22

45. There are many studies of ethnic minority issues in areas adjacent to border crossings that document negative as well as positive impacts of the economic corridors and GMS integration. These have been highlighted in a campaign by Oxfam Australia.23 Documentation of negative impacts refers to the intensification of pre-existing patterns of cross-border crime (drug trafficking, illegal labor migration, human trafficking) and increased potential for the spread of infectious diseases (HIV and viral influenzas), as well as a rapid increase in activities encouraging environmental degradation, and poverty impacts such as rural to urban migration, pressure on the informal economy, rising land prices and labor exploitation of the poor and of ethnic minorities. All these impacts have major implications for health and CDC.

46. At present, no complete inventory exists of national institutional arrangements for CDC surveillance and response on the seven international crossing on economic corridors through CLV or the 40 or more other GMS road and river border crossings. The CDC1 Regional Coordination Unit (RCU) has endeavored to collect information on cross-border quarantine activities but the results are not comprehensive nor include information from PRC, Thailand and Myanmar. 47. Furthermore, there is very limited data on the social and associated epidemiological impacts of the border regions of CLV adjacent to the more than 19 border crossings associated with economic corridor, of which at least seven are between CLV.24 ADB published a brief socioeconomic impact profile of the GMS corridors in 2008.25 Such health research and associated programs focused on border crossing areas that have been done address the spread of HIV, mainly focusing on Lao PDR. The most detailed study to date was in 2004, and examined the social and health impacts of Highway 17 and its border crossings from PRC and Thailand in north-eastern Luangnamtha Province in Lao

21 Asian Development Bank. 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (RCSP) 2004-2008 22 Asian Development Bank. 2008. Strategy 2020: The Long-term Strategic Framework for the Asian Development Bank (2008-2020) 23 . Cornford, Jonathan & Nathanial Matthew, 2007. Hidden Costs: The underside of economic transformation in the Greater Mekong Subregion. Oxfam Australia, Melbourne. See also: Oxfam Australia, 2008. A Citizen’s Guide to the Greater Mekong Subregion: Understanding the GMS Program and the Role of the Asian Development Bank. Melbourne Australia 24 Detailed analysis of border crossings in the GMS is being completed. 25 Asian Development Bank, 2008. Corridor Chronicles: Profiles of Cross Border Activities in the Greater Mekong Subregion. Manila, Philippines.



PDR. This road is linked but not integral to the north-south corridor.26 No comparable research for regional CDC policy and program development purposes has been done for provinces and districts linked by border crossings in CLV. 48. CDC1 was intended to facilitate cross-border cooperation in CLV on building compatible responses to potential cross-border disease outbreaks. However the CLV provinces or districts selected for participation in CDC1 (with a few notable exceptions) were rarely internationally contiguous, and the priority districts in the provinces were not on border areas, and/or lack a focus on border issues, thus undermining the potential for specific joint CDC surveillance and response activities in CLV. These issues and concerns will be addressed in the recommendations for CDC2.

2.3 Common CDC Socioeconomic Issues

49. Gender considerations - Data on gender and communicable disease is collected in CLV at the commune health centre level, but gender disaggregation and gender analysis is rarely if ever applied when data is collated by the provincial and national levels of government. Epidemiological data is not gender disaggregated in CLV except where special donor studies have been carried out, and is needed to improve the focus of prevention and control measures. 50. Recent research on gender and CDC in the CLV region shows than gender is a significant variable in understanding the spread and planning response to communicable diseases.27 Gender differences in disease rates can be interpreted in both the context of biological differences between men and women (sex differences) and the differences between the division of household and economic tasks between men and women and power relations between men and women (gender differences).28 Despite these important variables, MOH staff, including the clinical staff of health institutes, have difficulty in understanding why gender is a relevant consideration in CDC. Consultations suggest that it is generally assumed that because infectious diseases can affect any human being, gender and age are irrelevant. It is generally well understood that men are more at risk of illness due to accidents and industrial occupations because of behaviors and employment trends associated with men. However the evidence of communicable disease risk to women is not as well understood.

51. Women and children are more vulnerable to dengue, because they spend more time in the household compound area where Aedes Aegypi mosquitoes are most likely to breed in proximity to human beings; women may also be more biologically vulnerable to the acute hemorrhagic form of the disease than men. Small-scale poultry farming is most frequently done by women increasing the risk of women and children to avian influenza. Throughout the GMS women may more vulnerable than men to other forms of helminthiasis in the context of their roles in preparing food and caring for small children. While the MOHs of CLV recognize the need to include women of reproductive age in mass drug administration campaigns for soil-born helminthiasis, to combat anemia caused by hookworm,

26 Lyttleton, Chris et. al. 2004. Watermelons, bars and trucks: dangerous intersections in Northwest Lao PDR: An ethnographic study of social change and health vulnerability along the road through Muang Sing and Muang Long. Lao Institute for Cultural Research and Macquarie University, Australia. 27 ASEAN + 3 disseminated the findings of the studies at a regional workshop on gender and social issues related to emerging infection diseases on 13-14 October 2009 under the auspices of the Lao PDR Ministry of Health. Publication is forthcoming. 28 Differences between males and females arise because of biological differences and as a consequence of gender-based roles, behaviour and power. The distinction between these two concepts is important, it is not always easy to attribute differences in disease processes uniquely to either sex or gender, since sex and gender are not independent of one another. WHO. 2007. Addressing sex and gender in epidemic-prone infectious diseases. Geneva.



the resources allocated are often insufficient to extend the program to women, and efforts are concentrated on primary school children, and in Viet Nam, pre-school children. 29 52. Gender is now well understood as an issue in relation to HIV and other sexually transmitted diseases. Table 2 shows that while Thailand, which has had the highest rate of HIV infection, has made some progress in reducing infection, rates have increased in bordering Cambodia and Lao PDR, as well as in Viet Nam. Border corridor areas are well documented HIV hot spots. In all four countries the proportion of women who are HIV positive has increased.

Table 2: Estimated Numbers of Adults Living with HIV in Thailand, Cambodia and

Viet Nam

Indicator

(Aged 15 years and over, thousands)

Thailand Cambodia Lao PDR Viet Nam

Year of estimate 2001 2007 2001 2007 2001 2007 2001 2007

Estimated number of adults per thousand living with HIV

650.0 600.0 93.0 270.0 0.5 1.3 37.0 76.0

Estimated number of adult women living with HIV

240.0 250.0 10.0 54.0 1.1 5.4 0.5 1.3

Source: Asian Development Bank, 2009, Key Indicators for Asia and the Pacific

53. The trend is typical of a pattern throughout Asia, according to the Report of the United Nations Commission on AIDS in Asia (2008). Although three out of four adults living with HIV in Asia are men, the proportion of women has risen gradually throughout the region —from 19 percent in the region overall in 2000 to 24 percent in 2007. Most of these women were infected by husbands or boyfriends who were themselves infected during paid sex or through injecting drugs. As a conservative estimate, the number of women at risk being infected by an infected husband or regular (non-commercial) intimate partner could number more than 50 million in Asia, thus ‗generalising‘ the epidemic. At present HIV programs in the CLV region tend to focus on ‗at-risk groups‘ such as female entertainment service workers, men who have sex with men, and transient male workers in the transport and construction industry. The gradual ‗feminization‘ of HIV suggests that this approach must be widened so that all sexually active men and women understand the risk of HIV and other sexually transmitted infections (STIs) and how to prevent infection. 54. The relevance of gender analysis to CDC1 was not well understood by the Project Management Units (PMUs) and so were not communicated to the participating provincial health departments and national CDC institutes. The gender action plans (GAPS) for CDC1 have not been applied or mainstreamed into project activities. In addition the PMUs were unable to engage suitably qualified national consultants to advise on developing and implementing the GAPs. Gender disaggregation of training beneficiaries was done and women were well represented in district level training activities, as might be expected because most district level health workers are women.

29 Country Data from CLV presented at the first GMS-CDC Technical Forum on Control and Elimination of Parasitic Diseases in the Mekong Subregion. Lao PDR, 21-22 October, 2009



55. Poverty is the most significant overall factor in the persistence of NTDs in CLV and are associated with inadequate environmental sanitation, overcrowded housing, lack of access to safe drinking water, food insecurity and malnutrition, and low levels of education, especially among adult women. Table 3 illustrates the progress on the Millennium Development Goals (MDGs) for CLV. It indicates that there is still widespread poverty, with significant proportions of the populations of Cambodia and Lao PDR suffering from hunger, although these countries have made progress in poverty and hunger reduction since 2000. Viet Nam has comparatively less poverty and has achieved its MDG of halving the proportion of the population suffering from hunger.

Table 3: MDG Progress Indicators - Poverty and Hunger Reduction

Indicators Cambodia Lao PDR Viet Nam

2000-2009 Latest Year

Earliest Year

Latest Year

Earliest Year

Latest Year

Earliest Year

Goal One: Eradicate Extreme Poverty and Hunger

Percentage of the population below the poverty line

40.2 48.6 44.0 55.7 21.5 63.7

Percentage of the population suffering from hunger

26.0 38.0 19.0 27.0 14.0 28.0


56. Ethnic Minority Groups in the CLV region are concentrated in border provinces and in the highlands of each country and in parts of the lower Mekong Delta. EMGs in all three countries have higher levels of poverty and lower literacy rates than the majority population for similar reasons associated with isolation and past discrimination. Table 4 shows the proportion of the population made up of EMG in each country. Although EMGs comprise small minority of the population of Cambodia and Viet Nam they comprise significant proportion of the population in the districts of provinces close to the borders between Yunnan Province PRC, Cambodia, Lao PDR, Viet Nam and Thailand.



Table 4: Ethnic Minorities and Population Indicators for Cambodia, Lao PDR and

Viet Nam

Indicators Cambodia Lao PDR Viet Nam

1995-2007/8 Latest Year

Earliest Year

Latest Year

Earliest Year

Latest Year

Earliest Year

Population (million) 14.0 10.5 6.0 4.6 86.2 72.0

Ethnic Minority Groups % of population* - 4% 44.0 - - 14.0

Life expectancy at birth both sexes 59.5 56.1 64.4 58.1 74.2 65.9

Life expectancy at birth female 65.8 57.9 61.9 59.3 76.2 71.3

Life expectancy at birth male 57.3 54.3 63.0 56.9 72.3 67.8

Population growth rates (%) 1.3 5.2 2.2 0.3 1.2 1.7

Urban population (%) 17.9 14.8 29.7 17.4 28.1 20.7

Population 0-14 years (%) 35.0 46.3 38.1 44.6 28.2 37.0

Total fertility rate 3.2 4.9 3.2 5.2 2.1 2.8

Human development index rank 136 133 114

Sources: Asian Development Bank, 2009, Key Indicators for Asia and the Pacific. * ADB, 2002. Reports on Indigenous

Peoples / Ethnic Minorities and Poverty Reduction for Cambodia, Lao PDR, Viet Nam. 57. There is no data comparing CDC incidence and prevalence of EMGs with majority populations in CLV but the disparities are highlighted in data showing that provinces with high infant and child mortality rates also have high concentrations of EMGs, and that EMGs have lower education and literacy rates as well as poverty rates in the three countries. 30 58. EMG women are particularly disadvantaged. Maternal mortality, for example, varies widely by urban/rural, region and ethnicity. One MOH study conducted in Viet Nam (2000-2001) found maternal mortality rates of 79 per 100,000 live births in urban areas, compared to 145 in rural areas; 81 in the delta region compared to 269 in the mountainous and midland areas; and 81 among Kinh compared to 316 among EMGs. There is also evidence that pregnancies and maternal deaths are under-reported among ethnic women. 31 59. More economic research has been done on ethnicity and poverty in Viet Nam that in other countries of the sub-region. While Viet Nam has made remarkable progress in reducing poverty and improving the health status of its citizens, those who live in rural areas, particularly EMGs lag behind. Studies show that EMGs are much poorer than the ethnic majorities; the poverty headcount ratio was 64.3 percent in 2002, almost three times larger than that of ethnic majorities (22.3 percent). Poverty

30 ADB, 2001. Health and Education Needs of Ethnic Minorities in the Greater Mekong Subregion. Manila, Philippines 31 Ministry of Health, 2007. Vietnam Health Report 2006, Medical Publishing House (Draft)



among ethnic minorities has actually risen proportionately in Viet Nam from 20 percent in 1993 to 30 percent in 2002 because poverty has declined among ethnic majority groups whereas the economic condition of EMGs has stagnated.32 60. There is evidence that voluntary (or government-enforced) resettlement of highland EMGs to lowlands, lower altitudes and near access road and corridor areas renders them vulnerable to malaria, to which they have less acquired resistance: water-borne diseases; and HIV and other STIs.33 A study of road development impacts in northern Lao PDR showed that EMG populations living near regional economic corridors bear a disproportion burden of the health costs of the rapid social and economic changes created by these developments.34 Many similar historical, cultural, environmental and policy factors in CLV have contributed to the disparities between EMGs and majority ethnic groups.

61. The design of CDC1 included an Ethnic Minority Development Plan (EMDP), and requirements that it be further developed for the national situation and project locations in each country. This was not done because the relevance of the requirement to CDC was not understood by the PMUs and because they were unable to find suitably qualified national consultants to advise on developing and implementing the EMDPs. This suggests the need for a more focused approach on the inclusion of EMGs in CDC2.

2.4 Progress Towards Health Millennium Development Goals

62. Achievement of the health-related MDGs in CLV requires providing PHC to remote populations that are suffering from high burden of infectious and reproductive diseases, and improving the affordability and quality of health care, including mobilization of communities to contain emerging diseases. All three countries have made remarkable progress in improving the health of their populations over the last decades, and are making major efforts to put into place strong policy frameworks and PHC systems progress.35 63. Communicable disease prevention and control (Goal 6) is one of the four health-related MDGs, which aim to reduce child and maternal mortality and malnutrition, and contain the spread of HIV/AIDS and other communicable diseases, such as malaria, DD and NTDs. Illness and disability caused by NTDs have a tremendous social and economic impact. Efforts to reduce the burden of communicable diseases contribute indirectly to reduce poverty and hunger. Table 5 shows CLV progress towards meeting these health-MDGs.

32 E.g.: Imai, Katsushi and Raghav Gaiha, 2007. Poverty, Inequality and Ethnic Minorities in Vietnam. Brooks World Poverty Institute WPI Working Paper 10, University of Manchester. Asian Development Bank (2002) Indigenous Peoples / Ethnic Minorities and Poverty Reduction - Viet Nam. Manila, Philippines: ADB..van de Walle, D. and Gunewardena, D. (2001) Sources of ethnic inequality in Viet Nam, Journal of Development Economics, 65, 177-207 A detailed analysis is also provided in the forthcoming Word Bank background paper for the 2008-09 Vietnam Poverty Update. 33 See for example a literature review by Ian G. Baird and Bruce Shoemaker, 2007. ‗Unsettling Experiences: Internal Resettlement and International Aid Agencies in Laos‘. In Development and Change 38(5): 865–888. 34 Cornford, Jonathon and Nathaniel Matthews, 2008. Hidden Costs: The Underside of economic transformation in the Greater Mekong Subregion. Oxfam, Australia. Lyttleton, C. et. al., 2004 Watermelons, bars and trucks: Dangerous Intersection in Northwest Lao PDR. Institute for Cultural Research of Lao and Macquarie University, Asian Development Bank, 2009. Broken Lives: Trafficking in Human Beings in the Lao PDR. Manila 35 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project



Table 5: Health Sector Achievements, Projections and 2015 MDG Targets

Achievements Projected 2010-2015

MDGs 2015

Health Indicator 2001 2005 2008-2009 CAM LAO VN CAM LAO VNa CAM LAO VN

CAM LAO VN CAM LAO VN

Maternal mortality ratio 437 530 95 472 405 85 461d 400 83 140 250 60b 140 185 62

Under-5 mortality rate 124 107 42 83 98 31.5 44d 70 15 65 55 25b 65 55 18

Under-5 malnutrition rate (wt. for age)

45 40 31.9 36 39 26.6 28.4 36.4 20 36 20 20 22 20 22

HIV prevalence rate among pregnant women (%)

3.0c 0.06 0.22c 1.1 0.2 0.37 0.8e 0.3 0.25 0.6 0.76b 0.5b 1.8 <0.1 <1.0


64. Despite considerable progress towards meeting their health-related MDG goals, it is still a steep challenge to meet all the targets in Cambodia and Lao PDR, where for example, the bulk of the sick population gets by without taking up curative services despite improved access to health services.36

65. Viet Nam, however, has reached most of its MDGs, and the Government has set out a number of its own additional Viet Nam Development Goals (VDG). The maternal mortality ratio (MMR) has declined significantly, from 130 (per 100,000 live births) in 1992, to 95 in 2000, to an estimated 80 in 2005.37 Importantly, in 2005, 96.1 percent of deliveries were attended by a trained health worker. To continue its many advancements, and to extend their benefits more broadly, the Government of Viet Nam has set out an ambitious plan to address an array of continuing problems in the health sector, including deteriorating and poorly equipped infrastructure; shortages of skilled health workers; constraints on access to health services, especially for the poor; and limited capacity to govern and manage an increasingly complex health system.38 66. Since 2000, Cambodia has made significant progress in health. It has succeeded in reducing infant and under-five mortality from 95 to 66 and from 124 to 83 deaths per 1,000 live births, respectively.39 This progress has been attributed to the strong performance of the national immunization programme, successful exclusive breastfeeding promotion, the reduction of poverty

36 World Bank, 2006. Lao PDR Poverty Assessment Report From Valleys to Hilltops – 15 years of Poverty Reduction 37 Ministry of Health, 2007. Vietnam Health Report 2006, Medical Publishing House (draft) 38 Asian Development Bank, 2006. Country Strategy and Program: Viet Nam 2007-2010 38 Government of Viet Nam, 2006. Comprehensive Development Design for the Health System in Viet Nam to 2010 and Vision by 2020. 39 Cambodia Demographic and Health Survey 2005



levels, improved access to education, and better roads. The proportion of children aged 12 to 23 months fully immunized against six preventable diseases increased from 40 per cent in 2000 to 66 percent in 2005. Feeding practices have improved with an increase in babies being breastfed early and exclusively, from 11 percent to 35 percent and from 11 percent to 60 percent, respectively. Cambodia has also succeeded in arresting and reversing the growth of the HIV/AIDS epidemic, and has a declining prevalence currently at 0.8 percent.40

67. In 2003 Cambodia prepared its own set of nine Cambodian MDGs, which include an additional goal relating to mine injury risk and victim assistance. A 2006 CMDG progress report noted significant improvements in the situation of women and children, with the exception of the maternal mortality rate which remains high. Achievements also included progress in combating communicable diseases such as HIV/AIDS, malaria and TB.41 Malaria severe case fatality rate decreased to 7.9 percent (compared with a target of 10.2 percent), however malaria incidence increased to 7.9 percent. Dengue case fatality rate reached its target at less than 0.9 percent in 2005, and reporting time lag has decreased almost 50 percent.42 De-worming activities showed a remarkable increase in which 57 percent of children aged 12 to 59 months received treatment, against the target of 40 percent43.

68. One of the major challenges for Cambodia is the lack of human resources, particularly for achieving the health-related MDGs. Meeting these goals will require increased staffing and better distribution of health posts. Another specific constraint is motivating healthcare staff to provide 24-hour services and to work in underserved remote locations.

69. In Lao PDR, the child mortality rate was reduced from 170 to 98 per 1,000 live births from 1995 to 2005, but is unlikely to reach the MDG of 55 per 1,000 (a two thirds reduction) by 2015. The maternal mortality rate reduced from 656 to 405 per 100,000 live births from 1995 to 2005, and may reach 250 instead of the goal of 185 per 100,000 (a three fourths reduction) by 2015. Surrounded by countries with higher HIV prevalence, the spread of HIV/AIDS in Lao PDR is unlikely to halt at current levels (about 1 percent of service women and 0.1 percent of adults 15 to 45 years).44 70. The death rate associated with malaria fell due to an improvement of malaria risk areas through the provision of impregnated bed-nets, rapid tests at the village health volunteer (VHV) level, indicating correct diagnosis and early treatment. The number of tuberculosis cases detected and treated on direct observation increased45 Despite remarkable progress on lowering infant and maternal mortality rates, immunization coverage remains unsatisfactory, for example, infant immunization against measles declined from 61.5 percent in 199 to 46 percent in 2000.46 In order to improve these trends, and achieve MDGs, higher investments are needed. 71. Efforts to achieve MDGs that prioritize intensified control of NTDs will contribute directly to the reduction of the communicable disease burden (MDG 6) and indirectly to reduce poverty and hunger (MDG 1). Illness and disability caused by NTD such as schistosomiasis and intestinal parasites have a tremendous social and economic impact. Reducing DD (e.g. cholera and food borne diseases) will reduce malnutrition and mortality associated with all other diseases. People living in remote areas or urban slums with little or no access to clean water are most at risk. Many of these diseases can be controlled using low-cost technologies that are safe and rapidly effective and can be administered in

40 World Bank, 2006, Cambodia Halving Poverty by 2015? Poverty Assessment 41 UNICEF, 2008, Report of Mid-Term Review of the Country Program 42 World Health Organization, Cambodia.2007. GMS CDC 6th Regional Project Review Workshop, Vientiane. 43 Ministry of Health, Cambodia, 2007. Joint Performance Review (JPR) 44 Asian Development Bank, June 2007. Proposed ADB Fund Grant Lao PDR: Health System Development Project 45 World Bank, 2006. Lao PDR Poverty Assessment Report From Valleys to Hilltops – 15 years of Poverty Reduction 46 Ibid



resource low settings. Achieving these MDGs in the GMS will, to a large extent, depend on progress in CDC.47

72. DALYs is a summary measure of a population‘s disease burden which combines the number of healthy years of life lost due to premature morbidity and to disability.48 Table 6 presents the level of disease burden in each of the CLV countries, measured by the total disability adjusted life years (DALYs) lost per capita for all causes. The table also indicates the proportion of DALYs lost due to the health-related MDG indicators, which include factors related to communicable diseases (CD), nutrition, perinatal, and maternal conditions (CNPM). 73. Notably, more than half of the total DALYs in Cambodia and Lao PDR, and nearly one third the DALYs in Viet Nam, are attributed to CNPM health issues, which include CDs. This considerable proportion of disease burden attributed to CNPM indicates the need for increased investments in CDC, as well as on the related issues of nutrition, maternal and child health. DALYs country estimates for selected endemic and neglected diseases are also shown below:

Table 6: Disease Burden in CLV (Estimated DALYs per 100,000 population by cause)

Country Total DALYs lost per 100,000 pop

Percent DALYs lost to CNPM per 100,000 pop

DALYs lost to Malaria per 100,000 pop

DALYs lost to Dengue per 100,000 pop

DALYs lost to ARI per 100,000 population

DALYs lost to Intestinal Nematode Infections

Cambodia 36.464 21.153 (58%) 143 44 4,659 354

Lao PDR 29.205 14.897 (51%) 46 93 2,560 300

Viet Nam 15.327 4.598 (29%) 8 16 480 228

Source: WHO DALY Country Estimates 2004, WHO February 2009

47 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 48 WHO, 2003. Assessing the Environmental Burden of Disease at National and Local levels. Geneva



3. REGIONAL COOPERATION ON CDC

3.1 Current Regional Cooperative Initiatives in CDC

74. International Health Regulations (IHRs) were endorsed by WHO Member States, including CLV. The IHR provides the legal framework for actions to prevent the international spread of disease by meeting a set of minimum core capacity requirements which would enable a country to detect, assess, notify and report events that may constitute a public health emergency of international concern. CDC1 supports CLV toward their compliance with the IHR.

75. Under the revised IHR approved by WHO in 2007, countries are expected to establish and maintain minimum core surveillance and response capacities to successfully implement the global security, epidemic alert, and response strategy. These requirements entail: (i) at the community level, detecting illnesses and deaths above expected levels and reporting information to appropriate local health personnel; (ii) at the primary public health response level, verifying reported events implementing immediate control measures, and reporting information to the national level; and (iii) at the national level, assessing all health event reports within 24 hours and reporting public health emergencies or international concern to WHO.

76. The revised IHR provide a decision instrument to assist countries in assessing events and immediately notifying WHO about events that could signify a ―public health emergency of international concern‖. The latter phrase is fully defined in the revised IHR. The WHO IHR guidelines provide countries with the detailed technical information and understanding needed to establish functions that will meet their capacity requirements. WHO is currently partnering with ADB to support countries in building technical capacity to comply with the revised IHR. 77. The Asia-Pacific Strategy for Emerging Diseases (APSED) approved by WHO in 2005 provides a strategic framework to help guide national capacity building programs and productive partnerships to reduce the threat of emerging diseases in the Asia-Pacific region. It is an important stepping stone towards effective implementation of the broader IHR, which calls for the development of a bi-regional strategy for strengthening capacity for CDC surveillance and response. APSED is organized under five objectives to reduce the threat of emerging diseases: (i) reduce the risk; (ii) strengthen detection of outbreaks; (iii) strengthen early response; (iv) strengthen preparedness; and (v) develop sustainable technical collaboration within the region. APSED also offers a potential framework for training initiatives that can be adapted to each country context, in terms of levels of competence. The APSED strategy concludes in 2010, and is to be assessed for gaps and recommendations prior to being extended or built-upon.

3.2 Regional Organizations and Institutions Supporting CDC

78. The purpose of the GMS regional strategy is to develop a comprehensive framework to give people in the region better protection from emerging diseases that do not stop at borders. The focus is on preventing, detecting and controlling the emerging diseases that are posing new threats and challenges to the people and health systems in the region.49

79. The third component of CDC1 focuses on strengthening regional collaboration in CDC in three main areas (the three pillars): (i) regional strategy, policy and mechanism for regional cooperation in

49 Asian Development Bank. 2008. Strategy 2020: The Long-term Strategic Framework for the Asian Development Bank (2008-2020)



CDC; (ii) regional knowledge management and human resource development, and; (iii) cross-border (land crossings) collaboration and health services.

80. Component 3 of CDC1 aimed to build the necessary trust and confidence through: (i) frequent and focused dialogue and exchange; (ii) developing professional networks and relationships across the ministries of health, health institutes, and other stakeholders; (iii) learning from one another‘s experiences; and (iv) embarking on joint research on critical regional health issues. As the trust and networks develop, importantly the personal relationships, the GMS countries are expected to move on to more challenging regional cooperation on health initiatives such as sharing of data systems, standardization of health policies and regulatory frameworks, and coordination of responses to outbreaks of disease.50 81. Significant gaps remain in GMS cooperation in the health sector which require increased focus on strengthening the foundation for more effective and sustainable collaboration. Discussions with CDC1‘s Regional Coordination Unit (RCU) raised issues, including that mapping of project partners shows a high workload for the PMU, and thus, the wrong partners, who do not have sufficient time to commit to regional activities. The Regional Steering Committee meets only once per year and members are all high level, and busy people, e.g. vice ministers. Discussions within the GMS Public Health Forum on Regional Cooperation in CDC and Health Systems Development have proposed grouping project issues into regional policy, strategy and structures for regional cooperation. The political will for regional CDC cooperation seems to be in place, but the appropriate coordinating mechanism is still not clear, and there are some concerns about duplication (e.g. with APEC, ASEAN+3, MBDS, ACMECS etc) of advocacy and political support.51 82. Meaningful regional cooperation for CDC1 project initiatives have faced considerable challenges, including operationalizing high-level decisions and knowledge management (KM) in the region. Suggestions from the RCU included the possible need for a forum moderator in each country to manage the internet forum ‗Communities of Practice‘, and to carry out cross-border activities such as joint surveillance and response, and joint health services in remote communities. This area is moving more slowly and needs to be refocused and realigned.52 83. The CDC1 RCU has been a pilot experiment to learn how to harness ‗regional advantage‘ for improved CDC in the GMS. Two key issues affecting regional advantage are: (i) language barrier among participants – with 30 percent to 40 percent loss as a result whenever they meet; and (ii) selection of participants – technical or political, and those with sufficient leverage (e.g. PMU) are usually too busy to really contribute or follow-up. The ADB ‗project‘ image of the RCU (managed by an ADB consultant) may also contribute to the lack of buy-in among member government partners who therefore, see little advantage getting involved. A suitable institutional ‗home‘ needs to be found to make the RCU a sustainable reality 84. Suggested alternatives to the current RCU approach to enhance regional cooperation among CLV and create sustainable foundations for future cooperation include: (i) taking an institutional strengthening approach, whereby a senior government official acts as rotating RCU coordinator; (ii) RCU to function primarily as a regional ―information center‖ to be established within one of the existing regional bodies and initiatives (APEC, ASEAN, MBDS), not as a program manager, but to filter and re-distribute the vast amount of information and data on regional initiatives; (iii) linking with existing, established regional training facilities, such as the Mekong Institute, located in Thailand, as a venue

50 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 51 Discussions with RCU 52 Discussions with RCU



for regional training activities and workshops; and (iv) develop results monitoring and evaluation tools with indicators of integration to analyze and assess regional benefits, cost-effectiveness and associated risks of regional programs.53

3.3 Achievements and Challenges in Regional CDC Cooperation

85. Achievements - The Governments of the CLV countries and ADB confirmed that addressing communicable disease transmission across borders as well as the socio-economic and structural vulnerability leading to behaviors that put people at increased risk for acquiring HIV/AIDS and other communicable diseases, particularly among EMGs in remote, undeserved highland border areas was a priority. The CDC1 project design reflected understanding of the health sector in terms of governance and social challenges, as well as in epidemiological terms, having established linkages between poverty, mobility and the spread of communicable diseases, especially HIV/AIDS. However, in many cases, the CDC1 project sites and target populations selected did not fit CDC1 project criteria (e.g. border areas, economic corridors). 86. Challenges - Efforts to map and collaborate with other organizations regionally, such as MBDS, have been important to synergize activities and collaboration. The political will for regional CDC cooperation seems to be in place, but the appropriate coordinating mechanism is still not clear. Cross-border activity is also challenging, especially for sharing sensitive information across borders, which may infer potential political, national security or other consequences, and with multiple sectors involved, quarantine sites, vector control activities at schools, and communities - all need to be coordinated, and it is not clear if provincial or the central level should be the focal point, and for which issues.

3.4 Achievements and Challenges in CDC1

87. Achievements - ADB support to local and national CDC programs builds on existing systems for preparedness, surveillance and response capacities at all levels, including greater reach to community level. However, developing the regional linkages and international capacity for CDC programs has proved to be much more challenging, for reasons including: (i) the lack of an existing model, system or funding mechanism for regional development cooperation for health or social sector assistance; (ii) continued institutional and legal constraints that hamper international and cross-border sector cooperation; and (iii) lack of country ownership of the regional mechanism (e.g. RCU) which is seen simply as an ADB project. However, benefits of regional approaches being piloted are beginning to emerge, in terms of technology transfer for strategic planning and generating a healthy climate of professional cooperation, competition, and commitment.54 88. Implementation at individual country levels built on experiences, lessons and capacities developed from previous ADB projects, including adaptation to evolving decentralization policies by pioneering decentralized arrangements linked directly to local organizations at community level. The EA and IA performed their tasks according to their objectives, with some exceptions, notably in Viet Nam and Cambodia, where additional capacity building and clarification of roles and responsibilities is still needed to manage the project, and where decentralization of authority to provinces is still relatively weak.

53 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater Mekong Subregion: Maturing and Moving Forward 54 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater Mekong Subregion: Maturing and Moving Forward



89. Some adjustments in implementation were made over time, including changes in scope in response to local situations when coverage was not carefully rationalized. For example, the WHO regional consultant pointed out that CDC1 priority project sites for dengue in Cambodia are wrong, as three of the five project provinces are not priority dengue areas. In response, ADB approved expanded project coverage of emergency response support outside project provinces (in Cambodia and Viet Nam) and financed expansion of provincial preparedness and outbreak response, dengue control, and HIV/AIDS component (Lao PDR). The parasite control program in CDC1 has a clear strategy, and was expanded to all CDC1 project provinces in Viet Nam. 90. There are cases where a government proposed to adopt CDC1 project outputs, as in the case of Lao PDR‘s formalization of RRTs.55 However financing for disease prevention and treatment remains constrained beyond project completion, with the exception of HIV/AIDS and perhaps AHI which have substantial funding under GF and other donors, and an ADB regional dengue project, which is being planned, as the WB and USAID are winding down their dengue interventions.

91. Clear benefit was observed where there was full-time country-based international TA support. Cooperation from specialist partners (WHO) was generally satisfactory, however, much more so in the few cases where the WHO consultant was able to sit within the national institution or ministry. Joint planning could be improved for CDC2 to more fully benefit from the specialist technical support, and the institutional placement of EA and IA within the MOH needs to be reconsidered in some cases to ensure mainstreaming of CDC within the health system. 92. The CDC1 value-added is seen to be mainly capacity building at provincial and district levels. Viet Nam has done well in terms of policy work, but project progress is most advanced in Lao PDR and on dengue control, where the project is providing critical support for dengue control (expanded to two more provinces), and in Cambodia (project funds have been made available nationwide). School based interventions, including training of teachers in school health education departments to mobilize their students are popular and cost-effective communication channels for household and community-based dengue control. 93. Provincial level capacity has been enhanced to counter CDC outbreaks through surveillance and response, as well as for promoting community-based HIV/AIDS prevention. Specific GMS-RETA initiatives56 have pioneered targeted and culturally specific communication approaches to inform EMGs in cross border areas on the health and other social risks from greater connectivity. However, there has been less progress at the sub-regional level. Disease outbreaks are not being systematically reported in the sub-region, the basis for any joint disease control activities has not been laid down, and actual networking among these professionals has not taken root outside of forums and workshops. Only one sub-regional project country achieved substantial policy and regulatory reform in enabling and sustaining surveillance and response systems (the foremost of which is funding) compared to the other two countries, and the knowledge generated from the projects may not have been used effectively.57 94. Quarantine services in CLV have received CDC1 project support mainly for equipment, such as computers, and some capacity building in selected ports and border points. However, much more is needed to meet the requirements according to government plans, including for (i) civil works; (ii) equipment and supplies provision; (iii) a range of capacity building needs; and (iv) recurrent costs for these inputs. For example, in Cambodia, CDC1 has supported three of the twelve existing

55 Ibid 56 E.g.; RETA partnership with UNESCO for culturally appropriate communication strategies for EMG 57 Asian Development Bank, GMS-RCAPE, 2008.



international ports with computers and training for 40 staff in these centers in support of Cambodia‘s IHR obligations. However, the Government plans to significantly increase the number of international ports, all of which will require fixed facilities for quarantine and related services for CDC including basic clinical care services and laboratory, surveillance system capacity, equipment and supplies, and a range of related capacity building inputs and recurrent costs. Given the magnitude investments required, plans for further strengthening of quarantine in CLV will be deferred to another project specifically tailored to meet these needs. 95. Regional networking promoted by the RCU, including regional forums and a website for resource repository and exchange of information is going well, but this is not sufficient yet. There are common threads that all countries share, but there has been little evidence of ownership, sense of added value or interest from the country PMUs, which regard CDC1 regional activities and coordination as RCU responsibility. 96. Challenges - CDC1 project design objectives and scope were broadly stated, and some revisions were needed in terms of scope and coverage. Governments in consultation with ADB adjusted the targets, but greater flexibility on the part of both ADB and MOH is needed to encourage appropriate changes to suit local conditions, particularly at provincial and sub-provincial levels. For example, of the five project provinces in Cambodia, three are not dengue prone, and the other two are not highly so. Similarly, in Viet Nam, the districts chosen for project implementation do not fit the agreed selection criteria, for example, a number of project provinces are not located on international borders, or in areas with a high proportion of EMG. 97. Of considerable concern is the lack of baseline information and the level of project M&E and quality assurance at national and regional levels, which appears to remain weak overall, making it difficult to attribute improvement in key indicators to specific project strategies and interventions, before and after project implementation. The project impact of the regional component activities in particular are difficult to assess, and as yet, relies mainly on subjective information which is collected from participant feedback surveys. There were however, some smaller M&E surveys, surveillance surveys, and cross-province/cross-district comparative studies conducted to assess project and non-project sites. These small surveys during implementation serve not only to inform future interventions, but provide opportunities to address problems while interventions are on-going, and can support capacity for regular data collection and analysis, develop implementation guidelines and draft technical papers. 98. National M&E frameworks need to include collection of appropriate impact indicators at the lowest implementation level from the start of project activities. Instead of large, costly studies, small, periodic surveys and focused behavioral studies are suggested to help gather the data needed to monitor trends in accordance with various interventions, and draw clear, reliable conclusions, and these also integrate into routine and more sustainable activities within the health system. For example, community observation can assess impact of community-based surveillance and response interventions, and user observation, bed nets use, IEC in the community, have outbreaks or not, and coordination with local agriculture departments for joint investigation of dead birds reported. The WHO has reportedly working with partner governments to develop an M&E matrix for CDC, which requires more complete and detailed data.58 99. Significant delays in project start-up of up to one year or longer for reasons including: (i) ambitious planning; (ii) EA/IA managerial challenges, lack of staff or inadequate attention; (iii) identifying national consultants; (iv) typical government system bottlenecks; (v) lengthy negotiations

58 Discussion with WHO Regional Dengue TA for CDC1



with specialized partner agencies; and (vi) ADB and MOH review procedures, resulting in late approval of operational plans. Project processing and start-up tended to be time- and labor-intensive, and took much longer than envisaged The benefits of GMS sponsored workshops and forums have also been less optimal owing to the multiple translation requirements, and some 30 percent of the content is estimated to have been lost due to the translations. The phasing of projects has allowed project managers to learn from and build on previous experiences, particularly on HIV/AIDS.59 100. Participatory planning with project stakeholders could have been better, particularly at provincial and district levels, and with WHO, which could have helped improve technical design and quality, particularly for dengue. Substantial delays in replenishment of the imprest accounts were eventually addressed, and ADB agreed to raise the ceiling on second generation accounts at provincial levels to ensure adequate funding at provincial levels for rapid outbreak response. 101. Community-based models for preventing and controlling disease outbreaks, including HIV/AIDS and dengue prevention have tended to be more successful than the regional aspects of the project, which have only partly succeeded in reaching the regional coordination objectives through policy dialogue, operations research and project management, or for interventions to reduce vulnerability associated with cross-border mobility among EMGs, for example. 102. Capacity building is seen to have been modest overall as most programs focused on individual training rather than capacity development for planning and management of training. Capacity development in regional cooperation has also been modest, due to both management and administration in ADB and at country level in coordination between GMS and national projects. Coordination across sectors has also generally been weak, with notable exceptions, for example, where there has been good collaboration on CDC between the MOH and MOE.60

103. Integration of CDC into routine PHC activities has also not been as notable, due perhaps to the ‗project‘ perception of CDC1. However, lessons emerging for example, from the RETA Roll-back Malaria (RBM) initiative (2000-2005) and include: (i) efficiency could be improved by integrating other diseases (e.g. DD) into malaria control activities; and (ii) the huge amount of information generated from the project argues for an expansion of the TA scope into non-endemic areas and other EMGs, to take advantage of economies of scale.61 104. The governments of CLV are seen to have a good understanding that volunteerism of community-based workers is not enough, and that these people have to be supported with sufficient cash (and/or in-kind) incentives and recognition. TA financed incentive payments are often perceived to be a key element to successful implementation of community-based interventions, particularly in remote areas. However, recurrent cost for CHWs requires careful consideration. Experience from CDC1 and other ADB health projects (e.g. JFPR HIV/AIDS and RETA malaria) highlights the trade-off between effectiveness and sustainability, where incentive payments for CHWs in some cases have jumped to four to five times the usual government CHW payments under project funding, and with no evidence of government capacity or commitment to sustain this level of payment after project completion, or how CHW participation would be affected with post-project reinstatement of lower government incentive payments.

59 ibid 60 Discussion with WHO Regional Dengue TA for CDC1 61 Asian Development Bank. TA Assessment: RCAPE on GMS. RETA 5958: Rollback Malaria Initiative in the GMS



105. Similarly, the widespread project provision of abate for dengue control at the community level is expensive and may also become less effective in the long term due to resistance.62 Experience has also shown that by simply waiting for supplies and services to be provided, communities tend to passively participate in what, from the community standpoint, is often seen as the responsibility of the health authorities. Current and future widespread abate consumption in the community also needs to be monitored, and with appropriate BCC to ensure its safe use.

106. A balance needs to be struck between the desire for short-term (but unsustainable) CDC results, versus locally appropriate village level approaches which allow for sufficient time as well as appropriate and effective capacity building to develop the skills and ownership required to mobilize and sustain community resources over the long term. Projects with significant community involvement have also found this easier and more cost effective when working through NGOs, and CDC2 may consider involving more NGO support were possible.

107. While the provincial health systems supported under CDC1 are becoming stronger in general, the burden of communicable diseases remains high in remote communities, affecting child and maternal mortality, and thereby pushing achievement of MDGs out of reach. Complementary, multi-sector approaches are needed to promote environmental health, personal hygiene, food safety, and safe drinking water and proper sanitation. Further support is also needed for improved health services capacity and reach to remote areas, as well as for community preparedness and prevention including for CDC forecasting, risk mitigation, and reinforcing of public health fundamentals to contain transmission and exposure to pathogens.63 108. The greatest challenge (but also the only long-term solution for sustainable CDC locally, nationally and regionally, in particular for dengue control), is to mobilize greater individual, family and community responsibility for CDC. This includes promoting and modeling behavior changes that need to be established at village level for cost-effective, sustainable improvements in overall population health, including specific measures for vector control and eradication. Research has shown that the Communication for Behavior Impact (COMBI) model contributes to positive behavior outcomes, including for dengue control.64 COMBI uses structured, social marketing approaches to engage individuals to consider, adopt and maintain a range of healthy behaviors. However, COMBI pilots in CDC1 were described as challenging and expensive, and this will require closer review of the feasibility and potential of COMBI for effective community mobilization for CDC in CDC2. The Healthy Villages model is another approach to consider for encouraging behavior change within a context of inter-sector collaboration at the village level. 109. Suggestions for improved community participation in CDC offered by key stakeholders interviewed include: (i) knowledge contest, sports event, or drama to raise awareness, model behavior and convey key messages; (ii) a good communication channel is through school children, and appears to be working well in Cambodia and Viet Nam; (iii) local leadership support and commitment to programs; (iv) communication skills development and integration of appropriate BCC with other visible or evident diseases; and (iv) integration of preventive CDC with other sectors such as education, agriculture, and rural water supply and sanitation.65 The potential benefits of linking CDC with sectors such as water and sanitation, rural development, agriculture and infrastructure are apparent, as they all relate to the environment. For instance, WHO noted that recent dengue epidemics in Cambodia

62 Discussion with the WHO Regional Dengue TA for CDC1 63 Asian Development Bank, 2008. Aide Memoire: Fact Finding Mission for the PPTA for the Second GMS Regional Communicable Disease Control Project (CDC2) Cambodia, October 2008 64 Ministry of Health, Malaysia; WHO/WPR. 2004. Applying Communication-for-Behavioral-Impact (COMBI) in the prevention of dengue in Johor Bahru, Johore, Malaysia 65 Asian Development Bank, 2008.GMS-RCAPE Consultant‘s Report (Draft)



may be due to changes in the cash crop culture, wherein the shift in cultivation from cashew to rubber (the rubber from Cambodia is exported to Viet Nam, while the rubber in Lao goes to PRC) created a new vector for dengue.66

66 ibid



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Asian Development Bank. 2003. RRP:VIE 37115, Health Care in the Central Highlands Project. Manila.

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Asian Development Bank. 2008. Strategy 2020: The Long-term Strategic Framework for the Asian Development Bank (2008-2020)

Asian Development Bank. 2004. The GMS Beyond Borders: Regional Cooperation Strategy and Program (RCSP) 2004-2008

Asian Development Bank. 2007. Proposed Asian Development Fund Grant: Lao People’s Democratic Republic: Health System Development Project

Asian Development Bank, 2008. Corridor Chronicles: Profiles of Cross Border Activities in the Greater Mekong Subregion. Manila, Philippines. Development Bank, 2008. Aide Memoire: Fact Finding Mission for the PPTA for the Second GMS Regional Communicable Disease Control Project (CDC2) Cambodia, October 2008 Asian Development Bank, 2009. Monitoring and Supervision Mission Report: Rattanakiri. 30 March to 3 April 2009 Asian Development Bank, 2009. Review of the Gender Ethnic Development Plan in the RRP of the 2007 Lao PDR Health Systems Development Project Asian Development Bank, 2007. PPTA Report: Health Care in the South Central Coast Region Asian Development Bank, 2009. Broken Lives: Trafficking in Human Beings in the Lao PDR. Manila

Asia Development Bank, 2001. Health and Education Needs of Ethnic Minorities in the Greater Mekong Subregion. Manila, Philippines Asian Development Bank, 2002. Indigenous Peoples / Ethnic Minorities and Poverty Reduction - Viet Nam. Manila, Philippines Asian Development Bank, 2007. PPTA Report: South Central Coastal Region Project Asian Development Bank, 2006. Performance Evaluation Report. Lao PDR Primary Health Care Project



Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater Mekong Subregion: Maturing and Moving Forward Asian Development bank, 2005. Primary Health Care Expansion Project: Household Survey 2004, Vientiane Asian Development Bank, JFPR-9006. May 2005. Community Action for Preventing HIV/AIDS: Cambodia, Laos and Viet Nam. ADB’s Regional HIV/AIDS Project 2001-2004 Asian Development Bank, 2006. Country Strategy and Program: Viet Nam 2007-2010 Asian Development Bank, 2008. TA Assessment: RCAPE on GMS-RETA 5958: Rollback Malaria Initiative in the GMS (In partnership with WHO) Asian Development Bank, 2008. TA Assessment: RCAPE on GMS-RETA 6247: HIV/AIDS Vulnerability and Risk Reduction Among Ethnic Minority Groups Through Communication Strategies (in partnership with UNESCO) Asian Development Bank, 2008. GMS-RCAPE Consultant’s Report (Draft) Asian Development Bank, 2008. TA Assessment: RCAPE on GMS. RETA 5958: Rollback Malaria Initiative in the GMS Australian Agency for International Development (AusAID), 2003. Primary Health Care for Women and Children Project Evaluation, Viet Nam Care International, Viet Nam, 2008. Community-based Surveillance for Avian and Human Influenza in Vietnam Cornford, Jonathon and Nathaniel Matthews, 2008. Hidden Costs: The Underside of economic transformation in the Greater Mekong Subregion. Oxfam, Australia. Government of Cambodia. National Strategic Development Plan (2006-2010) Government of Viet Nam, Ministry of Health, 2007. Viet Nam National Strategy on Preventive Medicine to 2010 and Orientation towards 2020 Government of Viet Nam, Ministry of Health 2006. Comprehensive Development Design for the Health System in Viet Nam to 2010 and Vision by 2020. Hanoi Imai, Katsushi and Raghav Gaiha, 2007. Poverty, Inequality and Ethnic Minorities in Vietnam. Brooks World Poverty Institute WPI Working Paper 10, University of Manchester. Ian G. Baird and Bruce Shoemaker, 2007. ‘Unsettling Experiences: Internal Resettlement and International Aid Agencies in Laos’. In Development and Change 38(5): 865–888. Lyttleton, C. et. al., 2004 Watermelons, bars and trucks: Dangerous Intersection in Northwest Lao PDR. Institute for Cultural Research of Lao and Macquarie University Ministry of Health, Cambodia, 2005. Cambodia Demographic Health Survey



Ministry of Health, Cambodia, 2008. Health Strategic Plan 2008-2015 Ministry of Health, Cambodia, 2007.Joint Performance Review Ministry of Health, Cambodia. 2006. Strategic Plan for Emerging Diseases in Cambodia Ministry of Health, Lao PDR. The National Committee for the Control of AIDS. 2006. National Strategic and Action Plan on HIV/AIDS/STI 2006-2010. Vientiane Ministry of Health, Vietnam Health Report 2006, Medical Publishing House, 2007 (draft) Ministry of Health, Malaysia; WHO/WPR. 2004. Applying Communication-for-Behavioral-Impact (COMBI) in the prevention of dengue in Johor Bahru, Johore, Malaysia Ministry of Health, Lao PDR National Committee for the Control of AIDS, 2006. National Strategic and Action Plan on HIV/AIDS/STI 2006-2010. Vientiane Ministry of Health, Lao PDR. 2006. Sixth Five Year Health Development Plan, 2006-2010

Ministry of Heath, Cambodia. 2006. Strategic Plan for Emerging Diseases in Cambodia Ministry of Health, Lao PDR. 2006. Sixth Five Year Health Development Plan, 2006-2010 Ministry of Health, Cambodia. 2008. The Second Heath Sector Strategic Plan (HSP2). Strategic Plan Chapter 4: Communicable Disease Control Ministry of Health, Cambodia, 2008. Second Health Strategic Plan 2008-2015 Options for Developing Effective, Equitable and Sustainable Health System. Draft Health Note. (undated) Cited in UNICEF, Cambodia, Health Sector Analysis (Draft) Oxfam Australia, 2008. A Citizen’s Guide to the Greater Mekong Subregion: Understanding the GMS Program and the Role of the Asian Development Bank. Melbourne Australia Save the Children, Australia. 2008. Review of Save the Children’s Primary Health Care Projects in Sayabury and Luang Prabang Provinces: Review Report and PHC strategy for Lao PDR. UNICEF, 2008, Report of Mid-Term Review of the Country Program UNICEF, Cambodia, 2008, Report of Mid-Term Review of the Country Programme UNICEF, Cambodia, 2009. Health Sector Situation Analysis (Draft) Van de Walle, D. and Gunewardena, D. (2001) Sources of ethnic inequality in Viet Nam, Journal of Development Economics, 65, 177-207. World Bank, 2006. Lao PDR Poverty Assessment Report from Valleys to Hilltops – 15 years of Poverty Reduction World Bank, 2006, Cambodia. Halving Poverty by 2015? Poverty Assessment



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World Health Organization, 2003.Introduction and Methods: Assessing the Environmental Burden of Disease at National and Local levels. Geneva World Health Organization. 2007. Addressing sex and gender in epidemic-prone infectious diseases. Geneva. World Health Organization, Cambodia.2007. GMS CDC 6th Regional Project Review Workshop, Vientiane.


ANNEX 1: Project Structure

Regional Steering Committee Regional Coordination Unit

CAMBODIA

Ministry of Health

LAO PDR

Ministry of Health

VIET NAM

Ministry of Health

ADB

ADB

WHO MBDS

WHO

Health Sector Steering

Committee

MOH Steering Committee

Steering Committee of MOH for ADB Projects

Department of Planning and

Finance Project Management Unit

General Department of Preventive Medicine and

Environmental Health Project Management Unit

PROJECT MANAGEMENT UNIT

Communicable Diseases Control Department

Project Management Unit

Provincial Health Departments PPIU

District Health Offices

Health Sector Support Program 2 Supporting National Institutes NCPEMC, NCHDSC, NIPH,

Provincial Health Offices PPIU District Health Offices

Department of Hygiene and Prevention

Supporting National Institutes NCMPE, NCLE, NIA.

Supporting National Institutes NIHE, NIMPE, PIHCMC, VAHC.

ADB = Asian Development Bank; Lao PDR = Lao People‘s Democratic Republic; MOH = Ministry of Health; MBDS = Mekong Basin Disease Surveillance, NCHDSC = National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Diseases Control; NCLE = National Center for Laboratory and Epidemiology; NCMPE = National Center of Malariology, Parasitology, and Entomology; NCPEMC = National Center for Parasitology, Entomology and Malaria Control; NIHE = National Institute of Hygiene and Epidemiology; NIMPE = National Institute of Malariology, Parasitology and Entomology; NIPH = National Institute of Public Health; PIHCMC = Pasteur Institute of Ho Chi Minh City; VAHC = Viet Nam Administration of HIV/AIDS Center; WHO = World Health Organization (regional and country offices).

Provincial Health Department PPIU and Preventive Medicine Center

District Health Centres

S. PIU



ANNEX 2: Communicable Diseases Morbidity and Mortality Profile in

Cambodia, Lao PDR and Viet Nam

Cambodia Leading Causes of Communicable Disease Morbidity (2008)

No Diseases Number of Cases Percentage of CD Morbidity

1 ARI 66,387 38.45

2 TB 30,799 17.84

3 Diarrhea 22,688 13.14

4 Typhoid Fever 13,241 7.67

5 DF+DHF 12,035 6.97

6 Malaria 11,701 6.77

7 AIDS 6,239 3.61

8 Dysentery 6,355 3.68

9 Non-tubercular Meningitis 2,058 1.19

10 STDs 1,116 0.64

Total 172,619 Cases 100 Percent

Source: HIS 2008/MOH/Cambodia Leading causes of Communicable Disease Mortality (2008)

No Diseases Number of Deaths Percentage ofCD Mortality

1 ARI 1,188 45.57

2 AIDS 448 17.18

3 TB 283 10.85

4 Malaria 240 9.20

5 Meningitis 208 7.97

6 DF+DHF 110 4.21

7 Diarrhea 62 2.37

8 Tetanus 43 1.64

9 Typhoid Fever 16 0.61

10 Hepatitis B 9 0.34

Total 2,607 Deaths 100 Percent

Source: HIS 2008/MOH/Cambodia



Lao PDR Leading Causes of Communicable Disease Morbidity (2004 – October 2009)

No. Disease Number of Cases Percentage of CD Morbidity

1 Dengue Fever 29,620 29.40

2 Acute Watery Diarrhea 27,249 27.05

3 Typhoid Fever 11,362 11.28

4 Acute Mucous Bloody Diarrhea 7,871 7.81

5 ARI 7,509 7.45

6 Measles 3,939 3.91

7 Total Hepatitis 3,502 4.47

8 Food Poisoning 3,495 3.46

9 Dengue hemorrhagic Fever 2,651 2.63

10 Meningitis 1,782 0.17

Total 100,729 Cases 100 Percent

Source: Surveillance Report, CLE, MOH, Lao PDR Leading causes of Communicable Disease Mortality (2009)

No. Disease Number of Cases Percentage of CD Mortality

1 Dengue Shock Syndrome 53 22.75

2 Acute Watery Diarrhea 40 17.16


4 Measles 26 11.16

5 Dengue Hemorrhagic Fever 21 9.00

6 Food Poisoning 19 8.15

7 ARI 18 7.70

8 Anthrax 14 6.00

9 Typhoid Fever 09 3.86

10 Encephalitis 07 3.00

Total 233 Deaths 100 Percent

Source: Surveillance Report, CLE, MOH, Lao PDR



Viet Nam Leading Causes of Communicable Disease Morbidity (2007)

No Diseases Number of cases Percentage of CD Morbidity

1 ARI 1,657,738 48.50

2 Diarrhea 974,763 28.50

3 Rabies 381,262 11.10

4 Dysentery Syndrome 119,815 3.50

5 Dengue 101,154 2.95

6 Malaria 69,223 2.00

7 Varicella 36,622 1.07

8 Dysentery 34,240 1.00

9 APC – Adeno virus 29,781 0.87

10 Paratitis/Mumps 13,459 0.04

Total 3,417,757 Cases 100 Percent

Source: CDC Statistical Year Book, MOH, Vietnam 2008 Leading Causes of Communicable Disease Mortality (2007)

No Diseases Number of Deaths Percentage of CDC Mortality

1 Rabies 112 38.22

2 Dengue 85 29.00


4 Diarrhea 24 8.19

5 Infant Tetanus 13 4.43

6 Other tetanus 11 3.75

7 Streptococcus meningitis 5 1.70

8 AHI H5N1 5 1.70

9 Dysentery syndrome 4 1.36

10 Parotitis/mumps 4 1.36

Total 293 Deaths 100 Percent

Source: CDC Statistical Yearbook, MOH, Vietnam 2008



ANNEX 3 - CDC in Cambodia, Lao PDR, and Viet Nam

CONTENTS

1. CDC IN CAMBODIA ............................................................................................................... 35

1.1 Legal and Policy Frameworks ................................................................................... 35

1.2 Health System Organization for CDC ........................................................................ 36

1.3 Inter-Sector Cooperation ........................................................................................... 37

1.4 Donor and NGO Support ........................................................................................... 38

1.5 Achievements and Challenges under CDC1 ............................................................. 39

2. CDC IN LAO PDR .................................................................................................................. 42

2.1 Legal and Policy Framework ..................................................................................... 42

2.2 Health Sector Organization for CDC ......................................................................... 43

2.3 Inter-Sector Cooperation on CDC ............................................................................. 45

2.4 Donor and NGO Support ........................................................................................... 45


3. CDC IN VIET NAM ................................................................................................................. 48

3.1 Legal and Policy Framework ..................................................................................... 48

3.3 Inter-Sector Cooperation on CDC ............................................................................. 50

3.4 Donor and INGO Support for CDC ............................................................................ 51




1. CDC IN CAMBODIA

1. Over the past decade Cambodia has made substantial progress in improving the health of its population and in the provision of healthcare services. The MOH Joint Performance Review (2007) reported significant progress towards the four strategic goals set out in the HSSP (2006-2010), addressing: (i) infant and child mortality; (ii) maternal morality; (iii) communicable diseases; and (iv) an effective health system. However, the health sector still faces major and persistent challenges, including health financing and service delivery, before it can overcome the inequities that keep vulnerable groups from enjoying their right to health. 2. The poor can rarely afford to pay for public or private health care, and because the health sector lacks adequate capacity to provide quality health services, particularly for poor or lower income groups, many resort to self-medicating from pharmacies, drug sellers and traditional healers. The distance of the household to the health center is an immediate and important impediment to their effective utilization, with many of them not located conveniently near to a town or village center. 67 Many basic health services are simply out of reach due to the difficulty in accessing transportation to health centers and hospitals. Again, it is the poor who are the most vulnerable and excluded, particularly for those in remote locations.68 A related issue is the lack of road infrastructure and public transport systems. Continued improvements in these areas will have important implications for placing health facilities and health personnel in the more remote areas to reach the neglected segments of the population.

3. Recently, the MOH, with partner support, has supported innovative schemes to protect the poor from the costs of public sector user fees, such as Health Equity Funds (HEF), which have expanded to cover 30 Operating Districts.69 Eight community-based health insurance schemes have also been implemented, and are being considered for scaling up. The legal framework has been created to set up two schemes of compulsory social health insurance for the formal private sector and for civil servants. According to the Cambodia Demographic Health Survey (CDHS), between 2000 and 2005, the share of the population forced to sell their personal assets to access expensive treatment decreased significantly, with an increasing percentage of the population paying for services from their wages. It is believed that this reflects an overall improved socio-economic situation and reduction of poverty, as well as the possible impact of Health Equity Funds.70

1.1 Legal and Policy Frameworks

4. The National Strategic Development Plan 2006-2010 (NSDP) is a broad framework for national goals and strategies aimed at reducing poverty rapidly and achieving the Cambodian MDGs as well as other socio-economic development goals. It also underscores some of the measurable improvements in various social indicators such as the: expansion of primary education; reduction in infant and under-five mortality rates; significant reduction in communicable diseases, particularly in HIV/AIDS; and reduction in gender disparity, especially in primary education, adult literacy and wage employment in agriculture and industry.

5. The NSDP recognizes that achievement of the CMDGs strongly depends on the synergy created by a number of essential developments such as political and social stability, the rule of law,

67 Cambodia Demographic Health Survey. (CDHS) 2005 68 Ibid 69 Ministry of Health, Cambodia, 2007.Joint Performance Review 70 Options for Developing Effective, Equitable and Sustainable Health System. MOH Draft Health Note, Cambodia, undated



maintenance of public order, critical reforms in public administration and sectors, and steady, sustainable and equitable macro-economic growth.71 The NSDP particularly recognizes the importance of addressing rural development and improving the livelihoods of the rural poor.

6. The Second Health (Sector) Strategic Plan (HSP2) 2008–2015 builds on the experiences of the Health Strategic Plan 2003-2007 (HSP1), to increase demand for equitable access to quality services addressing the priority areas of maternal and child morbidity and mortality, communicable and non-communicable diseases. HSP2 provides the basis for sector-wide management (SWAp) and an umbrella for health activities under the National Poverty Reduction Scheme, and is to be integrated across various health institutions at all levels. The MOH delineated 15 priority activities for the health sector, including promoting village health support groups and health center management committees, improving IMCI, improving consumer confidence in health services, and improving ethical conduct.72

7. HSP2 also sets the MOH three year provincial targets. An Annual Operational Plan (AOP) is developed each year by the Provincial Health Department (PHD) with inputs from health centers and communities and consolidated by the PHD planning team before submission to MOH and Ministry of Economy and Finance (MOEF). Provincial CDC1 project activities are formulated into a Project AOP, which is integrated within the Provincial PHD AOP and is a sub-set of it. The CDC1 Project AOP 2009 was endorsed by ADB in January 2009, with several implementation suggestions, including: (i) improving project provincial funds flow; (ii) strengthening provincial supervision of project activities; and (iii) improving the quality of project monitoring and evaluation activities. These suggestions are currently being addressed by project authorities at all levels during 2009.73

8. The Government‘s Rectangular Strategy has stated aims to: (i) provide all citizens with clean and safe water; (ii) protect all citizens from water-related diseases; (iii) provide adequate water supply to ensure food security, economic activities and appropriate living standards; and (iv) ensure water resources and an environment free from toxic elements.74

1.2 Health System Organization for CDC

9. The MOH has made important progress by implementing a health service coverage plan (HCP) that consists of a nationwide network of public primary care health centers and posts. There is also a network of district, provincial/municipal and regional secondary care hospitals. The Operational District (OD) is the most peripheral sub-unit close to the population. It is aligned with administrative levels, (e.g. districts), however its size and coverage are determined by economic and public health considerations in order to minimize duplication of activities and waste of resources. Each OD is composed of health centers (HC) and referral hospitals (RH) to implement the operational district health objectives.75

10. In the wake of the SARS and AHI epidemics of 2003, Rapid Response Teams (RRTs) have been trained and deployed, however, mainly at provincial level.76 One of the major impediments is the lack of human resources, particularly in the remote areas, which requires both increased staffing and better distribution of health posts.77

71 Cambodia National Strategic Development Plan (2006-2010) 72 Ministry of Health, Cambodia, 2008. Health Strategic Plan 2008-2015 73 Asian Development Bank, 2009. Monitoring and Supervision Mission Report: Rattanakiri Province, Cambodia. 30 March to 3 April 2009 74 UNICEF, 2009. Health Sector Situation Analysis (Draft) 75 Ministry of Health, Cambodia, 2008. Second Health Strategic Plan 2008-2115 76 Ministry of Health, Cambodia. 2006. Strategic Plan for Emerging Diseases in Cambodia 77 UNICEF, Cambodia Health Situation Analysis (Draft 2009)



11. The CDC Department of the MOH has overall responsibility for surveillance, response, and preparedness through three bureaus: (i) Bureau of CDC and Prevention; (ii) Bureau of Disease Surveillance; and (iii) Bureau of Quarantine. In addition, there are national programs for HIV/AIDS, tuberculosis, leprosy, malaria, dengue, and schistosomiasis. The national programs are individually responsible for surveillance and control of cholera and other DD, ARI, and vaccine-preventable diseases (of the National Immunization Program). This structure presents challenges for institutional coordination of activities, including surveillance and response. For example, surveillance information should inform disease control and quarantine activities.

12. New provincial funding mechanisms are being developed in project provinces, including standard operating procedures (SOPs), whereby the PHD contracts with the MOH at central level through HSP2 to receive service delivery and other grant funds through this mechanism. PHD then contracts locally through a Special Operating Agreement (SOA) with the referral hospital and health centers to provide the agreed services, and to reach the agreed targets. Central to these new arrangements are the: (i) Provincial Three Year Rolling Plan, (ii) provincial service performance targets, and (iii) Provincial Annual Operational Plan.78 13. The CDC1 project is guided by the health sector steering committee (SC) of the MOH, chaired by the Minister of Health, and includes representatives from MOEF and the project coordinator of HSSP. The HSSP provides administrative support representing the Executing Agency (EA). The CDC Department is the coordinating Implementing Agency (IA). Five project provinces and three national institutions also serve as IAs, including: (i) the National Center for Parasitology, Entomology and Malaria Control (NCPEMC), the National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases Control (NCHDSC) and (iii) the National Institute for Public Health (NIPH). The director of the CDC Department serves as project director, assisted by the directors of the other IAs, and a team of technical staff and consultants, which form the project management office (PMO).79

1.3 Inter-Sector Cooperation

14. The Cambodian MOH is facing a number of new challenges, including decentralization of health services, increased autonomy of healthcare providers, and the growing involvement of the private and non-government organization (NGO) sector. These developments call for new approaches, institutions and systems, as well as new skills in MOH, such as the provision of strategic leadership and guidance. Consequently, certain functions need to be systematically strengthened, such as regulation and enforcement, quality assurance mechanisms for accreditation and licensing, and monitoring and contracting.80 It is reported that MOH plans to move from an integrated model of service delivery management and financing to an approach whereby it assumes responsibility for policy development and strategy formulation, guides high-level resource allocation, strengthens its regulatory and enforcement roles, develops ways of exercising leadership and is engaged with lower levels of government on national health priorities.81

15. Initial steps have been taken towards good inter-sector interface by the National Center for Health Promotion (NCHP) to promote Behavior Change Communication (BCC). National guidelines have been developed and the training of key staff has been conducted. MRD has adopted a more participatory approach to hygiene promotion through the use of simplified Participatory Hygiene and

78 ADB, 2009. Monitoring and Supervision Mission: Rattanakiri Province, Cambodia. 30 March to 3 April 2009 79 ADB, 2005. RRP. Regional Communicable Disease Control Project 80 Options for Developing Effective, Equitable and Sustainable Health System. Draft MOH Cambodia Note, undated 81 UNICEF, Cambodia Health Sector Situation Analysis (Draft 2009)



Sanitation Transformation tools. The Ministry of Rural Development (MRD) has initiated collaboration with the Ministry of Education, Youth and Sport (MOEYS) to strengthen sanitation and hygiene education through school WASH activities. A national strategy for rural water supply, sanitation and hygiene will be developed in 2009 with support from ADB and UNICEF.82 The NCHP has a good inter-sector interface with other ministries concerned with rural sanitation, animal health and education, including relevant information, education and communication (IEC) and BCC materials and resources.

1.4 Donor and NGO Support

16. Although public spending in the health sector has doubled and aid funding grew by 50 percent between 2003 and 2007, donor spending continues to exceed the Government‘s spending, and out-of-pocket expenses still account for 65 percent of total health expenditure. This means that many households face excessive healthcare costs, and with fewer health outcome achievements due to inefficiency in Cambodia‘s health sector, including: (i) fragmentation of donor support; (ii) skewed allocation towards HIV/AIDS, TB and malaria; (iii) delayed execution of the government budget, resulting in low public sector service quality and reliance on user fees that impedes access for the poor; (iv) low allocation to salaries, and low budget share reaching primary health centers at the sub-national level; (v) and the very low availability of health professionals.83

17. In Cambodia, the MOH has a policy of harmonizing and integrating projects into regular services to avoid creating separate PMUs. Formal agreements with the seven major health sector partners84 specify the arrangements and commitments between partners and the MOH in support of the HSSP, around which all partners are agreed to align. Within the HSSP there is already some pooling of funds as Cambodia moves closer to a full sector-wide approach. HSSP is supported by strong commitment within the Good Governance Framework, the Financial Management Guidelines, and (in December 2008) the signing of a Joint Partnership Arrangement between the Government and the seven HSSP partners. HSSP also defines sector support within the existing pooled funding which allows for donor support to pooled funding for activities under the HSP2, as well as for direct support to defined groups of activities. This allows donors to retain a range of options including for the pool itself. 18. GMS-Regional Technical Assistance (RETA)85 support for CDC among EMGs in Cambodia included support to: (i) Health Unlimited (HU), an INGO working in Ratanakiri, to train Kreung CHWs; (ii) BBC Trust, which was involved in the TV soap series on HIV/AIDS in Khmer language; and (iii) Equal Access, a local NGO that sets up digital satellight radio receivers; and (iv) UNAIDS, Cambodia. Ongoing funding from the Global Fund (GF), particularly for malaria control has been provided to Rattanakiri, Stung Treng and Mondulkiri, with support from HU and another NGO, Partnership for Development, which has also piloted successful models for child to child school-based surveillance for CDC at community levels. From 2004 to 2008, MOH and PHD contracted another INGO (HealthNet International) to manage health center services and operate the provincial referral hospital to agreed targets, including malaria control, supported under an ADB loan.86 19. In CDC1, WHO provides technical support through engagement and management of consulting services for CDC nationally and regionally, including for: surveillance and response, 82 ibid 83 Ibid. 84 BTC, AusAID, DIFD, WB, UNFPA, UNICEF, AFD 85 E.g.; RETA 5958; Roll Back Malaria Initiative in GMS, and RETA 6247: HIV/AIDS vulnerability and risk reduction among EMG through communication strategies (in partnership with UNESCO) 86 ibid



outbreak preparedness, virology, dengue control, and control of endemic diseases. Some WHO experts (e.g. the dengue control expert in Cambodia) also serve in a regional capacity. The implementation agreement between ADB and WHO, and agreed to by MOH in CLV specifies among others: (i) the type of experts to be provided by WHO; (ii) the manner in which these experts will operate in close coordination with MOH; and (iii) implementation arrangements for the selection of experts, reporting, disbursement and performance review.87

1.5 Achievements and Challenges under CDC1

20. Achievements - CDC1 capacity-building inputs have upgraded the existing health system, and provided a good model for quick response to dengue, DD, including better clinical identification, and greater reach to the community level. Proposed CDC research aims to identify evidence-based responses. Prior to CDC1, surveillance and response capacity extended to district level only, with training only available to district level. Now, training and capacity building extends to the local health center staff and village health volunteers, effectively extending the surveillance system to village level. This includes reporting capability, depending on phone networks and phone cards. Previously laboratory technicians received only HIV/STD training. Under CDC1, laboratory technicians at province and district levels can now test for other diseases such as cholera and DD, and do bacterial cultures.88 21. A recent monitoring visit to Rattankiri Province, which borders Lao PDR and Viet Nam reported a well-functioning, responsive and strengthened CDC investigation and reporting system is in place there, supported by the GMS CDC project. It extends from community reporting of unusual events to local administration to health centre to PHD, with a unified leadership, commitment and growing capacities to maintain it. The investigation of CDC outbreaks, reporting of unusual events and the maintenance of the weekly zero reporting of communicable diseases continues to be well-functioning from health centers to PHD.89 22. Major progress has been made by building on previous ADB grant support for improved institutional and staff capacities, in particular, for integrating HIV/AIDS care and treatment into CDC1, based on community-based prevention capacities developed under the Japanese Fund for Poverty Reduction (JFPR) Regional HIV/AIDS Project. HIV/AIDS voluntary counseling and confidential testing is now available at 150 sites in all ODs, and current HIV prevalence among adults aged 15 to 49 years, both male and female, is 0.6 percent, and targets were met or surpassed for both dengue and malaria case fatality rates.90 Significant challenges remain however, including: (i) general societal conditions such as poverty, low literacy, low availability of water and sanitation, particularly in the rural areas; and (ii) limited levels inter-sector coordination and community participation for vector control.91 23. Challenges in the health system as outlined in the 2008 HSP2 Strategic Plan for CDC include: (i) insufficient preparedness for outbreaks at provincial / OD and facility levels; (ii) demand for qualified health services is too low for effective CDC, due to widespread use of private sector pharmacists and alternative health care providers with misdiagnosis, incorrect prescription, poor monitoring of drug use, and development of drug resistance; (iii) low utilization of public health services, which contributes to low outbreak preparedness; (iv) shortages of trained health workers, particularly in remote areas, and low health worker salaries; (v) insufficient integration of vertical approaches to treatment leading to missed opportunities for diagnosis, treatment and counseling; (vi) 87 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 88 Asian Development Bank, 2008. RCAPE Consultant’s Report 89 CDC1 Supervision and Monitoring Mission Report, Rattankiri, 30 March to 3 April 2009 90 Cambodia Demographic Health Survey, 2005 91 Ministry of Health, Cambodia. 2008. HSP2 Strategic Plan Chapter 4: Communicable Disease Control



insufficient health worker training at provincial and sub-provincial levels (except possibly for HIV/AIDS, which has been well supported); and (vii) quality issues regarding private providers, including drug quality; (viii) the lack of a comprehensive communication strategy to inform and empower the general public on CDC; and (ix) insufficient processes for continued review of policies, guidelines, and SOP.92 24. CDC1 project-related challenges include: (i) planning and management issues, at central and provincial levels, and lack of participatory planning with lower levels of the health system; (ii) focus on individual training, rather than systematic capacity building for provincial training planning and management in the province, and significant overlap in training for health staff, but with limited capacity building for the CHW on BCC and community mobilization for CDC, and to link the CHWs with the health system; (iii) BCC activities are carried out mainly by the provincial CDC teams, and not decentralized to district or commune levels, and with no mass media collaboration (e.g. for radio broadcasting of CDC messages); (v) project M&E appears to be weak overall, with an overall lack of quality assessment of project training and BCC activities, no training needs analysis, and poor reporting and data analysis skills.93 25. WHO consultants interviewed felt that they were not adequately consulted by ADB on CDC1 project design, as the specific role of WHO in CDC1 was not clear at that point. As a result, WHO was unable to assist MOH with design adjustments that would have been better suited to local conditions. For example, WHO (and MOH) suggest that rather than targeting selected provinces, CDC1 should have been planned for the entire country, and then with WHO support, MOH could have targeted high burden areas based on local conditions, such as levels of rainfall, immunology and entomology. ADB will soon be the only donor providing important support to dengue. Therefore, WHO suggests reorganizing the ADB support, for example, to provide specific TA for BCC and community mobilization, vector control technology and M&E.94 26. Mechanisms for systematic assessment of project impact have been inadequate. Project benefit monitoring and evaluation information was established but had to be modified in 2009. The CDC1 project indicators were not in line with indicators collected as part of the routine health services, so PMO organized a participatory process at central level involving the relevant stakeholders from all levels to develop a revised Design Monitoring Framework (DMF) that is now more in line with the national health information system indicators. 27 In addition, a number of important quality issues were not addressed adequately, especially for capacity building at provincial and district level training, monitoring and supervision support to assess impact and for quality assurance.

28. Strategic interventions planned within the CDC Department include: (i) review of relevant legislation to explore options for a comprehensive legal approach to CDC; (ii) integration of health policy in decentralization and de-concentration planning for capacity building for provincial surveillance and outbreak preparedness systems, and at sub-provincial levels for participatory health promotion for CDC and water and sanitation measures for vector control; (iii) measures to increase demand for pubic health services, including staff remuneration reform, and national communication strategy; (iv) in-service training and development of SOP for improved system of medical guidance, focusing on integrated approaches to CDC in high disease burden areas; and (v) addressing quality of private provider services, including drug safety and related policy.95 92 Ibid 93 Discussion with PMU Consultants, Cambodia. 94 RCAPE Mission: Discussion with WHO Regional Consultant for Dengue 95 Ibid



29. Discussions with project partners during the mission field visits highlighted the success of the capacity building outcomes, but repeatedly pointed out that to remain effective and sustained, recurrent costs support to implement activities will be required, including (i) provincial funds kept on hand to respond to large CDC outbreaks; and (ii) abate that is currently supplied under the CDC1 project for dengue control is also expensive and showing signs of resistance, leaving the important but challenging community-based interventions as the only long-term solution to dengue. WHO was working with the MOH on a matrix of donor support to cover these and other recurrent costs that will be crucial to sustaining ABD‘s GMS project outcomes.96 30. Implementation - Slow start-up and other difficulties included: (i) the use of international bidding procedures for small amounts; (ii) excessive control of MOEF (stalled over special staff per diem rates for outbreak investigation and response97; (iii) rigid application of annual planning cycle; (iv) late approval of annual operational plan; (v) lack of standard operating procedures; (vi) delayed engagement of local consultants; (vii) poor coordination between EA and IA; (viii) project management capacity constraints (e.g. a split EA and IA which led to lack of initiative on both sides.98) These will need to be addressed in CDC2 to revise and clarify the structural linkages and roles and responsibilities between the PMO, CDC Department and the HSSP. 31. ADB has been willing to make adjustments to improve performance, for example, by increasing imprest accounts at provincial level to ensure rapid outbreak response, and for expanded coverage nationally from the border provinces originally targeted by the project for dengue control, but which were not high dengue prone areas. It would appear that most of the planning was done at the central level, and participatory planning with key stakeholders could have been stronger, particularly at lower levels of the health system, for improved ownership, appropriateness and understanding of the design, and delegation of authority to the provinces. 32. Key factors for success noted in the 2008 ADB-GMS Regional Cooperative Program Evaluation (RCAPE) mission include: (i) well functioning health system structure; (ii) CDC1 project supports existing system; (iii) multi-sector work; and (iv) strong support from the District Governor for multi-sector and community mobilization, indicating the importance of involvement and support of local authorities and village leaders, especially for the community-based interventions. Mobilizing community participation is seen as a major and continuing challenge, but a group of CDC CHWs interviewed say that the best way to get things done in the community is for the village chief to tell the villagers to do it.

96 Discussions with WHO Regional Dengue TA during the 2008 RCAPE mission 97 Discussions with MOH and HSSP staff 98 Asian Development Bank, 2008. Grant Assessment: RCAPE on GMS R-CDC Project, and Nov 2007 BTOR



2. CDC IN LAO PDR 33. Communicable diseases, malnutrition, and reproductive health problems are the major disease burden affecting the rural poor in Lao PDR. Malaria, DD and ARI are the common causes of child mortality, often in association with malnutrition. Only 22 percent of households in the Northern provinces used insecticide-treated bed nets in a 2004 survey. Full immunization coverage of children aged 12 to 23 months has stagnated at 40 to 50 percent in the past five years, and is among the lowest globally. The prevalence of HIV had reached 1.0 percent among service women and 0.1 percent in the general adult population by the end of 2005, from 0.0 percent in 1990, and may be doubling every two years. The country has had several outbreaks of AHI in poultry, including one in 2006, with two human cases identified. In addition to a growing HIV/AIDS epidemic, the population also faces the threat of AHI and H1N1 epidemics. The new threat of the H1N1 virus requires major investment in preparedness. Non-communicable diseases and road accidents are gaining in importance, and putting pressure on limited resources for health services.99

2.1 Legal and Policy Framework

33. Health is one of four priority sectors in the 6th National Social and Economic Development Plan (NSEDP6), which provides the overall strategy to increase and improve funding efficiency in the sector, including improved donor coordination. It calls for expanded PHC services to remote and poor villages, and for more village and district health personnel, and is being implemented according to the Prime Minister’s Instruction 01 of March 2000, which outlines the decentralized approach, whereby the province is the strategic unit for development, the district for planning and budgeting, and the village as the implementing unit. The decentralization instruction encourages results-based approaches to management. Health insurance and HEF for the poor are another priority under NSEDP6.

34. The Health Sector Strategy for the Year 2020 formulated in May 2000, is one of the key policy documents and is based on four overriding concepts related to health care: (i) full coverage and service equity; (ii) early integrated services; (iii) demand-based services; and (iv) self-reliant services. On the basis of these concepts, the Health Sector Strategy identifies six policy areas, including improving community-based health promotion and disease prevention, and ensuring the quality, safety, and rational use of food and drugs. The Health Development Plan (2006-2020)100 developed by MOH in 2006 calls for increasing the numbers of women and EMG health workers, with particular focus on HRD, nutrition, the package of health services, and integration and decentralization of health services. 35. The Prime Minister Instruction No. 01/PM of March 2000 established the principle of decentralization and the governance of planning and budgeting for all sectors. Under this policy, the province becomes the strategic unit, the district the budget planning unit and the village the implementing unit. The intention is to increase ownership at the local level and to improve responsiveness to local needs. Still, responsibilities and authority at the different levels are unclear. Provincial governments are often uncertain about their roles and responsibilities because implementation guidelines on decentralization are lacking, e.g.; for budgeting procedures. The responsibilities delegated often do not match the human and financial resources available. There is a

99 Asian Development Bank, 2007. RRP. Proposed Asian Development Fund Grant Lao PDR: Health System Development Project 100 Ministry of Health, The Lao PDR. 2006. Sixth Five Year Health Development Plan, 2006-2010



lack of analytical and managerial skills at all levels. Most provincial authorities cannot prepare medium-term (strategic) and annual plans and budgets.101

2.2 Health Sector Organization for CDC

36. The Department of Hygiene and Prevention (DHP) within MOH has the primary responsibility for preventive health services in Lao PDR. Strategic planning has been decentralized to the 17 provinces and operational management to the districts. In CDC1, the DHP as the coordinating IA, together with the National Center for Malaria, Parasitology and Entomology (NCMPE); the National Center for Laboratory and Epidemiology (NCLE); and the Center for HIV/AIDS/STI (CHAS) are the key health sector implementing partners for capacity building on CDC both nationally and regionally, including participation in regional technical forums and for joint research with counterpart institutes in Cambodia and Viet Nam. The Steering Committee (SC), chaired by MOH, reviews progress and guides implementation. 37. Provincial health offices have administrative and technical responsibilities for health services provision in their provinces, including managing units for hygiene and prevention, malaria, and the expanded program on immunization (EPI). Each district health office, with four to five health workers, is responsible for coordinating health services in its district. CDC is promoted through health centers, health committees, village health volunteers (VHV), and mass organization (e.g. Women‘s Union (WU) and Youth Union (YU). Household access to public health services is around 90 percent, if VHVs are included.102 In remote areas, where it would be highly inefficient to build fixed health facilities, VHVs are the only feasible source of PHC services, and their presence in the villages has particularly benefited EMG. Provision of drug kits has given many EMG villages access to health services, however, VHVs need more training in reproductive health, nutrition promotion and other areas.103 While physical access is becoming less of a barrier to health services for most people, physical and social access is still poor for women needing reproductive health care and for remote EMG communities in general.104

38. The PHC Policy (2000) directly addresses the MDGs, based on: (i) expanded coverage of the health service network; (ii) health care for women of reproductive age and children under five years; (iii) full community participation; (iv) dissemination of health information to people in rural areas; (v) use of resources with a sound scientific basis and appropriate to the actual situation and needs; (vi) collaboration with other government sectors and with the private sector; (vii) increased support for a more effective PHC system; and (viii) sustainability of health care services at all levels through community contribution and local ownership of the services. The family, the school and the pagoda will be the focal points for PHC implementation in the villages. 39. The system is not performing well, with low immunization rates and other shortcomings, particularly in remote areas, where CDC programs must be integrated to be effective. While much capacity building has been achieved in the past decade, capacities at all levels are still seriously constrained. One issue is staff skills. Another is low pay, combined with limited opportunities for income-generating activities in rural areas except for farming. The Government is also facing serious fiscal constraints. Hence, the number of health workers cannot be expected to increase significantly in the medium term and despite expanded government training opportunities for students from EMGs.

101 Asian Development Bank, 2007. RRP Proposed ADB Fund Grant Lao PDR: Health System Development Project 102 Asian Development bank, 2005. Primary Health Care Expansion Project: Household Survey 2004, Vientiane 103 Asian Development Bank, 2007. RRP. Proposed Asian Development Fund Grant Lao PDR: Health System Development Project 104 Asian Development Bank, 2005. Primary Health Care Expansion Project: Household Survey 2004, Vientiane



The private sector offers other challenges, such as the sale of imported counterfeit drugs, which poses a considerable health risk in Lao PDR.105

40. The quality of PHC services is particularly problematic. Many health workers cannot diagnose and treat common diseases such as malaria, diarrhea, and acute respiratory infections, according to national standards. At health facilities about only 20 percent of children with diarrhea receive adequate treatment and counseling (i.e. continued breast-feeding). Some of this stems from a lack of qualified trainers with field experience and familiar with modern teaching methods. Many hospitals also lack skilled staff in areas such as health services, laboratory, pharmacy, blood bank and some medical services. Also, critical shortages in recurrent budgets for public health facilities hamper effective and efficient operation.106 41. Human Resources Development within MOH has shifted from increasing quantity of health services to increasing their quality. Strengthening human resource planning, management and training in the health sector is a priority in achieving this goal. NSEDP6 assigns top priority to increasing the health staff in the villages and districts, and to improving the attitude, morale, and capacity of health personnel. MOH, however, does not have a comprehensive strategic human resource development policy or long-term plan specific to the health sector. MOH‘s Department of Organization and Personnel is developing a five-year national Human Resource Plan for the sector, but it lacks experts and facilities in this field. Workforce planning is constrained by difficulties in collecting reliable personnel data. MOH is also pilot-testing a human resource management information system and expanding its use.107 42. Affirmative action has been taken into the eight northern provinces under the ADB Health Systems Development Project and Program (HSDP) to address gaps in workforce by women and the smaller ethnic groups in the form of targeted recruitment, provision of scholarships and bridging courses. The gender and ethnic groups action plan recommends that the training approach should be disseminated to other parts of the country. MOH is developing an affirmative action program to address the issues of: (i) concentration of female workers in low paid and low level jobs; (ii) early departure from the workforce for female health workers; (iii) gaps in participation of female mid/high level health workers below provincial level; (iv) few women in senior health management positions outside central level; and (v) poor representation of smaller ethic groups at every level of the health sector.108

43. Health worker gaps are apparent in health centers and district hospitals, with a third of district hospitals in some areas lacking a doctor or trained medical staff. There are also significant skill deficiencies in many provincial hospitals, particularly in laboratory, pharmacy, blood bank and some medical services. There is a shortage of female health workers and health workers from EMGs. Plans for expanded PHC have introduced bridging training for new health staff recruits from remote areas who do not meet the basic education requirements.109

44. The training of PHC workers has added some 150 staff at health centers in the eight northern provinces. Refresher training for medical assistants (PHC officers) will make more mid-level staff available at health centers. Low salaries and lack of incentives (financial and non-financial) for rural

105 Asian Development Bank 2007. RRP. Proposed Asian Development Fund Grant Lao PDR: Health System Development Project 106 Ibid 107 Ibid 108 Asian Development Bank, 2009. Review of the Gender Ethnic Development Plan in the RRP of the 2007 Lao PDR Health Systems Development Project 109 Asian Development Bank, 2007. RRP Proposed ADB Fund Grant Lao PDR: Health System Development Project



and remote posting hamper the effective distribution of health workers to health centers and district hospitals. The Government has passed legislation to introduce financial incentives for rural civil servants (Decree 381PM). However, attractive salaries alone may not be enough to keep qualified health workers in remote areas. The provision of housing near the health center and land nearby that they can farm and live on are important incentives. Community engagement and ownership, and support of village committees were important.110 45. Many MOH staff lack appropriate skills, motivation and receive poor support in terms of human resource management. Many managers lack the skills and resources to properly manage, supervise and support their staff in performing at a high level. Furthermore, facilities often lack the equipment needed to provide the full range of services that the staff have been trained for. The quality of training needs to be improved to better prepare heath staff to deliver good quality services. Teacher trainers will have to be trained in modern teacher methods and training institution adequately equipped with teaching materials. Students should be admitted on the basis of needs and actual training capacity, including capacity for skill training.111 46. A review of PHC projects in two provinces found that both provincial and district health offices need major capacity building in governance, leadership and management to be able to fulfill the functions allocated to them. There was a lack of staff qualified in data and finance analysis, planning and budgeting, and provincial health offices found to be in need of improving their own financial management capacity to receive and account for funds. Further, they will need to increase their ability to provide guidance and supportive supervision to the districts for improved planning, budgeting, and financial management.112

2.3 Inter-Sector Cooperation on CDC

47. Key factors for success in CDC1 include good provincial - district coordination within the health system, as well as with other non-health sectors at the district level (e.g. WU, YU, Labor, Education, Police, Monks). Activities in some provinces visited exhibited good teamwork, and are better integrated into the PHC system than in other provinces. Individual PHD leadership styles tend to affect the degree to which integration is occurring among the vertical programs.113

48. There is strong collaboration between MOH and the Ministry of Education (MOE), particularly for school-based health education programs, and for de-worming campaigns. However there is less evidence of collaborative activities with other sectors, such as agriculture and animal health, food safety, water and sanitation, forestry, fisheries, or the private sector.

2.4 Donor and NGO Support

49. Over the past five years, there has been a substantial shift in donor assistance to the country, with several bilateral donors phasing out their assistance as global funds moved in. External assistance in the health sector is fragmented and typically supports a specific sub-sector or geographic area. PHC and CDC receive the most funding. Assistance for HRD is mostly for in-service training under various projects. For CDC, the Global Fund for AIDS, TB and Malaria (GF) has

110 Asian Development Bank, Performance Evaluation Report, 2006. Lao PDR Primary Health Care Project 111 Ibid 112 Save the Children, Australia. 2008. Review of Save the Children’s Primary Health Care Projects in Sayabury and Luang Prabang Provinces: Review Report and PHC strategy for Lao PDR. 113 GMS-RCAPE Consultant’s Report (Draft) 2008



significantly increased funding for malaria, tuberculosis and more recently for HIV/AIDS.114 The increased funding in the country, especially for HIV/AIDS, supports the justification to redirect ADB funding support away from HIV/AIDS to other priorities in CDC2. 50. In CDC1, WHO provides technical support through country-based and regional international experts and specialist consultants in areas of surveillance and response, dengue control and parasites control. WHO experts interviewed suggested key factors for scaling up of project activities include: (i) effective communication between the WHO and the project at national level; (ii) expansion of project training to non-project provinces; and (ii) even in the provinces where health staff have been trained, the key factor now is the availability of funding, which also needs to be effectively integrated into national planning to implement effective CDC and strengthen preparedness, and surveillance and response systems. A major constraint is insufficient human resources within the pubic health system to carry out all the activities. There was also difficulty recruiting national consultants, including for surveillance and response. The Field Epidemiology Training Program (FETP) being carried out includes seven participants from central level MOH and one from each of the six project provinces. CDC2 may consider seconding a FETP graduate for local TA, or consider seconding an expert from MOH Thailand. WHO experts also explained that because WHO works with many partner departments within MOH, with some exceptions, it is not always feasible for WHO staff to be located in the MOH.


51. Achievements - Major progress has been made, particularly in capacity building for expanded health services and CDC, and building on previous grant support for improved institutional and staff capacities, for example, to integrate HIV/AIDS care and treatment under CDC into the community-based prevention capacities developed under the JFPR regional HIV/AIDS project. Important quality issues require further attention however, particularly for training in new skill areas such as counseling and maintaining confidentiality.

52. The good progress and rapid start-up in Lao PDR has been attributed to existing ADB project management capacity, strong international consulting services support, and support from MOF. The project is also well-integrated into routine MOH activities. Effective donor coordination resulted from an annual project planning process that is based on province level, or ‗bottom-up‘ planning, and which is also well harmonized with GF planning, and the key link for success has been the placement of the CDC project in the Budget and Planning Department of the MOH. ADB agreed to raise the ceiling for provincial imprest accounts to ensure available funds for rapid outbreak response, and to encourage greater flexibility among partner agencies, and to encourage their adjustments to suit local situations. 53. Key factors for success - from the community-based health interventions indicate the importance of: (i) good coordination and communication across all levels of the health system; (ii) support from the province, both from the provincial governor and from the PHD; (iii) decentralized approach and management capacity building, whereby provinces adjust the national plan to the local context, with clearly defined roles and responsibilities at each level, and with activities and budget identified for each component that can easily be followed up with regular, integrated monitor activities; (iv) strong provincial support to the districts; (v) strong participation from the community, especially from the district governors; and (vi) local health center and village level capacity building and

114 National Committee for the Control of AIDS. 2006. National Strategic and Action Plan on HIV/AIDS/STI 2006-2010. Vientiane



involvement in the surveillance and response system using phone cards, and if there is no phone, the project supplies transportation costs.115 54. Challenges - There is recognition among the PMU that they were spread too thin trying to cover all districts in the project provinces, as per the CDC1 master plan. Attempts to work in small ways everywhere created difficulties in project management and in assessment of impact. The Government‘s Health Sector Strategy calls for combined reporting for surveillance, including the integration of data from the vertical programs. Support for this would benefit from specific technical assistance (TA) to support this in CDC2. A tighter focus on selected districts is also suggested for CDC2, rather than trying to cover all districts in project provinces, as was the case in CDC1.116

115 GMS-RCAPE Consultant’s Report, 2008 116 Discussion with the PMU



3. CDC IN VIET NAM

55. The Government of the Socialist Republic of Viet Nam has made significant progress in improving the health of the population over the past 25 years, with the support of many donors. Major reforms within the health sector have impacted on the way the workforce is planned, managed and trained. Legalization of private health facilities and practice, introduction of private health professional training institutions, and the decentralization of managerial authority for health service delivery have far reaching consequences for the future of health workers and health services.

3.1 Legal and Policy Framework

56. In its Socio-Economic Development Plan (SEDP), the Government gives health and education a central role.117 In health care, having reached their MDGs, Viet Nam has targeted further reductions in maternal mortality, infant mortality, and malnutrition; reversing the prevalence of malaria and tuberculosis; and halting the growth of HIV/AIDS.

57. At the same time, the Government has identified a number of problems that need to be addressed in order to achieve these objectives, including addressing: shortages of skilled health workers; limited access, especially for the poor; and the challenges of managing an increasingly complex health system.118 Limited financing also continues to constrain the Government‘s ability to achieve all its objectives in the desired timeframe. The Government‘s plans to address these problems are consistent with ADB‘s Country Strategy and Program.

58. Decision No 3653/1999/QD BYT of the Minister of Health of Viet Nam November 15 th 1999 identifies Village Health Worker (VHW) responsibilities to include: (i) health education and communication, including carrying out IEC activities on health promotion, protection and community safety; (ii) community hygiene and health prevention, including community health education on food safety, good nutrition, safe water, parasites control, hygiene latrine, and participation in immunization and epidemic prevention activities; (iii) maternal and child health care, including ANC/PNC promotion and safe delivery options, child health monitoring, and family planning education and provision of contraceptives; (iv) first aid and basic curative care, providing simple care for accidents and injuries, common diseases, and health problems in the community, home care; and (v) carry out activities of public health programs at village level, including vital registrations and epidemics, and manage and properly use medical kit for VHWs.

59. The National Strategy for People’s Health Care and Protection 2001-2010 sets forth more specific health targets and strategies. This medium term strategy explicitly calls for (i) reducing morbidity and mortality caused by malaria, dengue fever, hepatitis, and Japanese encephalitis; (ii) curbing the increase of HIV/AIDS; (iii) preventing and controlling non-communicable diseases; (iv) improving equity of access to and use of health services; and (v) enhancing the quality of health care. 60. Specifically for the preventive health system, Viet Nam prepared in 2007 the Vietnam National Strategy on Preventive Medicine to 2010 and orientations to 2020 and the Master Plan on Development of Vietnam’s Health Care System by 2010 with a vision to 2020. The objectives of the plan include, among others, strengthening the capacity of preventive medicine at the district level to

117 Asian Development Bank, 2006. Country Strategy and Program: Viet Nam 2007-2010 118 Government of Viet Nam, 2006. Comprehensive Development Design for the Health System in Viet Nam to 2010 and Vision by 2020.



implement epidemic prevention activities in the communities. This decision is now being actioned and has implications for provincial and district engagement in CDC2.

3.2. Health Sector Organization for CDC 61. The country, through the support of many donors in the last decades, has achieved a network of health facilities and health workers that reaches all areas of the country, although large variations exist between urban and remote, rural settings. From an initial focus on quantity of facilities and health workers to improve access to health services, the Government‘s focus has now shifted to quality of services, with strengthening health human resources planning, management and training seen as a priority in the achievement of this goal.

62. Among the 14 parallel departments of MOH, the Viet Nam General Department of Preventive Medicine (GDPM) leads the preventive sub-sector, while Drug Administration, Food Safety and Hygiene, the Center for Health Education, Department of Health Quarantine and Chemical Management, and others also play significant roles. VAPM is responsible for the overall management and supervision of communicable disease surveillance activities. The preventive health system includes services delivered by preventive institutions (12 preventive medicine institutes and two centers) and specific health programs. In CDC1, partner institutes are (i) the National Institute of Hygiene and Epidemiology (NIHE); (ii) National Institute of Malariology, Parasitology, and Entomology (NIMPE); (iii) Pasteur Institutes (PI) of Ho Chi Minh City (HCMC) and Nha Trang City, and; (iv) the Viet Nam Administration of HIV/AIDS Center (VAAC).119 Bureaucratic divisions of communicable disease programs across the MOH (e.g. HIV/AIDS, TB, malaria and VAPM) create difficulties and lack scope for integration, particularly at central level. 63. In CDC1, partner institutes provide specialist support for capacity building and technical guidance in project provinces. For example, NIMPE supports provincial capacity building for community-based de-worming campaigns nationwide, and in collaboration with local schools, and the Pasteur Institutes of HCMC and Nha Trang City support provincial capacity building for dengue control in project provinces in the south and south central regions.

64. A network of preventive institutions covers all levels from central to district level. This fragmentation has high transaction costs and makes planning difficult. However, this structure is firmly entrenched and makes integration difficult. In 2005, the Government established the Viet Nam Administration for HIV/AIDS Control (VAAC), which is responsible for all policy and coordination of MOH HIV/AIDS activities at all levels. This poses similar potential problems for integration, as with the other separate vertical programs like malaria and TB.

65. Provincial Health Departments (PHD) prepare annual plans for health services and programs and are responsible for managing and directing health care at the provincial level. They manage the provincial preventive medicine centers (PPMCs) and other facilities. The PPMCs provide preventive health services, including surveillance for the 26 notifiable diseases. However, there is a need to develop a complete and standard reference handbook of case definitions for all of the 26 reportable diseases in the country. For example, HIHE and Pasteur Institute have their own set of standards relevant to their mandates, but not for all 26 diseases.120

119 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 120 Discussion with PMU for the ADB PHSSP Project in Viet Nam



66. PHDs are also responsible for laboratory services in the province, including for preventive medicine and quarantine centers. An epidemiological team monitors diseases and responds to outbreaks. The district health centers manage and direct health care at the district level. The district preventive health teams provide services such as immunization and control of DD, malaria, vitamin A deficiency, and iodine deficiency disorders. The district preventive (mobile) teams consist of five to seven technical staff members. The VAPM plans to establish separate district preventive medicine centers, in line with the 2007 Vietnam National Strategy on Preventive Medicine to 2010. 67. The commune health center (CHC) is the front line operational level healthcare facility of the public health system. It is responsible for the primary level of care in the community, including preventive care, normal delivery, drug provision, family planning, CDC, and other PHC activities. Many CHCs do not have medical doctors and instead are staffed with assistance doctors and nurses. VHWs are an integral part of the health system for implementing PHC in the community, facilitating outreach programs, and conducting environmental health efforts. The current network of VHWs covers 80 percent of the villages. While the system is well established and can serve as an operational model, it needs to be more locally driven rather than simply responding to instructions from above, and with more support.121

68. New Initiatives in Preventive Medicine - Historically, preventive medicine activities have centered at the commune level. But in recent years, stimulated by the increasing prevalence of HIV/AIDS and the threats of SARS and AHI, efforts were introduced to establish a national system of province-based preventive medicine centers. In addition, and in line with the 2007 national preventive medicine strategy to 2010, district preventive medicine centers are to be split off from district hospitals to allow greater specialization of preventive health functions at the local level. Conceptually, these decentralized facilities are to receive programmatic and financial support from MOH to assure their continuing attention to current and potential threats to health, and to maintain readiness in case of an epidemic or natural disaster.122

69. Unfortunately, national and local health authorities do not always agree on how the preventive medicine system is to be organized and managed. At least at this stage of its development, the preventive medicine system is centrally directed, in contrast to the thrust toward decentralization underway throughout the rest of the health system. From a local perspective, the preventive medicine centers appear to duplicate some services, such as diagnostic laboratory services, which already exist in the curative sector, and the centers draw personnel from already short-staffed local hospitals. By policy, however, at the district level, every effort is to be made to avoid creating new laboratories for preventive medicine where suitable laboratory facilities already exist.123

3.3 Inter-Sector Cooperation on CDC

70. Inter-sector cooperation on CDC is generally weak, with some exceptions, notably with the education sector for school health. National guidelines have been developed for control of soil transmitted helminthe (STH) infections in pre-school and school children. However, the program is still weak, reportedly due to a lack of an approved national STH control program, and human resource deficiencies. WHO and other donors have been providing support, including drugs. Guidelines for de-worming in women of reproductive age are being developed.124

121 Asian Development Bank, 2007. PPTA Report: South Central Coastal Region Project 122 Ministry of Health, 2007. Vietnam Health Report 2006, Medical Publishing House 123 Government of Viet Nam, 2006. Comprehensive Development Design for the Health System in Viet Nam to 2010 and Vision by 2020. 124 Viet Nam‘s presentation at The GMS CDC First Technical Forum on Parasitic Diseases. Oct 2009



71. The capacity of provinces varies, but some provinces have shown a high degree to organize innovative and integrated programs. For example: the Can Tho Provincial Preventive Medicine Center (PPMC) has a close working relationship with a several sectors for CDC, notably with the (i) WU and YU for community-based activities; (ii) Provincial Agriculture Department for information sharing on zoonoses, and joint outbreak investigation and sterilization; and (iii) the Provincial Education Department to integrate CDC into school health programs. This includes TOT training on CDC for selected teachers, who then train their colleagues; and IEC materials for teachers, and also for students who act as a low cost alternative to networks of CDC community health workers set up under CDC1 and each paid $5-$25 monthly stipends. Under the partnership with the Education Department, students are assigned to fill weekly survey checklists at their homes on prevention measures for vector control. This also serves to raise awareness within the family and the community. WUs are also very strongly involved in community BCC for community mobilization for dengue control. 72. A variety of communication channels have been used, including reference booklets for health staff, leaflets, flip charts, posters (although no posters were seen) and a VCD was produced in Khmer language for use on the regional Khmer language TV station. A particularly good and cost effective communication channel is through school children (this is also working well in Cambodia). The biggest challenge is to mobilize community participation – and this also takes time. Additional training is needed. The local People‘s Committee is strongly committed supporting the fish breeding pilot with local funding even after CDC1 project funding finishes.

73. Can Tho also conducted and funded a case-control evaluation of their CDC activities based on a model tested by Care International for Care‘s community-based AHI surveillance activities.125 Collaboration between the PHD and the Provincial Department of Agriculture were also reported in Can Tho province, which, for example, entailed regular information sharing and joint outbreak investigation and surveillance and response for human and animal health issues.

3.4 Donor and INGO Support for CDC

74. MOH and its partners recognize that the health sector is fragmented and that foreign aid has contributed, resulting, for example, in multiple reporting systems at commune level, high transaction costs and imbalanced investments. The health sector has been selected as a pilot sector for aid harmonization. The Health Partnership Group (HPG), chaired by the MOH (and including ADB, EU working group on health, UN agencies, WB and other agencies), was established in 2004 to increase the coordination and efficiency of development assistance. Its terms of reference have recently been broadened to enable it to contribute more effectively to health policy and strategy development, and to guide the Joint Annual Health Review (JAHR). JAHR is expected to help ensure that MOH and donors share the same understanding of the health situation, and work collectively toward improving it. A series of joint performance indicators will be used both internally by MOH and externally by donor agencies.126

75. At present, ADB supports provincial health systems development through four projects (i) the 2005 Preventive Health Systems Support Project (PHSSP), which is helping to finance the upgrading of preventive medicine centers and providing computers, surveillance software and training for 46 provincial and four national institutes for more efficient and streamlined surveillance and data management systems at provincial levels, and at sub-provincial levels in 17 priority provinces; (ii) Health Care in the South Central Coastal Region Project, which began implementation in January 2009, supports eight provinces with equipment, facilities upgrading and HRD; (iii) the 2004 Health

125 Care International. 2008. Community-based Surveillance for Avian and Human Influenza in Vietnam 126 Asian Development Bank, 2007. PPTA Report: South Central Coastal Region Project



Care in the Central Highlands Project now nearing completion; and (iv) CDC1, supporting surveillance and response systems, control of neglected endemic diseases, and regional cooperation in 15 provinces, but not all of these border Cambodia and Lao PDR.

76. The World Bank (WB) is supporting similar projects in Northern Mountains, North Central Coastal and Mekong Delta regions. WB is also supporting a pilot for establishing computerized CDC surveillance software for ease of data analysis and management at commune level. Both banks have been asked by the Government to support similar projects along Viet Nam‘s central coast – an area lagging in health status indicators (women and children and EMG populations), and that has persistently poor access to health services.127

77. In CDC1, WHO provides technical support on CDC and surveillance and response systems strengthening, including efforts to operationalize cross-border collaboration, although this has moved more slowly. For example, despite the signing of formal memorandums of understanding (MOUs) on issues including health, quarantine and sharing of medicines, the challenge is to develop a framework for genuine cooperation between neighbor countries. The WHO specialist interviewed stressed the need for countries sharing the same border to develop detailed action plans to coordinate activities. Child health was also identified as a much bigger problem than was expected, and that CDC1 project focus on maternal and child health (MCH) and IMCI was an important opportunity to address this issue. 78. Another strength mentioned is that the individuals involved in CDC1 regional cooperation efforts are all from national programs, existing health managers and directors. But the challenge is that these people are either not the right people or are too busy. Thus, the challenge to balance integration with availability; and a less ambitious, phased, step-by-step approach is suggested. The WHO also worked with the MOE to put CDC in the formal curriculum, which is seen by WHO to be much more effective than printing leaflets. Good collaboration between MOH and MOE ensured good messages, as well as available de-worming medicines in schools. WHO also recommends scaling up the fish breeding models, e.g. to 5 provinces, not 5 villages. 79. The Government is planning to establish a computerized surveillance system and software on a national scale, based on the model currently being tested by PHSSP. Consideration should be given to building on from the surveillance software model being piloted under the PHSSP, which supports improved disease notification by improving data management and the ease of analysis. For example, CDC2 could provide pilot support in under-resourced international border sites to further refine the surveillance software that is being tested, and evaluate its effect on streamlining the heavy workload, particularly at lower levels of the health system. Support could also enhance the software capability to report on a ‗case by case‘ basis, instead of aggregated weekly and monthly reporting, as is the current practice.128 80. Training modules developed and tested for BCC and surveillance system operations in PHSSP are currently undergoing approval by the MOH Department of Science and Training. Action-oriented training methods training of trainers (TOT) for provincial master trainers were developed and provided by international TA, and provide provincial trainers with a set of training methodology skills for BCC training at local levels on community mobilization for CDC, and on the use of the surveillance software. The PHSSP has also benefited from a team of national TA based in each project province, and a team of international country-based TA to support and monitor implementation. Overlap

127 Asian Development Bank, 2006. Country Strategy and Program: Viet Nam 2007-2010 128 Discussions with PMU for the PHSSP Project



provinces would benefit if CDC2 were to pick up the continuing support when PHSSP finishes in December 2011. The PHSSP mid-term review is scheduled for 2010.


81. Achievements - Community-based fish breeding pilots visited in Can Tho and Dong Thap provinces129 were operating well, although these pilots were operating in just two or three communes in each province as per CDC1 project master plan, which was handed down to the provinces from the central level. The reporting format for districts and communes were designed and provided by the PMU, and should have been made simpler. Cross-province and cross-district monitoring is being conducted, but with no qualitative analysis.

82. Both Can Tho and Dong Thap provinces have a high prevalence of dengue, and Dong Thap is also a hotspot for HIV/AIDS, and shares a border with Cambodia. Building on the BCC for community-based prevention capacities developed under the ADB JFPR Regional HIV/AIDS Project (2001-2004), CDC1 has successfully integrated care and treatment capacities into provincial HIV/AIDS activities at province, district, health center, and community levels. Having built local capacity, they can now implement programs well, and can share experiences with neighboring provinces, for example, they can replicate prevention models for other provinces to implement. Dong Thap province has two cross border points, but there is no cross border check point for diseases. Animal cross border transportation is handled by the Ministry of Agriculture.

83. There has been a significant decrease in dengue recorded in the pilot communities, with one commune reporting no dengue cases since the pilot started in February 2007. Project activities included: (i) training activities; (ii) establishment of the steering committee; (iii) mobilizing project collaborators network; (iv) community communication; and (v) controlling larva through the fish breeding program. Pasteur Institute trainers conducted training on topics such as outbreak investigation and emergency response, behavior change communication methods, community-based care, and monitoring and evaluation (M&E). Monitoring forms reviewed by the mission were designed for collection of quantitative data, with little or no qualitative analysis. 84. Challenges include: (i) difficult to assess project objectives and outcomes mainly due to lack of a baseline; (ii) implementation issues has resulted in delays; (iii) activities covering 15 project provinces has spread resources thinly; and (iv) social safeguard provisions for EMGs and gender considerations were included in the project design, agreement and administration manual, but were not implemented in CDC1 at provincial level or by the participating institutes. 85. Within MOH, the General Department of Preventive Medicine (GDPM) has overall responsibility for CDC nationally and locally.130 HIV/AIDS, malaria and TB are separate national programs which present challenges for integration because they lie outside the responsibility of GDPM.131 IMCI and CDC were also programmed separately from one another under CDC1, with little evidence of CDC integration within IMCI or into the health system. 86. Although it is at the lower levels of the health system that mainstreaming typically takes place, NIMPE reported difficulty mainstreaming any other community-based health activities with the de-

129 Dong Thap province was visited during the RCAPE Evaluation Mission in 2008 130 Government of Viet Nam. 2007. Vietnam National Strategy on Preventive Medicine to 2010 and Orientation towards 2020 131 In Lao PDR, for example, the EA is located in the Department of Planning and Budgeting, which may serve to provide greater leverage over the various departments and programs involved.



worming campaigns at the community level, which they felt would be too much for commune health workers (CHWs) to handle. 87. NIHE is responsible for providing CDC1 technical support to the northern project provinces; NIMPE covers parasite-related programming, and Pasteur Institute regional centers in HCMC and Nha Trang cover dengue in CDC1 provinces in the other parts of the country. Although NIHE provided TOT for the five provinces with IMCI programs, the training plan provided to Pasteur and the PHDs by NIHE did not include TOT for PHD trainers, which could have strengthened provincial capacity to provide locally appropriate CDC training and supervision at provincial and sub-provincial levels. Training needs analysis (TNA) was also absent in both the IMCI and CDC training programs reviewed.

88. The difficulty of government bureaucracy in Viet Nam has been experienced in other ADB projects implemented in Viet Nam, such that the arrangements developed during the feasibility study stage are hard to change during the implementation stage. Moreover, new (inexperienced) staff teams are created for every project, and they need to be trained about management and procurement requirements every time. One option that has been proposed is that experienced PMU teams who have worked on prior ADB projects in Viet Nam could be nominated to serve as the PMU staff on subsequent ADB projects in Viet Nam. CDC1 startup delay was due to: (i) complex government procedures; and (ii) new PMU and multiple IAs (15 provincial PMUs and four institutes). Within MOH, almost all its departments and divisions are involved in regional cooperation but are unaware of each other‘s regional activities.132

89. Provincial project assistance is still needed to upgrade provincial health systems, but should be done in a more systematic and balanced manner based on clearly articulated national and provincial policies and priorities. For example, access to and authority over project funds at provincial level would enable provinces to program CDC initiatives according to local needs.

90. Comprehensive provincial plans and medium term expenditure frameworks would need to be developed to improve transparency on sources and uses of funds, enhance ownership and accountability, identify priorities and financing gaps, help mobilize resources, facilitate policy compliance and standard setting, and monitor sector performance for more balanced spending. Joint annual health reviews conducted by MOH and partners would identify priorities and a common agenda for CDC development and integration within the health sector, and in collaboration with other relevant sectors, including the private sector and NGOs, where feasible. Country-based international and national project TA is strongly recommended for CDC2, to work with the MOH at central and provincial levels for on-going management support.

132 Asian Development Bank, 2007.PPTA Report: Health Care in the South Central Coast Region

APPENDIX 5:

LESSONS LEARNED


Appendix 5: Lessons Learned – Final Consultant Report April 2010 Page 1

APPENDIX 5 – LESSONS LEARNED

This appendix set out a series of well documented lessons learned from the CDC1 Project that have been extracted from ADB review documents, consultations with senior management of MOH as part of the RPPTA Teams field activities, and reviews undertaken by CLV project staff on an annual basis. The most recent and valuable contributions to the lessons learned knowledge database have been the individual country evaluations which were presented at the 8th GMS Regional CDC Review Workshop. Phnom Penh, Cambodia, on the 11th and 12th November 2009. Overall the lessons learned have been valuable in helping to shape the scope and content of the CDC2 design. The main themes of the lessons learned are outlined in the following pages.

1. Regional and Cross-Border Collaboration in Health is not intended to replace national disease control efforts and health services. Instead, it is meant to supplement or reinforce these national and local efforts by addressing common gaps or pockets of infection that the national programs and services have missed.1 Despite the many advantages of regional health cooperation, collaboration has been difficult to achieve due to a number of barriers, which include: (i) political barriers; (ii) legal barriers; (iii) administrative barriers; (iv) cultural barriers; and (v) professional barriers.2 A key lesson that can be derived from these barriers is that cross–border collaboration in health must involve the central, state/provincial, and local levels, and public and private sectors, as well as community-focused interventions that support locally owned initiatives that enable communities to improve their own health.3 This experience here has helped determine the re-focusing of the project geographic to a cross border orientation within the context of the GMS economic corridors. (See CDC2 strategy for cross border engagement linked to the Project Rationale (Appendix 3) 2. In CDC1, close collaboration, experience and information sharing (e.g. personal contacts, activities, and websites) have been important to bring the CLV countries closer together. The Regional Coordination Unit (RCU) has provided vital support to project implementation in the CLV countries. However, there a need to look at the way national programs interact with the RCU, including clarification of RCU‟s role in this process over the longer term, the level of authority that the RCU should have in order to be effective, and the potential for partnerships or eventual handover of certain functions, to an established regional institution such as MBDS.4 This approach has been further developed with the development of a draft TORs for a Regional “Clearing House” to enhance Knowledge Management (KM) and partner‟s collaboration. (See Appendix 20) 3. A SWOT analysis conducted by the RCU identified CDC1 strengths, including: (i) Project officials are key ministry officials; (ii) CDC1 placed within the broader context of the ADB-GMS Program, (iii) significant project funding ($39M); and (iv) strong linkages developed among scientists in the CLV countries. Weaknesses included: (i) lack of high level coordination with established regional organizations like ASEAN and MBDS; (ii) RCU seen as a separate „project office‟ rather than an institutionalized structure; (iii) CDC1 limited to only three countries within the 6-country GMS; and (iv), insufficient multi-sector focus, including poor links to animal health. Opportunities included: (i) existing political will, (ii) senior health networks; (iii) a growing trust; (iv) development and use of ICT; (v) the APSED framework; and (vi) lessons learned from recent pandemics. Threats include: (i) a lack of momentum; (ii) donor fatigue (ii) abandoning initiatives before doing serious trials; (iii), lack of regionally focused staff; and (iv) unsustainable funding5 4. A suggested definition of what is meant by „regional‟ is that regional programming should concentrate on elements that are regional, and fill the gaps that are left by the national programs, such as addressing language barriers and clarifying the role of provincial offices for improved 1 Lemma Merid, 2003. “A Regional Perspective Towards Managing HIV/AIDS in Northeast Africa,” Journal of Health and

Population in Developing Countries. 2 Homedes, Nuria and Antonio Ugalde. 2003. “Globalization and Health at the US-Mexico Border” 3 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. Nov 2009. Phnom Penh 4 Ibid 5 Asian Development Bank. 2009. A Concise S.W.O.T. Analysis of the “Regionality” of the ADB GMS CDC. Discussion

Paper. Regional Coordination Unit, Hanoi



cross-border collaboration, mobilizing skills and resources from across the region, including from China and Thailand, clarifying the role of MDGs in Project M&E, and addressing the need for additional training and research, especially for dengue and NTDs in border areas.6

5. Health system strengthening is also important. In Lao PDR, placement of the EA and PMU in the Ministry of Planning and Finance has encouraged provincial planning processes in a way that has not been the case in Viet Nam and Cambodia, for example. However, greater understanding of the planning process at provincial level, especially on the borders is also needed. Funding for cross-border activities was under-utilized in CDC1. The Viet Nam Department of Preventive Medicine has a strong presence at the district and provincial levels which enhances understanding of the Project at those levels within the Planning Department. Institutional arrangements are important and there is a need to fully engage with each level. The provision of national consultants was also under-utilized in CDC1, with only Lao PDR using them fully. Countries need to ensure that provincial planning supports national initiatives.7 The approach to strengthen the provincial and district levels is the cornerstone of CDC2.

6. GMS cooperation for CDC. Agreements and frameworks for regional cooperation have been developed, and benefits of regional approaches being piloted are beginning to emerge, in terms of technology transfer for strategic planning and generating a healthy climate of professional cooperation, competition, and commitment.8 However, activities have been limited and have tended to follow vertical planning approaches, and progress on regional reporting needs strengthening. The basis for joint disease control activities has not been laid down, and networking among these professionals has not taken root outside of forums and workshops. Only one sub-regional project country achieved substantial policy and regulatory reform in enabling and sustaining surveillance and response systems (the foremost of which is funding) compared to the other two countries, and the knowledge generated from the projects may not have been used effectively.9 7. Within a regional context, a balance between quality and coverage is needed, including for inter-provincial and cross-border approaches. Financial sustainability must also be addressed. Partnerships with WHO-SEARO and WPRO will help to improve national and regional strategies. Coordination with ASEAN, MBDS and others should be explored as well. The activities of the Global Network for NTDs should be built on to leverage additional finance. There remains a question whether dengue should be harmonized across the three countries.10 CDC2 will continue to support funding support for dengue activities in the event of an emergency outbreak. It is foreseen that ADB will in 2010 begin the preparation of a five year regional dengue program. 8. The WHO-SEARO APSED bi-regional strategy provides a good framework to review and assess regional capacity for CDC. However, APSED is still largely overlooked in national program plans and strategies, and lack systematic assessment of country progress on APSED, such as for preparedness and capacity. The new IHR (2005), in force since June 2007, have provided a stronger international framework for cooperation in infectious diseases and other serious public health threats. It has also imposed strong legally binding obligations, whereby attention becomes focused on IHR-bound international check-points, for example, and may to neglect the „unofficial‟ border crossings where the risk of disease spread may sometimes be higher, given possible unchecked, illegal activities taking place (e.g. livestock smuggling, illegal immigrants, trafficking of counterfeit medicines, etc)11 The APSED strategy has helped shape the approach and components of the CDC2 and is recommended that it should form the framework for guiding CDC2. 6 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. Nov 2009. Phnom Penh 7 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. November 2009. Phnom Penh 8 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater

Mekong Subregion: Maturing and Moving Forward 9 Asian Development Bank, GMS-RCAPE, 2008. 10 Asian Development Bank. *th GMS Regional CDC Review Workshop Report. November 2009. Phnom Penh 11 Asian Development Bank. February 2009. Lessons Learned In Regional Cooperation in CDC.RCU, Hanoi



9. Although [ground] cross-border cooperation is considered a critical element of regional CDC and pandemic preparedness, few donors and partners have actively supported cross-border activities. Consultative workshops on cross-border collaboration supported under CDC1 have led to a three year plan for 5 cross-border sites, which will be followed up under CDC2 to develop and agree on specific operational guidelines and procedures for cross-border cooperation.12 Effective donor coordination in Lao PDR, for example, is reported to have resulted from an annual project planning process that is based on province level or “bottom-up” planning and which is also well harmonized with Global Fund (GF) planning, and the key link for success according to the project management team in Lao PDR (and as mentioned above) has been the placement of the EA and PMU for the CDC1 Project in the Budget and Planning Department of the MOH, which provides for greater overall management leverage for more effective implementation.13 10. Baseline data for M&E: Of considerable concern is the lack of baseline information and the level of project M&E and quality assurance at national and provincial levels, which appears to remain weak overall, making it difficult to attribute improvement in key indicators to specific project strategies and interventions, before and after project implementation. National M&E frameworks need to include collection of appropriate performance indicators at the lowest implementation level from the start of project activities. Experience from the Community Action for Preventing HIV/AIDS project (JFPR 9006), and later CDC1, demonstrated the importance of building a strong research component in pilot projects right from the start, to be able to measure outcome and impact from project interventions.14 The lack of good baseline in CDC1 is well recognised. A key feature of Component 1 of CDC2 is a comprehensive baseline survey designed to guide the provincial and district CDC cluster strategies for cross-border cooperation. This will identify EMG communities in border districts and identify their needs in more detail, and will assist to plan harmonised cross-border activities to improve CDC in these communities. Baseline information can be compiled from existing data, small, periodic targeted surveys and behavioral studies at the community level to identify the most effective and sustainable means of promoting the desired changes are also cost efficient options, appropriate to local capacities, and can more easily fit into the routine health M&E systems. The baseline will be monitoring and evaluation for the life of the project, outputs outcomes and impact will determine the performance of the project which will include the reduction of CDCs among EMG populations in Project provinces.

11. An international consultant Social Anthropologist with relevant GMS experience will advise on specific research activities on EMGs for the baseline and on the development of more appropriate ethnic and gender sensitive strategies for engagement and communication with linguistic/ethnic groups in the participating districts. The consultant will lead a team, working with national institutes for social and cultural research.

12. The interventions, depending on the needs assessments derived from baseline data may include: i) Mobile clinics, with provision of vehicles, trail bikes, boats and equipment for conducting outreach programs for vaccination, checkups of children under five years old, antenatal care, family planning and HIV and STI awareness, hookworm treatment, vitamin supplements, tetanus immunization, malaria treatment and bed nets, dengue vector eradication and other measures relevant to local CDC situations; i) IEC training package to retrain health volunteers and health workers using participatory, culturally and gender sensitive methods to raise community awareness on prevention of communicable diseases and environmental sanitation; and iii) provision of water and sanitation facilities where needs and additional donor funding is availabble. 13. Quarantine services in CLV have received CDC1 project support mainly for equipment, such as computers, and some capacity building in selected ports and border points. However, much more is needed to meet the requirements according to government plans, including for (i) civil works; (ii) equipment and supplies provision; (iii) a range of capacity building needs; and (iv) 12 Asian Development Bank. 2009.. A Concise S.W.O.T. Analysis of the “Regionality” of the ADB GMS CDC. Discussion

Paper. Regional Coordination Unit, Hanoi 13 Asian Development Bank, 2009. TA RCAPE Assessment Report. 14 Asian Development Bank, 2009. Regional Cooperation Assistance Program Evaluation (RCAPE) for the Greater

Mekong Subregion: Maturing and Moving Forward



recurrent costs for these inputs. Given the magnitude investments required, plans for further strengthening of quarantine in CLV should be addressed in a separate project outside CDC2 specifically tailored to meet these needs. 14. Addressing HIV: HIV is a major continuing CDC issue in CLV, particularly in rapidly developing border provinces linked by new roads. However considerable financial support is available from other sources, such as the Global Fund. Cambodia‟s effective use of INGO to source funding and design innovative programs for HIV prevention and treatment suggests a useful strategy for Lao PDR and Viet Nam. Experience from ADB‟s Regional HIV/AIDS Project (JFPR 9006) indicates that Project activities should be (i) evidence-based; (ii) respond to local priorities and plans; and (iii) be integrated with regular health services. In addition, the strong capacity-building focus of the JFPR HIVAIDS project established a strong foundation for CDC1 to build upon to integrate HIV/AIDS treatment and care into the prevention capacity built under JFPR, and to provide critical bridging support for community and local government preparedness for emerging diseases, with capacity-building inputs down to community level.15 Whilst CDC2 will not be directly funding HIV activities as in CDC1, it will still include HIVAIDs surveillance as part of the overall national surveillance system which is supported by CDC2. 15. Strengthening and rationalization of laboratory services is needed but should be a component in national health systems development assistance. Laboratory capacity in project provinces and districts has improved as a result of CDC1 support, although shortage of consumable reagents is reported to be a chronic problem. CDC2 should provide limited capacity-building assistance focused on border districts in the context of strengthening cross-border surveillance, and encourage adequate government budget support to essential laboratory recurrent costs. The Project will also provide short term TA Laboratory Specialist to undertake an assessment of the national support systems and the basic laboratory services at provincial and district levels to ensure that prompt and quality diagnosis is available to confirm or not suspected infectious communicable diseases. 16. Capacity building has so far focused on training individuals. There is a need for a more sustainable approach which builds capacity by developing training systems for planning and management of human resources, particularly at provincial and sub-provincial levels, and in keeping with national policies for the decentralization of health systems. This includes the development of master trainer teams, and improving training materials in each project province, and harmonizing the approach in CLV. While such training and capacity-building activities and structures have the potential to significantly improve knowledge and practice, the training processes need closely monitored support at implementation and supervisory levels to ensure quality, and at central and senior levels to ensure sustainability and continuing relevance. Frequent and careful monitoring of project implementation is essential to ensure that the newly established operational processes and procedures for CDC are clearly understood and activities carried out correctly and completely by the responsible parties at all levels. Experience from CDC1 and other ADB projects also indicate that attention should be given to build capacity for project management and implementation prior to project launch.16 Based on APSED and the lessons learned, CDC2 will largely be a capacity building project with a training system strengthening and TOT approach.

17. The level of institutional capacity building for provincial systems should be addressed and these is a need for greater emphasis on gender and ethnic minority needs. Issues surrounding the administrative and financial management process should also be examined. Understanding local contexts is important for rapid response and human resource issues, as are local linkages and improved testing. Synchronized cross-border mass drug administration (MDA) is also advocated and well as for improved financial management.17

15 Asian Development Bank. TA Assessment: RCAPE on GMS. 16 ibid 17 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. Nov 2009. Phnom Penh



18. Experience from CDC1 demonstrates that capacity building at all levels of the health system can lead to significant health benefits, including increased utilization of services (due to public trust and confidence in the skills that have been built up); improved outcomes (e.g. better preparedness and a more rapid response to disease outbreaks); and improved service quality. In many provinces and districts reviewed, CDC1 capacity building inputs were found to have helped to up-grade the existing health systems, and provided a good model for quick response to common serious endemic diseases like dengue, including better clinical diagnosis, and greater reach to the community level, enabling better management of dengue by local health departments. Prior to CDC1 support in project provinces, surveillance and response capacity extended to district level only, with training only available at district level. CDC1 extended training and capacity-building to the health center staff and village health volunteers, effectively extending the surveillance system to the village level. This includes reporting capability, depending on phone networks, and availability of phone cards.18 CDC2 will continue to support the approach that the staff at the provincial and district level have the supplementary resources that will enable them to provide the training services at all levels.

19. Training of village health volunteers‟ remains of vital importance. Involving and training the community, especially community health workers and ensuring a system of community surveillance are important for limiting the spread of disease in the region. The role of communities in disease prevention and containment needs to be prioritized to ensure that services are delivered at the highest possible standards. Innovative incentives for sustained community involvement such as salaries, stipends, preferential access to medicine and health care, training opportunities or public recognition will also be important to ensure buy-in from community health workers.19 20. Importantly, for the capacity building outcomes to remain effective and sustained, refresher training for health staff and community health workers will be required, as well as support for recurrent costs to implement activities. For disease surveillance, response and preparedness systems to be effective, sufficient cash support (on hand) is also required to respond to disease outbreaks, as a supplement to the existing government health budgets that are insufficient for rapid response.20

21. Integrating CDC programs within the national health systems are complex, and with some exceptions, proceeding at a slower pace. However, lessons are emerging on integration of CDC, for example, from the RETA Roll-back Malaria (RBM) initiative (2000-2005) and include: (i) efficiency could be improved by integrating other diseases (e.g. DD) into malaria control activities; and (ii) the information generated from the project argues for an expansion of the TA scope into non-endemic areas and other EMGs, to take advantage of economies of scale.21 To begin to address the integration CDC of CDC and other provincial services will be support with the establishment of a provincial technical management committee to ensure that planning and finance and other technical departments are engaged in the project. 22. Support to the decentralized arrangements of health systems require strong planning and management participation at provincial as well as district levels for enhanced ownership by local authorities, and to clearly define roles and responsibilities, User-friendly guidelines and SOPs are also needed for work within and external to the health system. For example, border quarantine check-point stations for agriculture and health observed in PPTA field visits were established side by side at international border crossings, but operational guidelines for joint operations or collaboration of any sort between health and agriculture stations were not in place. 23. TA financed incentive payments. Incentive payments are widely perceived to be a key element to successful implementation of community-based interventions, particularly in remote areas. However, recurrent cost for CHWs requires careful consideration. Experience from CDC1 and other ADB health projects (e.g. JFPR HIV/AIDS and RETA malaria) highlights the trade-off

18 Asian Development Bank. TA Assessment: RCAPE on GMS. 19 Asian Development Bank. 8th GMS Regional CDC Review Workshop Report. Nov 2009. Phnom Penh 20 ibid 21 Asian Development Bank. TA Assessment: RCAPE on GMS. RETA 5958: Rollback Malaria Initiative in the GMS



between effectiveness and sustainability, where incentive payments for CHWs in some cases have jumped to four to five times the usual government CHW payments under project funding, with no evidence of government capacity or commitment to sustain this level of payment after project completion, or how CHW participation would be affected with post-project reinstatement of lower government incentive payments. 24. Sustainable approaches to CDC: Experience has also shown when outbreaks occur, communities tend to passively participate in what, from the community standpoint, is often seen as the responsibility of the health authorities. Chemical vector eradication must be accompanied by community and household level participation in vector control. For example, the widespread project provision of abate for dengue control at the community level is expensive and may also become less effective in the long term due to resistance.22 Complementary, multi-sector approaches are needed to promote environmental health, personal hygiene, food safety, and safe drinking water and proper sanitation. Further support is also needed for improved health services capacity and reach to remote areas, as well as for community preparedness and prevention including for CDC forecasting, risk mitigation, and reinforcing of public health fundamentals to contain transmission and exposure to pathogens.23 In Component 2, CDC2 will provide outreach to underserved populations. Support will be given to districts to plan integrated village-based primary health care program based on national „healthy village‟ criteria for environmental sanitation and coordination of government services to support achievement of these criteria, including health care funds for the poor. Existing maternal and child health (MCH) services in rural areas will be strengthened to increase communicable disease prevention capacity, by increasing outreach services to border communities. The focus of activities and priorities will be determined by the district‟s comprehensive baseline study and will be tailored accordingly, with gender and cultural sensitivity, to the specific needs of each district. National women‟s organizations will be provided with support to promote women‟s participation (which is currently weak), MCH activities, immunization, healthy village concepts and associated CDC project activities at community level. 25. Participatory, multi-sector approaches among government departments and within the community have been shown to strengthen the outcomes and impacts of health and social development interventions. For example, schools were observed to be active, effective partners in CDC, including for: (i) integration of CDC information into school health education curricula, (ii) are key venues for regular de-worming and EPI campaigns; and (iii) to mobilize students as “cost effective” community mobilization workers, whereby students conduct regular hygiene and environmental sanitation surveys in and around their homes as part of their health education homework assignments. This model has proved to be highly successful in pilot communities in Viet Nam and Cambodia, especially for promoting vector control initiatives, such as fish breeding, and for modeling healthy behaviors and reinforcing health information in the home. 26. Experience from CDC1 has also demonstrated that community mobilization, IEC/ BCC and health education, if systematically implemented through local structures, such as multi-sector health committees, mass organizations, CHWs and other community volunteers (such as school children who carry out routine environmental sanitation surveillance at home as health education homework assignments) and with the support of the local political authority, can improve preventive actions, health seeking behavior and overall population health. CDC2 Project will continue to support this approach, but with a stronger focus on BCC.

22 Discussion with the WHO Regional Dengue TA for CDC1 23 Asian Development Bank, 2008. Aide Memoire: Fact Finding Mission for the PPTA for the Second GMS Regional

Communicable Disease Control Project (CDC2) Cambodia, October 2008

APPENDIX 6:

PROJECT COST ESTIMATES AND

FINANCING PLANS


Appendix 6: Project Cost Estimates & Financing Plans – Final Consultant Report April 2010 Page 2

PROJECT COST ESTIMATES AND FINANCING PLANS

(Final Report - 22 January 2010)

Currency Equivalents (As of 01 November 2009)

Cambodia

Currency Unit - Riel (KR) $1.00 = KR 4,200

Lao PDR Currency Unit - Kip (KN) $1.00 = KN 8,500

Viet Nam Currency Unit - Dong (D)

$1.00 = D 17,002

NOTES (i) The fiscal years (FY) of the Governments of Cambodia and Viet Nam ends on 31

December, and for Lao People’s Democratic Republic, on the 30th September each year.

(ii) In this report, “$” refers to US dollars.



I. INTRODUCTION

1. The proposed CDC2 for three countries (CLV) includes a Project Loan of $ 25 million and three Grants from ADB with a total amount of $ 25.0 million. The Government of Lao (GoL), Goverment of Viet Nam (GoV), Royal Government of Cambodia (RGoC) will contribute in kind and in cash counterpart funds of $ 0.856 million, $ 0.706 million, $ 2.704 million respectively equivalent.The Project has two major components: (i) Strengthening Regional Coorporation in Communicable Diseases Control; and (ii) Strenthening National Surveilance and Response Systems, and will be implemented from 2011-2015 in CLV countries. The Consultant has followed ADB’s Preparation and Presentation of Cost Estimates for Projects Financed by the Asian Development Bank: Technical Note (ADB, April 2008) to prepare cost estimates and financing plans. Since this report was written ADB have advised that an additional 1 million grant funds would be available for Lao PDR and an additional 8 million of loan funds would be available for Vietnam for civil works for Preventative Medicine Centres in the Project Provinces.

II. PROJECT COST ESTIMATES

2. Project cost estimates were prepared separately for each country and integrated in a set of cost table. Upon request of the Project Officer, the Consultant used the Microsoft Excel software to do costing works in a unlocked manner for easier amendment during ADB Appraisal Missions. The costant prices of November 2009 were used for calculating. Cost estimate summary for each project country is presented below in the table from 1-3 and detailed cost tables are attached in Annexes 1-3 of this Appendix 6. Base cost is not inluded taxes and duties.

3. ADB has a plan to finance grant funds to Lao PDR and the Kingdom of Cambodia and a loan fund from Asian Development Fund (ADF) for Viet Nam. Two grant funds amounts to Lao PDR and Cambodia are nonrefundable while the lending terms for ADF loans applied for Viet Nam are the following: 32-year maturity, including an 8-year grace period, 1% interest charge during the grace period and 1.5% during the amortization period.

Table No.1 Summary of Cost Estimates: Lao PDR Total Cost (US$ '000)

ADB GoL Total Percent

A. Base Costs 9,570 671 10,241 82.2%

B. Taxes and Duties

121 121 1%

C. Contingencies 629 65 694 5.6%

D. Pool Fund 1,400

1,400 11.2% TOTAL (A) + (B) + (C ) + (D) 11,600 856 12,456 100%

Table No.2 Summary of Cost Estimates: Cambodia

Total Cost (US$ '000) ADB RGoC Total Percent

A. Base Costs 8,762 562 9,323 82.4 %

B. Taxes and Duties 0 101 101 0.9 %

C. Contingencies 438 43 482 4.3%

D. Pool Fund 1,400 0 1,400 12.4% TOTAL (A) + (B) + (C) +(D) 10,600 706 11,306 100%



Table No.3 Summary of Cost Estimates: Viet Nam/a Total Cost (US$ '000)

ADB GoV Total Percent

A. Base Costs/b 23,551 2,063 25,614 92.5%

B. Taxes and Duties 0 506 506 1.8 %

C. Contingencies 1,450 135 1,585 5.7 %

TOTAL (A) + (B) + (C) 25,000 2,704 27,704 100% a/ The proposed Grant fund for Viet Nam is under discussion and not included and presented in Table 3. b/ Base costs include an unallocated amount of $4.716 million under SubComponent 2.5

4. Cost estimates for Technical Assistance and operation of the Regional Coordination Unit (RCU) include relevant costs for consulting services to be based in Viet Nam and an RCU office. The total cost for this TA/RCU is $ 5.6 million for 5-year- implementation with detailed costs attached in Annex 4 of this document. Lao PDR and Cambodia will contribute to this pool fund $ 1.4 million each and Viet Nam will contribute $ 2.8 million from ADB’s grant fund.

III. PROJECT FINANCING PLANS

5. The proposed CDC2 does not involve any cofinancing from other donors. There are also no local contributions either in kind or in cash from community beneficiaries. The financing plans for both Project Loan/ Grants have been verified, and the ADB loan/ grant funds and counterpart funds from three Governments will be made available on a timely fashion. A. Project Grant Financing Plan for Lao PDR

6. The GoL has requested a Grant from ADB in SDR equivalent to $ 11.6 million to help finance the Project (Table 5). The nonrefundable grant fund will have a 5-year term. The GoL will contribute US$ 0.856 million equivalent including $ 0.671 million in kind for recurrent costs (operation and maintainance, supplies) and $ 0.121 million in cash for local taxes purpose and contingencies. The total project investment cost and recurrent cost is estimated at $ 12.456 million, covering also physical and price contingencies, taxes and duties.

Table 5. Project Financing Plan

(US$ million)

Sources Total % Asian Development Bank 11.600 93.1

Government of Lao PDR 0.856 6.9

Total 12.456 100.00 B. Project Grant Financing Plan for Cambodia

7. The RGoC has requested a Grant from ADB in SDR equivalent to $ 10.6 million from ADB’s Special Fund resources to help finance the Project (Table 6). The grant fund will have a 5-year term. The GoV will contribute $ 0.706 million in kind and in cash of which $0.562 million is for recurrent costs (operation and maintainance, supplies) and $ 0.101 million is for local taxes and $0.043 million for contingencies. The total project investment cost and recurrent cost is estimated at $ 11.306 million, including physical and price contingencies, taxes and duties.



Table 6. Project Financing Plan (US$ million)

Source Total % Asian Development Bank 10.600 93.8

Government of RGoC 0.706 6.2

Total 11.306 100.00

C. Project Loan Financing Plan for Vietnam

8. The GoV has requested a Loan from ADB in SDR equivalent to $ 25 million from Asian Devlopment Fund resources to help finance the Project (Table 7). The loan will have a 32-year term, including a grace period of 8 years, and an interest rate of 1% during the grace period and 1.5% per annum thereafter. The GoV will contribute $ 2.704 million in kind and in cash of which $ 506 million, $ 1.422 million will be paid for local taxes,duties and recurrent costs repspectively, among the other espenses. The total project investment cost and recurrent cost is estimated at US$ 27.704 million, including physical and price contingencie, taxes and duties and other charges during implementation, unallocated amount ($4.716 million)1.

9. As to support project implementation, ADB is considering to finance a grant fund for technical assistance for Viet Nam valuing about $ 2.8 million (to be currently under ADB’s discussion). This grant fund amount is planned to be administered by ADB and placed under the Project Pool Fund for consulting services and other regional coorperation activities.

Table 7. Project Financing Plan2

(US$ million)

Source Total % Asian Development Bank (Loan) 25.000 90.2

Government of Viet Nam 2.704 9.8

Total 27.704 100.00

IV. PROJECT DETAILED COST ESTIMATES

Soft copies are attached as below: Annex 1: Cost tables for Lao PDR Annex 2: Cost tables for Cambodia Annex 3: Cost tables for Viet Nam Annex 4: Cost tables for TA/RCU

1 Government of Viet Nam will use other sources of fund to pay interest for this loan funds (see further information in Appendix 11) 2 Excluding a proposed Grant fund for technical assistance of about $ 2.8 million

ANNEX 1 COST TABLES FOR LAO PDR

ANNEX 2 COST TABLES FOR CAMBODIA

ANNEX 3 COST TABLES FOR VIETNAM

ANNEX 4 COST TABLES FOR TA / RCU

Second GMS Regional Communicable Disease Control ProjectAppendix 6 - Cost Estimates and Financing Plan - Annex 1 - Lao PDR

Table No. TABLE OF CONTENTS Page No.

1.1 Project Cost Estimates by Component/Subcomponent. 1

1.2 Summary Cost Tables 1

1.3 Base Cost Estimates by Component/Subcomponent 2

1.4 Cost Estimates, Financier and Funds Flow 3

1.5 Financing Plan by Expenditure Category 4

1.6 Base Cost Estimates by Expenditure Category and Component/Subcomponent 5

1.7 Base Cost Estimates by Expenditure Category (ADB and GOL) 6 to 7

1.8 Total Base Cost Estimates by Expenditure Category 8 to 16

1.9 Grant Proceeds 17

APPENDIX 6ANNEX 1 - LAO PDR

ADB TA - REG: Second GMS Regional Communicable Disease Control Project

Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total PercentA. Base Costs

1 Strengthening Regional Cooperation in Commmunicable Disease Controla Compatible and coordinated strategies for CDC across borders 11.8 7.5 7.5 7.5 7.5 41.8 0.0 0%b Cross-border planning, monitoring and evaluation for CDC 373.9 195.6 100.6 70.6 62.6 803.3 0.8 6%c Regional knowledge management 33.5 49.5 32.0 32.0 16.0 163.0 0.2 1%d Support for regional GMS CDC cluster implementation and coordination. 52.0 - - - - 52.0 0.1 0%

Subtotal (A) 471.2 252.6 140.1 110.1 86.1 1,060.1 1.1 9%

2 Strengthening National Surveillance, Response and Health Systemsa Strengthening institutional structures, partnerships, and policies. 5.7 7.3 5.3 0.5 0.5 19.3 0.0 0%b Strengthening systems for Human Resources Development 138.9 269.8 68.4 68.4 56.9 602.4 0.6 5%c Strengthening systems of surveillance, response, and preparedness 74.9 567.7 506.3 456.3 113.1 1,718.3 1.7 14%d Capacity Building of Provincial and District staff for CDC 31.4 729.8 516.5 441.8 86.0 1,805.5 1.8 15%e Targeted CDC and training activitives for rural populations in border districts 52.2 563.9 613.7 309.7 289.7 1,829.2 1.8 15%f Support for national project implementation 1,253.8 492.3 496.3 473.1 465.6 3,181.3 3.2 26%

Subtotal (B) 1,556.9 2,630.8 2,206.5 1,749.8 1,011.8 9,155.9 9.2 74%

B. Taxes and Duties 7 33 27 27 27 121 0.1 1%

C. Contingenciesa Physical Contingencies 22 17 10 10 10 68.8 0.1 1%b Price Contingencies 65 187 165 131 77 623.7 0.6 5%

Subtotal (C) 87 204 175 141 87 692.5 0.7 6%

280 280 280 280 280 1,400.0

TOTAL (A) + (B) + (C) 2,401.7 3,400.1 2,828.5 2,307.7 1,491.5 12,429.5 11 100%

Total Base Cost

ADB Gov't Total Percent

A. Base Costs 9,540 671 10,211 82%

B. Taxes and Duties 121 121 1%

C. Contingencies 628 65 692 6%

D. Pool Fund 1,400 1,400 11%TOTAL (A) + (B) + (C ) + (D) 11,568 857 12,424 100%

Second GMS Communicable Diseases Control Project_ Lao PDR

Table 1.1. Project Cost Estimates by Component/Subcomponent

Total Cost (US$ '000)

($ thousand)Total Cost (US$ '000)

Second Communicable Diseases Control Project: Lao PDR

Table 1.2. Summary Cost Table($ thousand)

D. Pool Fund Contribution

Appendix 6 - Cost Estimates and Financing Plan - Annex 1 - Lao PDR - Consultant Report April 2010. Page 1


Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total Percent

1 Strengthening Regional Cooperation in Commmunicable Disease Controla Compatible and coordinated strategies for CDC across borders 11.8 7.5 7.5 7.5 7.5 41.8 0.4%b Cross-border planning, monitoring and evaluation for CDC 373.9 195.6 100.6 70.6 62.6 803.3 7.9%c Regional knowledge management 33.5 49.5 32.0 32.0 16.0 163.0 1.6%

Grant Proceedsd Support for regional GMS CDC cluster implementation and coordination. 52.0 - - - - 52.0 0.5%

Subtotal (A) 471.2 252.6 140.1 110.1 86.1 1,060.1 10.4%2 Strengthening National Surveillance, Response and Health Systems

a Strengthening institutional structures, partnerships, and policies. 5.7 7.3 5.3 0.5 0.5 19.3 0.2%b Strengthening systems for Human Resources Development 138.9 269.8 68.4 68.4 56.9 602.4 5.9%c Strengthening systems of surveillance, response, and preparedness 74.9 567.7 506.3 456.3 113.1 1,718.3 16.8%d Capacity Building of Provincial and District staff for CDC 31.4 729.8 516.5 441.8 86.0 1,805.5 17.7%e Targeted CDC and training activitives for rural populations in border districts 52.2 563.9 613.7 309.7 289.7 1,829.2 17.9%f Support for national project implementation 1,253.8 492.3 496.3 473.1 465.6 3,181.3 31.1%Subtotal (B) 1,556.9 2,630.8 2,206.5 1,749.8 1,011.8 9,155.9 89.6%TOTAL (A) + (B) 2,028.1 2,883.4 2,346.6 1,859.9 1,097.9 10,216.0 100%a/ excluding contingencies, taxes and duties

Second GMS Regional Communicable Diseases Control Project_Lao PDR

($ thousand)Base Cost

Table 1.3. Base Cost Estimates by Component/Subcomponent

Appendix 6 - Cost Estimates and Financing Plan - Annex 1 - Lao PDR - Consultant Report April 2010 Page 2

ADB TA - REG: Second GMS Regional Communicable Disease Control Project.

Item Total Cost $% of Cost Category $

% of Cost Category

A. Investment Costs1 Strengthening Regional Cooperation in Commmunicable Disease Control 1,060 1,060 100.0 - -

a 42 42 100.0 - - b Cross-border planning, monitoring and evaluation for CDC 803 803 100.0 - - c Regional knowledge management 163 163 100.0 - - d Support for regional GMS CDC cluster implementation and coordination. 52 52 100.0 - -

2 Strengthening National Surveillance, Response and Health Systems 8,073 8,073 100.0 - - a Strengthening institutional structures, partnerships, and policies. 19 19 100.0 - - b Strengthening HRD for surveillance, response, and preparedness 524.90 525 100.0 - - c Strengthening systems of surveillance, response, and preparedness 1,718.30 1,718 100.0 - - d Capacity Building of Provincial and District staff for CDC 1,805.54 1,806 100.0 - - e Targeted CDC and training activitives for rural populations in border districts 1,782.35 1,782 100.0 - - f Support for national project implementation 2,222.85 2,223 100.0 - -

Subtotal (A) 9,133 9,133 - -

B. Recurrent Costs1 Supplies 124 124 100% - 0%2 Vehicle operations and maintainance 788 236 30% 552 70%3 Lab Equipment Operation and maintainance 170 51 30% 119 70%

Subtotal (B) 1,083 412 671

Total Base Cost (A + B) 10,216 9,545 671

C. Contingenciesa Physical Contingencies 69 49 70.7 20 29.3b Price Contingencies 624 579 92.8 45 7.2

Subtotal (C) 692 628 90.6 65 9.4

D. Taxes and Duties 121 - - 121 100.0

E. Pool Fund Contribution 1,400 1,400

Total Project Costs 12,429.48 11,573 856.75

% Total Project Costs 100.0 93.1 6.9

Second GMS Regional Communicable Diseases Control Project _ Lao PDRTable 1.4: Cost Estimates, Financier and Fund Flows

ADB Government($ thousands)

Appendix 6 - Cost Estimates and Financing Plan - Annex 1 - Lao PDR - Consultant Report April 2010 Page 3


ADB GOL ADB GOL ADB GOL ADB GOL ADB GOL ADB GOL Project

1 - - 0 - 0 - - - - - 0 - 02 364 - 108 - 0 - 0 - - - 472 - 472 3 829 0 - 0 - 0 - 0 - - 829 - 829 4 77 - 358 - 81 - 81 0 76 - 672 - 672 5 107 - 755 - 721 - 479 0 75 - 2,136 - 2,136 Grant

392 - 1,124 - 1,074 - 853 0 486 - 3,929 - 3,929 7 122 - 140 - 144 - 121 0 141 - 667 - 667 8 85 - 85 - 85 - 85 0 85 - 423 - 423 9 18 25 143 161 86 161 86 161 79 161 412 671 1,083

9.1 Supplies 7 - 73 - 17 - 17 0 10 - 124 - 124 9.2 Vehicle operations and maintainance 11 25 56 132 56 132 56 132 56 132 236 552 788 9.3 Lab Equipment Operation and maintainance 0 - 13 30 13 30 13 30 13 30 51 119 170

Subtotal (A) 1,993 25 2,712 161 2,190 161 1,704 161 942 161 9,540 671 10,211

7 33 27 27 27 121 121

21 1 12 5 5 5 5 5 5 5 49 20 6965 0 176 11 153 11 119 11 66 11 579 45 624

Subtotal (C) 86 1 188 16 158 16 124 16 71 16 628 65 692

2,079 33 2,900 210 2,349 205 1,828 205 1,012 204 10,168 857 11,024

C. Contingencies1. Physical Contingencies2. Price Contingencies

Total Cost (A+B+C)

A. Base Costs

B. Taxes and Duties (B)

Y1 Y2 Y3 Y4 Total

Second GMS Regional Communicable Diseases Control Project_ Lao PDR

Y5

Commutity Mobilization

Consulting services

Project Management

Recurrent Costs

Table 1.5 Financing Plan by Expenditure Category

Civil Works

Laboratory and Office Equipment

Vehicles

System Development

Training, workshop, fellowships



Com

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Total ($ '000)

Percent (%)

Base Cost1 Civil Works - - - - - - - - - - - 02 Laboratory and Office Equipment - 135 - - - 168 - - - 169 472 5

Grant Proceedsa. Office Equipment - 135 - - - - - - - 169 304 3b. Laboratory - - - - - 168 - - - - 168 2

3 Vehicles - - - - - - - - - 829 829 84 System Development 42 75.0 - - 10 88 114 240 74 5 647 65 Training, workshop, fellowships - - 35 - 10 173 - 1,495 322 103 2,136 216 Commutity Mobilization - 563 128 52 - - 1,605 71 1,387 124 3,929 397 Consulting services - - - - - 96 - - - 571 667 78 Project Management - - - - - - - - - 423 423 49 Recurrent Costs - - - - - 78 - - 47 958 1,083 11

9.1 Supplies - - - - - 78 - - 47 - 124 19.2 Vehicle operations and maintainance - - - - - - - - - 788 788 89.3 Lab Equipment Operation and maintainance - - - - - - - - - 170 170 2

Total 42 773.3 163 52 19 602 1,718 1,806 1,829 3,181 10,186 100Percentage 0 8 2 1 0 6 17 18 18 31 100

Component 2Increasing Access

Expenditure Category

Second GMS Regional Communicable Diseases Control Project _Lao PDR

Table 1.6 Base Cost Estimates by Expenditure Category and Component/Subcomponent($ thousand)

Plan & Fin CapacityComponent 1

Appendix 6 Cost Estimates and Financing Plan - Annex 1 - Lao PDR - Consultant Report April 2010. Page 5


Base GOL ADB Base GOL ADB Base GOL ADB Base GOL ADB Base GOL ADB Base GOL ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total totalBase costs excluding taxes and duties1 Civil Works - - - - - - - - - - - - - - - - - - 2 Laboratory and Office Equipment 364 - 364 108 - 108 - - - - - - - - - 472 - 472 3 Vehicles 829 - 829 - - - - - - - - - - - - 829 - 829 4 System Development 77 - 77 358 - 358 81 - 81 81 - 81 76 - 76 672 - 672

Grant ProceedsTraining, workshop, fellowships 107 - 107 755 - 755 721 - 721 479 - 479 75 - 75 2,136 - 2,136 6 Commutity Mobilization 392 - 392 1,124 - 1,124 1,074 - 1,074 853 - 853 486 - 486 3,929 - 3,929 7 Consulting services 122 - 122 140 - 140 144 - 144 121 - 121 141 - 141 667 - 667 8 Project Management 85 - 85 85 - 85 85 - 85 85 - 85 85 - 85 423 - 423 9 Recurrent Costs 43 25 18 304 161 143 248 161 86 248 161 86 241 161 79 1,083 671 412

9.1 Supplies 7 7 73 73 17 17 17 17 10 10 9.2 Vehicle operations and maintainance 36 25 11 188 132 56 188 132 56 188 132 56 188 132 56 9.3 Lab Equipment Operation and maintainance - - - 43 30 13 43 30 13 43 30 13 43 30 13

Total Base Costs 2,018 25 1,993 2,873 161 2,712 2,352 161 2,190 1,865 161 1,704 1,103 161 942 10,211 671 9,540

Physical contingencies cw 0%, lo 5%, veh 0%, sd 0%, twf 0%, cm 0%, cs 0%, pm 3%, rc 3% 1 Civil Works - - - - - - - - - - - - - 2 Laboratory and Office Equipment 18 - 18 5 5 - - - - - - 24 - 24 3 Vehicles - - - - - - - - - - - - 4 System Development - - - - - - - - 5 Training, workshop, fellowships - - - - - - - - 6 Commutity Mobilization - - - - - - - - 7 Consulting services - - - - - - - - 8 Project Management 3 - 3 3 - 3 3 - 3 3 - 3 3 - 3 13 - 13 9 Recurrent Costs 1 1 1 9 5 4 7 5 3 7 5 3 7 5 2 32 20 12

9.1 Supplies - 0 2 - 2 1 - 1 1 - 1 0 - 0 4 (0) 4 9.2 Vehicle operations and maintainance 1 1 0 6 4 2 6 4 2 6 4 2 6 4 2 24 17 7 9.3 Lab Equipment Operation and maintainance - - - 1 1 0 1 1 0 1 1 0 1 1 0 5 4 2

Total Physical contingencies: 22 1 21 17 5 12 10 5 5 10 5 5 10 5 5 69 20 49

Price Contingencies: see below1 Civil Works - - - - - - 2 Laboratory and Equipment 5 5 - - 5 - 5 3 Vehicles 12 12 - 12 - 12 4 System Development 5 - 5 24 - 24 6 - 6 6 - 6 5 - 5 45 - 45 5 Training, workshop, fellowships 6 - 6 51 - 51 50 - 50 33 - 33 5 - 5 147 - 147 6 Commutity Mobilization 24 - 24 76 - 76 75 - 75 60 - 60 34 - 34 268 - 268 7 Consulting services 7 - 7 9 - 9 10 - 10 8 - 8 10 - 10 45 - 45 8 Project Management 5 - 5 6 - 6 6 - 6 6 - 6 6 - 6 29 - 29 9 Recurrent Costs 1 - 1 21 11 10 17 11 6 17 11 6 17 11 6 73 45 28

9.1 Supplies 0 - 0 5 - 5 1 - 1 1 - 1 1 - 1 8 - 8 9.2 Vehicle operations and maintainance 1 0 1 13 9 4 13 9 4 13 9 4 13 9 4 53 37 16 9.3 Lab Equipment Operation and maintainance - - - 3 2 1 3 2 1 3 2 1 3 2 1 12 8 4

Total Price contingencies 65 - 65 187 11 176 165 11 153 131 11 119 77 11 66 624 45 579

(ADB and GoL) ( $ Thousand)Table 1.7 Base Cost Estimates by Expenditure Category

Second GMS Regional Communicable Diseases Control Project_ Lao PDR



Base GOL ADB Base GOL ADB Base GOL ADB Base GOL ADB Base GOL ADB Base GOL ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total total

Taxes: cw 10%, pm 3%, rc 10% (included above)1 Civil Works - - - - - - 2 Laboratory and Equipment - - - - - - 3 Vehicles - - - - - - 4 System Development - - - - - - 5 Training, workshop, fellowships - - - - - - 6 Commutity Mobilization - - - - - - 7 Consulting services - - - - - - 8 Project Management 3 3 3 3 3 13 9 Recurrent Costs 4 30 25 25 24 108

9.1 Supplies 1 7 2 2 1 12 9.2 Vehicle operations and maintainance 4 19 19 19 19 79 9.3 Lab Equipment Operation and maintainance - 4 4 4 4 17

Total Tax Costs 7 33 27 27 27 121

Total Cost including contingencies, taxes and duties1 Civil Works - - - - - - - - - - - - - - - - - - 2 Laboratory and Equipment 387 - 387 113 - 113 - - - - - - - - - 501 - 501 3 Vehicles 841 - 841 - - - - - - - - - - - - 841 - 841 4 System Development 81 - 81 382 - 382 86 - 86 86 - 86 81 - 81 717 - 717 5 Training, workshop, fellowships 113 - 113 806 - 806 771 - 771 512 - 512 80 - 80 2,283 - 2,283 6 Commutity Mobilization 416 - 416 1,200 - 1,200 1,149 - 1,149 913 - 913 520 - 520 4,198 - 4,198 7 Consulting services 129 - 129 149 - 149 154 - 154 129 - 129 151 - 151 712 - 712 8 Project Management 95 3 92 95 3 93 96 3 93 96 3 93 96 3 93 477 13 464 9 Recurrent Costs 50 30 20 364 208 156 297 202 95 297 202 95 289 202 87 1,297 844 452

9.1 Supplies 9 1 8 88 7 81 20 2 19 20 2 19 12 1 11 149 12 136 9.2 Vehicle operations and maintainance 41 30 12 225 163 62 226 164 62 226 164 62 226 164 62 943 684 260 9.3 Lab Equipment Operation and maintainance - - - 51 37 14 51 37 14 51 37 14 51 37 14 204 148 56

Total amount 2,112 33 2,079 3,110 210 2,900 2,554 205 2,349 2,033 205 1,828 1,216 204 1,012 11,024 857 10,168



Specifications Unit Y1 Y2 Y3 Y4 Y5 Total Unit Cost Y1 Y2 Y3 Y4 Y5 Total ($)

Specifications Unit Y1 Y2 Y3 Y4 Y5 Total Unit Cost Y1 Y2 Y3 Y4 Y5 Total ($)1.1 Compatible and coordinated strategies for CDC across borders

I. Investment costsSystem Development

1.1.1.4. Support the establishment of a National Steering committee National Meeting 1 1 500 500 0 0 0 0 5001.1.1.4. Support the establishment of provincial Steering committees Provincial Meeting 9 9 200 1,800 0 0 0 0 1,8001.1.1.4. Support to establish regional focal office in MOH National office 1 1 4,000 4,000 0 0 0 0 4,000Grant Proceeds.1.1.4.Support to participate in regional activities in MOH National Year 1 1 1 1 1 5 5,000 5,000 5,000 5,000 5,000 5,000 25,0001.1.1.4. Support to establish provincial focal point. Provincial focus point 1 1 1 1 1 5 1,000 1,000 1,000 1,000 1,000 1,000 5,0001.1.1.4. Support to participate in regional activities Provincial Year 5 9 9 9 9 41 500 2,500 4,500 4,500 4,500 4,500 20,5001.1.1.4. Regional Steering Committee Meeting on Roles and Responsiblities National WS 1 1 1 1 1 5 2,000 2,000 2,000 2,000 2,000 2,000 10,000

1.2 Cross-border planning, monitoring and evaluation for CDC

I. Investment costs


1.2.1.2.c Purchase of Computer sets for BLS Database National/Prov Set 12 12 3,000 36,000 0 0 0 0 36,000

1.2.1.2.c Purchase of Computer sets for BLS Database District Set 33 33 3,000 99,000 0 0 0 0 99,000

System Development

1.2.1.4. National Mulit-Sector Strategic/ Operational Planning Wkshop National WS 1 1 1 1 1 5 6,000 6,000 6,000 6,000 6,000 6,000 30,000

1.2.1.4. Provincial Muli-Sector Strategic/ Operational Planning W/shp Province WS 9 9 9 9 9 45 1,000 9,000 9,000 9,000 9,000 9,000 45,000

Training, Workshops, Fellowships

1.2.1.5. Training on research methods using existing data National Course 1 1 2,000 0 0 0 0 0 0

1.2.1.5. Training on research methods using existing data Province Course 9 9 1,000 0 0 0 0 0 0

1.2.1.5. Follow-up by trainers to support research in the provinces Province Course 5 5 1,000 0 0 0 0 0 0


1.2.1.. Study Tour on CDC Preparedness and S/R SystemsThailand or China Study tour 1 1 2 15,000 15,000 15,000 0 0 0 30,000

1.2.1.6. Study Tour on Community-based BCC for CDCCluster Provinces Study tour 1 1 2 10,000 10,000 10,000 0 0 0 20,000

1.2.1.6. TA Team Meeting to Prepare for the Baseline Study National (CLV) WGM 3 3 500 1,500 0 0 0 0 1,500

1.2.1.6. Regional Workshop to design the baseline National (CLV) WS 1 1 3,000 3,000 0 0 0 0 3,000

1.2.1.6. National Workshops to plan implementation of the baseline National WS 1 1 3,000 3,000 0 0 0 0 3,000

1.2.1.6. Provincial workshops to plan implementation of baseline Province WS 9 9 1,000 9,000 0 0 0 0 9,000

1.2.1.6. Dissemination workshops with Districts District WS 33 33 33 33 33 165 300 9,900 9,900 9,900 9,900 9,900 49,500

1.2.1.6. District Multi-Sector Strategic/ Operational Planning W/shop District WS 33 33 33 33 33 165 500 16,500 16,500 16,500 16,500 16,500 82,500

1.2.1.6. Community Awarenes program in target districts and villagesDistrict and villages Program 100 100 200 20,000 0 0 0 0 20,000

1.2.1.6.Recruitment of Ethnic village members to participate in Baseline Survey Prov/Districts Person 100 100 200 20,000 0 0 0 0 20,000

SECOND GMS REGIONAL COMMUNICABLE DISEASES CONTROL PROJECT_ LAO PDR$10,241,040TABLE 1.8 TOTAL BASE COST

I. STRENGTHENING REGIONAL COOPERATION IN COMMMUNICABLE DISEASE CONTROL




1.2.1.6.Institutes or research companies contracted to assist in Baseline National PMU Contract 1 1 1 3 30,000 30,000 30,000 30,000 0 0 90,000

1.2.1.6. Baseline survey undertaken and data analysed National/Prov Survey 1 1 2 70,000 70,000 70,000 0 0 0 140,000

1.2.1.6. Sentinel surveilance villages identified and monitored annually Village level Person 66 66 66 66 264 200 0 13,200 13,200 13,200 13,200 52,800

1.2.1.6. Quarterly consultations and review of District activities. Prov/Districts Review 4 4 4 4 2 18 4,000 16,000 16,000 16,000 16,000 8,000 72,000

II. Recurrent costs

1.3 Regional knowledge management

I. Investment costs


1.3.1.5.Training on Information and Communication Technology (ICT) for PMU, MOH, national institutes.

National (PMU/MOH) course 2 2 4 2,000 4,000 4,000 0 0 0 8,000

1.3.1.5.Training on Information and Communication Technology (ICT) for PPIU, PHD, DHO.

Province (PPIU/PHD) course 9 9 18 1,500 13,500 13,500 0 0 0 27,000


1.3.1.6.Provincial and cross border forums conducted quarterly and annually Prov/Districts Forum 2 4 4 4 2 16 8,000 16,000 32,000 32,000 32,000 16,000 128,000

II. Recurrent costs

1.4 Support for regional GMS CDC implementation and coordination.

I. Investment costsCommutity Mobilization

1.4.1.6. National Workshop to develop the M&E Framework National WS 1 1 5,000 5,000 0 0 0 0 5,000

1.4.1.6. Provincial Workshop to disemiante the M&E Framework Province WS 9 9 1,000 9,000 0 0 0 0 9,000

1.4.1.6. Workshops to Harmonize the M&E Framework Province WS 9 9 2,000 18,000 0 0 0 0 18,000

1.4.1.6. National Planning and Coordination Workshop National WS 1 1 5,000 5,000 0 0 0 0 5,000

1.4.1.6. Regional Planning and Coordination Workshop National/CLV WS 1 1 10,000 10,000 0 0 0 0 10,000

1.4.1.6. Disemination of Baseline information to local communities Village level Unit 1 1 5,000 5,000 0 0 0 0 5,000

II. Recurrent costs

II. STRENGTHENING NATIONAL SURVEILLANCE, RESPONSE AND HEALTH SYSTEMS


2.1 Strengthening institutional structures, partnerships, and policies.

I. Investment costs

System Development

2.1.1.4. National CDC Policy Workshops National WS 1 1 2 2,000 2,000 2,000 0 0 0 4,000

2.1.1.4.Multi-Sector Workshop on Roles and Responsibility for Nat. CDC National Workshop 1 1 3,200 3,200 0 0 0 0 3,200

2.1.1.4. Health Sector Donor (with emphasis on CDC) Meetings Workshop 1 1 1 1 1 5 500 500 500 500 500 500 2,500


2.1.1.5. Training in governance and policy development National Course 1 1 2 2,400 0 2,400 2,400 0 0 4,800

2.1.1.5. Training in multisector coordination and development National Course 1 1 2 2,400 0 2,400 2,400 0 0 4,800

2.2 Strengthening systems for Human Resource Development




I. Investment costs

Training Equipment

2.2.1.2.eProcure and deliver priority training equipment and supplies for TWGs. National and ProvSet 3 7 10 4,000 12,000 28,000.00 - - - 40,000.00

2.2.1.2.eProcure and deliver priority training equipment and supplies for District teams. Province Set 12 20 32 4,000 48,000 80,000.00 - - - 128,000.00

System Development

2.2.1.4.National HRD task force to endorse training systems development approach Set 1 1 200 200.00 - - - - 200.00

2.2.1.4. National Working Group establish framework for HRD. National Set 1 1 1,600 1,600.00 - - - - 1,600.00

2.2.1.4. Orientation Course for Nat. Institutes and specialist trainers. National 1 1 2,000 2,000.00 - - - - 2,000.00

2.2.1.4. Preparation of Training Program/ Training Groups Established National 1 1 2,400 2,400.00 - - - - 2,400.00

2.2.1.4. Annual Provincial HR Planning Meetings, with all levels Province WGM 9 9 9 9 9 45 1,000 9,000.00 9,000.00 9,000.00 9,000.00 9,000.00 45,000.00

2.2.1.4. Workshops to orient PTWGS on modules and approaches Province WGM 9 9 9 27 500 - 4,500.00 4,500.00 4,500.00 - 13,500.00

2.2.1.4. Establish inventory of existing IEC/BCC materials National and ProvPPIU 9 9 300 - 2,700.00 - - - 2,700.00

2.2.1.4.Meetings to identify/prioritize Training equipment and supply needs National and ProvWGM 9 9 300 - 2,700.00 - - - 2,700.00

2.2.1.4. Provincal workshops to develop IEC/BCC strategies Province WS 9 9 1,000 - 9,000.00 - - - 9,000.00

2.2.1.4. Audience Analysis, IEC/BCC Materials Testing & Revision Province WS 9 9 1,000 - 9,000.00 - - - 9,000.00


2.2.1.5. Training of National and provincial staff HRMIS. National Course 1 1 3,200 3,200.00 - - - - 3,200.00

2.2.1.5. Training of Master Trainers Province Course 3 3 2,000 6,000.00 - - - - 6,000.00

2.2.1.5. Training in work place assessment. Province Course 3 3 2,000 6,000.00 - - - - 6,000.00

2.2.1.5. Working Group Meetings to Prepare HR Plan w/ EMG/GAP Province WGM 9 9 9 9 9 45 2,000 18,000.00 18,000.00 18,000.00 18,000.00 18,000.00 90,000.00

2.2.1.5. Dissemination Workshops with Districts on HR Plan Province WS 9 9 9 9 9 45 400 3,600.00 3,600.00 3,600.00 3,600.00 3,600.00 18,000.00

2.2.1.5. Meetings of Inter-provincial Training Working Groups Province WGM 4 4 4 4 4 20 500 2,000.00 2,000.00 2,000.00 2,000.00 2,000.00 10,000.00

2.2.1.5. Meetings of Provincial Training Working Groups Province WGM 9 9 9 9 9 45 200 1,800.00 1,800.00 1,800.00 1,800.00 1,800.00 9,000.00

2.2.1.5. Meetings of District Training Teams Province WGM 9 33 33 33 33 141 100 900.00 3,300.00 3,300.00 3,300.00 3,300.00 14,100.00

2.2.1.5. Workshop to finalize Training Procedures Manual National WS 1 1 3,000 3,000.00 - - - - 3,000.00

2.2.1.5. Workshop to diseminate the Training Procedures Manual Province WS 9 9 1,000 - 9,000.00 - - - 9,000.00

2.2.1.5. Working Group Meetings to identify relevant curricula Province WS 9 9 500 - 4,500.00 - - - 4,500.00

Consulting Services

2.2.1.7. Training Consultant (National) National and ProvMonth 12 12 12 12 12 60 1,600 19,200.00 19,200.00 19,200.00 19,200.00 19,200.00 96,000.00

II. Recurrent costs

Supplies

2.2.2.9.s Printing and dissemination of Training Procedures Manual National and ProvLump Sum 1,000 1,000 10 - 10,000.00 - - - 10,000.00

2.2.2.9.s Printing and dissemination of SBT Modules National and ProvLump Sum 1,000 1,000 1,000 3,000 7 - 7,000.00 7,000.00 7,000.00 - 21,000.00

2.2.2.9.s Procure and deliver priority training suppplies for PTWGs Province Lump Sum 9 9 1,500 - 13,500.00 - - - 13,500.00

2.2.2.9.s Procure and deliver priority supplies for District teams District Lump Sum 33 33 1,000 - 33,000.00 - - - 33,000.00

2.3 Strengthening systems of surveillance, response and preparedness




I. Investment costs

System Development

2.3.1.4. Provincial and District S/R Action Planinng Workshops Province WS 9 9 2,500 - 22,500.00 - - - 22,500.00

2.3.1.4. Provincial CDC Equipment and Supplies Needs Assessment Province PPIU 9 9 500 - 4,500.00 - - - 4,500.00

2.3.1.4.Review/ disseminiation of findings from Communication Studies Province WS 9 9 1,100 - 9,900.00 - - - 9,900.00

2.3.1.4. Strategy Workshops for Engagement and Communication Province WS 9 9 1,200 - 10,800.00 - - - 10,800.00

2.3.1.4. Strategy Workshops for Engagement and Communication District WS 33 33 1,000 - 33,000.00 - - - 33,000.00

2.3.1.4. Cluster Workshops to Harmonize Strategies for Engagement Province WS 2 2 2,000 - 4,000.00 - - - 4,000.00

2.3.1.4. Provincial Planning Workshops for Communication for CDC Province WS 9 9 1,000 - 9,000.00 - - - 9,000.00

2.3.1.4. District Planning Workshops for Communication for CDC District WS 33 33 500 - 16,500.00 - - - 16,500.00

2.3.1.4.Meetings of oversight body for review and selection of research studies National Meeting 4 4 4 4 4 20 100 400 400 400 400 400 2,000

2.3.1.4. Development of criteria for selection of research studies National Meeting 1 1 1 1 1 5 100 100 100 100 100 100 500

2.3.1.4. Approve research proposals for selected researchers. National Meeting 2 2 2 2 2 10 100 200 200 200 200 200 1,000


2.3.1.6. Village small grants for Water, Sanitaion & Hygiene Program District/Village Block Grant 66 66 66 198 4,100 - 270,600 270,600 270,600 - 811,800.00

2.3.1.6. Support to Commune/Village committees Village Dev Program District/Village Block Grant 33 33 33 99 2,200 - 72,600 72,600 72,600 - 217,800.00

2.3.1.6. Support to Local schools for S&R and Community CDC District/Village Community Initiative 2 4 4 4 4 18 2,100 4,200.00 8,400.00 8,400.00 8,400.00 8,400.00 37,800.00

2.3.1.6.Support to Local remote communities for Env Cleanup prog. (Dengue Control. District/Village Community Initiative 2 4 4 4 4 18 2,200 4,400.00 8,800.00 8,800.00 8,800.00 8,800.00 39,600.00

2.3.1.6.Support to Village rainwater jar protection initiatives. (dengue control) District/Village Community Initiative 2 4 4 4 4 18 2,000 4,000.00 8,000.00 8,000.00 8,000.00 8,000.00 36,000.00

2.3.1.6. Facilitate cross-border liaision and meeting (CDC) District/Village Meeting 2 4 4 4 4 18 400 800.00 1,600.00 1,600.00 1,600.00 1,600.00 7,200.00

2.3.1.6. Meeting to establish Guidelines for Cross Border activities. District WS 2 2 4 600 1,200.00 1,200.00 - - - 2,400.00

2.3.1.6. Facilitate intersectoral meetings and information sharing. District/Village Meeting 4 4 4 4 4 20 400 1,600.00 1,600.00 1,600.00 1,600.00 1,600.00 8,000.00

2.3.1.6. Health Centre MCH/PHC Programs (phone cards, fuel, PD) Dist/HC- Village Subsidy 16 33 33 33 33 148 500 8,000.00 16,500.00 16,500.00 16,500.00 16,500.00 74,000.00

2.3.1.6. Support for National S&R emergency response. National Emergency Funds 1 1 2 50,000 50,000 - 50,000.00 - - 100,000.00

2.3.1.6. Support for Provincal S&R emergency response. Province Emergency Funds 0 9 9 9 9 36 2,000 - 18,000.00 18,000.00 18,000.00 18,000.00 72,000.00

2.3.1.6. Support for District S&R emergency response. District Emergency Funds 0 33 33 33 33 132 1,000 - 33,000.00 33,000.00 33,000.00 33,000.00 132,000.00

2.3.1.6. Community participation in Surveillance and M&E Dist/HC- Village Subsidy 33 33 33 33 132 500 - 16,500.00 16,500.00 16,500.00 16,500.00 66,000.00

II. Recurrent costs

2.4 Capacity Building of Provincial and District staff for CDC and Health Service Delivery

I. Investment costs

System Development

2.4.1.4. Preparation of TOT Program by Provincial Master Trainers Province Workshop 9 9 1,200 - 10,800.00 - - - 10,800.00

2.4.1.4. PTWG meetings to prepare TNA for DHDs and CHSs Province WGM 9 9 300 - 2,700.00 - - - 2,700.00

2.4.1.4. Worshop to prepare/build capacity of district teams for TNA Province Workshop 9 9 960 - 8,640.00 - - - 8,640.00




2.4.1.4. District training teams visit all DHDs, CHCs to conduct TNA District Field Visit 465 465 200 - 93,000 - - - 93,000.00

2.4.1.4. Compilation, analysis and prioritizing of District training needs District WGM 33 33 300 - 9,900.00 - - - 9,900.00

2.4.1.4. M&E from Provincial to District (Phone card, Fuel, PD) Province Subsidy 5 9 9 9 9 41 1,000 5,000.00 9,000.00 9,000.00 9,000.00 9,000.00 41,000.00

2.4.1.4. M&E from District to Village (Phone card, Fuel, PD) District Subsidy 16 33 33 33 33 148 500 8,000.00 16,500.00 16,500.00 16,500.00 16,500.00 74,000.00


2.4.1.5. TOT for Provincial and District Trainers (5 days x 2 trainings) Province and Dist Course 33 33 2,000 - 66,000.00 - - - 66,000.00

2.4.1.5. Follow-up on the job by Master Trainers Province and Dist Course 33 33 900 - - 29,700.00 - - 29,700.00

2.4.1.5.Training of District staff by PTWG and District teams, based on TNA District Course 80 80 80 240 1,000 - 80,000 80,000 80,000 - 240,000.00

2.4.1.5. Training of CHS staff by District teams, based on TNA District Course 160 160 160 480 1,000 - 160,000 160,000 160,000 - 480,000.00

2.4.1.5. Training of provincial supervisors on altternative approaches Province and Dist Course 9 9 9 27 900 - 8,100.00 8,100.00 8,100.00 - 24,300.00

2.4.1.5.Field training of Provincial supervisors in Targeted communities Province and Dist Course 9 9 9 27 900 - 8,100.00 8,100.00 8,100.00 - 24,300.00

2.4.1.5. Training of district supervisors in targeted districts. District Course 9 9 9 27 700 - 6,300.00 6,300.00 6,300.00 - 18,900.00

2.4.1.5.Training team support to DHD for on-the-job training and problem solving District Course 0 15 15 15 15 60 800 - 12,000.00 12,000.00 12,000.00 12,000.00 48,000.00

2.4.1.5. English lanuage training for Provincial staff. Province Course 0 9 9 18 3,000 - 27,000.00 27,000.00 - - 54,000.00

2.4.1.5. English lanuage training for District staff. District Course 0 33 33 66 2,000 - 66,000.00 66,000.00 - - 132,000.00

2.4.1.5. Develop and disseminate selection criteria for staff in CHSs Province WGM 2 2 250 500.00 - - - - 500.00

2.4.1.5.Meetings to identify, contract eligible candidates from remote communes District Meeting 13 5 5 5 5 33 100 1,300.00 500.00 500.00 500.00 500.00 3,300.00

2.4.1.5. Develop & disseminate selection criteria for new staff. Province WGM 2 2 200 400.00 - - - - 400.00

2.4.1.5. Meetings to evaluate training impact on staff performance. Province and Dist WS 16 16 16 48 200 - 3,200.00 3,200.00 3,200.00 - 9,600.00

2.4.1.5.Revision of training curriculum to improve impact on staff performance Province WS 9 9 9 27 400 - 3,600.00 3,600.00 3,600.00 - 10,800.00

2.4.1.5. Develop & disseminate selection criteria by IPTWG & MOH Province WGM 2 2 200 400.00 - - - - 400.00

2.4.1.5.Meetings to identify, contract eligible candidates from communes Province Meeting 10 5 5 5 25 500 5,000.00 2,500.00 2,500.00 2,500.00 - 12,500.00

2.4.1.5.Scholarships for candidates to attend bridging courses as needed Nat & Province Scholarship 0 20 20 20 20 80 700 - 14,000.00 14,000.00 14,000.00 14,000.00 56,000.00

2.4.1.5. Scholarships for up-grading training at local SMS or colleges National/ Prov Scholarship 0 20 20 20 20 80 1,000 - 20,000.00 20,000.00 20,000.00 20,000.00 80,000.00

2.4.1.5. Scholarships for Master's or Speciality Training (eg FETP) National Scholarship 0 12 12 12 36 3,000 - 36,000.00 36,000.00 36,000.00 - 108,000.00

2.4.1.5. Scholarships for Master's or Speciality Training (eg FETP) International Scholarship 0 4 4 8 12,000 - 48,000.00 - 48,000.00 - 96,000.00


2.4.1.6. Support to Mobile teams for outreach to remote communities. District/Village Unit 16 33 33 33 33 148 200 3,200.00 6,600.00 6,600.00 6,600.00 6,600.00 29,600.00

2.4.1.6. Support to District & Health Centre COMBI/BCC Programs District/Village Unit 16 33 33 33 33 148 200 3,200.00 6,600.00 6,600.00 6,600.00 6,600.00 29,600.00

2.4.1.6. Support Implementaion of Community Engagement Strategy District/Village Unit 4 4 8 1,000 4,000.00 4,000.00 - - - 8,000.00

2.4.1.6. Community engagement in Quarterly meetings. District/Village Unit 2 4 4 4 4 18 200 400.00 800.00 800.00 800.00 800.00 3,600.00

II. Recurrent costs

2.5 Targeted CDC and training activites for rural populations in border districts




I. Investment costs

System Development

2.5.1.4.National Institutes provide technical support and training for staff in 9 Provinces Province and Dist Advisory Support 12 12 12 12 48 1,000 - 12,000.00 12,000.00 12,000.00 12,000.00 48,000.00

2.5.1.4.Formation of Technical Management Committees within PHDs and DHOs Province WGM 9 9 18 300 2,700.00 2,700.00 - - - 5,400.00

2.5.1.4. Provincial Equipment/ Supplies Needs Assessment for PHC Province WGM 9 9 300 2,700.00 - - - - 2,700.00

2.5.1.4. Provinical Workshops for Feedback from Study Tours Province WS 0 9 9 300 - 2,700.00 - - - 2,700.00

2.5.1.4. Mulit-sector Provincial CDC Strategy Workshops Province WS 0 9 9 1,250 - 11,250.00 - - - 11,250.00

2.5.1.4. PTWGS and MOH approval of final IEC/BCC versions National/Province WGM 10 10 400 4,000.00 - - - - 4,000.00


2.5.1.5. Training in use and maintenance of Lab equipment Province and Dist Course 0 25 25 25 75 800 - 20,000.00 20,000.00 20,000.00 - 60,000.00

2.5.1.5. Training working groups review existing IEC materials Province and Dist WGM 9 9 900 8,100.00 - - - - 8,100.00

2.5.1.5. Modify, pre-test and evaluate IEC/BCC materials Province and Dist WGM 9 9 1,000 9,000.00 - - - - 9,000.00

2.5.1.5. Training of VHWs, WU and other volunteers, based on TNA District Course 0 100 200 300 350 - 35,000.00 70,000.00 - - 105,000.00

2.5.1.5. Conduct Audience Analysis of Community Perceptions of CD Dist and CommuneCourse 0 100 200 300 350 - 35,000.00 70,000.00 - - 105,000.00

2.5.1.5. Conduct Needs Assessments for Community-based CDC Dist and CommuneCourse 0 100 200 300 100 - 10,000.00 20,000.00 - - 30,000.00

2.5.1.5. Follow-up of trainees by trainers / supervisors Dist and CommuneCourse 0 300 600 900 5 - 1,500.00 3,000.00 - - 4,500.00


2.5.1.6. Conduct Field Assessments in Target Communities District WS 24 24 500 - 12,000.00 - - - 12,000.00

2.5.1.6. Cluster Workshops to Harmonize Heatlhy Village Criteria Province WS 2 2 2,000 4,000.00 - - - - 4,000.00

2.5.1.6. Provincial Planning Meetings to identify Underserved Villages Province WS 9 9 500 4,500.00 - - - - 4,500.00

2.5.1.6. Study tours for VHWs/volunteers on successful CDC Dist and CommuneCourse 0 16 17 33 1,000 - 16,000.00 17,000.00 - - 33,000.00

2.5.1.6. Intersectoral meetings locally and cross border in CDC. Province and Dist Lump Sum 2 4 4 4 4 18 500 1,000.00 2,000.00 2,000.00 2,000.00 2,000.00 9,000.00

2.5.1.6. Healthy Village concept developed in community forum. District/Village Lump Sum 0 4 4 1,000 - 4,000.00 - - - 4,000.00

2.5.1.6. Quarterly intersectoral & cross border review of performance District/Village WS 2 4 4 4 4 18 900 1,800.00 3,600.00 3,600.00 3,600.00 3,600.00 16,200.00

2.5.1.6. Feedback research findings to the communities studied Commune WS 0 300 300 600 100 - 30,000.00 30,000.00 - - 60,000.00

2.5.1.6.Multi-Sector Community Strategy meetings for CDC developed. Commune WS 0 300 300 600 100 - 30,000.00 30,000.00 - - 60,000.00

2.5.1.6. Commune Workshops on Audience Analysis for IEC/BCC Commune WS 0 160 160 320 200 - 32,000.00 32,000.00 - - 64,000.00

2.5.1.6. Commune Workshops to Prioritise Community Needs for CDC Commune WS 160 160 320 200 - 32,000.00 32,000.00 - - 64,000.00

2.5.1.6. District Action-Planning Meetings for CDC activities District WS 0 33 33 33 33 132 200 - 6,600.00 6,600.00 6,600.00 6,600.00 26,400.00

2.5.1.6.Healthy Village activities implemented and monitored in selected villages. Commune Lumpsum/year 33 33 33 33 33 7,000 - 231,000.00 231,000.00 231,000.00 231,000.00 924,000.00

2.5.1.6. Plan and conduct CDC campaigns in selected communes Commune Campaign 0 66 66 66 66 264 300 - 19,800.00 19,800.00 19,800.00 19,800.00 79,200.00

2.5.1.6. Support to Local schools for S&R and Community CDC District/Village Community Initiative 0 4 4 4 4 16 500 - 2,000.00 2,000.00 2,000.00 2,000.00 8,000.00

2.5.1.6.Support to Local remote communities for Env Cleanup prog. (Dengue Con. District/Village Community Initiative 0 4 4 4 4 16 500 - 2,000.00 2,000.00 2,000.00 2,000.00 8,000.00

2.5.1.6. Quarterly meetings at DHO to monitor community activities District WGM 0 4 4 4 4 16 200 - 800.00 800.00 800.00 800.00 3,200.00

2.5.1.6.PPIUs develop and distribute local and provincial broadcast messages Province WGM 9 9 800 7,200.00 - - - - 7,200.00




II. Recurrent costs

Supplies

2.5.2.9.s Purchase of basic laboratory supplies & consumables. National Unit 0 33 33 33 33 132 300 - 9,900.00 9,900.00 9,900.00 9,900.00 39,600.00

2.5.2.9.s PPIUs print and distribute IEC/BCC materials Province WGM 9 9 800 7,200.00 - - - - 7,200.00

2.6 Support for National Project Implementation

I. Investment costs

Office Equipment

2.6.1.2.c Office Equipment for Central level (EA, NIA, CLE, CMPE) Set 4 4 10,000 40,000.00 - - - - 40,000.00

2.6.1.2.c Office Equipment for Project Provinces (PPIUs) Set 9 9 7,000 63,000.00 - - - - 63,000.00

2.6.1.2.c Office Equipment for Project Districts Set 14 14 4,000 56,000.00 - - - - 56,000.00

2.6.1.2.c Purchase of Computer sets for BLS Database (EA) Set 5 5 2,000 10,000.00 - - - - 10,000.00

Vehicles

2.6.1.3. 4WD cars for Central level (EA, NIA, CLE, CMPE, CEO) Unit 5 5 30,000 150,000 - - - - 150,000.00

2.6.1.3. Pick up cars for Project Provinces (PPIUs) Unit 11 11 17,000 187,000 - - - - 187,000.00

2.6.1.3. Pick up cars for Project Districts Unit 22 22 17,000 374,000 - - - - 374,000.00

2.6.1.3. Motobikes for Central level (EA, NIA, CLE, CMPE) Unit 0 0 1,300 - - - - - -

2.6.1.3. Motobikes for Project Provinces (PPIUs) Unit 27 27 1,300 35,100 - - - - 35,100.00

2.6.1.3. Motobikes for Project Districts Unit 33 33 1,300 42,900 - - - - 42,900.00

2.6.1.3. Boats, bicycles, for for selected communes. Unit 10 10 4,000 40,000 - - - - 40,000.00

System Development2.6.1.4. Support for provincial steering committee meetings Province Course 1 1 1 1 1 5 500 500.00 500.00 500.00 500.00 500.00 2,500.00

2.6.1.4.Support for provincial technical management committee meetings Province Course 1 1 1 1 1 5 400 400.00 400.00 400.00 400.00 400.00 2,000.00


2.6.1.5.

Training of Prov and Dist staff by PTWGs, based on TNA, i.e. Project management, financial accounting, clinical training, CDC. National Course 5 9 9 9 32 2,500 12,500.00 22,500.00 22,500.00 22,500.00 - 80,000.00

2.6.1.5.Project Management Training for PMU/ PPIU staff (ADB Proceedures National WS 2 2 2 2 8 2,500 5,000.00 5,000.00 5,000.00 5,000.00 - 20,000.00

2.6.1.5. Procurement Training for PMU/ PPIU staff (ADB Proceedures) Province WS 2 2 1,250 2,500.00 - - - - 2,500.00


2.6.1.6. Quarterly and annual performance review workshops District WS 2 4 4 4 4 18 4,000 8,000.00 16,000.00 16,000.00 16,000.00 16,000.00 72,000.00

2.6.1.6. Quarterly and annual performance review workshops National Audit (Internal) 1 4 4 4 4 17 2,000 2,000.00 8,000.00 8,000.00 8,000.00 8,000.00 34,000.00

2.6.1.6. Quarterly and annual performance review workshops National Review 2 4 4 4 4 18 1,000 2,000.00 4,000.00 4,000.00 4,000.00 4,000.00 18,000.00

Consulting services (including per diem)

2.6.1.7. Project Implementation Consultant National and Prov.p-month 9 12 12 12 12 57 1,675 15,075.00 20,100.00 20,100.00 20,100.00 20,100.00 95,475.00

2.6.1.7. Procurement specialist National and Prov.p-month 9 12 12 33 1,600 14,400.00 19,200.00 19,200.00 - - 52,800.00

2.6.1.7. Surveillance and Response specialist National and Prov.p-month 9 12 12 12 12 57 1,500 13,500.00 18,000.00 18,000.00 18,000.00 18,000.00 85,500.00




2.6.1.7. IT/Database/GIS specialist National and Prov.p-month 9 12 12 12 12 57 1,375 12,375.00 16,500.00 16,500.00 16,500.00 16,500.00 78,375.00

2.6.1.7. Accounting services company (contracted in Lao PDR) National Year 1 1 1 1 1 5 35,000 35,000.00 35,000.00 35,000.00 35,000.00 35,000.00 175,000.00

2.6.1.7. Annual Audit All levels Year 1 1 1 1 1 5 12,000 12,000.00 12,000.00 12,000.00 12,000.00 12,000.00 60,000.00

2.6.1.7. Mid Term Review All levels Review 1 1 4,000 - - 4,000.00 - - 4,000.00

2.6.1.7. Project Completion Mission review. All levels Review 1 1 20,000 - - - - 20,000.00 20,000.00

Operating Costs

2.6.1.8. Remuneration, Incentives and per diem for PMU staff National Lumpsum per month 12 12 12 12 12 60 1,125 13,500.00 13,500.00 13,500.00 13,500.00 13,500.00 67,500.00

2.6.1.8. Monthly Incentives for PPIU staff Provincial lumpsum per year 9 9 9 9 9 45 4,320 38,880.00 38,880.00 38,880.00 38,880.00 38,880.00 194,400.00

2.6.1.8. PMU office opperating costs (excluding costs for car) National lumpsum per year 1 1 1 1 1 5 4,800 4,800.00 4,800.00 4,800.00 4,800.00 4,800.00 24,000.00

2.6.1.8. Support for PPIU office operating costs Provincial lumpsum per year 9 9 9 9 9 45 840 7,560.00 7,560.00 7,560.00 7,560.00 7,560.00 37,800.00

2.6.1.8. Support for District Health Center operating costs Districts lumpsum per year 33 33 33 33 33 165 600 19,800.00 19,800.00 19,800.00 19,800.00 19,800.00 99,000.00

II. Recurrent costs

Vehicle operations and maintainance

2.6.2.9.v PMU National lumpsum per year 2 2 2 2 2 10 6,000 12,000.00 12,000.00 12,000.00 12,000.00 12,000.00 60,000.00

2.6.2.9.v Support to NIA, CLE, CMPE, MOH National lumpsum per year 2 4 4 4 4 18 2,000 4,000.00 8,000.00 8,000.00 8,000.00 8,000.00 36,000.00

2.6.2.9.v Support to PPIUs Provincial lumpsum per year 5 9 9 9 9 41 4,000 20,000.00 36,000.00 36,000.00 36,000.00 36,000.00 164,000.00

2.6.2.9.v Support to Project Districts District lumpsum per year 33 33 33 33 132 4,000 - 132,000.00 132,000.00 132,000.00 132,000.00 528,000.00

Lab Equipment Operation and maintainance

2.6.2.9.l Support to NIA, CLE, CMPE, MOH National lumpsum per year 0 4 4 4 4 16 2,400 - 9,600.00 9,600.00 9,600.00 9,600.00 38,400.00

2.6.2.9.l Support to Project Districts District lumpsum per year 33 33 33 33 132 1,000 - 33,000.00 33,000.00 33,000.00 33,000.00 132,000.00

TOTAL 2,033,090 2,888,430 2,351,640 1,864,940 1,102,940 10,241,040


ADB TA - REG: Second GMS Regional Communicable Diseases Control Project

ADB Financing

Number Item Amount allocated (US$ 1,000)

Percentage & Basis for Withdraw from the Grant account (%)

1 Laboratory and Office Equipment 501 100% of total expenditures2 Vehicles 841 100% of total expenditures3 System Development 717 100% of total expenditures4 Training, workshop, fellowships 2,283 100% of total expenditures5 Commutity Mobilization 4,198 100% of total expenditures6 Consulting services 712 100% of total expenditures7 Project Management 464 97% of total expenditures8 Grant Proceeds 452

8A Supplies 136 92% of total expenditures8B Vehicle O&M 260 28% of total expenditures8C Lab Equipment O&M 56 28% of total expenditures

9 Pooled Fund 1,400 100% of total expenditures

Total 11,568

Category

Table 1.9: Grant Proceeds



Second GMS Regional Communicable Disease Control ProjectAppendix 6 - Cost Estimates and Financing Plan - Annex 2. - Cambodia











APPENDIX 6ANNEX 2 - CAMBODIA

Appendix 6 - Cost Estimates and Finacing Plan - Annex 2 - Cambodia - Consultant Report April 2010.


Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total PercentA. Base Costs

1 Strengthening Regional Cooperation in Commmunicable Disease Controla Compatible and coordinated strategies for CDC across borders 25.1 19.0 19.0 19.0 19.0 101.1 0.1 1%b Cross-border planning, monitoring and evaluation for CDC 352.5 162.5 67.5 67.5 59.5 709.5 0.7 6%c Regional knowledge management 20.2 45.8 28.8 28.8 28.8 152.4 0.2 1%d Support for regional GMS CDC cluster implementation and coordination. 49.0 - - - - 49.0 0.0 0%

Subtotal (A) 446.8 227.3 115.3 115.3 107.3 1,012.0 1.0 9%

2 Strengthening National Surveillance, Response and Health Systemsa Strengthening institutional structures, partnerships, and policies. 8.0 9.6 7.2 2.4 2.4 29.6 0.0 0%b Strengthening systems for HRD 121.7 184.4 59.3 59.3 51.1 475.8 0.5 4%c Strengthening systems of surveillance, response, and preparedness 72.0 503.0 463.3 413.3 107.8 1,559.4 1.6 14%d Capacity Building of Provincial and District staff for CDC 22.7 673.8 500.6 514.1 75.2 1,786.4 1.8 16%e Targeted CDC and training activitives for rural populations in border districts 64.6 499.0 542.4 262.6 132.6 1,501.2 1.5 13%f Support for national project implementation 1,117.7 464.9 484.9 444.5 447.0 2,959.1 3.0 26%

Subtotal (B) 1,406.7 2,334.7 2,057.8 1,696.3 816.1 8,311.5 8.3 74%

B. Taxes and Duties 8 26 22 22 22 101 0.1 1%

C. Contingenciesa Physical Contingencies 17 12 8 8 8 54.1 0.1 0%b Price Contingencies 57 125 109 91 46 427.5 0.4 4%

Subtotal (C) 74 138 117 99 54 481.5 0.5 4%

280 280 280 280 280 1,400.0

TOTAL (A) + (B) + (C) 2,215.6 3,005.4 2,592.5 2,212.9 1,279.6 11,306.0 10 100%

Total Base Cost

ADB RGoC Total Percent

A. Base Costs 8,762 562 9,323 82%

B. Taxes and Duties 0 101 101 1%

C. Contingencies 438 43 482 4%

D. Pool Fund 1,400 0 1,400 12%TOTAL (A) + (B) + (C) 10,600 706 11,306 100%



Second Communicable Diseases Control Projectt: Cambodia

Table 2.2 Cost Table Summary($ thousand)

D. Pool Fund Contribution

Second GMS Regional Communicable Diseases Control Project_ Cambodia

Table 2.1 Project Cost Estimates by Component/Subcomponent

Appendix 6 - Cost Estimates and Finacing Plan - Annex 2 - Cambodia - Consultant Report April 2010. Page 1


Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total Percent

1 Strengthening Regional Cooperation in Commmunicable Disease Controla Compatible and coordinated strategies for CDC across borders 25.1 19.0 19.0 19.0 19.0 101.1 1.1%b Cross-border planning, monitoring and evaluation for CDC 352.5 162.5 67.5 67.5 59.5 709.5 7.6%c Regional knowledge management 20.2 45.8 28.8 28.8 28.8 152.4 1.6%d Support for regional GMS CDC cluster implementation and coordination. 49.0 - - - - 49.0 0.5%

Subtotal (A) 446.8 227.3 115.3 115.3 107.3 1,012.0 10.9%

2 Strengthening National Surveillance, Response and Systemsa Strengthening institutional structures, partnerships, and policies. 8.0 9.6 7.2 2.4 2.4 29.6 0.3%b Strengthening systems for Human Resources Development 121.7 184.4 59.3 59.3 51.1 475.8 5.1%c Strengthening systems of surveillance, response, and preparedness 72.0 503.0 463.3 413.3 107.8 1,559.4 16.7%d Capacity Building of Provincial and District staff for CDC 22.7 673.8 500.6 514.1 75.2 1,786.4 19.2%e Targeted CDC and training activitives for rural populations in border districts 64.6 499.0 542.4 262.6 132.6 1,501.2 16.1%f Support for national project implementation 1,117.7 464.9 484.9 444.5 447.0 2,959.1 31.7%

Subtotal (B) 1,406.7 2,334.7 2,057.8 1,696.3 816.1 8,311.5 89.1%

TOTAL (A) + (B) 1,853.5 2,562.0 2,173.1 1,811.6 923.4 9,323.5 100%a/ excluding contingencies, taxes and duties

Second GMS Regional Communicable Diseases Control Project_Cambodia

($ thousand)Base Cost (US$)

Table 2.3 Base Cost Estimates by Component/Subcomponent/a




% of Cost Category

A. Investment Costs1 Strengthening Regional Cooperation in Communicable Disease Control 1,012 1,012 100.0 - -

a Compatible and coordinated strategies for CDC across borders 101 101 100.0 - - b Cross-border planning, monitoring and evaluation for CDC 710 710 100.0 - - c Regional knowledge management 152 152 100.0 - - d Support for regional GMS CDC cluster implementation and coordination. 49 49 100.0 - -

2 Strengthening National Surveillance, Response and Health Systems 7,418 7,418 100.0 - - a Strengthening institutional structures, partnerships, and policies. 30 30 100.0 - - b Strengthening HRD for surveillance, response, and preparedness 424.56 425 100.0 - - c Strengthening systems of surveillance, response, and preparedness 1,559.40 1,559 100.0 - - d Capacity Building of Provincial and District staff for CDC 1,786.42 1,786 100.0 - - e Targeted CDC and training activitives for rural populations in border districts 1,461.80 1,462 100.0 - - f Support for national project implementation 2,156.65 2,157 100.0 - -

Subtotal (A) 8,430 8,430 - -

B. Recurrent Costs1 Supplies 91 91 100% - 0%2 Vehicle operations and maintainance 524 157 30% 367 70%3 Lab Equipment Operation and maintainance 278 84 30% 195 70%

Subtotal (B) 893 331 562

Total Base Cost (A + B) 9,323 8,762 562

C. Contingenciesa Physical Contingencies 54 37 69% 17 31%b Price Contingencies 427 401 94% 27 6%

Subtotal (C) 482 438 91.0 43 9.0


E. Pool Fund Contribution 1,400 1,400

Total Project Costs 11,306 10,600 706


Second GMS Regional Communicable Diseases Control Project _Cambodia

Table 2.4: Cost Estimates, Financier and Fund Flows




ADB RGoC ADB RGoC ADB RGoC ADB RGoC ADB RGoC ADB RGoC Project

2 Laboratory and Office Equipment 260 - 52 - 0 - 0 - - - 312 - 312 3 Vehicles 700 0 - 0 - 0 - 0 - - 700 - 700 4 System Development 95 - 316 - 101 - 101 0 85 - 697 - 697 5 Training, workshop, fellowships 104 - 723 - 675 - 556 0 88 - 2,146 - 2,146 6 Commutity Mobilization 434 - 1,009 - 949 - 747 0 324 - 3,463 - 3,463 7 Consulting services 122 - 149 - 169 - 129 0 154 - 723 - 723 8 Project Management 78 - 78 - 78 - 78 0 78 - 389 - 389 9 Recurrent Costs 30 31 103 133 68 133 68 133 63 133 331 562 893

9.1 Supplies 17 - 46 - 11 - 11 0 6 - 91 - 91 9.2 Vehicle operations and maintainance 13 31 36 84 36 84 36 84 36 84 157 367 524 9.3 Lab Equipment Operation and maintainance 0 - 21 49 21 49 21 49 21 49 84 195 278

Subtotal (A) 1,823 31 2,429 133 2,040 133 1,679 133 791 133 8,762 562 9,323

8 26 22 22 22 101 101

16 1 8 4 4 4 4 4 4 4 37 17 5457 0 119 7 102 7 84 7 40 7 401 27 427

Subtotal (C) 73 1 127 11 106 11 88 11 44 11 438 43 482

1,895 40 2,556 169 2,147 166 1,767 166 834 165 9,200 706 9,906

Second GMS Regional Communicable Diseases Control Project_ Cambodia

Y5Y3 Y4 Total

Total Cost (A+B+C)

A. Base Costs

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Total ($ '000)

Percent (%)

Base Cost2 Laboratory and Office Equipment - 58 - - - 100 - - - 154 312 3

a. Office Equipment - 58 - - - - - - - 154 212 2b. Laboratory - - - - - 100 - - - - 100 1

3 Vehicles - - - - - - - - - 700 700 84 System Development 101 75.0 - - 20 92 92 210 51 57 697 75 Training, workshop, fellowships - - 34 - 10 143 - 1,525 282 153 2,146 236 Commutity Mobilization - 577 118 49 - - 1,467 52 1,129 72 3,463 377 Consulting services - - - - - 90 - - - 633 723 88 Project Management - - - - - - - - - 389 389 49 Recurrent Costs - - - - - 51 - - 39 802 893 10

9.1 Supplies - - - - - 51 - - 39 - 91 19.2 Vehicle operations and maintainance - - - - - - - - - 524 524 69.3 Lab Equipment Operation and maintainance - - - - - - - - - 278 278 3

Total 101 709.5 152 49 30 476 1,559 1,786 1,501 2,959 9,323 100Percentage 1 8 2 1 0 5 17 19 16 32 100



Second GMS Rerional Communicable Diseases Control Project _Cambodia





Base RGoC ADB Base RGoC ADB Base RGoC ADB Base RGoC ADB Base RGoC ADB Base RGoC ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total totalBase costs excluding taxes and duties

1 Civil Works - - - - - - - - - - - - - - - - - - 2 Laboratory and Office Equipment 260 - 260 52 - 52 - - - - - - - - - 312 - 312 3 Vehicles 700 - 700 - - - - - - - - - - - - 700 - 700 4 System Development 95 - 95 316 - 316 101 - 101 101 - 101 85 - 85 697 - 697 5 Training, workshop, fellowships 104 - 104 723 - 723 675 - 675 556 - 556 88 - 88 2,146 - 2,146 6 Commutity Mobilization 434 - 434 1,009 - 1,009 949 - 949 747 - 747 324 - 324 3,463 - 3,463 7 Consulting services 122 - 122 149 - 149 169 - 169 129 - 129 154 - 154 723 - 723 8 Project Management 78 - 78 78 - 78 78 - 78 78 - 78 78 - 78 389 - 389 9 Recurrent Costs 61 31 30 236 133 103 201 133 68 201 133 68 195 133 63 893 562 331

9.1 Supplies 17 17 46 46 11 11 11 11 6 6 9.2 Vehicle operations and maintainance44 31 13 120 84 36 120 84 36 120 84 36 120 84 36 9.3 Lab Equipment Operation and maintainance- - - 70 49 21 70 49 21 70 49 21 70 49 21

Total Base Costs 1,853 31 1,823 2,562 133 2,429 2,173 133 2,040 1,812 133 1,679 923 133 791 9,323 562 8,762

Physical contingencies cw 0%, lo 5%, veh 0%, sd 0%, twf 0%, cm 0%, cs 0%, pm 3%, rc 3% 2 Laboratory and Office Equipment 13 - 13 3 3 - - - - - - 16 - 16 3 Vehicles - - - - - - - - - - - - 4 System Development - - - - - - - - 5 Training, workshop, fellowships - - - - - - - - 6 Commutity Mobilization - - - - - - - - 7 Consulting services - - - - - - - - 8 Project Management 2 - 2 2 - 2 2 - 2 2 - 2 2 - 2 12 - 12 9 Recurrent Costs 2 1 1 7 4 3 6 4 2 6 4 2 6 4 2 27 17 10

9.1 Supplies 0 - 0 1 - 1 0 - 0 0 - 0 0 - 0 3 - 3 9.2 Vehicle operations and maintainance1 1 0 4 3 1 4 3 1 4 3 1 4 3 1 16 11 5 9.3 Lab Equipment Operation and maintainance- - - 2 1 1 2 1 1 2 1 1 2 1 1 8 6 3


Table 2.7 Base Cost Estimates by Expenditure Category(ADB and RGoC) ($ Thousands)

Second GMS Regional Communicable Diseases Control Project_Cambodia



Base RGoC ADB Base RGoC ADB Base RGoC ADB Base RGoC ADB Base RGoC ADB Base RGoC ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total total

Table 2.7 Base Cost Estimates by Expenditure Category(ADB and RGoC) ($ Thousands)

Price Contingencies: see below2 Laboratory and Equipment 4 4 - - 4 - 4 3 Vehicles 10 10 - 10 - 10 4 System Development 5 - 5 16 - 16 5 - 5 5 - 5 4 - 4 35 - 35 5 Training, workshop, fellowships 5 - 5 36 - 36 34 - 34 28 - 28 4 - 4 107 - 107 6 Commutity Mobilization 22 - 22 50 - 50 47 - 47 37 - 37 16 - 16 173 - 173 7 Consulting services 6 - 6 7 - 7 8 - 8 6 - 6 8 - 8 36 - 36 8 Project Management 4 - 4 4 - 4 4 - 4 4 - 4 4 - 4 19 - 19 9 Recurrent Costs 1 - 1 12 7 5 10 7 3 10 7 3 10 7 3 43 27 17

9.1 Supplies 1 - 1 2 - 2 1 - 1 1 - 1 0 - 0 5 - 5 9.2 Vehicle operations and maintainance1 0 1 6 4 2 6 4 2 6 4 2 6 4 2 25 17 8 9.3 Lab Equipment Operation and maintainance- - - 3 2 1 3 2 1 3 2 1 3 2 1 14 10 4

Total Price contingencies 57 - 57 125 7 119 109 7 102 91 7 84 46 7 40 427 27 401

Taxes: cw 10%, pm 3%, rc 10% 2 Laboratory and Equipment - - - - - - 3 Vehicles - - - - - - 4 System Development - - - - - - 5 Training, workshop, fellowships - - - - - - 6 Commutity Mobilization - - - - - - 7 Consulting services - - - - - - 8 Project Management 2 2 2 2 2 12 9 Recurrent Costs 6 24 20 20 20 89

9.1 Supplies 2 5 1 1 1 9 9.2 Vehicle operations and maintainance 4 12 12 12 12 52 9.3 Lab Equipment Operation and maintainance- 7 7 7 7 28

Total Tax Costs 8 26 22 22 22 101

Total Cost including contingencies, taxes and duties2 Laboratory and Equipment 277 - 277 55 - 55 - - - - - - - - - 331 - 331 3 Vehicles 710 - 710 - - - - - - - - - - - - 710 - 710 4 System Development 99 - 99 332 - 332 106 - 106 106 - 106 89 - 89 732 - 732 5 Training, workshop, fellowships 109 - 109 759 - 759 709 - 709 584 - 584 92 - 92 2,253 - 2,253 6 Commutity Mobilization 456 - 456 1,059 - 1,059 997 - 997 785 - 785 340 - 340 3,637 - 3,637 7 Consulting services 128 - 128 157 - 157 178 - 178 135 - 135 161 - 161 759 - 759 8 Project Management 86 2 84 86 2 84 86 2 84 86 2 84 86 2 84 432 12 420 9 Recurrent Costs 70 38 32 279 167 112 237 163 73 237 163 73 230 163 68 1,052 694 358

9.1 Supplies 20 2 18 55 5 50 13 1 12 13 1 12 7 1 6 107 9 98 9.2 Vehicle operations and maintainance50 36 14 142 103 39 142 103 39 142 103 39 142 103 39 617 447 170 9.3 Lab Equipment Operation and maintainance- - - 82 60 23 82 60 23 82 60 23 82 60 23 329 238 90

Total amount 1,936 40 1,895 2,725 169 2,556 2,312 166 2,147 1,933 166 1,767 1,000 165 834 9,906 706 9,200



SECOND GMS REGIONAL COMMUNICABLE DISEASES CONTROL PROJECT_ CAMBODIA




1.1.1.4. Support the establishment of a National Steering committee National Meeting 1 1 1,000 1,000 0 0 0 0 1,0001.1.1.4. Support the establishment of provincial Steering committees Provincial Meeting 6 6 600 3,600 0 0 0 0 3,6001.1.1.4. Support to establish regional focal office in MOH National office 1 1 3,000 3,000 0 0 0 0 3,0001.1.1.4. Support to participate in regional activities in MOH National Year 1 1 1 1 1 5 5,000 5,000 5,000 5,000 5,000 5,000 25,0001.1.1.4. Support to establish provincial focal point. Provincial focus point 1 1 1 1 1 5 1,000 1,000 1,000 1,000 1,000 1,000 5,0001.1.1.4. Support to participate in regional activities Provincial Year 3 6 6 6 6 27 500 1,500 3,000 3,000 3,000 3,000 13,5001.1.1.4. Regional Steering Committee Meeting on Roles and Responsiblities National WS 1 1 1 1 1 5 10,000 10,000 10,000 10,000 10,000 10,000 50,000


I. Investment costs




System Development




1.2.1.5. Training on research methods using existing data National Course 1 1 2,000 0 0 0 0 0 0

1.2.1.5. Training on research methods using existing data Province Course 6 6 2,000 0 0 0 0 0 0

1.2.1.5. Follow-up by trainers to support research in the provinces Province Course 6 6 2,000 0 0 0 0 0 0


1.2.1.6. TA Team Meeting to Prepare for the Baseline Study National (CLV) WGM 3 3 2,500 7,500 0 0 0 0 7,500






1.2.1.6. Study Tour on CDC Preparedness and S/R SystemsThailand or China Study tour 1 1 2 15,000 15,000 15,000 0 0 0 30,000

1.2.1.6. Study Tour on Community-based BCC for CDCCluster Provinces Study tour 1 1 2 10,000 10,000 10,000 0 0 0 20,000

1.2.1.6. Community Awarenes program in target districts and villagesDistrict and villages Program 75 75 200 15,000 0 0 0 0 15,000


TABLE 2.8 TOTAL BASE COST





1.2.1.6.Institutes or research companies contracted to assist in Baseline National PMU Contract 3 3 30,000 90,000 0 0 0 0 90,000


1.2.1.6. Sentinel surveilance villages identified and monitored annually Village level Person 35 35 35 35 140 500 0 17,500 17,500 17,500 17,500 70,000

1.2.1.6. Quarterly consultations and review of District activities. Prov/Districts Review 4 4 4 4 2 18 4,000 16,000 16,000 16,000 16,000 8,000 72,000


I. Investment costs



National (PMU/MOH) course 1 1 2 5,000 5,000 5,000 0 0 0 10,000

1.3.1.5.Training on Information and Communication Technology (ICT) for PIU, PHD, DHO.

Province (PIU/PHD) course 6 6 12 2,000 12,000 12,000 0 0 0 24,000


1.3.1.6.Provincial and cross border forums conducted quarterly and annually Prov/Districts Forum 4 36 36 36 36 148 800 3,200 28,800 28,800 28,800 28,800 118,400

1.4 Support for regional GMS CDC cluster implementation and coordination.



1.4.1.6. Provincial Workshop to disemiante the M&E Framework Province WS 6 6 2,000 12,000 0 0 0 0 12,000

1.4.1.6. Workshops to Harmonize the M&E Framework Province WS 6 6 2,000 12,000 0 0 0 0 12,000



1.4.1.6. Disemination of Baseline information to local communities Village level Unit 1 1 5,000 5,000 0 0 0 0 5,000




I. Investment costs

System Development



2.1.1.4. Health Sector Donor (with emphasis on CDC) Meetings Workshop 1 1 1 1 1 5 2,400 2,400 2,400 2,400 2,400 2,400 12,000





I. Investment costs

Training Equipment




2.2.1.2.eProcure and deliver priority training equipment and supplies for TWGs. National and Prov Set 3 3 6 4,000 12,000 12,000.00 - - - 24,000.00

2.2.1.2.eProcure and deliver priority training equipment and supplies for District teams. Province Set 9 10 19 4,000 36,000 40,000.00 - - - 76,000.00

System Development

2.2.1.4.National HRD task force to endorse training systems development approach Set 0 - - - - - -

2.2.1.4. National Working Group establish framework for HRD. National Set 1 1 1,600 1,600.00 - - - - 1,600.00

2.2.1.4. Orientation Course for Nat. Institutes and specialist trainers. National 1 1 2,400 2,400.00 - - - - 2,400.00

2.2.1.4. Preparation of Training Program/ Training Groups Established National 1 1 2,400 2,400.00 - - - - 2,400.00

2.2.1.4. Annual Provincial HR Planning Meetings, with all levels Province WGM 6 6 6 6 6 30 1,500 9,000.00 9,000.00 9,000.00 9,000.00 9,000.00 45,000.00

2.2.1.4. Working Group Meetings to identify relevant curricula Province WS 6 6 500 - 3,000.00 - - - 3,000.00

2.2.1.4. Workshops to orient PTWGS on modules and approaches Province WGM 6 6 6 18 500 - 3,000.00 3,000.00 3,000.00 - 9,000.00

2.2.1.4. Establish inventory of existing IEC/BCC materials National and Prov PIU 6 6 320 - 1,920.00 - - - 1,920.00

2.2.1.4.Meetings to identify/prioritize Training equipment and supply needs National and Prov WGM 6 6 1,440 - 8,640.00 - - - 8,640.00

2.2.1.4. Provincal workshops to develop IEC/BCC strategies Province WS 6 6 1,500 - 9,000.00 - - - 9,000.00

2.2.1.4. Audience Analysis, IEC/BCC Materials Testing & Revision Province WS 6 6 1,500 - 9,000.00 - - - 9,000.00


2.2.1.5. Training of National and provincial staff HRMIS. National Course 1 1 3,200 3,200.00 - - - - 3,200.00

2.2.1.5. Training of Master Trainers Province Course 3 3 2,000 6,000.00 - - - - 6,000.00

2.2.1.5. Training in work place assessment. Province Course 3 3 2,000 6,000.00 - - - - 6,000.00

2.2.1.5. Working Group Meetings to Prepare HR Plan w/ EMG/GAP Province WGM 6 6 6 6 6 30 2,000 12,000.00 12,000.00 12,000.00 12,000.00 12,000.00 60,000.00

2.2.1.5. Dissemination Workshops with Districts on HR Plan Province WS 6 6 6 6 6 30 400 2,400.00 2,400.00 2,400.00 2,400.00 2,400.00 12,000.00

2.2.1.5. Meetings of Inter-provincial Training Working Groups Province WGM 4 4 4 4 4 20 720 2,880.00 2,880.00 2,880.00 2,880.00 2,880.00 14,400.00

2.2.1.5. Meetings of Provincial Training Working Groups Province WGM 6 6 6 6 6 30 500 3,000.00 3,000.00 3,000.00 3,000.00 3,000.00 15,000.00

2.2.1.5. Meetings of District Training Teams Province WGM 9 19 19 19 19 85 200 1,800.00 3,800.00 3,800.00 3,800.00 3,800.00 17,000.00

2.2.1.5. Workshop to finalize Training Procedures Manual National WS 1 1 3,000 3,000.00 - - - - 3,000.00

2.2.1.5. Workshop to diseminate the Training Procedures Manual Province WS 6 6 1,000 - 6,000.00 - - - 6,000.00

Consulting Services

2.2.1.7. Training Consultant (National) National and Prov Month 12 12 12 12 12 60 1,500 18,000.00 18,000.00 18,000.00 18,000.00 18,000.00 90,000.00

II. Recurrent costs

Supplies

2.2.2.9.s Printing and dissemination of Training Procedures Manual National and Prov Lump Sum 750 750 10 - 7,500.00 - - - 7,500.00

2.2.2.9.s Printing and dissemination of SBT Modules National and Prov Lump Sum 750 750 750 2,250 7 - 5,250.00 5,250.00 5,250.00 - 15,750.00

2.2.2.9.s Procure and deliver priority training suppplies for PTWGs Province Lump Sum 6 6 1,500 - 9,000.00 - - - 9,000.00

2.2.2.9.s Procure and deliver priority supplies for District teams District Lump Sum 19 19 1,000 - 19,000.00 - - - 19,000.00


I. Investment costs




System Development

2.3.1.4. Provincial and District S/R Action Planinng Workshops Province WS 6 6 2,500 - 15,000.00 - - - 15,000.00

2.3.1.4. Provincial CDC Equipment and Supplies Needs Assessment Province PIU 6 6 500 - 3,000.00 - - - 3,000.00

2.3.1.4. Review/ disseminiation of findings from Communication Studies Province WS 6 6 2,000 - 12,000.00 - - - 12,000.00

2.3.1.4. Strategy Workshops for Engagement and Communication Province WS 6 6 2,000 - 12,000.00 - - - 12,000.00

2.3.1.4. Strategy Workshops for Engagement and Communication District WS 19 19 1,000 - 19,000.00 - - - 19,000.00 2.3.1.4. Workshops to Harmonize Strategies for Engagement Province WS 2 2 2,000 - 4,000.00 - - - 4,000.00

2.3.1.4. Provincial Planning Workshops for Communication for CDC Province WS 3 3 1,500 - 4,500.00 - - - 4,500.00

2.3.1.4. District Planning Workshops for Communication for CDC District WS 19 19 1,000 - 19,000.00 - - - 19,000.00





2.3.1.6. Village small grants for Water, Sanitation & Hygiene Program District/Village Block Grant 60 60 60 180 4,300 - 258,000 258,000 258,000 - 774,000.00

2.3.1.6. Support to Commune/Village committees Village Dev Program District/Village Block Grant 19 19 19 57 2,500 - 47,500 47,500 47,500 - 142,500.00

2.3.1.6. Support to Local schools for S&R and Community CDC District/Village Community Initiative 2 4 4 4 4 18 2,300 4,600.00 9,200.00 9,200.00 9,200.00 9,200.00 41,400.00

2.3.1.6.Support to Local remote communities for Env Cleanup prog. (Dengue Control. District/Village Community Initiative 2 4 4 4 4 18 2,200 4,400.00 8,800.00 8,800.00 8,800.00 8,800.00 39,600.00

2.3.1.6.Support to Village rainwater jar protection initiatives. (dengue control) District/Village Community Initiative 2 4 4 4 4 18 2,100 4,200.00 8,400.00 8,400.00 8,400.00 8,400.00 37,800.00

2.3.1.6. Facilitate cross-border liaision and meeting (CDC) District/Village Meeting 2 4 4 4 4 18 400 800.00 1,600.00 1,600.00 1,600.00 1,600.00 7,200.00

2.3.1.6. Meeting to establish Guidelines for Cross Border activities. District WS 2 2 4 600 1,200.00 1,200.00 - - - 2,400.00

2.3.1.6. Facilitate intersectoral meetings and information sharing. District/Village Meeting 4 4 4 4 4 20 400 1,600.00 1,600.00 1,600.00 1,600.00 1,600.00 8,000.00

2.3.1.6. Health Centre MCH/PHC Programs (phone cards, fuel, PD) Dist/HC- Village Subsidy 9 19 19 19 19 85 500 4,500.00 9,500.00 9,500.00 9,500.00 9,500.00 42,500.00

2.3.1.6. Support for National S&R emergency response. National Emergency Funds 1 1 2 50,000 50,000 - 50,000.00 - - 100,000.00

2.3.1.6. Support for Provincal S&R emergency response. Province Emergency Funds 0 6 6 6 6 24 5,000 - 30,000.00 30,000.00 30,000.00 30,000.00 120,000.00

2.3.1.6. Support for District S&R emergency response. District Emergency Funds 0 19 19 19 19 76 1,500 - 28,500.00 28,500.00 28,500.00 28,500.00 114,000.00

2.3.1.6. Community participation in Surveillance and M&E Dist/HC- Village Subsidy 19 19 19 19 76 500 - 9,500.00 9,500.00 9,500.00 9,500.00 38,000.00

2.4 Capacity Building of Provincial and District staff for CDC

I. Investment costs

System Development

2.4.1.4. Preparation of TOT Program by Provincial Master Trainers Province Workshop 6 6 1,200 - 7,200.00 - - - 7,200.00

2.4.1.4. PTWG meetings to prepare TNA for DHDs and CHSs Province WGM 6 6 1,200 - 7,200.00 - - - 7,200.00

2.4.1.4. Worshop to prepare/build capacity of district teams for TNA Province Workshop 6 6 960 - 5,760.00 - - - 5,760.00

2.4.1.4. District training teams visit all DHDs, CHCs to conduct TNA District Field Visit 310 310 200 - 62,000 - - - 62,000.00




2.4.1.4. Compilation, analysis and prioritizing of District training needs District WGM 19 19 400 - 7,600.00 - - - 7,600.00

2.4.1.4. M&E from Provincial to District (Phone card, Fuel, PD) Province Subsidy 3 6 6 6 6 27 1,000 3,000.00 6,000.00 6,000.00 6,000.00 6,000.00 27,000.00

2.4.1.4. M&E from District to Village (Phone card, Fuel, PD) District Subsidy 9 19 19 19 19 85 500 4,500.00 9,500.00 9,500.00 9,500.00 9,500.00 42,500.00

2.4.1.4. Develop and disseminate selection criteria for staff in CHSs Province WGM 2 2 600 1,200.00 - - - - 1,200.00

2.4.1.4.Meetings to identify, & contract eligible candidates from remote communes District Meeting 12 5 5 5 5 32 300 3,600.00 1,500.00 1,500.00 1,500.00 1,500.00 9,600.00

2.4.1.4. Develop & disseminate selection criteria for new staff. Province WGM 2 2 600 1,200.00 - - - - 1,200.00

2.4.1.4. Meetings to evaluate training impact on staff performance. Province and Dist WS 16 16 16 48 800 - 12,800.00 12,800.00 12,800.00 - 38,400.00


2.4.1.5. TOT for Provincial and District Trainers (5 days x 2 trainings) Province and Dist Course 19 19 2,500 - 47,500.00 - - - 47,500.00

2.4.1.5. Follow-up on the job by Master Trainers Province and Dist Course 19 19 1,500 - - 28,500.00 - - 28,500.00

2.4.1.5.Training of District staff by PTWG and District teams, based on TNA District Course 60 60 60 180 1,000 - 60,000 60,000 60,000 - 180,000.00

2.4.1.5. Training of CHS staff by District teams, based on TNA District Course 120 120 120 360 1,000 - 120,000 120,000 120,000 - 360,000.00

2.4.1.5. Training of provincial supervisors on altternative approaches Province and Dist Course 6 6 6 18 1,000 - 6,000.00 6,000.00 6,000.00 - 18,000.00

2.4.1.5. Field training of Provincial supervisors in Targeted communities Province and Dist Course 6 6 6 18 1,000 - 6,000.00 6,000.00 6,000.00 - 18,000.00

2.4.1.5. Training of district supervisors in targeted districts. District Course 6 6 6 18 800 - 4,800.00 4,800.00 4,800.00 - 14,400.00

2.4.1.5.Training team support to DHD for on-the-job training and problem solving District Course 12 12 12 12 48 800 - 9,600.00 9,600.00 9,600.00 9,600.00 38,400.00

2.4.1.5. English lanuage training for Provincial staff. Province Course 0 12 12 12 36 5,000 - 60,000.00 60,000.00 60,000.00 - 180,000.00

2.4.1.5. English lanuage training for District staff. District Course 0 20 20 20 60 3,000 - 60,000.00 60,000.00 60,000.00 - 180,000.00

2.4.1.5.Revision of training curriculum to improve impact on staff performance Province WS 6 6 6 18 720 - 4,320.00 4,320.00 4,320.00 - 12,960.00

2.4.1.5. Develop & disseminate selection criteria by IPTWG & MOH Province WGM 2 2 200 400.00 - - - - 400.00

2.4.1.5.Meetings to identify, contract eligible candidates from communes Province Meeting 0 15 15 30 1,200 - 18,000.00 18,000.00 - - 36,000.00

2.4.1.5.Scholarships for candidates to attend bridging courses as needed Nat & Province Scholarship 0 20 20 20 20 80 700 - 14,000.00 14,000.00 14,000.00 14,000.00 56,000.00

2.4.1.5. Scholarships for up-grading training at local SMS or colleges National/ Prov Scholarship 0 25 25 25 25 100 1,000 - 25,000.00 25,000.00 25,000.00 25,000.00 100,000.00

2.4.1.5. Scholarships for Master's or Speciality Training (eg FETP) National Scholarship 0 15 15 15 45 3,000 - 45,000.00 45,000.00 45,000.00 - 135,000.00

2.4.1.5. Scholarships for Master's or Speciality Training (eg FETP) International Scholarship 5 5 10 12,000 - 60,000.00 - 60,000.00 - 120,000.00


2.4.1.6. Support to Mobile teams for outreach to remote communities. District/Village Subsidy (PD,Fuel) 9 19 18 18 18 82 200 1,800.00 3,800.00 3,600.00 3,600.00 3,600.00 16,400.00

2.4.1.6. Support to District & Health Centre COMBI/BCC Programs District/Village HC Staff/Community 9 19 18 18 18 82 200 1,800.00 3,800.00 3,600.00 3,600.00 3,600.00 16,400.00

2.4.1.6. Support Implementaion of Community Engagement Strategy District/Village HC Staff/Community 4 4 8 1,000 4,000.00 4,000.00 - - - 8,000.00

2.4.1.6. Community engagement in Quarterly meetings. District/Village HC Staff/Community 2 4 4 4 4 18 600 1,200.00 2,400.00 2,400.00 2,400.00 2,400.00 10,800.00



ADB Financing



1 Laboratory and Office Equipment 331 100% of total expenditures2 Vehicles 710 100% of total expenditures3 System Development 732 100% of total expenditures4 Training, workshop, fellowships 2,253 100% of total expenditures5 Commutity Mobilization 3,637 100% of total expenditures6 Consulting services 759 100% of total expenditures7 Project Management 420 97% of total expenditures8 Recurrent Costs 358


9 Pooled Fund 1,400 100% of total expenditures

Total 10,600

Category




Second GMS Regional Communicable Disease Control ProjectAppendix 6 - Cost Estimates and Financing Plan - Annex 3. - Vietnam











APPENDIX 6ANNEX 3 - VIETNAM

Appendix 6 Cost Estimates and Financing Plan - Annex 3 - Vietnam - Consultant Report April 2010.

ADB TA - REG: Second GMS regional Communicable Disease Control Project

Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total PercentageA. Base Costs

1 Strengthening Regional Cooperation in Commmunicable Disease Controla Compatible and coordinated strategies for CDC across borders 37.0 26.0 26.0 26.0 26.0 141.0 1%b Cross-border planning, monitoring and evaluation for CDC 736.5 304.0 204.0 176.0 134.0 1,554.5 6%c Regional knowledge management - 72.0 72.0 20.0 10.0 174.0 1%d Support for regional GMS CDC cluster implementation and coordination. 60.0 60.0 - - - 120.0 0%

Subtotal (A) 833.5 462.0 302.0 222.0 170.0 1,989.5 7%

2 Strengthening National Surveillance, Response and Health Systemsa Strengthening institutional structures, partnerships, and policies. 5.9 7.5 5.1 0.3 0.3 19.1 0%b Strengthening systems for Human Resources Development 242.0 503.7 75.4 75.4 55.4 952.1 3%c Strengthening systems of surveillance, response, and preparedness 64.1 1,081.1 948.7 888.7 168.7 3,151.3 11%d Capacity Building of Provincial and District staff for CDC 20.5 1,088.0 1,000.5 762.0 175.0 3,046.0 11%e Targeted CDC and training activitives for rural populations in border districts82.6 1,400.8 2,823.8 2,607.3 2,473.2 9,387.6 34%f Support for national project implementation 1,259.9 3,036.1 953.1 914.1 905.0 7,068.1 26%

Subtotal (B) 1,675.1 7,117.2 5,806.6 5,247.8 3,777.6 23,624.3 85%

B. Taxes and Duties 14 325 56 56 55 506 2%

C. Contingenciesa Physical Contingencies 44 36 20 20 19 138.8 1%b Price Contingencies 85 430 367 328 237 1,445.7 5%

Subtotal (C) 129 465 386 348 256 1,584.5 6%

TOTAL (A) + (B) + (C) 2,651.4 8,369.6 6,550.9 5,873.8 4,258.5 27,704.3 100%


A. Base Costs 23,550 2,063 25,614 92%

B. Taxes and Duties 0 506 506 2%

C. Contingencies 1,450 135 1,585 6%

TOTAL (A) + (B) + (C) 25,000 2,704 27,704 100%

($ thousand)Table 3.1 Project Cost Estimates by Component/Subcomponent

Second GMS Regional Communicable Diseases Control Project: Viet Nam



Second Communicable Diseases Control Project: Viet Nam

Table 3.2 Summary Cost Table($ thousand)

Appendix 6 Cost Estimates and Financing Plan - Annex 3 - Vietnam - Consultant Report April 2010. Page 1


Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total Percent1 Strengthening Regional Cooperation in Commmunicable Disease Control

a Compatible and coordinated strategies for CDC across borders 37.0 26.0 26.0 26.0 26.0 141.0 0.6%b Cross-border planning, monitoring and evaluation for CDC 736.5 304.0 204.0 176.0 134.0 1,554.5 6.1%c Regional knowledge management - 72.0 72.0 20.0 10.0 174.0 0.7%d Support for regional GMS CDC cluster implementation and coordination. 60.0 60.0 - - - 120.0 0.5%Subtotal (A) 833.5 462.0 302.0 222.0 170.0 1,989.5 7.8%

2 Strengthening National Surveillance, Response and Health Systemsa Strengthening institutional structures, partnerships, and policies. 5.9 7.5 5.1 0.3 0.3 19.1 0.1%b Strengthening systems for Human Resources Development 242.0 503.7 75.4 75.4 55.4 952.1 3.7%c Strengthening systems of surveillance, response, and preparedness 64.1 1,081.1 948.7 888.7 168.7 3,151.3 12.3%d Capacity Building of Provincial and District staff for CDC 20.5 1,088.0 1,000.5 762.0 175.0 3,046.0 11.9%

e Targeted CDC and training activitives for rural populations in border districts 82.6 1,400.8 2,823.8 2,607.3 2,473.2 9,387.6 36.7%f Support for national project implementation 1,259.9 3,036.1 953.1 914.1 905.0 7,068.1 27.6%

Subtotal (B) 1,675.1 7,117.2 5,806.6 5,247.8 3,777.6 23,624.3 92.2%TOTAL (A) + (B) 2,508.6 7,579.2 6,108.6 5,469.8 3,947.6 25,613.8 100%


($ thousand)Base Cost





% of Cost Category

A. Investment Costs1 Strengthening Regional Cooperation in Commmunicable Disease Control 1,990 1,990 100.0 - -

a Compatible and coordinated strategies for CDC across borders 141 141 100% - - b Cross-border planning, monitoring and evaluation for CDC 1,555 1,555 100% - - c Regional knowledge management 174 174 100% - - d Support for regional GMS CDC cluster implementation and coordination. 120 120 100% - -

2 Strengthening National Surveillance, Response and Health Systems 21,274 20,633 97.0 641 - a Strengthening institutional structures, partnerships, and policies. 19 19 100% - - b Strengthening HRD for surveillance, response, and preparedness 770.14 770 100% - - c Strengthening systems of surveillance, response, and preparedness 3,151.30 3,151 100% - - d Capacity Building of Provincial and District staff for CDC 3,046.00 3,046 100% - - e Targeted CDC and training activitives for rural populations in border districts 9,251.64 9,252 100% - - f Support for national project implementation 5,036.14 4,395 87% 641 13%

Subtotal (A) 23,264 22,623 97% 641 3%

B. Recurrent Costs1 Supplies 318 318 100% - 0%2 Vehicle operations and maintainance 1,752 526 30% 1,226 70%3 Lab Equipment Operation and maintainance 280 84 30% 196 70%

Subtotal (B) 2,350 928 1,422

Total Base Cost (A + B) 25,613.8 23,550 2,063

C. Contingenciesa Physical Contingencies 139 92 66.2 47 33.8b Price Contingencies 1,446 1,358 93.9 88 6.1

Subtotal (C) 1,585 1,450 91.5 135 8.5


Total Project Costs 27,704 25,000 2,704







ADB GOV ADB GOV ADB GOV ADB GOV ADB GOV ADB GOV Project

1 Civil Works - - 0 - 0 - - - - - 0 - 02 Laboratory and Office Equipment 741 - 204 - 0 - 0 - - - 945 - 945 3 Vehicles 322 81 1,680.000 420 - 0 - 0 - - 2,002 501 2,503 4 System Development 110 - 410 - 153 - 149 0 106 - 928 - 928 5 Training, workshop, fellowships 207 - 1,229 - 1,085 - 793 0 67 - 3,382 - 3,382 6 Commutity Mobilization 634 - 2,583 - 3,990 - 3,685 0 2,911 - 13,803 - 13,803 7 Consulting services 174 - 202 - 222 - 183 0 218 - 1,000 - 1,000 8 Project Management 112 28 112 28 112 28 112 28 112 28 562 140 702 9 Recurrent Costs 30 69 372 338 180 338 180 338 166 338 928 1,422 2,350

9.1 Supplies 0 - 227 - 35 - 35 0 21 - 318 - 318 9.2 Vehicle operations and maintainance 30 69 124 289 124 289 124 289 124 289 526 1,226 1,752 9.3 Lab Equipment Operation and maintainance 0 - 21 49 21 49 21 49 21 49 84 196 280

Subtotal (A) 2,331 178 6,793 786 5,742 366 5,103 366 3,581 366 23,550 2,063 25,613.8

14 325 56 56 55 506 506

41 3 25 11 9 11 9 11 8 11 92 47 13985 0 408 22 345 22 306 22 215 22 1,358 88 1,446

Subtotal (C) 126 3 432 33 353 33 315 33 223 33 1,450 135 1,585

2,457 195 7,225 1,145 6,095 455 5,418 455 3,804 454 25,000 2,704 27,704


Total Cost (A+B+C)


A. Base Costs


Y1 Y2 Y3 Y4 TotalY5




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Total ($ '000)

Percent (%)

Base Cost1 Civil Works - - - - - - - - - - - 02 Laboratory and Office Equipment - 180 - - - 368 - - - 397 945 4

a. Office Equipment - 180 - - - - - - - 397 577 2b. Laboratory - - - - - 368 - - - - 368 1

3 Vehicles - - - - - - - - - 2,503 2,503 104 System Development 141 120.0 - - 5 103 66 386 80 28 928 45 Training, workshop, fellowships - 83.0 104 - 14 200 208 2,227 382 164 3,382 136 Commutity Mobilization - 1,172 70 120 - - 2,874 434 8,789 345 13,803 547 Consulting services - - - - - 99 4 - - 898 1,000 48 Project Management - - - - - - - - - 702 702 39 Recurrent Costs - - - - - 182 - - 136 2,032 2,350 9

9.1 Supplies - - - - - 182 - - 136 - 318 19.2 Vehicle operations and maintainance - - - - - - - - - 1,752 1,752 79.3 Lab Equipment Operation and maintainance - - - - - - - - - 280 280 1

Total 141 1,554.5 174 120 19 952 3,151 3,046 9,388 7,068 25,613.8 100Percentage 1 6 1 0 0 4 12 12 37 28 100




Base Cost Estimates by Expenditure Category and Component/Subcomponent($ thousand)




Base GoV ADB Base GOV ADB Base GoV ADB Base GOV ADB Base GOV ADB Base GOV ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total totalBase costs excluding taxes and duties1 Civil Works - - - - - - - - - - - - - - - - - - 2 Laboratory and Office Equipment 741 - 741 204 - 204 - - - - - - - - - 945 - 945 3 Vehicles 403 81 322 2,100 420 1,680 - - - - - - - - - 2,503 501 2,002 4 System Development 110 - 110 410 - 410 153 - 153 149 - 149 106 - 106 928 - 928 5 Training, workshop, fellowships 207 - 207 1,229 - 1,229 1,085 - 1,085 793 - 793 67 - 67 3,382 - 3,382 6 Commutity Mobilization 634 - 634 2,583 - 2,583 3,990 - 3,990 3,685 - 3,685 2,911 - 2,911 13,803 - 13,803 7 Consulting services 174 - 174 202 - 202 222 - 222 183 - 183 218 - 218 1,000 - 1,000 8 Project Management 140 28 112 140 28 112 140 28 112 140 28 112 140 28 112 702 140 562 9 Recurrent Costs 98 69 30 710 338 372 518 338 180 518 338 180 504 338 166 2,350 1,422 928

9.1 Supplies - - 227 227 35 35 35 35 21 21 9.2 Vehicle operations and maintainance 98 69 30 413 289 124 413 289 124 413 289 124 413 289 124 9.3 Lab Equipment Operation and maintainance - - - 70 49 21 70 49 21 70 49 21 70 49 21

Total Base Costs 2,509 178 2,331 7,579 786 6,793 6,109 366 5,742 5,470 366 5,103 3,948 366 3,581 25,614 2,063 23,550

Physical contingencies cw 0%, lo 5%, veh 0%, sd 0%, twf 0%, cm 0%, cs 0%, pm 3%, rc 3% 1 Civil Works - - - - - - - - - - - - - 2 Laboratory and Office Equipment 37 - 37 10 10 - - - - - - 47 - 47 3 Vehicles - - - - - - - - - - - - 4 System Development - - - - - - - - 5 Training, workshop, fellowships - - - - - - - - 6 Commutity Mobilization - - - - - - - - 7 Consulting services - - - - - - - - 8 Project Management 4 1 3 4 1 3 4 1 3 4 1 3 4 1 3 21 4 17 9 Recurrent Costs 3 2 1 21 10 11 16 10 5 16 10 5 15 10 5 71 43 28

9.1 Supplies - - - 7 - 7 1 - 1 1 - 1 1 - 1 10 - 10 9.2 Vehicle operations and maintainance 3 2 1 12 9 4 12 9 4 12 9 4 12 9 4 53 37 16 9.3 Lab Equipment Operation and maintainance - - - 2 1 1 2 1 1 2 1 1 2 1 1 8 6 3


Price Contingencies: see below1 Civil Works - - - - - - - 2 Laboratory and Equipment 10 10 12 12 - - - - - - 23 - 23 3 Vehicles 5 5 101 101 - - - - - - 105 - 105 4 System Development 6 - 6 25 - 25 9 - 9 9 - 9 6 - 6 55 - 55 5 Training, workshop, fellowships 11 - 11 74 - 74 65 - 65 48 - 48 4 - 4 202 - 202 6 Commutity Mobilization 35 - 35 155 - 155 239 - 239 221 - 221 175 - 175 825 - 825 7 Consulting services 10 - 10 12 - 12 13 - 13 11 - 11 13 - 13 59 - 59 8 Project Management 6 - 6 8 2 7 8 2 7 8 2 7 8 2 7 40 7 33 9 Recurrent Costs 2 - 2 43 20 22 31 20 11 31 20 11 30 20 10 137 81 56

9.1 Supplies 0 0 - 14 - 14 2 - 2 2 - 2 1 - 1 19 0 19 9.2 Vehicle operations and maintainance 2 0 2 25 17 7 25 17 7 25 17 7 25 17 7 101 70 31 9.3 Lab Equipment Operation and maintainance - - - 4 3 1 4 3 1 4 3 1 4 3 1 17 12 5


(ADB and GOV) ($ Thousands)Table 3.7 Base Cost Estimates by Expenditure Category



Base GoV ADB Base GOV ADB Base GoV ADB Base GOV ADB Base GOV ADB Base GOV ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total total

(ADB and GOV) ($ Thousands)Table 3.7 Base Cost Estimates by Expenditure Category

Total Price contingencies 85 - 85 430 22 408 367 22 345 328 22 306 237 22 215 1,446 88 1,358

Taxes: cw 10%, pm 3%, rc 10% (separated from the base costs above)1 Civil Works - - - - - - 2 Laboratory and Equipment - 20 - - - 20 3 Vehicles - 168 - - - 168 4 System Development - - - - - - 5 Training, workshop, fellowships - 61 - - - 61 6 Commutity Mobilization - - - - - - 7 Consulting services - - - - - - 8 Project Management 4 4 4 4 4 21 9 Recurrent Costs 10 71 52 52 50 235

9.1 Supplies - 23 4 4 2 32 9.2 Vehicle operations and maintainance 10 41 41 41 41 175 9.3 Lab Equipment Operation and maintainance - 7 7 7 7 28

Total Tax Costs 14 325 56 56 55 506

Total Cost including contingencies, taxes and duties1 Civil Works - - - - - - - - - - - - - - - - - - 2 Laboratory and Equipment 788 - 788 247 20 226 - - - - - - - - - 1,035 20 1,015 3 Vehicles 408 81 327 2,369 588 1,781 - - - - - - - - - 2,776 669 2,108 4 System Development 116 - 116 434 - 434 162 - 162 158 - 158 113 - 113 984 - 984 5 Training, workshop, fellowships 219 - 219 1,365 61 1,303 1,150 - 1,150 841 - 841 71 - 71 3,645 61 3,584 6 Commutity Mobilization 669 - 669 2,738 - 2,738 4,229 - 4,229 3,906 - 3,906 3,086 - 3,086 14,628 - 14,628 7 Consulting services 184 - 184 214 - 214 236 - 236 194 - 194 231 - 231 1,060 - 1,060 8 Project Management 155 33 122 157 35 122 157 35 122 157 35 122 157 35 122 784 172 612 9 Recurrent Costs 113 81 32 845 440 406 617 421 196 617 421 196 600 419 181 2,792 1,781 1,011

9.1 Supplies 0 0 - 270 23 247 42 4 38 42 4 38 25 2 23 378 32 347 9.2 Vehicle operations and maintainance 113 81 32 492 357 135 492 357 135 492 357 135 492 357 135 2,081 1,508 573 9.3 Lab Equipment Operation and maintainance - - - 83 60 23 83 60 23 83 60 23 83 60 23 333 242 92

Total amount 2,651 195 2,457 8,370 1,145 7,225 6,551 455 6,095 5,874 455 5,418 4,259 454 3,804 27,704 2,704 25,000



SECOND GSM REGIONAL COMMUNICABLE DISEASES CONTROL PROJECT: Viet Nam




1.1.1.4. Support the establishment of a National Steering committee National Meeting 1 1 1,000 1,000 0 0 0 0 1,0001.1.1.4. Support the establishment of provincial Steering committees Provincial Meeting 20 20 600 12,000 0 0 0 0 12,0001.1.1.4. Support to establish regional focal office in MOH National office 1 1 3,000 3,000 0 0 0 0 3,0001.1.1.4. Support to participate in regional activities in MOH National Year 1 1 1 1 1 5 5,000 5,000 5,000 5,000 5,000 5,000 25,0001.1.1.4. Support to establish provincial focal point. Provincial focus point 1 1 1 1 1 5 1,000 1,000 1,000 1,000 1,000 1,000 5,0001.1.1.4. Support to participate in regional activities Provincial Year 10 20 20 20 20 90 500 5,000 10,000 10,000 10,000 10,000 45,0001.1.1.4. Regional Steering Committee Meeting on Roles and Responsiblities National WS 1 1 1 1 1 5 10,000 10,000 10,000 10,000 10,000 10,000 50,000


I. Investment costs




System Development




1.2.1.5. Training on research methods using existing data National Course 1 1 3,000 3,000 0 0 0 0 3,000

1.2.1.5. Training on research methods using existing data Province Course 20 20 2,000 40,000 0 0 0 0 40,000

1.2.1.5. Follow-up by trainers to support research in the provinces Province Course 20 20 2,000 40,000 0 0 0 0 40,000


1.2.1.6. Study Tour on CDC Preparedness and S/R SystemsThailand or China Study tour 2 2 2 6 15,000 0 30,000 30,000 30,000 0 90,000

1.2.1.6. Study Tour on Community-based BCC for CDCCluster Provinces Study tour 4 4 8 7,000 0 28,000 28,000 0 0 56,000

1.2.1.6. TA Team Meeting to Prepare for the Baseline Study National (CLV) WGM 3 3 2,500 7,500 0 0 0 0 7,500






1.2.1.6.Community Awarenes program in target districts and villages (BLS)

District and Communes Program 200 200 200 40,000 0 0 0 0 40,000


1.2.1.6.Institutes or research companies contracted to assist in Baseline National PMU Contract 5 5 30,000 150,000 0 0 0 0 150,000


1.2.1.6. Sentinel surveilance villages identified and monitored annually Commune level Unit 140 140 140 140 560 300 0 42,000 42,000 42,000 42,000 168,000


TABLE 3.8 TOTAL BASE COST




1.2.1.6. Quarterly consultations and review of District activities. Prov/Districts Review 20 20 20 10 70 1,200 0 24,000 24,000 24,000 12,000 84,000

II. Recurrent costs


I. Investment costs



National (PMU/MOH) course 4 4 8 3,000 0 12,000 12,000 0 0 24,000

1.3.1.5.Training on Information and Communication Technology (ICT) for PPIU, PHD, DHO.

Province (PPIU/PHD) course 20 20 40 2,000 0 40,000 40,000 0 0 80,000


1.3.1.6.Provincial and cross border forums conducted quarterly and annually Prov/Districts Forum 20 20 20 10 70 1,000 0 20,000 20,000 20,000 10,000 70,000

II. Recurrent costs

1.4 Support for regional GMS CDC cluster implementation and coordination.


1.4.1.6. Disemination of Baseline information to local communities Village level Unit 1 1 20,000 0 20,000 0 0 0 20,000


1.4.1.6. Provincial Workshop to disemiante the M&E Framework Province WS 10 10 20 2,000 20,000 20,000 0 0 0 40,000

1.4.1.6. Cluster Workshops to Harmonize the M&E Framework Province WS 10 10 20 2,000 20,000 20,000 0 0 0 40,000



II. Recurrent costs




I. Investment costs

System Development






2.1.1.5. Health Sector Donor (with emphasis on CDC) Meetings National Roundtable discussion 1 1 1 1 1 5 300 300 300 300 300 300 1,500


I. Investment costs

Training Equipment

2.2.1.2.eProcure and deliver priority training equipment and supplies for TWGs. National and Prov Set 11 11 22 4,000 44,000 44,000 0 0 0 88,000

2.2.1.2.eProcure and deliver priority training equipment and supplies for District teams. District Set 30 40 70 4,000 120,000 160,000 0 0 0 280,000

System Development

2.2.1.4.National HRD task force to endorse training systems development approach Set 0 0 0 0 0 0 0




2.2.1.4. National Working Group establish framework for HRD. National Set 1 1 2 1,600 1,600 1,600 0 0 0 3,200

2.2.1.4. Orientation Course for Nat. Institutes and specialist trainers. National 1 1 2 2,400 2,400 2,400 0 0 0 4,800

2.2.1.4. Preparation of Training Program/ Training Groups Established National 1 1 2,400 2,400 0 0 0 0 2,400

2.2.1.4. Annual Provincial HR Planning Meetings, with all levels Province WGM 20 20 20 20 20 100 200 4,000 4,000 4,000 4,000 4,000 20,000

2.2.1.4. Workshops to orient PTWGS on modules and approaches Province WGM 20 15 15 50 400 0 8,000 6,000 6,000 0 20,000

2.2.1.4. Establish inventory of existing IEC/BCC materials National and Prov PPIU 20 20 300 0 6,000 0 0 0 6,0002.2.1.4.

Meetings to identify/prioritize Training equipment and supply needs National and Prov WGM 21 21 300 0 6,300 0 0 0 6,300

2.2.1.4. Provincal workshops to develop IEC/BCC strategies Province WS 20 20 1,000 0 20,000 0 0 0 20,000

2.2.1.4. Audience Analysis, IEC/BCC Materials Testing & Revision Province WS 20 20 1,000 0 20,000 0 0 0 20,000


2.2.1.5. Training of National and provincial staff HRMIS. National Course 1 1 3,200 3,200 0 0 0 0 3,200

2.2.1.5. Training of Master Trainers Province Course 6 6 2,000 12,000 0 0 0 0 12,000

2.2.1.5. Training in work place assessment. Province Course 6 6 2,000 12,000 0 0 0 0 12,000

2.2.1.5. Working Group Meetings to Prepare HR Plan with EMG/GAP Province WGM 10 20 20 20 20 90 300 3,000 6,000 6,000 6,000 6,000 27,000

2.2.1.5. Dissemination Workshops with Districts on HR Plan Province WS 10 20 20 20 20 90 400 4,000 8,000 8,000 8,000 8,000 36,000

2.2.1.5. Meetings of Inter-provincial Training Working Groups Province WGM 4 4 4 4 4 20 400 1,600 1,600 1,600 1,600 1,600 8,000

2.2.1.5. Meetings of Provincial Training Working Groups Province WGM 20 20 20 20 20 100 100 2,000 2,000 2,000 2,000 2,000 10,000

2.2.1.5. Meetings of District Training Teams Province WGM 35 70 70 70 70 315 200 7,000 14,000 14,000 14,000 14,000 63,000

2.2.1.5. Workshop to finalize Training Procedures Manual National WS 1 1 3,000 3,000 0 0 0 0 3,000

2.2.1.5. Workshop to diseminate the Training Procedures Manual Province WS 20 20 1,000 0 20,000 0 0 0 20,000

2.2.1.5. Working Group Meetings to identify relevant curricula Province WS 20 20 300 0 6,000 0 0 0 6,000

Consulting Services

2.2.1.7. Training Consultant (National) National and Prov Month 12 12 12 12 12 60 1,654 19,848 19,848 19,848 19,848 19,848 99,240

II. Recurrent costs

Supplies

2.2.2.9.s Printing and dissemination of Training Procedures Manual National and Prov Lump Sum 2,000 2,000 20 0 40,000 0 0 0 40,000

2.2.2.9.s Printing and dissemination of SBT Modules National and Prov Lump Sum 2,000 2,000 2,000 6,000 7 0 14,000 14,000 14,000 0 42,000

2.2.2.9.s Procure and deliver priority training suppplies for PTWGs Province Lump Sum 20 20 1,500 0 30,000 0 0 0 30,000

2.2.2.9.s Procure and deliver priority supplies for District teams District Lump Sum 70 70 1,000 0 70,000 0 0 0 70,000


I. Investment costs

System Development

2.3.1.4. Provincial and District S/R Action Planinng Workshops Province WS 20 20 1,500 0 30,000 0 0 0 30,000

2.3.1.4. Provincial CDC Equipment and Supplies Needs Assessment Province PPIU 20 20 300 0 6,000 0 0 0 6,000

2.3.1.4. Review/ disseminiation of findings from Communication Studies Province WS 20 20 1,500 0 30,000 0 0 0 30,000


2.3.1.5. Strategy Workshops for Engagement and Communication Province WS 20 20 1,500 0 30,000 0 0 0 30,000

2.3.1.5. Strategy Workshops for Engagement and Communication District WS 70 70 700 0 49,000 0 0 0 49,0002.3.1.5. Workshops to Harmonize Strategies for Engagement Province WS 20 20 20 60 1,000 0 20,000 20,000 20,000 0 60,000




2.3.1.5. Provincial Planning Workshops for Communication for CDC Province WS 20 20 1,000 0 20,000 0 0 0 20,000

2.3.1.5. District Planning Workshops for Communication for CDC District WS 70 70 700 0 49,000 0 0 0 49,000


2.3.1.6.Commune small grants for Water, Sanitation & Hygiene Program District/commune Block Grant 140 140 140 420 3,000 0 420,000 420,000 420,000 0 1,260,000

2.3.1.6. Support to Commune committees/ Commune Dev Program District/commune Block Grant 140 140 140 420 2,000 0 280,000 280,000 280,000 0 840,000

2.3.1.6. Support to Local schools for S&R and Community CDC District/Commune Community Initiative 0 2 4 4 4 14 4,000 0 8,000 16,000 16,000 16,000 56,000

2.3.1.6.Support to Local remote communities for Env Cleanup prog. (Dengue Control. District/Commune Community Initiative 0 2 4 4 4 14 4,000 0 8,000 16,000 16,000 16,000 56,000

2.3.1.6.Support to Village rainwater jar protection initiatives. (dengue control) District/Commune Community Initiative 0 2 4 4 4 14 4,000 0 8,000 16,000 16,000 16,000 56,000

2.3.1.6. Facilitate cross-border liaision and meeting (CDC) District/Commune Meeting 0 4 4 4 4 16 1,000 0 4,000 4,000 4,000 4,000 16,000

2.3.1.6. Meeting to establish Guidelines for Cross Border activities. District WS 2 2 4 1,200 2,400 2,400 0 0 0 4,800

2.3.1.6. Facilitate intersectoral meetings and information sharing. District/Commune Meeting 2 4 4 4 4 18 500 1,000 2,000 2,000 2,000 2,000 9,000

2.3.1.6. Health Centre MCH/PHC Programs (phone cards, fuel, PD) Dist/HC-CommuneSubsidy per year 70 70 70 70 280 500 0 35,000 35,000 35,000 35,000 140,000

2.3.1.6. Support for National S&R emergency response. National Emergency Funds 1 1 2 60,000 60,000 0 60,000 0 0 120,000

2.3.1.6. Support for Provincal S&R emergency response. Province Emergency Funds 0 20 20 20 20 80 1,500 0 30,000 30,000 30,000 30,000 120,000

2.3.1.6. Support for District S&R emergency response. District Emergency Funds 0 70 70 70 70 280 500 0 35,000 35,000 35,000 35,000 140,000

2.3.1.6. Community participation in Surveillance and M&E Dist/HC-CommuneSubsidy 0 70 70 70 70 280 200 0 14,000 14,000 14,000 14,000 56,000

Consulting Services




II. Recurrent costs

2.4 Capacity Building of Provincial and District staff for CDC

I. Investment costs

System Development

2.4.1.4. Preparation of TOT Program by Provincial Master Trainers Province Workshop 20 20 700 0 14,000 0 0 0 14,000

2.4.1.4. PTWG meetings to prepare TNA for DHDs and CHSs Province WGM 20 20 700 0 14,000 0 0 0 14,000

2.4.1.4. Worshop to prepare/build capacity of district teams for TNA Province Workshop 20 20 700 0 14,000 0 0 0 14,000

2.4.1.4. District training teams visit all DHDs, CHCs to conduct TNA District Field Visit 1000 1,000 60 0 60,000 0 0 0 60,000

2.4.1.4. Compilation, analysis and prioritizing of District training needs District WGM 50 50 360 0 18,000 0 0 0 18,000

2.4.1.4. M&E from Provincial to District (Phone card, Fuel, PD) Province Subsidy 10 20 20 20 20 90 1,000 10,000 20,000 20,000 20,000 20,000 90,000

2.4.1.4. M&E from District to Village (Phone card, Fuel, PD) District Subsidy 35 70 70 70 70 315 300 10,500 21,000 21,000 21,000 21,000 94,500

2.4.1.4. Develop and disseminate selection criteria for staff in CHSs Province WGM 20 20 40 100 0 2,000 2,000 0 0 4,000

2.4.1.4.Meetings to identify, contract eligible candidates from remote communes District Meeting 0 70 70 70 70 280 100 0 7,000 7,000 7,000 7,000 28,000

2.4.1.4. Develop & disseminate selection criteria for new staff. Province WGM 0 20 20 40 100 0 2,000 2,000 0 0 4,000

2.4.1.4. Meetings to evaluate training impact on staff performance. Province and Dist WS 0 30 30 30 90 500 0 15,000 15,000 15,000 0 45,000


2.4.1.5. TOT for Provincial and District Trainers (5 days x 2 trainings) Province and Dist Course 20 20 4,000 0 80,000 0 0 0 80,000

2.4.1.5. Follow-up on the job by Master Trainers Province and Dist Course 70 70 750 0 0 52,500 0 0 52,500

2.4.1.5.Training of District staff by PTWG and District teams, based on TNA (4 course /district/year) District Course 280 280 280 840 550 0 154,000 154,000 154,000 0 462,000




2.4.1.5. Training of CHS staff by District teams, based on TNA District Course 280 280 280 840 550 0 154,000 154,000 154,000 0 462,000

2.4.1.5. Training of provincial supervisors on altternative approaches Province and Dist Course 20 20 20 60 1,000 0 20,000 20,000 20,000 0 60,000

2.4.1.5. Field training of Provincial supervisors in Targeted communities Province and Dist Course 20 20 20 60 1,000 0 20,000 20,000 20,000 0 60,000

2.4.1.5. Training of district supervisors in targeted districts. District Course 20 20 20 60 800 0 16,000 16,000 16,000 0 48,000

2.4.1.5.Training team support to DHD for on-the-job training and problem solving District Course 70 70 70 70 280 500 0 35,000 35,000 35,000 35,000 140,000

2.4.1.5. English language training for Provincial staff. Province Course 0 20 20 40 2,000 0 40,000 40,000 0 0 80,000

2.4.1.5. English language training for District staff. District Course 0 70 70 140 2,000 0 140,000 140,000 0 0 280,000

2.4.1.5.Revision of training curriculum to improve impact on staff performance Province WS 0 20 20 20 60

5000 10,000 10,000 10,000 0 30,000

2.4.1.5. Develop & disseminate selection criteria by IPTWG & MOH Province WGM 0 20 20 40100

0 2,000 2,000 0 0 4,000

2.4.1.5.Meetings to identify &contract eligible candidates from communes Province WGM 0 20 20 20 60 100 0 2,000 2,000 2,000 0 6,000

2.4.1.5.Scholarships for candidates to attend bridging courses as needed Nat & Province Scholarship 0 20 20 20 60

7000 14,000 14,000 14,000 0 42,000

2.4.1.5. Scholarships for up-grading training at local SMS or colleges National/ Prov Scholarship 0 40 40 40 1201,000

0 40,000 40,000 40,000 0 120,000

2.4.1.5. Scholarships for Master's or Speciality Training (eg FETP) National Scholarship 0 20 20 20 603,000

0 60,000 60,000 60,000 0 180,000

2.4.1.5. Scholarships for Master's or Speciality Training (eg FETP) International Scholarship 0 5 5 1012,000

0 0 60,000 60,000 0 120,000


2.4.1.6. Support to Mobile teams for outreach to remote communities. District/Commune Unit 0 70 70 70 70 280 500 0 35,000 35,000 35,000 35,000 140,000

2.4.1.6. Support to District & Health Centre COMBI/BCC Programs District/Commune Unit 0 70 70 70 70 280 500 0 35,000 35,000 35,000 35,000 140,000

2.4.1.6. Support Implementaion of Community Engagement Strategy District/Commune Unit 20 20 20 10 70 2,000 0 40,000 40,000 40,000 20,000 140,000

2.4.1.6. Community engagement in Quarterly meetings. District/Commune Unit 0 4 4 4 2 14 1,000 0 4,000 4,000 4,000 2,000 14,000

II. Recurrent costs

2.5 Targeted CDC and training activites for rural populations in border districts

I. Investment costs

System Development

2.5.1.4.National Institutes provide technical support and training for staff in 20 Provinces Province and Dist Lump Sum 0 1 1 1 3 20,000 0 20,000 20,000 20,000 0 60,000

2.5.1.4.Formation of Technical Management Committees within PHDs and DHOs Province WGM 20 20 40 500 10,000 10,000 0 0 0 20,000


2.5.1.5. Training in use and maintenance of Lab equipment Province and Dist Course 0 20 20 20 60 1,000 0 20,000 20,000 20,000 0 60,000

2.5.1.5. Training working groups review existing IEC materials Province and Dist WGM 20 20 1,000 20,000 0 0 0 0 20,000

2.5.1.5. Modify, pre-test and evaluate IEC/BCC materials Province and Dist WGM 20 20 1,000 20,000 0 0 0 0 20,000

2.5.1.5. Training of VHWs, WU and other volunteers, based on TNA District Course 0 280 280 280 840 200 0 56,000 56,000 56,000 0 168,000

2.5.1.5. Conduct Audience Analysis of Community Perceptions of CD Dist and CommuneCourse 0 280 280 280 840 50 0 14,000 14,000 14,000 0 42,000

2.5.1.5. Conduct Needs Assessments for Community-based CDC Dist and CommuneCourse 0 280 280 280 840 50 0 14,000 14,000 14,000 0 42,000

2.5.1.5. Follow-up of trainees by trainers / supervisors Dist and CommuneCourse 0 840 840 840 2,520 12 0 10,080 10,080 10,080 0 30,240


2.5.1.6. Study tours for VHWs/volunteers on successful CDC Dist and CommuneCourse 0 35 35 70 1,500 0 52,500 52,500 0 0 105,000




2.5.1.6. Workshops to Harmonize Heatlhy Village Criteria Province WS 0 10 10 20 2,400 0 24,000 24,000 0 0 48,000

2.5.1.6. Provincial Planning Meetings to identify Underserved Villages Province WS 20 20 600 12,000 0 0 0 0 12,000

2.5.1.6. Conduct Field Assessments in Target Communities District WS 70 70 500 0 35,000 0 0 0 35,000

2.5.1.6. Provincial Equipment/ Supplies Needs Assessment for PHC Province WGM 20 20 550 11,000 0 0 0 0 11,000

2.5.1.6. Provinical Workshops for Feedback from Study Tours Province WS 20 20 1,000 0 20,000 0 0 0 20,000

2.5.1.6. Mulit-sector Provincial CDC Strategy Workshops Province WS 20 20 1,600 0 32,000 0 0 0 32,000

2.5.1.6. Intersectoral meetings locally and cross border in CDC. Province and Dist Lump Sum 2 4 4 4 4 18 3,000 6,000 12,000 12,000 12,000 12,000 54,000

2.5.1.6. Healthy Village concept developed in community forum. District/Commune Lump Sum 0 280 280 560 100 0 28,000 28,000 0 0 56,000

2.5.1.6. Quarterly intersectoral & cross border review of performance District/Commune WS 2 4 4 4 4 18 1,800 3,600 7,200 7,200 7,200 7,200 32,400

2.5.1.6. Feedback research findings to the communities studied Commune WS 280 280 560 100 0 28,000 28,000 0 0 56,000

2.5.1.6. Multi-Sector Community Strategy meetings for CDC developed. Commune WS 280 280 560 100 0 28,000 28,000 0 0 56,000

2.5.1.6. Commune Workshops on Audience Analysis for IEC/BCC Commune WS 280 280 560 100 0 28,000 28,000 0 0 56,000

2.5.1.6. Commune Workshops to Prioritise Community Needs for CDC Commune WS 280 280 560 100 0 28,000 28,000 0 0 56,000

2.5.1.6. District Action-Planning Meetings for CDC activities District WS 0 70 70 70 70 280 200 0 14,000 14,000 14,000 14,000 56,000

2.5.1.6.Healthy Village activities implemented and monitored in selected villages. Village Lump Sum 0 70 70 70 70 280 10,300 0 721,000 721,000 721,000 721,000 2,884,000

2.5.1.6. Plan and conduct CDC campaigns in selected communes Commune Campaign 140 140 140 140 560300

0 42,000 42,000 42,000 42,000 168,000

2.5.1.6. Support to Local schools for S&R and Community CDC District/commune Community Initiative 0 70 70 70 70 280 500 0 35,000 35,000 35,000 35,000 140,000

2.5.1.6.Support to Local remote communities for Env Cleanup prog. (Dengue Con. District/commune Community Initiative 0 70 70 70 70 280

5000 35,000 35,000 35,000 35,000 140,000

2.5.1.6. Quarterly meetings at DHO to monitor community activities District WGM 0 70 70 70 70 280200

0 14,000 14,000 14,000 14,000 56,000

2.5.1.6. Unallocated amount District Unit 0 0 1 1 1 31,572,000

0 0 1,572,000 1,572,000 1,572,000 4,716,000

II. Recurrent costs

Supplies

2.5.2.9.s Purchase of basic laboratory supplies & consumables. District Unit 0 70 70 70 70 280 300 0 21,000 21,000 21,000 21,000 84,000

2.5.2.9.s PTWGS and MOH approval of final IEC/BCC versions National/Province WGM 20 20 1,000 0 20,000 0 0 0 20,000

2.5.2.9.s PPIUs print and distribute IEC/BCC materials Province WGM 20 20 800 0 16,000 0 0 0 16,000

2.5.2.9.sPPIUs develop and distribute local and provincial broadcast messages Province WGM 20 20 800 0 16,000 0 0 0 16,000

2.6 Support for National Project Implementation

I. Investment costs

Office Equipment

2.6.1.2.c Office Equipment for PMU National Set 1 1 17,000 17,000 0 0 0 0 17,000

2.6.1.2.cOffice Equipment for National Institutes: PASTEUR, HIHE, NIMPE, etc. National Set 5 5 6,000 30,000 0 0 0 0 30,000

2.6.1.2.c Office Equipment for Project Provinces (PPIUs) Province Set 20 20 7,000 140,000 0 0 0 0 140,000

2.6.1.2.c Office Equipment for Project Districts District Set 70 70 3,000 210,000 0 0 0 0 210,000

Vehicles

2.6.1.3. Pick up cars for Project Districts Unit 70 70 30,000 0 2,100,000 0 0 0 2,100,000

2.6.1.3. Motobikes for Project Provinces (PPIUs) Unit 20 20 1,100 22,000 0 0 0 0 22,000

2.6.1.3. Motobikes for Project Districts Unit 210 210 1,100 231,000 0 0 0 0 231,000

2.6.1.3. Boats, bicycles for selected communes. Unit 50 50 3,000 150,000 0 0 0 0 150,000




System Development2.6.1.4. Support for provincial steering committee meetings Province Course 2 2 2 2 2 10 1,000 2,000 2,000 2,000 2,000 2,000 10,000

2.6.1.4.Support for provincial technical management committee meetings Province WGM 20 20 20 20 12 92 200 4,000 4,000 4,000 4,000 2,400 18,400


2.6.1.5.

Training of Prov and Dist staff by PTWGs, based on TNA, i.e. Project management, financial accounting, clinical training, CDC. National Courses 10 15 15 15 55 2,500 25,000 37,500 37,500 37,500 0 137,500

2.6.1.5.Project Management Training for PMU/ PPIU staff (ADB Proceedures National WS 2 2 2 2 8 2,500 5,000 5,000 5,000 5,000 0 20,000

2.6.1.5. Procurement Training for PMU/ PPIU staff (ADB Proceedures) Province WS 2 2 4 1,500 3,000 3,000 0 0 0 6,000


2.6.1.6. Quarterly and annual performance review workshops District WS 35 70 70 70 70 315 500 17,500 35,000 35,000 35,000 35,000 157,500

2.6.1.6. Quarterly and annual performance review workshops National Review 1 4 4 4 4 17 1,000 1,000 4,000 4,000 4,000 4,000 17,000

2.6.1.6. Quarterly and annual performance review workshops Province Review 20 80 80 80 80 340 500 10,000 40,000 40,000 40,000 40,000 170,000

Consulting services (including per diem)

2.6.1.7. Project Implementation Consultant National and Prov.p-month 9 12 12 12 12 57 1,640 14,760 19,680 19,680 19,680 19,680 93,480

2.6.1.7. Procurement specialist National and Prov.p-month 9 12 12 33 1,580 14,220 18,960 18,960 0 0 52,140

2.6.1.7. Surveillance and Response Consultants National and Prov.p-month 9 12 12 12 12 57 1,440 12,960 17,280 17,280 17,280 17,280 82,080

2.6.1.7. IT/Database/GIS Consultant National and Prov.p-month 9 12 12 12 12 57 1,340 12,060 16,080 16,080 16,080 16,080 76,380

2.6.1.7. Chief Accountant (1) (Rem. And per diem) National p-month 9 12 12 12 12 57 1,280 11,520 15,360 15,360 15,360 15,360 72,960

2.6.1.7. Accountants (2) (Rem. And per diem) National p-month 18 24 24 24 24 114 880 15,840 21,120 21,120 21,120 21,120 100,320

2.6.1.7. Accounting Assistants (1) (Rem. And per diem) National p-month 9 12 12 12 12 57 340 3,060 4,080 4,080 4,080 4,080 19,380

2.6.1.7.Monthly Remuneration and per diem for PPIU contractedaccountant Provincial PPIU lumpsum per year 20 20 20 20 20 100 2,460 49,200 49,200 49,200 49,200 49,200 246,000

2.6.1.7. Annual Audit All levels Year 1 1 1 1 1 5 20,000 20,000 20,000 20,000 20,000 20,000 100,000

2.6.1.7. Mid Term Review All levels Review 1 1 20,000 0 0 20,000 0 0 20,000

2.6.1.7. Project Completion Mission review. All levels Review 1 1 35,000 0 0 0 0 35,000 35,000

Operating Costs

2.6.1.8. Remuneration, per diem for Seconded PMU staff National Lumpsum per year 1 1 1 1 1 5 13,200 13,200 13,200 13,200 13,200 13,200 66,000

2.6.1.8. Remuneration Support for PPIU Manager and Technical Officer Provincial lumpsum per year 20 20 20 20 20 100 2,400 48,000 48,000 48,000 48,000 48,000 240,000

2.6.1.8. PMU office operating costs (including costs for office rental) National lumpsum per year 1 1 1 1 1 5 13,200 13,200 13,200 13,200 13,200 13,200 66,000

2.6.1.8. Support for PPIU office operating costs Provincial lumpsum per year 20 20 20 20 20 100 1,200 24,000 24,000 24,000 24,000 24,000 120,000

2.6.1.8. Support for District Health Center operating costs Districts lumpsum per year 70 70 70 70 70 350 600 42,000 42,000 42,000 42,000 42,000 210,000

II. Recurrent costs

Vehicle operations and maintainance

2.6.2.9.v PMU National lumpsum per year 1 1 1 1 1 5 8,400 8,400 8,400 8,400 8,400 8,400 42,000

2.6.2.9.v Support to PPIUs Provincial lumpsum per year 20 20 20 20 20 100 4,500 90,000 90,000 90,000 90,000 90,000 450,000

2.6.2.9.v Support to Project Districts District lumpsum per year 70 70 70 70 280 4,500 0 315,000 315,000 315,000 315,000 1,260,000

Lab Equipment Operation and maintainance

2.6.2.9.l Support to Project Districts District lumpsum per year 70 70 70 70 280 1,000 0 70,000 70,000 70,000 70,000 280,000

TOTAL 2,508,568 7,579,188 6,108,588 5,469,828 3,947,648 25,613,820



ADB Financing



1 Laboratory and Office Equipment 1,015 98% of total expenditures2 Vehicles 2,108 76% of total expenditures3 System Development 984 100% of total expenditures4 Training, workshop, fellowships 3,584 98% of total expenditures5 Commutity Mobilization 14,628 100% of total expenditures6 Consulting services 1,060 100% of total expenditures7 Project Management 612 78% of total expenditures8 Recurrent Costs


Total 25,000

Category




Second GMS Regional Communicable Diseases Control ProjectAppendix 6 - Cost Estimates and Financing Plan - Annex 4. - Regional Coordination Unit

Table No. TABLE OF CONTENTS Page No.4.1 Project Cost Estimates by Component/Subcomponent 1






4.7 Base Cost Estimates by Expenditure Category (ADB and GOV) 6 to 7


ANNEX 4 - REGIONAL COORDINATION UNIT

Appendix 6 - Cost Estimates and Financing Plan - RCU - Consultant Report April 2010


Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total Percentagef RCU 1,732.4 1,832.9 987.9 561.4 339.4 5,453.9 98%

Subtotal (B) 1,732.4 1,832.9 987.9 561.4 339.4 5,453.9 98%

B. Taxes and Duties - - - - - - 0%

C. Contingenciesa Physical Contingencies 3 2 2 2 2 9.1 0%b Price Contingencies 31 34 23 17 10 115.0 2%

Subtotal (C) 34 36 24 18 12 124.1 2%

TOTAL (A) + (B) + (C) 1,766.1 1,868.9 1,012.0 579.6 351.4 5,578.0 100%


A. Base Costs 5,454 0 5,454 98%

1 B. Taxes and Duties 0 0 0 0%23 C. Contingencies 124 0 124 2%45 TOTAL (A) + (B) + (C) 5,578.0 0 5,578.0 100%

Table 4.1 Project Cost Estimates by Component/Subcomponent

Second GMS Regional Communicable Diseases Control Project: RCU



Second Communicable Diseases Control Project: Pool Fund

Table 4.2 Summary of Cost Estimates for RCU($ thousand)

Appendix 6 - Cost Estimates and Financing Plan - RCU - Consultant Report April 2010 Page 1


Component/Sub-Component Y1 Y2 Y3 Y4 Y5 Total Percentf TA/RCU 1,732.4 1,832.9 987.9 561.4 339.4 5,453.9 100.0%

Subtotal (B) 1,732.4 1,832.9 987.9 561.4 339.4 5,453.9 100.0%

TOTAL (A) + (B) 1,732.4 1,832.9 987.9 561.4 339.4 5,453.9 100%a/ excluding contingencies, taxes and duties


($ thousand)Base Cost (US$)




Item Total Cost

$

% of Cost

Category $

% of Cost Category

f TA/RCU 5,453.92 5,454 100% - 0%

Subtotal (A) 5,454 5,454 100% - 0%

Total Base Cost (A + B) 5,453.9 5,454 -

C. Contingenciesa Physical Contingencies 9 9 100.0 - 0.0b Price Contingencies 115 115 100.0 - 0.0

Subtotal (C) 124 124 100.0 - 0.0

D. Taxes and Duties - - - - 100.0

Total Project Costs 5,578.0 5,578.0 -







ADB GOV ADB GOV ADB GOV ADB GOV ADB GOV ADB GOV Project

2 Laboratory and Office Equipment 21 - 0 - 0 - 0 - - - 21 - 21.00 1 Training, workshop, fellowships 110 - 160 - 160 - 160 0 85 - 675 - 675.00 7 Consulting services 1,548 - 1,619 - 774 - 348 0 201 - 4,490 - 4,490.32 2 Project Management 54 - 54 - 54 - 54 0 54 - 268 - 267.60

Subtotal (A) 1,732 0 1,833 0 988 0 561 0 339 - 5,454 - 5,453.92

0 0 0 - - 0 -

3 0 2 0 2 0 2 - 2 - 9 - 9.08 31 0 34 0 23 0 17 - 10 - 115 - 115.00

Subtotal (C) 34 0 36 0 24 0 18 - 12 - 124 0 124.08

1,766 0 1,869 0 1,012 0 580 - 351 - 5,578 0 5,578.00 Total Cost (A+B+C)


8


A. Base Costs

Y1 Y2 Y3 Y5Table 4.5 Financing Plan by Expenditure Category


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1 Laboratory and Office Equipment - - - - - - - - - 21 21 0a. Office Equipment - - - - - - - - - 21 21 0b. Laboratory - - - - - - - - - - - 0

2 Vehicles - - - - - - - - - - - 03 System Development - - - - - - - - - - - 04 Training, workshop, fellowships - - - - - - - - - 675 675 125 Commutity Mobilization - - - - - - - - - - - 06 Consulting services - - - - - - - - - 4,490 4,490 827 Project Management - - - - - - - - - 268 268 58 Recurrent Costs - - - - - - - - - - - 0

9.1 Supplies - - - - - - - - - - - 09.2 Vehicle operations and maintainance - - - - - - - - - - - 09.3 Lab Equipment Operation and maintainance - - - - - - - - - - - 0

Total 0 0.0 0 0 0 0 0 0 0 5,454 5,453.9 100Percentage 0 0 0 0 0 0 0 0 0 100 100








Base GoV ADB Base GOV ADB Base GoV ADB Base GOV ADB Base GOV ADB Base GOV ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total totalBase costs excluding taxes and duties1 Civil Works - - - - - - - - - - - - - - - - - - 2 Laboratory and Office Equipment 21 - 21 - - - - - - - - - - - - 21 - 21

- - - - - - - - - - - - - - - - - - 1 System Development - - - - - - - - - - - - - - - - - - 5 Training, workshop, fellowships 110 - 110 160 - 160 160 - 160 160 - 160 85 - 85 675 - 675 6 Commutity Mobilization - - - - - - - - - - - - - - - - - - 2 Consulting services 1,548 - 1,548 1,619 - 1,619 774 - 774 348 - 348 201 - 201 4,490 - 4,490 3 Project Management 54 - 54 54 - 54 54 - 54 54 - 54 54 - 54 268 - 268 4 Recurrent Costs - - - - - - - - - - - - - - - - - - 5 9.1 Supplies - - - - - - - - - - 6 9.2 Vehicle operations and maintainance - - - - - - - - - - - - - - - 7 9.3 Lab Equipment Operation and maintainance - - - - - - - - - - - - - - -

8Total Base Costs 1,732 - 1,732 1,833 - 1,833 988 - 988 561 - 561 339 - 339 5,454 - 5,454

Physical contingencies cw 0%, lo 5%, veh 0%, sd 0%, twf 0%, cm 0%, cs 0%, pm 3%, rc 3% 1 Civil Works - - - - - - - - - - - - - 2 Laboratory and Office Equipment 1 - 1 - - - - - - - - 1 - 1 3 Vehicles - - - - - - - - - - - - 4 System Development - - - - - - - - 5 Training, workshop, fellowships - - - - - - - - 6 Commutity Mobilization - - - - - - - - 7 Consulting services - - - - - - - - 8 Project Management 2 - 2 2 - 2 2 - 2 2 - 2 2 - 2 8 - 8 9 Recurrent Costs - - - - - - - - - - - - - - - - - -

9.1 Supplies - - - - - - - - - - - - - - - - - - 9.2 Vehicle operations and maintainance - - - - - - - - - - - - - - - - - - 9.3 Lab Equipment Operation and maintainance - - - - - - - - - - - - - - - - - -

Total Physical contingencies: 3 - 3 2 - 2 2 - 2 2 - 2 2 - 2 9 - 9

Price Contingencies: see below1 Civil Works - - - - - - - 2 Laboratory and Equipment 0 0 - - - - - - - - 0 - 0 3 Vehicles - - - - - - - - - - - - - 4 System Development - - - - - - - - - - - - - - - - - - 5 Training, workshop, fellowships 6 - 6 9 - 9 9 - 9 9 - 9 5 - 5 37 - 37 6 Commutity Mobilization - - - - - - - - - - - - - - - - - - 7 Consulting services 22 - 22 23 - 23 11 - 11 5 - 5 3 - 3 63 - 63 8 Project Management 3 - 3 3 - 3 3 - 3 3 - 3 3 - 3 15 - 15 9 Recurrent Costs - - - - - - - - - - - - - - - - - -

9.1 Supplies - - - - - - - - - - - - - - - - - - 9.2 Vehicle operations and maintainance - - - - - - - - - - - - - - - - - - 9.3 Lab Equipment Operation and maintainance - - - - - - - - - - - - - - - - - -

Second Communicable Diseases Control Project: RCU

Table 4.7: Base Cost Estimates by Expenditure Category(ADB and GOV)



Base GoV ADB Base GOV ADB Base GoV ADB Base GOV ADB Base GOV ADB Base GOV ADBExpenditure Category Y1 Y1 Y2 Y2 Y3 Y3 Y4 Y4 Y5 Y5 total total

Table 4.7: Base Cost Estimates by Expenditure Category(ADB and GOV)

Total Price contingencies 31 - 31 34 - 34 23 - 23 17 - 17 10 - 10 115 - 115

Taxes: cw 0%, pm 0%, rc 0% (separated from the base costs above)1 Civil Works - - - - - - 2 Laboratory and Equipment - - - - - - 3 Vehicles - - - - - - 4 System Development - - - - - - 5 Training, workshop, fellowships - - - - - 6 Commutity Mobilization - - - - - - 7 Consulting services - - - - - - 8 Project Management - 9 Recurrent Costs - - - - - -

9.1 Supplies - - - - - - 9.2 Vehicle operations and maintainance - - - - - - 9.3 Lab Equipment Operation and maintainance - - - - - -

Total Tax Costs - - - - - -

Total Cost including contingencies, taxes and duties- - - - - - - - - - - - - - - - - -

1 Laboratory and Equipment 22 - 22 - - - - - - - - - - - - 22 - 22 2 Vehicles - - - - - - - - - - - - - - - - - - 3 System Development - - - - - - - - - - - - - - - - - - 4 Training, workshop, fellowships 116 - 116 169 - 169 169 - 169 169 - 169 90 - 90 712 - 712 5 Commutity Mobilization - - - - - - - - - - - - - - - - - - 6 Consulting services 1,570 - 1,570 1,642 - 1,642 785 - 785 353 - 353 204 - 204 4,553 - 4,553 7 Project Management 58 - 58 58 - 58 58 - 58 58 - 58 58 - 58 290 - 290 8 Recurrent Costs - - - - - - - - - - - - - - - - - -

a Supplies - - - - - - - - - - - - - - - - - - b Vehicle operations and maintainance - - - - - - - - - - - - - - - - - - c Lab Equipment Operation and maintainance - - - - - - - - - - - - - - - - - -

Total amount 1,766 - 1,766 1,869 - 1,869 1,012 - 1,012 580 - 580 351 - 351 5,578 - 5,578



SECOND GMS REGIONAL COMMUNICABLE DISEASES CONTROL PROJECT: REGIONAL COORDINATION UNITTABLE 4.8 TOTAL BASE COST



Regional Coordination Office and Consulting Services

I. Investment costs

Office Equipment

2.6.1.2.c Office Equipment for RCU National Set 1 1 21,000 21,000 0 0 0 0 21,000


2.6.1.5. Regional Technical Workshops Regional WS 3 5 5 5 2 20 25,000 75,000 125,000 125,000 125,000 50,000 500,000

2.6.1.5. Regional Annual Review Workshops Regional Review 1 1 1 1 1 5 35,000 35,000 35,000 35,000 35,000 35,000 175,000

Consulting services based in RCU (Remuneration and per diem)

2.6.1.7. Int’l Chief Technical Adviser (CTA) (Also Manages RCU & Int Forums) p-month 9 12 12 12 9 54 14,500 130,500 174,000 174,000 174,000 130,500 783,000

2.6.1.7. Int'l Social Anthropologist p-month 4 2 6 13,000 52,000 26,000 0 0 0 78,000

2.6.1.7. Regional Gender Specialist p-month 6 6 6,000 36,000 0 0 0 0 36,000

2.6.1.7. Int'l Training Systems Adviser p-month 9 3 3 15 13,000 117,000 39,000 39,000 0 0 195,000

2.6.1.7. Int’l or Regional Project Implementation Advisers ( x 3) p-month 27 36 12 75 13,000 351,000 468,000 156,000 0 0 975,000

2.6.1.7. Int’l Laboratory Management Specialist p-month 6 2 8 12,000 72,000 24,000 0 0 0 96,000

2.6.1.7. International IT/database/GIS Specialist for BLS (IT/GIS Sp) p-month 6 2 8 12,000 72,000 24,000 0 0 0 96,000

2.6.1.7. Program Officer (remuneration) p-month 9 12 12 12 9 54 2,500 22,500 30,000 30,000 30,000 22,500 135,000

2.6.1.7. Per diem for all international and regional consultants Month 76 69 39 24 18 226 2,500 190,000 172,500 97,500 60,000 45,000 565,000

2.6.1.7. National Gender specialist (1 @3 countries) p-month 6 6 2,500 15,000 0 0 0 0 15,0002.6.1.7. Per diem for Program coordinator Month 2.4 3.2 3.2 3.2 2.4 14.4 1,200 2,880 3,840 3,840 3,840 2,880 17,280

2.6.1.7. Per diem for national gender specialist Month 4.2 0 0 0 0 4 1,200 5,040 0 0 0 0 5,040

Consulting services seconded to WHO (Remuneration) 0 0 0 0 0 0

2.6.1.7. NTD Specialist Month 9 11 3 23 13,000 117,000 143,000 39,000 0 0 299,000

2.6.1.7. Surveillance and Response Specialist Month 9 11 3 23 13,000 117,000 143,000 39,000 0 0 299,000

2.6.1.7. Dengue Specialist Person-month 9 11 3 23 13,000 117,000 143,000 39,000 0 0 299,000

2.6.1.7. Per diem for all international consultants seconded to WHO Month 27 33 9 0 0 69 3,000 81,000 99,000 27,000 0 0 207,000

Other Consulting services

2.6.1.7. Quarterly Consulting services MBDS Unit 4 4 4 0 0 12 12,500 50,000 50,000 50,000 0 0 150,000

2.6.1.7. Researchs 0 0 0 0 0 0

2.6.1.7. Various researchs Unit 2 2 2 6 40,000 0 80,000 80,000 80,000 0 240,000

Operating Costs

2.6.1.8. Remuneration and per diem for Interpreter (1) National LS per year 1 1 1 1 1 5 8,040 8,040 8,040 8,040 8,040 8,040 40,200

2.6.1.8. Remuneration and per diem for RCU Secretary/Finance National LS per year 1 1 1 1 1 5 8,040 8,040 8,040 8,040 8,040 8,040 40,200




2.6.1.8. RCU office rental National LS per year 1 1 1 1 1 5 10,800 10,800 10,800 10,800 10,800 10,800 54,000

2.6.1.8. RCU office operating costs (various) National LS per year 1 1 1 1 1 5 5,040 5,040 5,040 5,040 5,040 5,040 25,200

2.6.1.8. Land travel (taxis, car rental) National Month 12 12 12 12 12 60 300 3,600 3,600 3,600 3,600 3,600 18,000

2.6.1.8. National air travel National Month 12 12 12 12 12 60 400 4,800 4,800 4,800 4,800 4,800 24,000

2.6.1.8. International and regional travel International Month 12 12 12 12 12 60 1,100 13,200 13,200 13,200 13,200 13,200 66,000

TOTAL 1,732,440 1,832,860 987,860 561,360 339,400 5,453,920


ADB TA - 7279-REG: Second GMS Regional Communicable Disease Control Project.

1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q


A. Component 1: Strenghening Regional Cooperation in CDC.

Etablishment of regional focal point in MOH.

MOH active in regional policy development.

Harmonised approach to CDC (MOH, WHO & ADB) established.

GMS MOHs establish CDC2 regional steering committee.

MOHs participate in regional steering committee meetings.

MOHs formalise agreements on CDC border crossing activities.

Provincial management engaged in cross border dialogue.


Technical Group established to develop Baseline Survey.

Regional meeting to confirm baseline design and implementation.

Study tours to China and Thailand undertaken.

Baseline Survey undertaken in border districts.

Analysis of Baseline Survey findings and additional studies identified.

Provincial and district multisector long term strategic plan established.

Provincial workshops to harmonise priorities, plans with other donors.

M&E criteria and performance indicators established.

Sentinel surveillance villages identified and surveyed.

Quarterly consultations, monitoring and reviews undertaken.

National and regional annual consultations and reviews undertaken.

1.1 Compatible and coordinated strategies for CDC across borders

Major Activity/Tasks

Project Year

National and provincial steering committees and technical committees meet regularly.

MOHs establish national and provincial steering committees and technical committees.

2013 2013 20142010 2011 2012

Year 1 Year 2 Year 3 Year 4 Year 5

APPENDIX 7 - IMPLEMENTATION SCHEDULE

Appendix 7 - Implementation Schedule - Final Consultant Report April 2010 Page 1



3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2QMajor Activity/Tasks

Project Year

2013 2013 20142010 2011 2012



Clearing House concept agreed and established in RCU.

Training on Information and Communications Technology (ICT).

Activities to promote KM and community of practice.

GIS mapping and database services functioning.

Technical forums and workshps conducted.

Technical TA support for national regional coordination.

Training workshops on M&E, planning and coordination.

Coordination with other projects engaged in CDC activities.Active cross border intersectoral meetings undertaken.


National workshop on inter-sectoral CDC policy.Training on governance and policy development.

National multi-sector strategies and policies established.

MOHs conduct Intersectoral meetings relating to CDC.

MOHs conduct regular donor meetings relating to CDC activities.

2.2 Strengthening Systems for Human Resource DevelopmentMOHs adopts "Training Systems Development Framework" for HRD.

National Institutes participate in TSDF for HRD development.

Provincial TNA undertaken in project provinces and districts.

Training of Trainer courses developed and undertaken.

Provincial Training Working Group established.

Training equipment procured.

Provincial Training plans estabilshed and training commences.IEC Materials reviewed, revised, and printed.

Followup work place assessments undertaken.

B. Component 2: Stregthening National Surveillance, Response and Health Systems

1.4 Support for regional GMS CDC implementation and coordination.

National multi-sector guidelines and roles and responsibilities for CDC emergency established and implemented.





Project Year

2013 2013 20142010 2011 2012


National surveillance system reviewed and revised.National and provincial emergency response initiatives agreed. National and provincial emergency response funding allocated.

Harmonised surveillance plans based on MBDS seven strategies.

Criteria for small grants program established.

Village small grants for WASH & other activities implemented.

Support to village development committees implemented.

Support to local schools and community for S&R.

Community environmental clean up (Dengue control).

Village rain water jar protection (Dengue control).

Community based surveillance and response scheme established.Develop criteria for small scale studies and implement.Cross border criteria established and liaison meetings undertaken,Vehicles and equipment purchased for operational CDC activities.

TOT and PTWG established and functioning.

Assessment of laboratory capability and equipment (Prov & Dist).Procurement of laboratory equipment and supplies.

Training of laboratory staff.Training in reporting and basic analysis and computer skills.

Skills training and planning for facility based and outreach services.

Supervisory visits and on-the-job training.

National Institutes provide specialist technical support to Provs & Districts.

Training of district hospital and health centre staff.

Training of commune and village health workers.

Provincial & District assessment to identify underserved villages.

Healthy Village criteria established and program undertaken.

Support to mobile teams for outreach services.

Support to district and health centre for COMBI/BCC training.

Support to villages to implement community engagement strategy.

Training of provincial and district staff in field epidemiology, clinical diagnosis & treatments, communications skills, and env health.

2.5 Targeted CDC and training Activities for Rural Populations in Border Districts

2.4 Strengthening Provincial and District staff for CDC and Health Service Delivery.

2.3 Strengthening systems of surveillance, response, and preparednessNational policies, IHR, APSED and MBDS Action plan adopted as the basis for CDC regional activities.





Project Year

2013 2013 20142010 2011 2012


Scholarships for upgrading qualifications and skills.

Community participation in quarterly meetings.

2.6 Support for National Project ImplementationPMUs and PPIUs established and functioning.

Training senior staff in project planning and management.

Management M&E indicators and performance criteria estabilshed.

Management Performance assessed and report quarterly.RCU provides technical and management support to PMUs and PPIUs.

Annual operating plan and training plan developed and implemented.

National consultants and PMU and PPIU staff engaged.

International TA consultants inputs coordinated by PMUs and RCU.

Motor vehicles, motor bikes, boats and office supplies procured.

Annual operating plan and training plan developed.Quarterly and annual performance reviews and reporting completed.

Annual Audit.

Mid Term Review.

Project Completion Review.


APPENDIX 8:

IMPLEMENTATION ARRANGEMENTS


Appendix 8: Implementation Arrangements – Final Consultant Report April 2010 Page i

TABLE OF CONTENTS

I. PLANNING OF PROJECT ACTIVITIES ................................................................................ 1

II. PROCUREMENT .................................................................................................................... 2

III. CONSULTING SERVICES ..................................................................................................... 2

IV. ADVANCE ACTIONS ............................................................................................................. 3

V. EXTERNAL AUDIT ARRANGEMENTS ................................................................................ 3

VI. REPORTING ........................................................................................................................... 4

VII. DISBURSEMENT ARRANGEMENTS ................................................................................... 5 A. Detailed disbursement arrangements in Cambodia .......................................................... 6 B. Detailed disbursement arrangements in Lao PDR ............................................................ 6 C. Detailed disbursement arrangements in Viet Nam ............................................................ 6

VIII. ANTICORRUPTION MEASURES .......................................................................................... 8

IX. PROJECT PERFORMANCE MONITORING SYSTEM ......................................................... 8

ANNEXES Annex 1: Staffing of PMUs and PPIUs in CLV countries .............................................. 10

Annex 2: Consultants financed by the Pooled Fund working for three countries ........... 11

Annex 3: Outline Terms of reference for key positions in PMUs and PPIUs (government and National consultants) ......................................................... 12

Annex 4: Outline Terms of Reference for International consultants and RCU staff ....... 18


Appendix 8: Implementation Arrangements – Final Consultant Report April 2010 Page 1

PROJECT MANAGEMENT ARRANGEMENTS

1. Project management will be done through the Governments‟ systems of the CLV countries. The three Ministries of Health (MOHs) will be three Executing Agencies (EAs) and MOH will assign a department under it to work as the Implementing Agency (IA) for day to day management of the project at central level, in cooperation with other relevant departments, agencies (hereafter called as the national IA). The national IAs will be the Communicable Diseases Control Department (CDCD) in Cambodia, Department of Planning and Finance (DPF) in Lao PDR and General Department of Preventive Medicine and Environmental Health (GDPMEH) in Viet Nam.

2. Under each central IA, a Project Management Unit will be established based on the CDC1‟s PMU. The MOH will need to evaluate performance and availablility of CDC1 staff. Those who performed well in CDC1 and still are available for CDC2, will be considered to be retained for CDC2. In Cambodia, as CDC1, CDC2 will be partly incoporated into the HSSP2 and implemented under support of this multi- donor-funded program, especially procurement and financial management. In Lao PDR and Viet Nam, CDC2 will be independant to other projects under the MOHs in their management. Specific names of the technical and management staffing positions and an outline of the Terms of Reference (TORs) in each country are attached in Annex 1 and Annex 3.

3. At provincial level, the Provincial Health Department (PHD) will be working as provincial level Implementing Agencies (provincial level IAs). There are 35 provincial IAs in total; 6, 9 and 20 in Cambodia, Lao PDR and Viet Nam respectively. There are 3 positions in each PPIU to be financially supported by the Project, including a Provincial Project Manager, a Technical Officer and an Accountant. The Accountant could be contracted from the market so as to reduce workloads of PHDs. TORs for these positions are attached in Annex 3.

4. Noting that in CDC2, there is a difference to CDC1 in that no national medical research institutes will be assigned to work as IAs, so as to reduce the complication in project management and to partly build up their capacity by engaging them to provide technical support to the project via contracting arrangements. Relevant training courses in project management, procurement and financial management will be conducted to build capacity for the whole project management system, from central to provincial levels.

I. PLANNING OF PROJECT ACTIVITIES

5. In the three CLV countries, all project activities will be fully incoporated into the goverment planning cycle of each country. Based on the project design and actual needs, PPIUs will propose their Annual Operation Plans (AOPs) and submit to the PHDs for review and approval before submitting to PMUs for review, endorsement and incoporation into the Project AOPs. Similarly PMUs themself will need to prepare their own AOPs, obtain relevant approvals from the Central IA and incoporate these into the Project AOPs. These Project AOPs will be submited to MOHs and ADB for review and approval. In Cambodia and Viet Nam, MOHs and ADB should approve AOPs between 15 December to 15 January, if not sooner, while in Lao PDR, these approvals should be done between 15 September to 15 October1, if not sooner.

6. Most of the project activities at both PMU and PPIU levels should be planned through participatory methods, except what are fixed during project design and loan

1 Lao PDR financial year cover a period from 01 October this year to 30 September next year.



negotiations2. Consultation with relevant agencies, not only in MOHs or PHDs but also other external agencies, is required. Since this is a regional project, PMUs and PPIUs will be encouraged to share draft AOPs and then final AOPs between CLV countries and neigboring provinces for reference and awareness of „what they are doing and what are to cooporate with them‟. Annual planning workshops at provicial and national levels to discuss draft AOPs will be required and budget lines for these activities are provided in the project design.

7. Under Cambodia‟s CDC1, there was a contingencies budget for immediate response, and this provided a good support to national surveilance and response systems. Under CDC2, this will be placed under an emergency fund, under the subcomponent 2.3, to be allocated both to national and provincial levels and managed by PMUs and PPIUs. Key activities financed by this budget include: “immediate response to investigate an outbreak and confirm a plan of action if the investigation is confirmed, and to allow staff to take immediate action to prevent or minimise the spread of the outbreak”. Because these kinds of activities can not be planned in advance, it requires a more flexibile spending mechanizm, and detailed guidance for this will be reflected in the draft Project Administration Manual (PAM) of the Consultant team.

II. PROCUREMENT

8. All ADB-financed procurement will be done in according to ADB‟s Procurement Guidelines (2007, as amended from time to time). The procurement plans for CLVs with indicative contract packages are at Appendix 9. International competitive biddding procedures will be applied for any packages with a value of equal or greater than $0.5 million in the case of Goods; and equal or greater than $1 million in the case of Civil Works. Any bid packages of Goods and Civil Works with a value of less than $ 0.5 million and less than $1 million respectively will be procured through national competitive bidding. In addition, project vehicles for Lao PDR and Cambodia will be procured through the United Nations system, with procurement procedures acceptable to ADB.

9. Smaller goods and civil works packages costing less than $0.1 million may be procured through shopping procedures. In CDC2, so as to partly build capacity at the provincial level, small contracts of goods may be directly procured by PPIUs rather than PMUs, including, but not limited to, medical supplies, office equipment and consumables.

III. CONSULTING SERVICES

10. Technical assistance consulting services, including international and national consultants for CLV countries and RCU, will be financed by grant funds under a budget line of the pooled fund. There will be 9 international and national consultants to be engaged as individual consultants. ADB will directly recruit and pay these individual consultants. The Guidelines on the Use of Consultants by Asian Development Bank and Its Borrowers 2/2007 (ADB Consultant Guidelines) will be applied as amended from time to time. A list of consultants and outlines of TORs for each position are presented in Annex 3 and Annex 4.

11. In addition, in PMUs of Cambodia and Viet Nam, there will be a number of national staff consultants to be recruited by PMUs following ADB Consultant Guidelines as mentioned above3. These postions are: (i) one project accountant and two accounting assistants (in Cambodia); and (ii) a Chief Accountant and two Accountants and one Accounting Assistant (in Viet Nam). In Lao PDR, an accounting firm will be recruited by 2 For example the number of vehicles for PMU and PPIUs, etc. 3 In addition, PMUs can refer to ADB‟s Consulting Services Operations Manual for more detailed guidance



PMU using CQS procedures to undertake all accounting works from the begining of project. TORs for finance staff for the Deputy Director position for Viet Nam can be seen in Annex 3. More detail on consulting packages (individual and firm engagements) and assigned recruitment procedures can be seen in Appendix 9 - Procurement Plans.

12. International consultants will be all recruited as individuals because of the following reasons: (i) it will save substantial time for recruitment because recuitment of individual consultants will need only a short time (maximum 2.5 months4), thus consultants can be on board to work much sooner than recruitment of a firm (it will take at least 6 months); (ii) there are not many financially stable and highly capabile consulting firms in the world and all good firms are very busy; (iii) it would be better for ADB to directly recruit high calibre consultants to reduce the cost and improve the quality of its employees as the employed firms may not use appropriate consultants because they may not know many good consultants, etc; (iv) in cases where an individual consultant retires from the project (due to various different reasons), ADB will be able to find an appropriate replacement rather than only relying on the firm.

13. However, experience from CDC1 indicates that in the three PMUs, it was difficult to recruit good national consultants as individuals due to the low national salary cost norms and specialist expertise required. In CDC2, it is recommended that market based remuneration cost norms for national consultants be attached to the project documents (i.e RRP of ADB and Feasibility Study in case of Viet Nam), discussed and agreed during loan/grant negotiation between ADB and CLV governments.

IV. ADVANCE ACTIONS

14. The MOHs of CLV may want to take advance action (retroactive financing model) to speed up project implementation. They could hire national consultants (who will be working in the project office as full time staff consultants and the accounting firm for Lao PDR), train project and provincial staff to work in the Project, and prepare bidding documents for important and substantial contracts. ADB will not finance any expenditures paid by the Government before the grant and loan were approved by ADB‟s Board of Directors. ADB‟s concurrence with advance actions does not commit ADB to finance the related expenditures under the Project or to finance the Project. This will be included in the Loan/Grant agreements.

V. EXTERNAL AUDIT ARRANGEMENTS

15. As usual, external audits will be mandatory for CDC2. The audit5 coverage will include a special audit of the project imprest account, including separate opinions on: (i) the utilization of the primary and secondary imprest accounts; (ii) the statement of expenditures, including whether the amount claimed is duly supported and verified; (iii) whether the PMU is operating the imprest account in accordance with ADB procedures; and (iv) compliance with financial covenants specified in the loan/grant agreements.

16. The annual project accounts should contain detailed descriptions of the fund sources and expenditures. The annual financial statements of the project should consist of a balance sheet, cash flow statement, and related notes to financial statements. As also mentioned in Appendix 12 , a very helpful model of a TOR for annual audit can be downloaded from ADB website (http://www.adb.org/Documents/Guidelines/Financial/part071700.asp) or 4 including 1 month mandatory advertisement in ADB website (CSRN) 5 CDC2‟s PMUs will need to prepare Terms of reference acceptable to ADB for the annual project audit. The auditing company should review and substantiate the accuracy and sustainability of accounting documents, figures and other accounting liquidation reports kept by PMU and PPIUs.

http://www.adb.org/Documents/Guidelines/Financial/part071700.asp



obtained from HSSP26 (in case of Cambodia). This will also assist PMU to prepare a sound TOR for auditing services.

17. The audit reports, management letter, and related financial statements will be submitted to ADB not later than 6 months7 after the end of the fiscal year (31 December in case of Cambodia and Viet Nam and 30 September in case of Lao PDR) to which they relate, or the project closing date, whichever is earlier. The annual financial statements will be a consolidation of all project‟s operations. ADB will review the implementation and operation of the Project Loan/Grants, based on these reports and other relevant reports, and meet with MOH, PMU and other relevant Government agencies annually to discuss project progress. It is also noted that ADB has informed three EAs of its policy on submission of audited accounts, which covers failure of submitting audited accounts and financial statements by the due date. A formal warning will be issued for accounts more than 6 months overdue, and disbursements will be suspended for accounts that are 6 months overdue.

VI. REPORTING

18. Reporting systems of projects in CLV are, in-principle, similar. Reports will be prepared and submited from lower level agencies to higher level agencies as assigned by the Government. Reports also need to be submitted to the donor – the Asian Development Bank, as agreed in the signed Loan/grant agreements of CDC2.

19. Specifically, it is the same in CLV that PPIUs have to submit monthly financial reports8 to PMU using the standard forms created and provided by PMU (in excel worksheets). These reporting forms are available under CDC1 and there will be some minor revision needed to customize these for CDC2. In addition, PPIUs will need to prepare and submit to PMU a quarterly technical report (QTR) which summarizes achievement of AOP activities conducted, outputs produced, problems, constraints encountered if any, planning of actions to overcome constraints and recommendations. A template of this QTR is attached in the draft PAM.

20. PMU then will consoliate information gathered from PPIUs, including their own project implementation and fund disbursement information, etc. The quarterly reports are submitted respectively to (i) the Communicable Disease Control Department (Ministry of Cambodia), Department of Planning and Finance (Ministry of Health in Lao PDR and Viet Nam); (ii) Ministry of Health in each CLV; (iii) Ministry of Finance in each and (iv) Ministry of Planning and Investment in Lao PDR and Viet Nam and ADB (the Social Sectors Division of South East Asia Department)

21. The forms of quarterly reports applied in CDC1 should be used for CDC2. In Viet Nam, the PMU has to prepare an annual report and submit to relevant agencies through the AMT system designed and managed by Ministry of Planning and Investment. The proposed date of report submission of each relevant agencies involved in CDC2 can be seen in the draft PAM.

22. In CDC2, PMUs will need to prepare a Mid Term Report and submit to ADB and relevant government agencies within 15 days before ADB implements the Mid Term Review (MTR) misison. ADB will discuss and agree with EAs on the date to conduct the MTR. It is

6 Attachment 20 of the Financial Policies & Procedures Manual, Ministry of Health, January 2009 7 In CDC1 it is a 9 month- term however given the fact that PMUs‟s capacity is improved after 4 years, 6 month- term is proposed for CDC2. 8 This is submitted together with the withdrawal application of funds of PPIU.



recommended that ADB‟s MTR of CDC2 should be better-planned with sufficient time spent by the ADB9.

23. Finally, within 6 months of the physical completion of the Project Grant/Loan, the PMU will submit to the ADB a Project Completion Report (PCR) that describes in general: (i) the physical progress of the Project; (ii) actual costs incurred in relation to cost estimates; (iii) the results of capacity-building activities; (iv) the outcome of safeguard efforts to equipment; (v) a preliminary assessment of achieved benefits; and, (vi) other relevant project implementation matters requested by ADB. Guidance for preparation of PCR is available on the ADB website, but normally there should be a consultancy service to assist PMU to complete this job to ensure that the quality of report is acceptable to ADB. The contents of PCR for CDC2 should be discussed during the ADB appraisal mission of this proposed Project.

VII. DISBURSEMENT ARRANGEMENTS

24. In each CLV country,disbursement arrangements are designed in accordance with ADB guidelines and specific conditions of the locality. Careful consideration was given to the design of disbursement mechanisms to ensure that smoothness in disbursement can be achieved and any associated risks can be minimized.

25. There will be three First Generation Imprest Accounts (FGIAs) to be opened in CLV. In Cambodia and Lao PDR, the MEF and MOF will respectively manage this account directly, while in Viet Nam, the MOH will be assigned to manage the FGIA. The initial amount to be deposited by ADB in the imprest account of each country will be based on the estimated expenditure for the first 6 months of project implementation or $900,000 for Cambodia, $1,000,000 for the Lao PDR, and $2,500,000 for Viet Nam, whichever is lower. The imprest account will be established, managed, replenished, and liquidated according to ADB‟s Loan Disbursement Handbook of 2007, as amended from time to time, and detailed arrangements agreed upon between the MOH of each country and ADB. The aforementioned ceilings are very tentative, ADB and CLVs governments will discuss and decide during loan/grant negotiations.

26. The SOE procedures may be used to reimburse expenditures and liquidate the FGIA for all individual payments not exceeding $ 50,000 for Cambodia and Lao PDR and $100,000 for Viet Nam. The FGIA will be flexibly replenished on a monthly or quarterly basis to ensure liquidity of funds or when the accounts are drawn down to 20% of the initial deposit. For consulting services through firms (such as auditing services, accounting services in Lao PDR, surveys etc.) and large goods contracts, PMUs should use direct payment and committment letter procedures as guided in the ADB‟s Loan Disbursement Handbook 2007, as amended from time to time.

27. PPIUs in three countries will be reimbursed for funds spent from their designated accounts up to 2 times per month at the middle and end of the month, depending on disbursement progress in each PPIU. This will help speed up disbursement and ensure that PPIUs always have sufficient funds to use. District Heath Center/Office or Commune/ Village Authority will be authorized by the PPIU to spend a number of budget lines for the planned project activities at these levels as designed by the project and they may open a bank account10 at any local bank convinient for them to receive and pay out the eligible

9 ADB stated in the MTR report of CDC1- Viet Nam that they have limited time to do MTR 10 This procedures is designed to avoid the complication in opening and managing any kind of imprest account as the „son‟ of PPIU‟s imprest account.



project funds provided that the ADB funds will not be retained in such bank account more than 48 hours (fourty eight) from the time of deposit.

A. Detailed disbursement arrangements in Cambodia

28. Disbursement of CDC2 grant funds in Cambodia will follow current HSSP2 procedures. This grant fund will be disbursed from ADB‟s account to a FGIA (opened with the National Bank of Cambodia) and managed by MEF. In Cambodia, the MOH will open a project FGIA at the National Bank of Cambodia, which will be managed by the HSSP2 administration of MOH. Project funds will flow from ADB through HSSP to provincial health departments using SGIAs.

29. Each PPIU will open a SGIA in a commercial bank acceptable to MOH and ADB. There will be 9 SGIAs for CDC2 in Cambodia. As currently arranged under CDC1, PPIUs will disburse grant funds from the SGIAs based on the AOP proposed by them and approved by HSSP2. The initial advance of SGIA values $20,000, and twice per month, PPIUs submit a request for funds transfer to HSSP2 for liquidation and replenishment of their respective SGIAs.

B. Detailed disbursement arrangements in Lao PDR

30. Disbursement arrangements for the CDC2 should be kept as currently in place for CDC1. The PMU will open a SGIA in the Banque Pour Le Commerce Exterieur Lao PDR (BCEL), while each PPIU will open a Third Generation Imprest Account (TGIA) in a commercial bank acceptable to ADB and Ministry of Finance (i.e. BCEL or other commercial banks if possible). As mentioned in Appendix 12, it is strongly recommended that the leaders of MOH (i.e. Minister or his/her Vice Minister) should not be assigned to sign W/A to withdraw funds from FIGA (MOF manages this) to SGIA of PMU as to simplify procedures, save time and partly reform the administration system. The Project Director should do this instead of MOH‟s leaders.

31. After approval of Year 1 AOP, the PMU will initially advance $ 20,000 from SGIA to each TGIA. The PPIUs will submit requests for funds transfer for replenishment of their project accounts twice per months as the current arrangements in CDC1 or even more frequently if needed. For an approved project activity which requires more than $ 20,000, the PPIU can request PMU to transfer funds directly to the beneficiary(ies) or to the project accounts, using a separate request for funds transfer.

C. Detailed disbursement arrangements in Viet Nam

32. For the Project Loan, MOH will authorize the PMU to open three bank accounts. A FGIA, in US$, will be opened in a commercial bank acceptable to ADB and SBV to receive funds from ADB and disburse to beneficiaries. Another account in VND will be opened in that commercial bank for US$-VND conversion when needed. PMU will also open an account in State Treasury (ST) in Hanoi, convenient for them for counterpart funds transaction purpose.

33. Generally, payments using ODA funds in Viet Nam are still subjected to either prior or post procedures compliance review11 by the State Treasury, and approval by MOF before forwarding to donor for reimbursement or direct payment. Similar procedures are applied for counterpart funds but payment will be made by the ST after their review and acceptance of eligible payment amount. These procedures are detailed in four key documents as listed in

11 This may be also called as Payment Checking or Payment Control in other papers.



the Footnote 2 below12. These procedures are under revision by MOF, in the spirit of being “more open” and this hopefully will help improve faster ODA funds disbursement.

34. PPIUs will open 15 SGIAs at provincial level to receive and disburse ADB funds in a commercial bank, and funds can be tranfered from the FGIA to these accounts based on AOPs prepared by PPIU and acceptable to PMU13. The maximum limit of this SGIA is $50,000. In the case that any PPIU has to arrange any payment valued at more than $50,000, the eligible payment to contractor/ supplier is arranged to be paid directly from PMU‟s FGIA or even from ADB to their own accounts, upon specific written requests of PPIU.

35. Similar to Cambodia and Lao PDR, PPIUs in Viet Nam will submit requests for funds transfer for replenishment of their project accounts twice per months as the current arrangements in CDC1, or more frequently if needed. In addition, each PPIU will also open other bank accounts in VND in the ST for counterpart funds transaction purpose. Detailed disbursement arrangements for the Project Loan can be seen in Chart 1. PPIUs are guided to submit disbursement dossiers to PMU for liquidate funds twice per month.

Chart 1. Disbursement Arrangements for the Project Loan in Viet Nam ST= State Treasury; B.Account= Bank Account; W/A= Withdrawal Application; PMU = Project Management Unit; PPIU = Project Implementation Unit Key Steps: (1A &1B) Contractors submit requests for payment to PMU, PPIUs (2A &2B) PMU, PPIUs submit payment dossier to ST for prior payment control (3A&3B) STs complete payment control and pay counterpart fund proportion, if any (4) PPIUs submit reimbursement dossiers to PMU including ST‟s Certificates of payment control (5A &5B) PMU submits the integrated reimbursement dossier to MOF, MOF approves and sends back to PMU for W/A signing; (6) PMU submits the signed W/A and supporting documents to ADB for review (7A &7B) ADB pays contractor directly and/or replenishes funds to FGIA of PMU (8) PMU either transfers funds to PPIU‟s account or pays contractor directly upon specific request of PPIU, or both flexibly

12 Including Circular No. 108/2007/TT-BTC dated 07 September 2007 of MOF; Circular No. 27/2007/TT-BTC dated 03 April 2007 of MOF; Circular No. 130/2007/TT-BTC dated 02 November 2007 of MOF and Circular No 88/TT-BTC date April 2009. 13 This contract will be prepared based on the value of the AOP proposed by PPIU and approved by the PMU and to be attached as an appendix of the contract.

(5A)

(1B)

(7A)

(3A)

(2A)

(3B)

(2B)

(1A)

(6)

(7B)

(8)

or

(4)

(5B)

(9)

CEN

TRA

L L

EVE

L

MOF

PRO

VIN

CIA

L L

EVEL

ADB

FGIA

Contractors

B.Account

B.Accounts

B.Accounts

PMU

PPIU

Beneficiaries

ST

ST



(9) PPIU pays as soon as possible after receiving funds from PMU if not yet paid before.

VIII. ANTICORRUPTION MEASURES

36. ADB‟s Anticorruption Policy (1998, as amended to date) was discussed with MOHs of CLV, as the EAs for the Project. Consistent with its commitment to good governance, accountability, and transparency, the ADB reserves the right to investigate, directly or through its agents, any alleged corrupt, fraudulent, collusive, or coercive practices relating to the Project. These MOHs have handled several ADB projects and are now familiar with ADB procedures and anticorruption measures. The previous projects helped set clear procedures for the procurement of equipment and civil works, with financial management support from a private accounting firm. There have not been any major audit issues or instances of suspected fraud.

37. The EAs will plan activities in detail, under the supervision of an international consultant, and hold weekly meetings to plan and report on activities and generally ensure transparency. To support these efforts, MOH staff who are not familiar with ADB‟s Anticorruption Policy will undergo orientation, and ADB review missions will include discussions on corruption. A statement of this policy will be part of the bidding documents for the Project. In particular, all contracts financed by ADB in connection with the Project will specify the right of ADB to audit and examine the records and accounts of the EA and all contractors, suppliers, consultants, and other service providers as they relate to the Project. Governance-related risks will be further minimized through the implementation of a Governance Action Plan, to be developed jointly by the MOHs and project provinces to improve efficiency of program implementation, enhance the quality of outputs, and prevent fraud and corruption.

IX. PROJECT PERFORMANCE MONITORING SYSTEM (PPMS)

38. Project outcomes and other relevant factors, as discussed in the Design and Monitoring Framework (DMF), will be monitored through a designated Project Performance Monitoring System (PPMS). To do this and so as to have information for surveilance and response, project baseline information including two key parts ( i) health and CDC indicators and ii) performance indicators [refer to the column 2 of DMF]) will be set up at the begining of the project through a baseline survey with participation of both regional, national and provincial levels. In each country, an NGO or social institute experienced in health and socoeconomic baselines survey will be engaged to collect baseline information and update the changes periodically.

39. Baseline information to be updated every 12 months and will help monitor the changes of project performance indicators, as mentioned in the DMF, from time to time and reflected in Project Quarterly Reports, the Mid Term Report and the Project Completion Report (PCR). On one hand, based on these and other physical investment, project management information collected during project life, project performance can be assessed by PMUs themself and other relevant agencies such as MOHs, Governments‟ line agencies of CLV countries and ADB. On the other hand, baseline information of heath and CDC indicators will certainly help plan and monitor serveilance and response activities under the Project.

40. MOHs and relevant Goverments‟ line agencies of CLV countries14 will also monitor project implementation in cooperation with ADB. They will send staff to join ADB supervision missions or meet and discuss with ADB officer assigned to the project or send their staff to monitor performance of PMU and/or PPIU levels. ADB will conduct supervision mission every six months and, in addition, a Mid Term Review and a Project Completion Review will be required.

14 Not limited to Ministry of Economy and Finance, Ministry of Finance and Ministry of Finance and Ministry of Planning and Investment in Cambodia, Lao and Viet Nam respectively.


Appendix 8: Implementation Arrangements –Final Consultant Report February 2010 Page 9

Regional Steering Committee Regional Coordination Unit

CAMBODIA

Ministry of Health

LAO PDR

Ministry of Health

VIET NAM

Ministry of Health

ADB

b. ADB

WHO MBDS

a. WHO

Health Sector Steering Committee

MOH Steering Committee

Steering Committee of MOH for ADB Projects

Department of Planning and Finance


General Department of Preventive Medicine and

Environmental Health Project Management Unit


Communicable Diseases Control Department


Provincial Health Departments PPIU

District Health Offices

Health Sector Support Program 2 Supporting National Institutes NCPEMC, NCHDSC, NIPH,

Provincial Health Offices PPIU District Health Offices

Department of Hygiene and Prevention

Supporting National Institutes NCMPE, NCLE, NIA.

Supporting National Institutes NIHE, NIMPE, PIHCMC, VAHC.

ADB = Asian Development Bank; Lao PDR = Lao People‟s Democratic Republic; MOH = Ministry of Health; MBDS = Mekong Basin Disease Surveillance, NCHDSC = National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Diseases Control; NCLE = National Center for Laboratory and Epidemiology; NCMPE = National Center of Malariology, Parasitology, and Entomology; NCPEMC = National Center for Parasitology, Entomology and Malaria Control; NIHE = National Institute of Hygiene and Epidemiology; NIMPE = National Institute of Malariology, Parasitology and Entomology; NIPH = National Institute of Public Health; PIHCMC = Pasteur Institute of Ho Chi Minh City; VAHC = Viet Nam Administration of HIV/AIDS Center; WHO = World Health Organization (regional and country offices).

Provincial Health Department PPIU and Preventive Medicine Center

District Health Centres

s. PPIU



Annex 1: Staffing of PMUs and PPIUs in CLV countries

Name of Position Input

allocated (person-month)

Quantity in each country

CAM Lao PDR VIE Central level (PMU) A. Government assigned staff Project Director (PD) 60 1 1 1 Deputy Project Director (DPD) MOH should designate this as a 100% position

60 1 1 1

B. National Staff consultants Deputy Project Director (DPD)Disagree that this is contracted position for VN

60 - - 1

Project Implementation Consultant (PIC) (Including M&E)

60 1 1 1

Procurement Specialist 36 1 1 1 Surveillance and Response Consultant (SRC)

60 1 1 1

Training Consultant (TC) 60 1 1 1 IT/Database/GIS Specialist (IT/GIS Sp) 60 1 1 1 Chief Accountant /or Chief Financial Officer (CFO)

60 1 1 1

Project Accountant (PO) 60 1 1 2 Accounting Assistant (AA) 60 1 1 1 C. Other contracted staff Project Secretary (PS) 60 1 1 1 Driver 55 1 1 1 Total 13 13 14 Provincial Level (PPIUs) Provincial Project Manager (PPM) 60 1 x 6 (*) 1 x 9 1 x 20 Project Technical Officer (PTO) 60 1 x 6 1 x 9 1 x 20 Accountant (Acc) 60 1x 6 1 x 9 1 x 20 District Level Accountant Assistant (AA) 60 6 19 70

Total 24 46 130 Total 37 59 144

(*) 1x 6 means 1 in each PPIU



Annex 2: Consultants financed by the Pooled Fund working for three countries

Name of Position

Input allocated for each position (person-month)

Quantity in each country

CAM

Lao PDR

VIE

Int‟l Chief Technical Adviser (CTA) (Also Manages RCU & Int Forums)

60 1

Int‟l Social Anthropologist (Regional) 6 1 Int‟l Gender Specialist (Regional) 6 1 National Gender Consultant x 3 6 1 1 1 Int‟l Training Systems Adviser (Regional)

15 1

Int‟l Project Implementation Adviser (PIA) (3 persons (CLV), 22 p-months each)

84 1 1 1

Int‟l Laboratory Management Specialist

8 1

International IT/database/GIS Specialist (IT/GIS Sp) (No Budget provided)

8 1

MBDS Consulting Services (Part Time over 5 years)

10 1

Program Officer RCU 60 1 RCU Accountant/ Secretary 60 1 Specialist consultants to be contracted by ADB and seconded to WHO NTD Specialist 23 1 Surveillance and Response Specialist 23 1 Dengue Specialist 23 1 Optional Extra – “Clearing House” International Regional Knowledge Management Adviser (RKMA) (

24

National IT//GIS Specialist (IT/GIS Sp) Commence in RCU and later based in MBDS) (No Budget provided)

24



Annex 3: Outline Terms of reference for key positions in PMUs and PPIUs (government and National consultants)

Position and Minimum Required Qualification

Outline of Terms of Reference

Project Director (PD) (Part Time) A Master Degree in a health related field. At least five years experience in managing projects in health sector. Good knowledge of project management in health sector. Good written and spoken English.

(i) Lead PMU to implement the Project. Ensure a sound management of FGIA (SGIA in case of Lao PDR). Ensure AOPs completed in a timely manner and approved by MOH and ADB.

(ii) Ensure that equipment and consulting services are delivered timely manner. (iii) Ensure a meta analysis of surveys and report writing is implemented. (iv) Guide the Deputy Director to conduct a monitoring training program for

provincial and district staff on both management and relevant technical aspects.

(v) Guide the Deputy Director to develop and test supervisory checklist. (vi) Prepare quarterly report and annual reports as required by the donor and

Government. (vii) Coordinate activities with other projects and programs to avoid overlapping of

funds. (viii) Act as the secretary for the Steering Committee, when needed. (ix) Other tasks as required by the Government‟s regulation not mentioned here.

Deputy Project Director (DPD) Full Time A Masters degree in a health related field. At least five years experiences in managing similar CDC projects. Good knowledge of statistical analysis in health. Conversant in English. Ability to build capacity of counterpart staff at different levels.

(i) Assist the Project Director (PD) to lead the PMU when the PD is absent and assist the PD to lead the PMU to prepare AOP and obtain approvals.

(ii) Assist the PD to ensure that equipment and consulting services are delivered timely manner.

(iii) Assist the PD to conduct meta analysis of surveys and report writing. (iv) Conduct a monitoring training program for provincial and district staff on both

management and relevant technical aspects. (v) Develop and test supervisory checklist. (vi) Prepare quarterly reports and annual reports as required by the donor and

Government. (vii) Assist the PD to coordinate activities with other projects and programs to avoid

overlapping of funds. (viii) Perform other tasks assigned by the Project Director.

(National ) Project Implementation Consultant (PIC) (including responsibility for M&E) At least a Bachelor Degree in Economics, Medicine, Public Health or a similar development qualification. At least 5 years proven experience in project management, planning and budgeting. Strong monitoring and evaluation experience as well as in the implementation of ADB/ WB funded projects. Strong interpersonal skills and experience in capacity building of counterpart staff at different levels. English

TOR for this position will be carried out in conjunction with the International Project Implementation Adviser (PIA) (see Annex 4). The PIC will work under the direct authority of the PD and DPD and undertake the following tasks: (i) Review outbreak preparedness within the Government system and coordinate

with relevant staff of the PMU to prepare an emergency response and preparedness strategy and implementation plan.

(ii) Ensure that project baseline data has been collected and a process and indicators for project monitoring and evaluation formulated.

(iii) Ensure that project planning, reporting and evaluation is carried out through cooperative management structures in accordance with policy and strategic guidelines adopted by the MOH, including establishment and support to project management units (PMUs) at national and provincial levels.

(iv) Together with the Training Consultant, assist with project management Training Needs Analysis.

(v) Participate in the project management training for provincial and district health managers and for provincial and district project coordinators.





language skills (both spoken and written). Ability to work independently at national, provincial and district levels.

(vi) Work with PMU and PPIUs to develop a Project Monitoring framework. Identify key indicators and sources of data.

(vii) Assist in the organization of the baseline surveys, and quarterly and annual review of project performance measured against the baseline.

(viii) Work with Senior Management and, supported by the PIA, assist in the establishment of a Results Based Management System.

(ix) Other duties as directed by the Project Director. (National) Procurement Consultant (PC) At least a Bachelor Degree in Economics, Logistics or another related field. At least 5 years experiences in ADB/ WB procurement practices of goods and consulting services. Spoken and written skills in English. Ability to build capacity in staff at provincial level in procurement.

(i) Prepare procurement plans for goods and consulting services. Obtain approval from the PD; submit to relevant agencies for review and approval (MOH and ADB).

(ii) Finalize TORs for national consultant positions and follow ADB procedures to recruit them.

(iii) Procure goods at central level following ADB procedures. (iv) Train PPIUs‟ staff the in procedures required for purchasing of minor goods

and services at provincial level and provide technical assistance to them when needed.

(v) Assist the Deputy Project Director (DPD) and the Project Implementation Consultant in the preparation of the PMU‟s AOP and Project AOP.

(vi) Assist the DPD and the Project Implementation Consultant in review and approval of AOPs submitted by PPIUs.

(National) Surveillance and Response Consultant (SRC) At least 5 years experience in the health sector relating to surveillance and response systems management and reporting and laboratory services Qualifications in Public Health or similar.

Based in the PMU at national level and working under the direct authority of the PD and DPPD and receive guidance from the International PIA. Working on the establishment of a project surveillance system. Duties include (i) Liaison with the staff at PPIU and ensure that the surveillance and response

system is implemented and managed accordance to the S&R Guidelines. (ii) Assist in the training of national, provincial and district staff in S&R. (iii) Ensure that project reports are submitted on a regular basis. Analyze and

report on a monthly and quarterly basis. (iv) Assist senior management of the PMU, and staff from the PPIU, in the event

of disease outbreaks. (v) Provide support for health services analysis. (vi) Organize meta analysis of surveys and report writing. (vii) Conduct monitoring training program for provincial and district staff.

(National) Training Consultant (TC)

At least 5 years experience in human resource development, including capacity building using adult learning methodologies for training systems development, preferably in the health sector. Advanced University Degree in Public Health, Education, Social Sciences, or other relevant technical field. Excellent written and spoken skills in English

Operating from the National PMU and working with the International Training Systems Adviser to assist the staff of the HRD in national and provincial health authorities in developing and implementing a training system framework for human resource development (HRD) in the Project. Tasks would include (i) Assist HRD specialists to support the provincial health authorities to develop

sustainable systems for human resources development and quality of care at provincial, district and commune levels.

(ii) Identify or design appropriate training resources and materials for doctors, nurses, midwives, technicians, and other health personnel.

(iii) Assist health staff in the national and provincial health authorities to identify and design appropriate training resources and materials for doctors, nurses, midwives, technicians, community volunteers, and other clinical or preventive health personnel for CDC.

(iv) Assist provincial training groups, to develop regular needs-based training for district and commune-level health staff to improve quality of care and community knowledge and participation for improved behavior for prevention





of communicable diseases. (v) Assist PMU, PPIU and training staff to monitor and evaluate clinical and

preventive health/ health promotion activities at community level, and at all health care levels and the referral system at commune, district, and provincial levels for beneficiaries and non-beneficiaries

(National) IT/Database/GIS Consultant (IT/GISC) At least 5 years experience in GIS, (preferably in Arc view) and database management. Good knowledge of database building. Degree or Diploma in IT with a specialty in GIS. Proficient in spoken and written English. Good ability working in a team environment.

Working under the direction of the PD and working with the International IT/GIS Specialist on the following tasks: (i) Develop the database for the baseline data and the performance reporting

system for the Project (ii) Assist in the develop and management of the Project MIS at the national

levels and for each provincial and district health department. (iii) Assist in the development and management of a HMIS for selected provincial

and district hospitals. (iv) Together with the procurement consultant, prepare bidding documents for

software and hardware (v) Work with the Training Consultant to identify or develop courses for training

personnel in MIS, HMIS and GIS (vi) Supervise the installation of a database systems to assist in the management

and monitoring of training programs (vii) Provide GIS Maps for project reports and for presentation, as well as ensuring

the integrity of the data. (viii) Ensure that GIS mapping and information is shared with the RCU IT/GIS

consultant. (National) Chief Accountant/Chief Financial Officer (CFO) At least 7 years experience in donor funded project financial management and a recognized post graduate level qualifications (Bachelor or Master Degree in Accounting). Good English language skills (both written and spoken). Practical experience with the relevant computer software application for the financial management.

Under the direction of the PD or DPD undertake the following tasks: (i) Ensure that the FGIA (SGIA in case of Lao PDR) is opened in a commercial

bank acceptable to ADB and Government. Manage project funds according to the requirements of ADB and Government.

(ii) Review and provide recommendations to the Project Director on the day-to-day operating expenses and other financial transactions.

(iii) In collaboration with other concerned people, prepare annual budget plan for the Project and monitor the expenditure using the required format.

(iv) Ensure sound financial control, documentation and flow of information of Project. Ensure proper authorization and accounting of operating costs which will be classified by nature of expenses and sources of funding and by categories.

(v) Ensure withdrawal applications are prepared and submitted to relevant agencies and follow up on payments.

(vi) Timely consolidation of financial report and disseminate to all concern parties on a timely fashion. Follow up the subsequent replenishment from ADB and MOH.

(vii) Manage all accounting staff and assist to develop a clear responsibility for each staff to avoid overlapping task and to ensure achievement of best performance.

(viii) Provide training to the Project accounting staff of all levels and provide regular supervision.

(ix) Assist the internal and external auditors to conduct audit by furnishing them with appropriate documents. Assist in identifying the location of assets and facilitate communication with the concerned units/departments for the audit purpose.

(x) Other tasks as regulated by government for this CA/CFO position in donor





funded projects not yet mentioned here. (National) Project Accountant (PO) At least 3 years experience in the donor funded financial management. Recognized Bachelor of Accounting or another other relevant field. Good communications skills in English. Good knowledge of relevant computer accounting software program.

(i) Manage the Project funds according to the relevant guidelines and the requirements of the Ministry of Finance and ADB.

(ii) Review and recommend the Chief Accountant/ or Chief Financial Officer (CA/CFO) on the day-to-day operating expenses and other financial transactions of the Project.

(iii) Assist the CA/CFO to prepare annual budget plan for the Project and monitor the expenditure using the required formats.

(iv) Ensure sound financial control, documentation and flow of information of Project expenditures incurred at national and provincial levels.

(v) Ensure proper authorization and accounting of operating costs which will be classified by nature of expenses and sources of funds and by categories.

(vi) Prepare withdrawal applications for submitting to ADB through MOF (MOEF in case of Cambodia) and follow-up the payment.

(vii) Manage the Project‟s fixed assets in compliance with the Government and ADB policies.

(viii) Assist the CA/CFO to provide training to Project accounting staff of all levels and provide regular supervision.

(ix) Assist the internal and external auditors to conduct audit by furnishing them with appropriate documents. Assist in identifying the location of assets and facilitate communication with the concerned units/departments for the audit purpose.

(x) Perform other tasks as may be assigned by the Chief Financial Officer. (National) Accounting Assistant (AA) Bachelor's Degree in Accounting or equivalent. Accountancy Certification from an accredited financial / accounting institute. At least 2 years prior experience in accounting. Knowledge of professional accounting software, Microsoft Excel and Microsoft Words; Proficiency in written and spoken English.

Under the direction of the CFO, undertake the following Tasks: (i) Assist in document preparation for Project disbursements. (ii) Assist in following-up disbursement requests with MOF (MOEF in case of

Cambodia) and ADB. (iii) Assist with preparation of Project staff payroll. (iv) Assist in maintaining Project accounting files in accordance with project-

designed accounting procedures. (v) Assist in review and verification of provincial petty cash expenditure

statements. (vi) Assist the Project Accountant to conduct spot visits to PPIUs to review petty

cash registers and procedures. (vii) Assist in reconciliation of bank accounts (MOH and provincial) with

statements. (viii) Assist in disbursement of Project petty cash funds as authorized. (ix) Share responsibility with other Accounting Assistant if any to manage the

project budget (x) Assist the external financial audit team in reviewing accounting documents at

central level and accompany them to provinces for reviewing accounting documents and controlling fixed assets.

(xi) Assist the Project Accountant to prepare financial and accounting information as requested by the Chief Accountant (or Chief Financial Officer).

(xii) Other functions assigned by the Chief accountant (or Chief Financial Officer).





(National) Project Secretary (PS) University or technical college degree/certificate. At least three years experience as a secretary. Spoken and written English language. Familiarity with Microsoft Word and Microsoft Excel.

Under the authority of the PD or DPD undertake the following tasks: (i) Receive visitors and respond to incoming and outgoing calls. Record all

personal/office overseas calls/faxes and submit to the telephone company in timely manner.

(ii) Make appointments as necessary for the Project staff. (iii) Deliver all incoming mail, pouches, faxes and parcels immediately to staff in

the office. (iv) Ensure timely dispatch of all outgoing mail, faxes and parcels. Register all

incoming and outgoing letters. (v) Maintain an office registry filing system, ensuring easy retrieval. Act as focal

person for all office supplies. (vi) Make sure that electricity in all office rooms is turned off after work and make

sure that all office rooms are locked after work. (National) Provincial Project Manager (PPM) Five years of experience in management at a provincial or higher level. Qualified as a Medical Doctor with Public Health or similar post graduate qualifications.

The Provincial Project Manager will be responsible to the Director of PHD‟s , Tasks will include: (i) Project implementation at provincial level. (ii) Lead Project staff to prepare AOP and submit to PHD for review and approval

before submitting to PMU for final approval. (iii) Plan the day-to-day management of the project activities. (iv) Guide Project Accountant to open SGIA (or TGIA in case of Lao PDR) to

receive and spend ADB funds. (v) Responsible for proper, effective and timely use of project funds allocated for

PPIU. (vi) Lead the PPIU staff to implement Project activities at provincial level in

conformity with the approved AOP. (vii) Ensure a sound internal control implemented within PPIU. (viii) Ensure a good management of project fixed assets and ensure good O&M of

project financed equipment. (ix) Assist the Project Accountant in the financial management and the liquidation

of project expenses and closing of project accounts at the end of the account period.

(National) PPIU Project Technical Officer (PTO) Five years experience at provincial or higher level with technical level qualification at diploma level. Experience working in PHC service teams at provincial, district and community level.

The PTO will work under the authority of the PPM and undertake the following tasks: (i) Plan the day-to-day management of the project activities. (ii) Prepare a detailed plan, timetable, and annual budget for implementation. (iii) Establish operating procedures for all project activities. (iv) Assist the PPM in procurement, disbursement, reporting, and monitoring. (vi) Undertake project supervision and monitoring visits to the project districts, (i) Support the provincial training team in organising staff training and work place

assessment. (ii) Participate in the Baseline Survey and quarterly reviews. (iii) Ensure that Baseline data and follow-up evaluations are entered into the

provincial database. (National) PPIU Accountant (PA) At least 3 years experience in the donor funded financial management and

The PPIU Accountant will work under the authority of the PPM to undertake the financial management of the Project funds and expenditure at provincial and district level. Tasks will include:





accounting management. Recognized Bachelor of Accounting or other relevant field. Written and spoken English at acceptable level. Good knowledge of relevant computer software applications for accounting.

(i) Establish the project accounting system following the project Guidelines and open any relevant accounting books. Open SGIA or TGIA at a commercial bank as guided by the CFO/CA of the PMU.

(ii) Assist the Project Manager to prepare the AOP and obtain approvals from relevant agencies including PMU.

(iii) Manage project costs and ensure proper and effective use of funds. (iv) Undertake Financial management training on ADB financial and procurement

procedure and procure goods and services as a decentralized PPIU as prescribed in the Project Design.

(v) Twice a month, replenish SGIA/TGIA. (vi) Ensure that a robust internal control system is implemented within the PPIU. (vii) Liquidate all project costs at before loan/grant closing date and close

SGIA/TGIA. (viii) Maintain accounting books and store supporting documents. (ix) Other tasks as assigned by the PMM.

Accounting Assistant (AA) District Level Diploma in Book Keeping, Accounting or equivalent; Accountancy Certification from an accredited financial / accounting institute. At least 2 years prior experience in accounting. Ability to work independently and manage cash book and reconciliations based on an excel spreadsheets.

Under the direction of the Provincial Accountant and with support from the Manager of District Health services, undertake the following tasks: (i) Funds disbursement for district and community level project disbursements. (ii) Assist in review and verification of provincial petty cash expenditure

statements. (iii) Maintain the Project accounting files in accordance with project designed

accounting procedures. (iv) Assist the PPIU Accountant to conduct spot checks on petty cash

expenditures. (v) Assisted by the PPIU Accountant reconcile of cash book and, if applicable,

the bank statement. (vi) Disburse project petty cash funds as authorized. (vii) Assist the external financial audit team in reviewing accounting documents at

central level and accompany them to provinces for reviewing accounting documents and controlling fixed assets.

(viii) Assist the Project PPIU Accountant to prepare financial and accounting information as requested by the Chief Accountant (or Chief Financial Officer).

(ix) Maintain the Project Asset Register. (x) Other tasks as assigned by the PPIU Accountant or the District Manager of

Health Services. (National) Gender Consultant (GC) x 3 (Lao PDR, Cambodia, Vietnam) Advanced degree in Social Science and/or Public Health with at least one year of experience in research including gender analysis.

In close consultation with the Regional Gender Specialist: (i) Collect relevant national data for evidence-based training on gender and

communicable disease vulnerabilities and related health data in country of employment.

(ii) Adapt the generic (English language) training material produced by the regional gender specialist for national use, in national languages, using national data, for mainstreaming gender into the Project training activities.

(iii) Conduct workshops on mainstreaming the national material in national language for master trainers.

(vii) Actively participate in the design, implementation and analysis of the Baseline Survey.



Annex 4: Outline Terms of Reference for International consultants and RCU staff Positions and Minimum Required Qualification


(International) Chief Technical Adviser (CTA) At least 10 years experience in public health and project management with a Masters Degree in Public Health or Management. Proven experience in project management, planning and budgeting. Strong monitoring and evaluation and Results Based Management (RBM) performance. Preferable with experience in the implementation of ADB/ WB funded projects. Technical skills in NTD or NED‟s. Strong English language skills (both spoken and written). Strong interpersonal skills and experience in capacity building of counterpart staff at different levels. Ability to work independently at national, provincial and district levels.

The CTA will have the overall responsibility for management of the RCU, supporting the ADB Principle Health Specialist and coordinating the ADB recruited consultants, and with the PMU managers in CLV, coordinating the tasks relating to the baseline survey. In particular, undertake the following tasks: (i) Plan the day-to-day management of the Project activities. (ii) Prepare a detailed plan, timetable, and annual budget for implementation. (iii) Prepare work plans, timetables, and budgets for project implementation. (iv) Establish operating procedures for all RCU project activities including

disbursement, reporting, and financial monitoring. (v) Select, supervise, and monitor activities of TA consultants. (vi) Prepare regional communication materials and facilitate the dialogue to

promote regional technical forums, seminars, and workshops (vii) Facilitate and arrange annual review workshops, meetings, and seminars. (viii) Manage the regional CDC2 fund and coordinate with ADB to ensure smooth

fund flow. (ix) Ensure that the project is implemented in accordance with the cooperative

agreement, donor regulations, and internationally recognized quality standards;

(x) Participate in the development of strategic work-plans with clear objectives and achievement benchmarks, long-term and short-term priorities, implementation plans, financial projections and tools for evaluation;

(xi) Plan, monitor and evaluate activities in accordance with the cooperative agreement.

(xii) Facilitate the organizational development and capacity building of local partner organizations involved in the provision of CDC services.

(xiii) Coordinate with ADB to ensure that adequate and timely technical, logistical and administrative support is provided to the project.

(xiv) Ensure appropriate quality control systems are in place and implemented across programs (includes the development of indicators, monitoring and evaluation systems).

(xv) Support project staff by creating and maintaining a work environment that promotes teamwork, trust, mutual respect, and empowers staff to take responsibility and show initiative.

(xvi) Undertake consultation meetings with partners (multilateral and bilateral organizations, International and national NGOs) and other stakeholders as part of the policy development process and ensure that adequate technical inputs are provided: - Representing RCU in consultation meetings with partners and

stakeholders to ensure good collaboration and to avoid any duplication of program activities.

- Present the CDC2 program to other organizations as needed. - Attend regular meetings with all partners to ensure that all partners

understand the framework defined for the GMS-ADB Project approach to health development and policies.

- Liaison with the technical agencies that technical inputs are provided to support the project activities.



Positions and Minimum Required Qualification


(International) Social Anthropologist (SA) Advanced degree in Social Anthropology with at least three years field research experience on EMGs in the GMS, preferably with a public health background.

Working in close consultation with the regional and national coordinators of the comprehensive baseline study, undertake the following tasks: (i) Identify and design health needs assessment surveys of border populations; (ii) Identify a suitable national social and cultural research institute or market

research company, and together with the Procurement Consultant prepare a scope of services and contract for contracting part of the Baseline surveys.

(iii) Work in close consultation with the Training Specialist prepare training materials to mainstream specific and gender sensitive EMG needs into training activities.

(iv) Work in close consultation with District Health Departments and develop an engagement strategy to increase and improve the delivery of CDC and health services to EMGs in border villages.

(Regional) Gender Specialist (GS) Advanced degree in Social Science. At least 5 years experience in gender and development, preferably with relevant experience in the GMS region. and within a rural public health background setting.

The Gender Specialist (Regional), together with the national Gender Consultant, will undertake the following tasks: In close consultation with the National Gender specialists and the International Training Adviser: (i) Develop training material for mainstreaming gender and CDC into the

project training activities in CLV, using the gender and health training workshop materials developed for MOH Lao PDR as a model.

(ii) Produce a generic English-language version of the training material. (iii) Advise and assist national gender specialist consultants to identify and

collect relevant national evidence-based data on gender and communicable diseases and related health data in their countries of employment.

(iv) Oversee and advise the national gender specialist to adapt the generic training material from national use, in national languages, using relevant national gender and health data as the evidence base for training.

(v) Provide training as requires for the national gender specialists on mainstreaming the material into Project training activities, to prepare each national gender specialist to run a workshop on the use of the materials from the training of master trainers.

(vi) Advise on the incorporation of gender considerations in the design, implementation and analysis of the Baseline survey and subsequent monitoring and evaluation.

(vii) Propose a strategy to ensure Baseline analysis and M&E results on gender issues are utilized in the development of policies and programs at the provincial level

(International) Training Systems Specialist (TSS) High level of programmatic knowledge and at least 7 year‟s experience in human resource development, including capacity building using participatory adult learning methodologies for training systems development, including skills based training, preferably in the health sector. Advanced University Degree in Public Health, Education, Social Sciences, or other relevant technical field. Excellent

The International Training Systems Adviser together with the national Training Consultant will undertake the following tasks: (i) Review MOH current National HRD Plan and policies and guidelines in the

context of the Project adopting a Training Systems development approach for the HRD aspects of the Project.

(ii) Together with the MOH (or nominated institute) review training needs as identified by national, provincial and district staff and local institutions.

(iii) Identify training modalities, successfully used in CLV, that use science-based, participatory learning methods for doctors, nurses, and other health workers and community volunteers.

(iv) Based on the review work with the training institutes to undertake a Training Needs Assessment (TNA) of staff engaged in the Project.

(v) Assist the key institutes, PMU and MOH to establish the Training Systems





written and spoken skills in English. Fluency in one or more of the languages of CLV a distinct advantage.

Framework and strategy to guide all training to be undertaken in the Project. (vi) Assist in the development of training packages for skills based training and

TOT for Master Trainers from provincial health departments. (vii) In consultation with Provincial Training Working Groups and relevant

national institute training experts, develop a common approach to the training of Provincial and District Trainers, and design and produce the training procedures manual.

(viii) Work with health management specialists to identify programs for training managers in leadership, planning, financial management, information systems, and other management topics.

(ix) Provide technical assistance and guidance to program staff and partners during the development of new programs, and with best practice methodologies instituted.

(x) Assist in design training modules and materials for training trainers and educators in the use of adult-training methodologies

(xi) Work with the Public Health Specialist to help strengthen local capacity to train VHW and other health workers in reproductive health, safe motherhood, and other topics.

(xii) Review of existing training materials for PHC, MCH, CDC approved by the MOH for use in health training classes.

(xiii) Facilitate the identification of training equipment and supplies needed for procurement.

(xiv) Advise on development of curricula and IEC/BCC materials based on three steps: 1. training needs analysis of target groups; 2. review of existing curricula and materials; and, 3. adoption of existing materials and/or development of new materials.

(xv) Identify and manage short-term technical training advisors to facilitate the specialist training courses.

(xvi) Monitor project training program activities to ensure quality including on-site training for health staff at province, district, commune levels.

(xvii) Attend regular project review meetings at province, district and commune levels.

(xviii) Report to the Chief Technical Advisor through both formal and informal debriefings, monthly and semi-annual reports.





(International) Project Implementation Adviser (PIA) At least Bachelor Degree in Public Health or similar development qualifications; At least 5 years proven experience in project management, planning and budgeting. Experienced in monitoring and evaluation and Results Based Management (RBM) performance. Preferably with experience in the implementation of ADB/ WB funded projects. Technical skills in NTD or NED‟s. English language skills (Both spoken and written). Fluency in one or more of the languages of CLV a distinct advantage. Strong interpersonal skills and experience in capacity building of counterpart staff at different levels. Ability to work independently at national, provincial and district levels.

The Project Implementation Adviser will be responsible for assisting the National PMU in all aspect of project implementation, and work with the project provinces in a collaborative manner to improve project management skills and the implementation performance of the PPIU, Technical staff and District teams. In particular: (i) Assist PMU team to help participating provinces to strengthen CDC,

including strengthening provincial strategic planning and budgeting for CDC, cross-border cooperation, improving CDC training programs, and assessment and improvement of financial flows.

(ii) Preparation of baseline design, implementation and monitoring. (iii) Capacity building of PMU staff and provincial and district staff. (iv) M&E with a focus on Results-Based Management. (v) Provide administrative and technical support to the project. (vi) Work with concerned MOH departments in Project Provincial Health Offices,

WHO offices, and other partners. (vii) Assist in planning the day-to-day management of the project activities. (viii) Prepare a detailed plan, timetable, and annual budget for implementation. (ix) Prepare work plans, timetables, and budgets for project implementation. (x) Assist PMU to facilitate the dialogue to promote regional technical forums,

seminars, workshops and arrange annual review workshops. (xi) Ensure that the project is implemented in accordance with the cooperative

agreement, donor regulations, and internationally recognized quality standards.

(xii) Participate in the development of strategic work-plans with clear objectives and achievement benchmarks, long-term and short-term priorities, implementation plans, financial projections and tools for evaluation;

(xiii) Plan, monitor and evaluate activities in accordance with the cooperative agreement.

(xiv) Facilitate the organizational development and capacity building of local partner organizations involved in the provision of CDC services.

(xv) Coordinate with ADB to ensure that adequate and timely technical, logistical and administrative support is provided to the project.

(xvi) Ensure appropriate quality control systems are in place and implemented across programs (includes the development of indicators, monitoring and evaluation systems).

(xvii) Support project staff by creating and maintaining a work environment that promotes teamwork, trust, mutual respect, and empowers staff to take responsibility and show initiative.

(xviii) Undertake consultation meetings with partners (multilateral and bilateral organizations, international and national NGOs) and other stakeholders as part of the policy development process and ensure that adequate technical inputs are provided: - Representing RCU in consultation meetings with partners and

stakeholders to ensure good collaboration and to avoid any duplication of program activities.

- Present the CDC2 program to other organizations as needed. - Attend regular meetings with all partners to ensure that all partners

understand the framework defined for the GMS-ADB Project approach to health development and policies.

- Liaison with the technical agencies that technical inputs are provided to support the project activities.





(xix) Report to the Chief Technical Advisor through both formal and informal debriefings, monthly and semi-annual reports.

(International) Laboratory Management Specialist (LMS) Experienced in medical laboratory technology and operations as provincial and district hospital environment in a developing country setting in the health sector. Experience in supply chain consumable and disposal of biomedical waste. Qualifications in Biomedical Engineering, Laboratory Technology and Quality Assurance standards.

The Laboratory Management Specialist, together with the MOH laboratory services, will undertake an assessment of the laboratory equipment, needs at provincial, and district hospital and HC levels to be able to provide quality diagnosis relating to NTD and communicable diseases. In particular: (i) Review the status of the national laboratory services in CLV. (ii) Together with the senior staff of the national laboratory services establish a

representative sample of CDC2 project provinces to assess laboratory capacity at selected provincial and district hospitals, and health centres,

(iii) Based on the assessment, formulate a detailed report detailing issues, action required and gaps in the availability of basis diagnostic equipment and consumables supply chain issues.

(iv) Convene a national workshop to present the finding and plan of action to address the key issues.

(v) Together with MOH counterparts establish a detailed costing and plan of action to address the issues in the short, medium and long term.

(International) IT/database/GIS specialist (IT/GIS Sp) The IT/database/GIS consultant will be engaged to work with the technical team designing and implementing the Baseline Survey will have IT Degree or Diploma in IT with at least 5 years experience in GIS, (preferably in Arc view), and Diploma in database and website management. Proven experience in database building, (notably in MS Access). Proficient in spoken and written English. Good interpersonal skills and the ability to work in a team environment.

Working under the direction of the Chief Technical Adviser and the designated Baseline Survey Coordinator, the consultant will design of the Baseline Survey database and produce GIS mapping and project information. The consultants will undertake two inputs to complete the following tasks: 1st Input (i) Together with the Technical Working Team responsible for the development

of the Baseline Survey (BLS) establish design brief for the development of Baseline Survey database.

(ii) Together with the team establish data collection formats, and the systems to utilize this data for M&E and other project requirement.

(iii) Undertake a capacity assessment of each of the National IT/GIS consultants and ensure that they receive the necessary skills training to raise their capacity.

(iv) Work with the National IT/GIS consultants of CLV establish a training program that the national consultants can implement to train national and provincial staff.

(v) Together with the national IT/GIS consultants establish the Baseline Survey data base and associated software programs and data collection and reporting formats.

(vi) Together with the National IT/GIS consultants prepare all the operational and training manual

2nd Input (vii) During the conduct of the BLS, together with the CLV National IT/GIS

consultants begin to input the survey data, ensuring that there are data integrity checks.

(viii) Together with the national IT/GIS consultants produce the final BLS data and outputs for Technical Working Group.

(ix) Undertake a similar presentation to senior management in CLV. (x) During the period that the National IT/GIS consultants introduce the BLS

database system to the provinces the International IT/database/GIS consultant will provide technical remote support from his country of residence.

(xi) Other tasks as required





MBDS Consultant (Part time over 5 years) MBDS Program Coordinator

The MBDS Program Coordinator will provide specialist advice to key representatives from CLV relating to the design of the BLS and cross border programs. The Consultant will undertake, but not be limited to, the following tasks:

(i) Participate in the Technical Group for the design of the Baseline Survey,

(ii) Review quarterly reports from CLV.

(iii) Participate in the annual reviews of CDC Project performance and M& E activities.

(iv) Provide advise on the establishment of CDC cross border activities.

(v) Participate in cross border workshops and share MBDS Action Plan and seven inter-related core strategies,

(vi) Share the MBDS cross border training manuals, guidelines, and reporting formats, can be used in CDC2 cross border activities.

(vii) Explore options with CDC2 regarding MBDS the utilisation of the same IT surveillance data base, and perhaps further develop the system to provide real time reporting on a regional basis.

(National) Program Officer (PO) - RCU At least a Bachelor Degree in Economics, Medicine, Public Health or similar. At least 5 years proven experience in project management, planning and budgeting. Strong monitoring and evaluation experience as well as in the implementation of ADB/ WB funded projects; Strong interpersonal skills and experience in capacity building of counterpart staff at different levels. English language skills (Both spoken and written). Ability to work independently at regional, national, provincial and district levels. Experience in IT Database management an advantage.

The PO tasks for this position will be carried out in conjunction with the International Chief Technical Adviser (CTA). To assist in the implementation of activities of the RCU detailed TOR. (see Appendix 20.1) The PO will work under the direct management of the CTA and undertake the following tasks:

(i) Assist the CTA in the management of the regional component of the Project for the three CLV countries, notably in the practical organization of regional events (trainings, workshops, meetings, international consultants' missions, etc).

(ii) Liaise with the Ministry of Health (MOH) Viet Nam and the Vietnamese Project Management Unit (PMU) and other Vietnamese Implementing Agencies (IA).

(iii) Follow up on specific project-issues and programmatic matters. These may include regularly liaising with project offices in Cambodia, Lao PDR or Viet Nam, as well as with respective MOH counterparts to obtain data and information.

(iv) Update on a regular basis the project database and programmatic maps and assist in uploading information onto the GMS CDC website

(v) Assist in the logistical arrangement of regional events organized jointly by the RCU and the host country. For this purpose the PO may be asked to travel to the host country.

(vi) Assist the RC in the preparation of reports and in translating and interpreting (English to Vietnamese and Vietnamese to English) including during official meetings and field visits.

(vii) Collaborate closely with the RCU Accountant/Project Controller to follow CLV projects finances, and notify promptly RC of any bottlenecks/difficulties encountered.

(viii) Assist in the daily management of the RCU in the absence of the RC. (ix) Prepare the overall and detailed planning of the regional activities, and

follow their implementation with the CLV officials involved. (x) Work with senior PMU and PPIU to assist in the establishment of a Results

Based Management System.





(National) RCU Accountant/ Secretary At least 3 years experience in the financial and accounting management. A recognized Bachelor of Accounting or other relevant fields. Competent in spoken and written English. Practical knowledge and experience in the RCU computer software accounting package.

(i) Manage the Project funds under the responsibility the RCU according to the relevant guidelines and the requirements of ADB.

(ii) Assist RCU management to prepare annual budget plan for the Project and monitor the expenditure using the required formats.

(iii) Ensure sound financial control, documentation and flow of information of project expenditures incurred at national and provincial levels.

(iv) Ensure proper authorization and accounting of operating costs which will be classified by nature of expenses and sources of funds and by categories.

(v) Prepare withdrawal application for submitting to ADB through MOF (MOEF in case of Cambodia) and follow-up the payment.

(vi) Manage the project fixed asset in compliance with the Government and ADB policies.

(vii) Assist the CA/CFO to provide training to the Project accounting staff of all levels and provide regular supervision.

(viii) Assist the internal and external auditors to conduct audit by furnishing them with appropriate documents. Assist in identifying location of assets and facilitate communication with the concerned units/departments for the audit purpose.

(ix) Perform other tasks as may be assigned by the Chief Financial Officer. Specialist Consultants to be contracted by ADB and seconded to WHO Country offices in CLV (International) Neglected Tropical Disease (NTD) Specialist Qualifications as an Epidemiologist or in public health with 5 years‟ experience in the control of endemic diseases, particularly intestinal parasites. Experience and language skills of one of the GMS countries, and advantage.

The NTD Specialist will work with the technical national institutes and specialists in CLV and assist in the following tasks: (i) Assist in the design and implementation of the selected endemic disease

programs in CLV countries. (ii) Provide technical advice to staff in the departments or institutes

implementing the Project‟s endemic disease activities. (iii) Assist the Training Specialist and Consultant in the development of

curriculum for the training of provincial and district health staff. (iv) Develop evaluation and monitoring tools.

(International) Surveillance and Response Specialist Epidemiologist or equivalent with at least 10 years‟ experience in surveillance and response systems and laboratory diagnostic services

The Surveillance and Response Specialist will work collaboratively the CDC departments and be supported by the national S&R consultant and project staff. Tasks would include: (i) Review outbreak preparedness in CLV countries and design implementation

plan. (ii) Support the design and implementation of the selected endemic disease

activities in CLV countries. (iii) Support country implementation of system capacity building and revised

IHR requirements. (iv) Support country implementation of system capacity building and revised

IHR requirements. (v) Provide technical advice to the appropriate departments and laboratories

responsible for disease S&R. (vi) Train provincial staff in best practices in preparedness and outbreak

management. (vii) Coordinate training with regional disaster management institutes. (viii) Facilitate and organize teams for national outbreak simulation exercises.





(International) Dengue Specialist Qualifications in entomology, epidemiology or public health. At least 10 years‟ experience in dengue control. Experience and language skills of one of the GMS countries an advantage.

The Dengue Specialist will be based in one of the CLV countries and will provide technical expertise and support to the National Dengue programs in the three countries. Tasks will include, but not be limited to: (i) Support for the design and implementation of dengue fever activities in CLV

countries. (ii) Provide technical advice to departments or institutes dealing with dengue

fever. (iii) Support the preparation of guidelines and standard operating procedures for

the central and provincial levels. (iv) Support the development of training programs for central and provincial

managers in Dengue control and management. Optional Extra for RCU (International) Regional Knowledge Management Adviser (RKMA) – Clearinghouse At least 5-10 years of experience in similar Knowledge Management concepts and practices. Good interpersonal skills and detailed knowledge of the GMS development & political sensitivities and have good experience in at least 3 of the 6 GMS countries). Well acquainted with communicable diseases control programs and projects in the GMS countries Good computing skills in Microsoft Word, Excel, Access and Outlook, and acquainted with webmaster administration as well as GIS software. Fluent in spoken and written English. Good command of one or more of the languages of the GMS countries is an asset. Qualifications: Master of Public Health, International Relations, Political Science, Public Administration or Development.

The Regional Knowledge Management Adviser main tasks will include but not be limited to: (i) Ensuring that the Clearinghouse is well established (initially in the RCU) and

fulfilling its purpose. (ii) Supervise the good running of each of the Clearinghouse functions. (iii) Provide a leadership role in regional Knowledge Management in CDC,

notably working closely with Program managers to ensure clearinghouse‟s KM products contribute to the enhancement of programme results and impact in a quick and measurable way.

(iv) Supervise the output of the National Consultant. (v) Regularly liaise with partners for sharing their programmatic data, news,

announcements. (vi) Pro-actively collect all news related to Communicable Diseases, and

especially in the GMS, filter them and dispatch them to the relevant professionals by the specific group lists.

(vii) Liaise closely with the respective GMS countries‟ Ministries of Health and Institutions for a back-and-forth exchange of data.

(viii) Arrange with newspapers and various publications publishers the right for free dispatching of their CDC-related news by the Clearinghouse.

(ix) Develop and maintain email group list so as to target at best the sending of information/news.

(x) Proactively collect all CDC-related announcements for upcoming CDC-related events in the region and have them posted in the calendar of CDC Events on the website.

(xi) Proactively collect all CDC-related materials (various project progress reports, other partners‟ newsletters, guidelines, manuals, research findings, articles, etc) and have them uploaded onto the website as well as in the GMS-CDC/MBDS newsletter.

(xii) Ensure programmatic data sent out by partners is entered into the GIS system and maps produced. Check the quality of the maps and their usefulness for analysis.

(xiii) Review all partners‟ reports and extract from them the lessons learnt and good practices. Produce Technical Cards accordingly. Have their draft posted for discussion on the forum before finalization, then have them posted on the website as KM resources made available to all.

(xiv) Assist in the developing and nurturing of various Communities of Practice, notably by providing advices to regional events organizers on how to optimize the KM aspects.

(xv) Liaise regularly with all Stakeholders, in support of the MBDS coordinator.





(xvi) Moderate the English electronic forum, and provide technical support to the GMS countries‟ moderators.

(xvii) Review all incoming regional events‟ program and provide advice to organizers on how to optimize their KM aspects for a better output.

(xviii) Facilitate Working Groups of experts to discuss Knowledge Management Products needed by professionals, etc.

(National) IT/GIS Specialist (IT/GIS Sp) – Clearing House The national IT/GIS consultant with at least 5 years experience in GIS, (preferably in Arc view), in database management. Good knowledge of database building. Degree or Diploma in IT with a specialty in GIS. Proficient in spoken and written English. Good ability working in a team environment.

The IT/GIS Specialist task is to work with the International IT/GIS/Database Specialist in the development of the Baseline Database. The national consultant task will also include process all the data received and collected at the district and provincial levels. Specific task will include: (i) Ensure that the Baseline data base is maintained and the provide training to

staff at the Provincial and district levels. (ii) Introduce GIS, training at national and provincial levels. This will also

include creating all the provincial and district maps based on the data provided.

(iii) Work in conjunction with the Short Term IT/GIS consultant responsible for Baseline Survey Database and share GIS maps and data.

(iv) Able to work without direct supervision. ADB = Asian Development Bank; BCC = behavioural change communication; CDC = communicable disease control; CLV = Cambodia, Lao PDR, and Viet Nam; EA = Executing Agency; EMDP = ethnic minority development plan; GAP = gender action plan; GIS = geographic information system; GMS = Greater Mekong Subregion; HIS = health information system HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome; IA = Implementing Agency; IHR = international health regulations; JFPR = Japan Fund for Poverty Reduction; MOH = Ministry of Health; S&R = surveillance and response; TA = technical assistance. a ADB-financed, WHO-managed. b WHO-financed and WHO-managed. c ADB-financed and ADB-managed . Source: Asian Development Bank estimates.

APPENDIX 9: PROCUREMENT PLANS

CAMBODIA LAO PDR

& VIET NAM

APPENDIX 9.1: PROCUREMENT PLAN

CAMBODIA


Appendix 9.1: Procurement Plan – Final Consultant Report April 2010 Page 1

Basic Data Unit: US$Project Name: Second Communicable Diseases Control ProjectCountry: Cambodia Executing Agency: Ministry of HealthGrant Amount: $10,600,000 Loan (Grant) Number:___Date of First Procurement Plan (grant) approval: Date of this Procurement Plan: 22 January 2010

A. Process Thresholds, Review and 18-Month Procurement Plan

1. Project Procurement Thresholds

Procurement of Goods and WorksMethod Threshold

International Competitive Bidding (ICB) for Works 1 Not applicable

International Competitive Bidding for Goods 1 >= $500,000

National Competitive Bidding (NCB) for Works 1 Not applicable

National Competitive Bidding for Goods 1 Below $500,000Shopping for Works Not applicableShopping for Goods Below $100,000Community Participation Procurement Below $10,000

2. ADB Prior or Post Review

Procurement Method CommentsProcurement of Goods and WorksICB Works All contractsICB Goods All contractsNCB Goods All contractsShopping for Goods All contracts

PriorPost

PROCUREMENT PLAN

2. Except as ADB may otherwise agree, the following prior or post review requirements apply to the various procurement and consultant recruitment methods used for the project.

1. Except as the Asian Development Bank (ADB) may otherwise agree, the following process thresholds shall apply to procurement of goods and works.

Prior or Post

PriorPrior



Community Participation Procurement Prior review of the first 1 contract in each project

province

Recruitment of Consulting FirmsQuality- and Cost-Based Selection (QCBS) N/AQuality-Based Selection (QBS) N/A

Yes

Recruitment of Individual ConsultantsIndividual Consultants Yes

3. Goods and works contracts estimated to cost more than $ 1 million (first 18 months)

No. General Description Contract value ($)

Procurement method

Pre qualification

Advertisement date Comments

Not applicable

4. Consulting services contracts estimated to cost more than $ 100,000 (first 18 months)


Recruitment method

Advertisement date Int'l or national Comments

1 Project Implementation Specialist 112,575 IS 15/04/2010 National N/A

Prior and Post

PriorPriorPrior

Prior

Other selection methods: Consultants Qualifications (CQS), Least-Cost Selection (LCS), Fixed Budget (FBS), and Single Source (SSS)

3. The following table lists goods and works contracts for which procurement activity is either ongoing or expected to commence within the next 18 months.

4. The following table lists consulting services contracts for which procurement activity is either ongoing or expected to commence within the next 18 months.

5. Goods and Works Contracts Estimated to Cost Less than $1 Million and Consulting Services Contracts Less than $100,000 (first18 months)

5. The following table groups smaller-value goods, works and consulting services contracts for which procurement activity is either ongoing or expected to commence within the next 18 months.



No. Value of contracts (cumulative)

Number of contracts

Procurement method Comments

Goods

1 100,000 1 NCB2 64,000 1 NCB

3 30,000 1 shopping

4 118,000 9 NCB5 125,000 1 ICB6 425,000 1 ICB7 90,000 1 shopping8 40,000 3 shopping9 20,000 3 shopping10 16,045 various shopping

1 112,575 1 IS2 56,100 1 IS3 96,900 1 IS4 78,375 1 IS5 76,950 1 CQS6 Project Accountant 54,150 1 IS7 Accounting Assistant 37,500 1 IS8 75,000 1 CQS9 90,000 1 IS10 300,000 1 CQS

B. Indicative List of Packages Required Under the Project

Goods

4 WD cars for central level

Project Implementation Consultant

Surveillance and Response specialistProcurement specialist

General Description

Procure and deliver priority training equipment and supplies for TWGs and district teams

Office Equipment for Central level

Computers for BL survey (all)

Office Equipment for Project Provinces (PPIUs) and Project districts

Pick up cars for the projectMotobikes for the projectBoats for communesBycles for communesSuppliesConsulting services

Baseline survey undertaken and data analysed

6. The following table provides an indicative list of all procurement (goods, works and consulting services) over the life of the project. Contracts financed by the Borrower and others should also be indicated, with an appropriate notation in the comm

IT/Database/GIS specialistChief Accountant

Annual AuditTraining Consultant (National)



General Description Estimated Value (cumulative)

Estimated Number of contracts

Procurement method

Domestic preference applicable

Comments

GoodsProcure and deliver priority training equipment and supplies for TWGs and district teams 100,000 1 NCB NoComputers for BL survey (all) 64,000 1 NCB NoOffice Equipment for Central level 30,000 1 shopping NoOffice Equipment for Project Provinces (PPIUs) and Project districts 118,000 9 NCB No

decentralized to province to procure

4 WD cars for central level 125,000 1 ICB YesBuy through UN system if EA agrees

Pick up cars for the project 425,000 1 ICB YesBuy through UN system if EA agrees

Motor bikes for the project 90,000 1 shopping NoBoats for communes 40,000 3 shopping No purchased by PPIUsBicycles for communes 20,000 3 shopping No purchased by PPIUs

Supplies 106,967 various shopping No

purchased by districts and PPIUs and national agencies

Community Initiatives and other community mobilization activities 3,636,570 various

community participation, DC No

Procured with participation of Project Communes, Shools, villages

System development activities 732,081 various shopping NoProcured by by PMU and PPIUs

O&M activities 945,338 various shopping NoIncluding government counterpart fund



No. General Description Estimated Value (cumulative)


Recruiment method Type of proposal Comments

Consulting services1 Project Implementation Specialist 112,575 1 IS Biodata2 Procurement specialist 56,100 1 IS Biodata

3Surveillance and Response specialist

96,900 1 IS Biodata4 IT/Database/GIS specialist 78,375 1 IS Biodata5 Chief Accountant 76,950 1 CQS Biodata6 Project Accountant 54,150 1 CQS Biodata7 Accounting Assistant 37,500 8 Annual Audit 75,000 1 CQS Biodata9 Mid Term Review 20,000 1 CQS Biodata10 Project Completion Mission review. 25,000 1 CQS Biodata11 Training Consultant (National) 90,000 1 IS Biodata

12Baseline survey undertaken and data analysed 300,000 1 CQS STP

13 Various workshops, training courses 2,253,468 various CQS & SSS Biodata

Note: $1,4 million contribution to the pooled fund (RCU) is not included in this procurement plan



C. National Competitive Bidding

1. General 7. The procedures to be followed for national competitive bidding shall be those set forth for the “National Competitive Bidding” method in the Government’s Procurement Manual of September 2005 issued under Decree Number 14 ANKR.BK dated 26 February 2007 with the clarifications and modifications described in the following paragraphs required for compliance with the provisions of the Procurement Guidelines.

2. Application

8. Contract packages subject to National Competitive Bidding procedures will be those identified as such in the project Procurement Plan. Any changes to the mode of procurement from those provided in the Procurement Plan shall be made through updating of the Procurement Plan, and only with prior approval of ADB.

3. Eligibility

9. Bidders shall not be declared ineligible or prohibited from bidding on the basis of barring procedures or sanction lists, except individuals and firms sanctioned by ADB, without prior approval of ADB.

4. Advertising

10. Bidding of NCB contracts estimated at $500,000 or more for goods and related services or $1,000,000 or more for civil works shall be advertised on ADB’s website via the posting of the Procurement Plan.

5. Anti-Corruption

11. Definitions of corrupt, fraudulent, collusive and coercive practices shall reflect the latest ADB Board-approved Anti-Corruption Policy definitions of these terms and related additional provisions

6. Rejection of all Bids and Rebidding 12. Bids shall not be rejected and new bids solicited without ADB’s prior concurrence.

7. Bidding Documents

13. The bidding documents provided with the government’s Procurement Manual shall be used to the extent possible. The first draft English language version of the procurement documents shall be submitted for ADB review and approval, regardless of the estimated contract amount, in accordance with agreed review procedures (post and prior review). The ADB-approved procurement documents will then be used as a model for all procurement financed by ADB for the project, and need not be subjected to further review unless specified in the procurement plan.

8. Member Country Restrictions

14. Bidders must be nationals of member countries of ADB, and offered goods, works and services must be produced in and supplied from member countries of ADB.


LAO PDR


Appendix 9.2: Procurement Plan Lao PDR – Final Consultant Report April 2010 Page 1

Basic Data Unit: US$Project Name: Second Communicable Diseases Control ProjectCountry: Lao PDR Executing Agency: Ministry of HealthGrant Amount: $ 11,600,000 Loan (Grant) Number:___Date of First Procurement Plan (grant) approval: Date of this Procurement Plan: 22 January 2010




International Competitive Bidding (ICB) for Works 1 Not applicable

International Competitive Bidding for Goods 1 >= $500,000

National Competitive Bidding (NCB) for Works 1 Not applicable

National Competitive Bidding for Goods 1 Below $500,000Shopping for Works Not applicableShopping for Goods Below $100,000Community Participation Procurement Below $10,000



PriorPost

PROCUREMENT PLAN



Prior or Post

PriorPrior




province


Yes



No. General Description Contract value ($ 1000)

Procurement method

Pre qualification


Not applicable

4. Consulting services contracts estimated to cost more than $ 100,000 (first 18 months)

No. General Description Contract value ($ 1000)

Recruitment method


1 Accounting services firm 175,000 CQS 15/4/2010 National Biodata

2Baseline survey undertaken and data analysed 230,000 CQS 30/08/2010 National Biodata


Prior and Post

PriorPriorPrior

Prior







Goods

1

Procure and deliver priority training equipment and supplies for TWGs and district teams 168,000 1 NCB No

2 Computers for BL survey (all) 145,000 1 NCB No

3Office Equipment for Central level (EA, NIA, CLE, CMPE) 40,000 1 shopping No

4

Office Equipment for Project Provinces (PPIUs) and Project districts 119,000 9 NCB No


5 4 WD cars for central level 150,000 1 ICB YesBuy through UN system if EA agrees

6 Pick up cars for the project 561,000 1 ICB YesBuy through UN system if EA agrees

7 Motor bikes for the project 78,000 1 shopping No8 Boats for communes 26,667 3 shopping No purchased by PPIUs9 Bicycles for communes 13,333 3 shopping No purchased by PPIUs

10 Supplies 135,500 various shopping No


11Community Initiatives and other community mobilization activities 4,229,636 various



12 System development activities 717,261 various shopping NoProcured by by PMU and PPIUs

13 O&M activities 1,147,677 various shopping NoIncluding government counterpart fund



No. General Discription Estimated Value (cummulative)



Consulting services1 Project Implementation Consultant 95,475 1 IS Biodata2 Procurement specialist 52,800 1 IS Biodata

3Surveillance and Response specialist

85,500 1 IS Biodata4 IT/Database/GIS specialist 78,375 1 IS Biodata5 Accounting services firm 175,000 1 CQS Biodata6 Annual Audit 60,000 1 CQS Biodata7 Mid Term Review 4,000 1 CQS Biodata8 Project Completion Mission review. 20,000 1 CQS Biodata9 Training Consultant (National) 96,000 1 IS Biodata



Note: $1,4 million contribution to the pooled fund (RCU) is not included in this procurement plan


Appendix 9: Procurement Plan – Final Consultant Report April 2010 Page 5


1. General

7. The procedures to be followed for National Competitive Bidding (NCB) shall be those set forth for “Public Bidding” in Prime Minister’s Decree No. 03/PM of the Lao People’s Democratic Republic, effective 09 January 2004, and Implementing Rules and Regulations effective 12 March 2004, with the clarifications and modifications described in the following paragraphs required for compliance with the provisions of the Procurement Guidelines.

2. Application

8. Contract packages subject to NCB procedures will be those identified as such in the project Procurement Plan. Any changes to the mode of procurement from those provided in the Procurement Plan shall be made through updating of the Procurement Plan, and only with prior approval of ADB.

3. Eligibility

9. Bidders shall not be declared ineligible or prohibited from bidding on the basis of barring procedures or sanction lists, except individuals and firms sanctioned by ADB, without prior approval of ADB.

4. Advertising

10. Bidding of NCB contracts estimated at $500,000 or more for goods and related services or $1,000,000 or more for civil works shall be advertised on ADB’s website via the posting of the Procurement Plan.

5. Procurement Documents

11. The standard procurement documents provided with Ministry of Finance, Procurement Monitoring Office shall be used to the extent possible. The first draft English language version of the procurement documents shall be submitted for ADB review and approval, regardless of the estimated contract amount, in accordance with agreed review procedures (post and prior review). The ADB-approved procurement documents will then be used as a model for all procurement financed by ADB for the project, and need not be subjected to further review unless specified in the procurement plan.

6. Preferences

(i) No preference of any kind shall be given to domestic bidders or for domestically manufactured goods.

(ii) Suppliers and contractors shall not be required to purchase local goods or

supplies or materials. 7. Rejection of all Bids and Rebidding

12. Bids shall not be rejected and new bids solicited without ADB’s prior concurrence.

8. National Sanctions List 13. National sanctions lists may be applied only with prior approval of ADB.

9. Corruption Policy


Appendix 9: Procurement Plan – Final Consultant Report April 2010 Page 6

14. A bidder declared ineligible by ADB, based on a determination by ADB that the bidder has engaged in corrupt, fraudulent, collusive, or coercive practices in competing for or in executing an ADB-financed contract shall be ineligible to be awarded ADB-financed contract during the period of time determined by ADB

10. Disclosure of Decisions on Contract Awards 15. At the same time that notification on award of contract is given to the successful bidder, the results of the bid evaluation shall be published in a local newspaper or well-known freely accessible website identifying the bid and lot numbers and providing information on (i) name of each Bidder who submitted a Bid, (ii) bid prices as read out at bid opening, (iii) name of bidders whose bids were rejected and the reasons for their rejection, (iv) name of the winning Bidder, and the price it offered, as well as the duration and summary scope of the contract awarded. The executing agency/implementing agency shall respond in writing to unsuccessful bidders who seek explanations on the grounds on which their bids are not selected.

11. Member Country Restrictions 16. Bidders must be nationals of member countries of ADB, and offered goods, works and services must be produced in and supplied from member countries of ADB.


VIETNAM


Appendix 9.3: Procurement Plan Vietnam – Final Consultant Report April 2010 Page 1

Basic Data Unit: US$Project Name: Second Communicable Diseases Control ProjectCountry: Viet Nam Executing Agency: Ministry of HealthLoan Amount: $ 25,000,000 Loan Number:___Date of First Procurement Plan (grant) approval: Date of this Procurement Plan: 22 January 2010




International Competitive Bidding (ICB) for Works1 Not applicable

International Competitive Bidding for Goods1 >= $500,000

National Competitive Bidding (NCB) for Works1 Not applicable

National Competitive Bidding for Goods1 Below $500,000Shopping for Works Not applicableShopping for Goods Below $100,000Community Participation Procurement Below $10,000



PriorPost

PROCUREMENT PLAN



Prior or Post

PriorPrior




province


Yes




Procurement method

Pre qualification


N/A

4. Consulting services contracts estimated to cost more than $100,000 (first 18 months)


Recruitment method


N/A



Prior and Post

PriorPriorPrior

Prior






No. Value of contracts (cumulative)

Number of contracts

Procurement method Comments

Goods

1 368,000 1 NCB2 180,000 1 NCB

3 47,000 1 shopping

4 350,000 9 NCB5 2,100,000 1 ICB6 253,000 1 shopping7 100,000 3 shopping8 50,000 3 shopping9 56,770 various shopping

1 93,480 1 IS2 52,140 1 IS3 82,080 1 IS4 76,380 1 IS5 72,960 1 CQS6 Project Accountant 1 50,160 1 IS7 Project Accountant 2 50,160 1 IS8 Accounting Assistant 19,380 1 IS9 100,000 1 CQS10 99,240 1 IS11 350,000 1 CQS

B. Indicative List of Packages Required Under the Project

Goods

Consulting services

Baseline survey undertaken and data analysed

6. The following table provides an indicative list of all procurement (goods, works and consulting services) over the life of the project. Contracts financed by the Borrower and others should also be indicated, with an appropriate notation in the comm

IT/Database/GIS specialistChief Accountant

Annual AuditTraining Consultant (National)

Office Equipment for Project Provinces (PPIUs) and Project districtsPick up cars for the projectMotobikes for the projectBoats for communesBycles for communesSupplies

Project Implementation Consultant

Surveillance and Response specialistProcurement specialist

General Description

Procure and deliver priority training equipment and supplies for TWGs and district teams

Office Equipment for Central level

Computers for BL survey (all)



Goods

1

Procure and deliver priority training equipment for TWGs and district teams 368,000 1 NCB No

2 Computers for BL survey (all) 180,000 1 NCB No3 Office Equipment for Central level 47,000 1 shopping No

4

Office Equipment for Project Provinces (PPIUs) and Project districts 350,000 9 NCB No


5 Pick up cars for the project 2,100,000 1 ICB Yes6 Motor bikes for the project 253,000 1 shopping No purchased by PPIUs7 Boats for communes 100,000 5 shopping No purchased by PPIUs8 Bicycles for communes 50,000 5 shopping No purchased by PPIUs

10 Supplies 378,466 various shopping No


11Community Initiatives and other community mobilization activities 14,628,222 various



12 System development activities 983,553 various shopping NoProcured by by PMU and PPIUs

13 O&M activities 2,413,913 various shopping NoIncluding government counterpart fund









Consulting services1 Project Implementation Specialist 93,480 1 IS Biodata2 Procurement specialist 52,140 1 IS Biodata

Surveillance and Response specialist82,080 1 IS Biodata

4 IT/Database/GIS specialist 76,380 1 IS Biodata5 Chief Accountant 72,960 1 CQS Biodata6 Project Accountant 1 50,160 1 CQS Biodata7 Project Accountant 2 50,160 8 Accounting Assistant 19,380 9 Annual Audit 100,000 1 CQS Biodata10 Mid Term Review 20,000 1 CQS Biodata11 Project Completion Mission review. 35,000 1 CQS Biodata12 Training Consultant (National) 99,240 1 IS Biodata



Note: A proposed Grant of about $3.6 million contribution to the pooled fund (RCU) is not included in this procurement plan




1. General

7. The laws to be followed for national competitive bidding shall be those set forth in the Law on Procurement No. 61/2005/QH11 of 29 November 2005 and the Construction Law no. 16/2003/QH11 of 26 November 2003 and with the processes described in Decree No. 111/20006/DD-CP of 29 September 2006 with the clarifications and modifications described in the following paragraphs required for compliance with the provisions of the Procurement Guidelines.

2. Registration

(i) Bidding shall not be restricted to pre-registered firms and such registration shall not be a condition for participation in the bidding process.

(ii) Where registration is required prior to award of contract, bidders: (i) shall be

allowed a reasonable time to complete the registration process; and (ii) shall not be denied registration for reasons unrelated to their capability and resources to successfully perform the contract, which shall be verified through post-qualification.

(iii) Foreign bidders shall not be required to register as a condition for submitting

bids.

(iv) Bidder’s qualification shall be verified through post-qualification process.

3. Eligibility

(i) National sanction lists may only be applied with approval of ADB1. (ii) A firm declared ineligible by ADB cannot participate in bidding for an ADB

financed contract during the period of time determined by ADB. 4. Prequalification and Post qualification

(i) Post qualification shall be used unless prequalification is explicitly provided for in the loan agreement/procurement plan. Irrespective of whether post qualification or prequalification is used, eligible bidders (both national and foreign) shall be allowed to participate.

(ii) When pre-qualification is required, the evaluation methodology shall be based on

pass/ fail criteria relating to the firm’s experience, technical and financial capacities.

1 Section 52 of the Integrity Principles and Guidelines allows ADB to sanction parties who fail to meet ADB's high ethical standards based on the decisions of third parties, such a decision can only be made by the Integrity Oversight Committee on the basis of ADB's own independent examination of the evidence. As such, the process should follow the normal assessment and investigative processes prescribed by the Integrity Principles and Guidelines. http://www.adb.org/Documents/Guidelines/Integrity-Guidelines-Procedures/integrity-guidelines-procedures-2006.pdf

http://www.adb.org/Documents/Guidelines/Integrity-Guidelines-Procedures/integrity-guidelines-procedures-2006.pdf



(iii) Qualification criteria shall be clearly specified in the bidding documents, and all criteria so specified, and only criteria so specified, shall be used to determine whether a bidder is qualified. The evaluation of the bidder’s qualifications should be conducted separately from the technical and commercial evaluation of the bid.

(iv) In carrying out the post-qualification assessment, the Employer/ Purchaser shall

exercise reasonable judgment in requesting, in writing, from a bidder missing factual or historical supporting information related to the bidder’s qualifications and shall provide reasonable time period (a minimum of 7 days) to the bidder to provide response.

5. Preferences

(i) No preference of any kind shall be given to domestic bidders or for domestically manufactured goods.

(ii) Regulations issued by a sectoral ministry, provincial regulations and local

regulations which restrict national competitive bidding procedures to a class of contractors or a class of suppliers shall not be applicable.

(iii) Foreign bidders shall be eligible to participate in bidding under the same

conditions as local bidders, and local bidders shall be given no preference (either in bidding process or in bid evaluation) over foreign bidders, nor shall bidders located in the same province or city as the procuring entity be given any such preference over bidders located outside that city or province

6. Advertising

(i) Invitations to bid (or prequalify, where prequalification is used) shall be advertised in Government Public Procurement Bulletin. In addition, the procuring agency should publish the advertisement in at least one widely circulated national daily newspaper or freely accessible, nationally-known website allowing a minimum of twenty-eight (28) days for the preparation and submission of bids and allowing potential bidders to purchase bidding documents up to at least twenty-four (24) hours prior the deadline for the submission of bids. Bidding of NCB contracts estimated at $500,000 or more for goods and related services or $1,000,000 or more for civil works shall be advertised on ADB’s website via the posting of the Procurement Plan.

(ii) Bidding documents shall be made available by mail, or in person, to all who are

willing to pay the required fee, if any.

(iii) The fee for the bidding documents should be reasonable and consist only of the cost of printing (or photocopying) the documents and their delivery to the bidder. (Currently set at 1 Million VND, increase subject to approval of ADB)

7. Standard bidding documents

(i) The Borrower’s standard bidding documents, acceptable to ADB, shall be used. The bidding documents shall provide clear instructions on how bids should be



submitted, how prices should be offered, and the place and time for submission and opening of bids.

(ii) Bidders shall be allowed to submit bids by hand or by mail/ courier.

8. Bid Opening

8. A copy of the bid opening record shall be promptly provided to all bidders who submitted bids.

9. Bid Evaluation

(i) Merit points shall not be used in bid evaluation. (ii) Bidders shall not be eliminated from detailed evaluation on the basis of minor,

non-substantial deviations.2 (iii) Except with the prior approval of ADB, no negotiations shall take place with any

bidder prior to the award, even when all bids exceed the cost estimates. (iv) A bidder shall not be required, as a condition for award of contract, to undertake

obligations not specified in the bidding documents or otherwise to modify the bid as originally submitted.

(v) Bids shall not be rejected on account of arithmetic corrections of any amount.

However, if the Bidder that submitted the lowest evaluated bid does not accept the arithmetical corrections made by the evaluating committee during the evaluation stage, its bid shall be disqualified and its bid security shall be forfeited.

10. Rejection of All Bids and Rebidding

(i) No bid shall be rejected on the basis of a comparison with the owner's estimate or budget ceiling without the ADB’s prior concurrence.

(ii) Bids shall not be rejected and new bids solicited without the ADB’s prior

concurrence. 11. Participation by Government-owned enterprises

9. Government-owned enterprises shall be eligible to participate as bidders only if they can establish that they are legally and financially autonomous, operate under Enterprise law and are not a dependent agency the contracting entity. Furthermore, they will be subject to the same bid and performance security requirements as other bidders.

12. Non-eligibility of military or security units

10. Military or security units, or enterprises which belong to the Ministry of Defense or the Ministry of Public Security shall not be permitted to bid.

2 Minor, non-substantial deviation is one that, if accepted, would not affect in any substantial way the scope, quality, or performance specified in the contract; or limit in any substantial way, the Contracting entity rights or the Bidder’s obligations under the proposed contract or if rectified, would not unfairly affect the competitive position of other bidders presenting substantially responsive bids.



13. Participation by Foreign contractors and suppliers. Joint Ventures and Associations

(i) Foreign suppliers and contractors from eligible countries shall, if they are interested, be allowed to participate without being required to associate or form joint ventures with local suppliers or contractors, or to subcontract part of their contract to a local bidder.

(ii) A bidder declared the lowest evaluated responsive bidder shall not be required to

form a joint venture or to sub-contract part of the supply of goods as a condition of award of the contract.

(iii) License for foreign contractors operation in Vietnam would be provided in a

timely manner and will not be arbitrarily withheld. 14. Publication of the Award of Contract. Debriefing.

(i) For contracts subject to prior review, within 2 weeks of receiving ADB’s “No-objection” to the recommendation of contract award, the borrower shall publish in the Government Public Procurement Bulletin, or well-known and freely-accessible website the results of the bid evaluation, identifying the bid and lot numbers, and providing information on: i) name of each bidder who submitted a bid; ii) bid prices as read out at bid opening; iii) name and evaluated prices of each bid that was evaluated; iv) name of bidders whose bids were rejected and the reasons for their rejection; and v) name of the winning bidder, and the price it offered, as well as the duration and summary scope of the contract awarded.

(ii) For contracts subject to post review, the procuring entity shall publish the bid

evaluation results no later than the date of contract award.

(iii) In the publication of the bid evaluation results, the borrower shall specify that any bidder who wishes to ascertain the grounds on which its bid was not selected, should request an explanation from the procuring entity. The procuring entity shall promptly provide an explanation of why such bid was not selected, either in writing and / or in a debriefing meeting, at the option of the borrower. The requesting bidder shall bear all the costs of attending such as debriefing. In this discussion, only the bidder’s bid can be discussed and not the bids of competitors.

15. Handling of Complaints

11. The national competitive bidding documents shall contain provisions acceptable to ADB describing the handling of complaints in accordance with Article 47 of Decree No. 111/20006/DD-CP, read with Articles 72 and 73 of Law on Procurement No. 61/2005/QH11.

16. ADB Member Country Restrictions

12. Bidders must be nationals of member countries of ADB, and offered goods, works, and services must be produced in and supplied from member countries of ADB.



17. Fraud and Corruption

13. ADB will sanction a party or its successor, including declaring ineligible, either indefinitely or for a stated period of time, to participate in ADB-financed activities if it at any time determines that the firm has, directly or through an agent, engaged in corrupt, fraudulent, collusive, or coercive practices in competing for, or in executing, an ADB-financed contract.

18. Right to Inspect/ Audit

14. Each bidding document and contract financed from by ADB shall include a provision requiring bidders, suppliers, contractors to permit ADB or its representative to inspect their accounts and records relating to the bid submission and contract performance of the contract and to have them audited by auditors appointed by ADB.

APPENDIX 10:

TRAINING SYSTEMS DEVELOPMENT FRAMEWORK


Appendix 10: Training Systems Development Framework – Final Consultant Report April 2010 Page i

CONTENTS

ABBREVIATIONS ................................................................................................................................. ii

I. Overview of CDC2 Project Training Systems Development Framework .......................................... 1

II. Training Strategy............................................................................................................................. 2

A. Project Training Management System ......................................................................................... 2

B. Training Methodology and Approach ........................................................................................... 4

C. Skills Based Training (SBT) ......................................................................................................... 5

D. Guidelines for Implementation of Training ................................................................................... 5

E. Selection Criteria ......................................................................................................................... 8

F. Gender and Ethnic Minority Strategies ........................................................................................ 8

G. On-site Training ........................................................................................................................... 9

H. Team Teaching ........................................................................................................................... 9

I. Training Materials ........................................................................................................................ 9

J. Provincial Training Working Groups: Develop, deliver, manage and evaluate training ................. 9

K. Training Monitoring, Evaluation and Validation .......................................................................... 10

L. Training Records and Reporting ................................................................................................ 10

M. Training Structure and Process ................................................................................................. 10

III. General Training System .............................................................................................................. 13

ANNEX 1 - INDICATIVE LIST OF TRAINING ACTIVITIES ................................................................. 14


Appendix 10: Training Systems Development Framework – Final Consultant Report April 2010 Page ii

ABBREVIATIONS


BCC Behaviour Change Communication

CHS Commune Health Station

CHV Community Health Volunteer

CLV Cambodia, Lao PDR and Viet Nam

DMAR Data Management, Analysis and Reporting


FE Field Epidemiology

FETP Field Epidemiology Training Program

HP Health Promotion

HRD Human Resources Development


ITWG Inter-Provincial Training Working Group




INGO International Non-governmental Organization

PPSC Provincial Project Steering Committee

PHC Provincial Health Department

PHD Primary Health Care

PHS Provincial Health Service


PPC Provincial People‟s Committee

PPMU Provincial Project Management Unit

PTWG Provincial Training Working Group

RH Reproductive Health

RHC Reproductive Health Center

SBT Skills Based Training

SMS Secondary Medical School

STA Short Term Technical Assistance

TA Technical Assistance

TNA Training Needs Analysis

TOT Training of Trainer

TWG Training Working Group


WHO World Health Organization


Appendix 10: Training Systems Development Framework – Final Consultant Report April 2010 Page 1

TRAINING SYSTEMS DEVELOPMENT FRAMEWORK

1. The Project Objective of the Second GMS Regional Communicable Diseases Project (CDC2) is to contain the spread of epidemic diseases at a local level, and reduce the burden of common endemic diseases in selected shared border provinces and districts of Cambodia, Lao PDR and Vietnam to improve the health status of the poor, women of child-bearing age, children under 5, ethnic minority groups (EMG), and other vulnerable groups, and strengthen health systems for CDC in 6 provinces in Cambodia, 9 provinces in Lao PDR and 15 provinces in Viet Nam. The Project has two components: (i) Strengthening Regional Cooperation in Communicable Disease Control, and (ii) Strengthening National Surveillance, Response and Health Systems.

I. OVERVIEW OF CDC2 PROJECT TRAINING SYSTEMS DEVELOPMENT FRAMEWORK

2. CDC2 will strengthen sustainable systems for training, supervision, referral and capacity-building to increase the number and retention of skilled health staff providing quality CDC services at provincial, district and commune levels in the 30 Project provinces. In addition, CDC2 will increase the knowledge and health awareness of selected remote and/or border communities through training in behavior change communication (BCC) and community mobilization for CDC.

3. Project training activities will promote the development of personnel and institutional capacities in the context of working systems rather than teaching skills in isolation. Emphasis will be placed on Skills Based Training (SBT), inter-active teaching methods, on-the-job training, the application of skills in the workplace with follow-up workplace assessment of learning outcomes, and linking the provision of material resources to workplace needs. Recognizing the limitations of cascade training methods, a team-teaching model will be adopted where national or provincial “master” trainers work alongside and mentor provincial and district trainers. The Project„s training strategy will be implemented through a management system which recognizes the need for local involvement in, and ownership of, both training process and content. This participatory approach will enable the customization of training activities to meet local needs and conditions, and to provide sustainable capabilities after completion of the Project.

4. Project in-service training, upgrading training, and scholarships for Masters or Specialist training will reflect the primary goals of the CDC2 project, which include a focus on the poor, women and ethnic minority groups. Priority will be given to training to improve the quality of staff at health facilities and health volunteers in the most disadvantaged communities, particularly those in remote border areas where quality health facilities are not located nearby. Priority will also be given to women and ethnic minority candidates, particularly for upgrading (Masters and Specialist training), to increase the proportion of women with high level qualifications.

5. A wide diversity of participants will be involved, including technical support from scientific researchers and trainers from national and regional research and training institutions. Following a clearly planned strategy from inter-provincial, to provincial, to district, to community levels, with gender issues an integral part of all activities, CDC2 will support: (i) strengthening human resource planning; (ii) strengthening of systems for training, supervision, referral and capacity building; (iii) short-term clinical training for doctors, nurses, midwives, and laboratory technicians; (iv) in-service training of district and commune health staff, and for mass organization members, village health volunteers, school health education teachers, agriculture extension workers, water and sanitation workers, and others; and (v) scholarships for advanced education. Socio-economic, cultural and language differences and geographic distance between the groups and the regions where CDC2 is implemented will require adaptable strategies and methods to address trainees‟ differing needs, educational backgrounds and work environments.



6. Provincial and district trainers will participate in Training of Trainer (TOT) courses according to t heir t raining a nd s upervision r ole i n t he province. T hey w ill dev elop t heir s kills t o c onduct training needs analyses (TNA) and plan, design, develop, deliver and evaluate SBT materials and courses for health workers at district and commune levels and for village health workers, especially in underserved border areas. Sustainability w ill be enhanced by working w ithin ex isting national programs, i nstitutes and d epartments, and i n c ompliance w ith es tablished g overnment p olicies, guidelines and prioritized health agendas for effective CDC and quality primary health care.

7. Topics for the training will be identified from project baseline information and ongoing TNA, and may include: (i) field epidemiology, (ii) information and communication technology; (iii) clinical diagnosis and t reatment; (i v) laboratory m anagement a nd haematology; (v) behaviour c hange communication (BCC) for community-based surveillance and prevention; (vi) audience analysis for Information, Education a nd C ommunication ( IEC) testing and development; (vii) health s ervices management, monitoring and evaluation; (viii) pr oject m anagement; Master‟s and Specialist training; and ( viii) training of t rainers. Training w ill t ake place as t raining w orkshops, on-site training, exchanges, study tours and field practice.

II. TRAINING STRATEGY

8. The Project training strategy is designed to support the achievement of the overall CDC2 Project objective, and is based on the following key principles and assumptions:

“Master Trainers” who complete the Project‟s Training of M aster T rainers C ourse are available to support t he implementation o f provincial and district t raining activities and have the capacity to assess training needs, develop, monitor and evaluate courses, and conduct follow-up work-place assessments;

District Trainers who have satisfactorily completed a Training of Trainers (TOT) Course are available to coordinate, monitor and report on locally conducted training activities;

Expert lecturers and t rainers who have satisfactorily completed a re-training course in interactive teaching methods are available to develop and deliver effective courses, and to conduct follow-up workplace assessments;

Training ac tivities are designed to fill t he k nowledge and s kills g aps n ecessary t o achieve CDC2 Project outcomes, and to support Ministry of Health (MOH) training and development pl ans. G aps ar e i dentified by t raining needs a nalysis ( TNA), b oth geographic and thematic, in key Project priority areas including CDC, maternal and child health ( MCH), c ommunity based behavior c hange c ommunication ( BCC) for hea lth promotion and effective CDC.

Training objectives are described i n performance t erms, and l earning outcomes – the skills and knowledge gained, and regularly assessed;

Skills ba sed t raining ( SBT), i ncorporating w orkplace training and assessment, will b e implemented and evaluated in selected locations, then expanded in other areas.

A. Project Training Management System

9. At the apex of the t raining management s tructure i s the Inter-provincial Training Working Group (ITWG) w hich i s r esponsible for a dvising t he P roject o n ov erall t raining policies an d priorities, and assisting in the coordination of training activities that involve more than one province.



The ITWG comprises one member from each of the Provincial Training Working Groups (PTWG), plus Project Training Technical Assistance (International Training Consultant and National Training Consultant), National Institute trainers and other specialist support (e.g. WHO, INGOs).

10. Provincial Training Working Groups (PTWG) composed of senior clinical and preventive health trainers and supervisors (from provincial and district hospitals, preventive health and health education departments, reproductive health centers, secondary medical schools, etc) in each province will be the key mechanism for effective management, coordination, monitoring and evaluation of training activities across the project components. This will include management and coordination of TNA, clarifying needs, recruiting trainees, materials and curriculum development in each province, organizing training delivery and monitoring and reporting outcomes to the Provincial Project Steering Committee (PPSC), and to the Provincial Project Management Unit (PPMU). PTWG meetings are held quarterly, and when necessary for the ITWG to consider CDC2 project-wide training policy and issues.

11. Provincial Project Steering Committees (PPSCs) oversee training plans and programs and are responsible for advising the Project on provincial training priorities and approving training funds. The Project‟s training consultants are in turn responsible for approving training plans and activities, monitoring progress and reporting outcomes to ADB. Finally, MOH counterparts are responsible for approving all training curricula used by the Project to ensure consistency with other health training nationwide.

12. The day-to-day implementation of Project training activities is guided by the Project‟s Training Procedures Manual which will be developed collaboratively by the PTWGs and Project Training Consultants. The manual will detail the standard operating procedures to be followed, including documenting training requests, registering participants, monitoring feedback and reviewing progress, recording course content, and reporting training outcomes. A computerized training database will also be established and maintained by the Project Training TA to record training participant and provider details and to facilitate reporting to MOH and ADB. General audio-visual training equipment and learning resources will be procured and distributed. Supplementary training will also be provided in the application of power point software.

13. Project support to collaborative TA working with the PTWGs will help strengthen the capacity of national and regional research and training institutions to organize and provide in-service and refresher training programs based on adult-learning methodologies. Strategic use of SBT and the formation of provincial and district training working groups will oversee and coordinate training at the provincial, district and commune levels to guide this process. Ultimately, with their own qualified trainers able to teach in their respective specialities using up-to-date approaches and methodologies, the provincial health services will be able to conduct their own training for local commune staff with less reliance on national institutions.

14. General and specialist medical English training will be provided for provincial personnel, and the higher level English-for-study-purposes training may be arranged for post-graduate Master‟s course candidates. Ethnic minority language training will be arranged as necessary to facilitate communication between local health center staff and their EMG target audiences. General audio-visual training equipment and learning resources will be procured and distributed as necessary. Supplementary training will also be provided in equipment maintenance and relevant software. Skills Based Training (SBT) will be trialed in selected Project provinces based on the skills training needs of district and commune health workers. An inter-provincial review of the trial results will be carried out prior to application the SBT approach to the training courses.



15. To assist the PTWGs to develop and implement quality TOT courses, Project will support TA for the production of a comprehensive TOT Training Guide comprising essential learning and reference materials along with agreed guidelines for course content and structure. The MOH and national institutes will be involved in this process to assist in achieving official support for the TOT Training Guide and ensuring it satisfies national guidelines and policies

Project Training Management System

Inter-provincial Training Working Groups (ITWG) • One Master Trainer from each PTWG • Advise overall training policies and priorities Provincial Training Working Groups (PTWG) • Provincial and District Master Trainers • Develop, deliver, manage and evaluate training • Report outcomes to Provincial Project Steering Committees (PPSC) District Trainers/ Technical Working Groups • Represent on PTWG • Report on local training needs • Organize and facilitate District and Commune level training Provincial Project Steering Committees (PPSC) • Oversee provincial training plans and programs • Advise PPMU on training priorities, and for approval of training funds

B. Training Methodology and Approach

16. Training methodologies selected will encourage participative and active learning, recognize the needs of adult learners, and support the development of workplace knowledge, attitudes and skills. Wherever possible, existing, approved MOH curricula will be used, but may be modified to reflect the specific situation within the Provinces, provided technical accuracy and educational SBT principles are maintained. Short sections may be extracted from longer MOH curriculum, to provide training focused on just one or two topics, and where existing materials are not suitable, new packages will be developed, tested and implemented.

17. Training of District and Commune health staff will be skills based training (SBT), where the emphasis is on the skills required in the workplace. Training is not considered complete until the identified skills have been practised and assessed in the workplace. This requires several fundamental changes to the conventional approach to training. Project training activities typically involve short, in-service courses (5 to 10 days) with refresher training, and take the form of: Formal Courses, Workshops/ Seminars, Informal Courses/Discussion Groups; Staff Exchanges/ Work Placements, Study Tours, Specialized Training, Scholarships for Advanced Education

18. In-service training courses for District and Commune Health Staff will be costed based on two-week courses, and a three-month course, with one month refresher course for VHWs. Where appropriate, and providing quality of training can be assured, the Province can choose to provide shorter 1 week courses to more staff, or longer (e.g. 1 month courses) to fewer staff, or depending on training participants availability, it may prove more feasible to break longer courses (e.g.; VHW training and refresher courses) into a series of 5 to 10 days course duration. The Province should discuss any changes proposed with the Provincial Management Unit.



C. Skills Based Training (SBT)

19. Skills B ased T raining ( SBT) i s a simple, f lexible approach b ased on the pr inciple t hat training i s c omplete only w hen t he l earner c an dem onstrate t hat s he or he c an p erform t he particular skills or processes. Programs such as IMCI in V iet Nam have used the SBT approach successfully. The SBT model involves the following elements:

Development and pilot testing of simple CDC skills checklists which are based on MOH standards, and which were adapted to each province‟s needs by the Provincial Training Working Groups (PTWG).

Development of TOT Courses to prepare trainers to be able to understand and apply the SBT principles, on topics such as adult learning principles, interactive learning, how to teach s kills, a nd h ow t o c onduct w orkplace a ssessments. Trainers ar e given t he opportunity t o u pdate t heir ow n CDC skills an d k nowledge t o ensure t hat t he l atest information is being passed on to the learners.

Provision of essential equipment to commune health centers to ensure that the skills and knowledge can be applied

Workplace as sessment t o c heck whether t he t rainee i s able t o apply t he s kills an d knowledge i n t heir r egular w ork s ituation. Where t he trainee c annot apply t he s kills, further on-the-job coaching is provided until they are proficient.

20. The be nefits observed from t he S BT approach in V iet Nam an d elsewhere include t he following:

“Ownership” of the training programs by the provincial and district trainers through their involvement in the customization of the skills checklists

Focus on the learner and the learner‟s needs that comes from the SBT approach

Motivation and satisfaction that the learner receives from having their skills and abilities recognized through the workplace assessment process

Improved relationship between district and commune level staff established through the training and workplace assessment activities.

D. Guidelines for Implementation of Training

21. Project i n-service t raining, upgrading t raining, and s cholarships for Masters or S pecialist training will reflect the primary goals of the Project, which include a focus on the poor, women and members of ethnic minority groups (EMG). Priority will be given to training to improve the quality of staff at health facilities and health volunteers in the most disadvantaged communities, particularly those in remote, mountainous areas where quality health facilities are not located nearby. Priority will be gi ven t o w omen a nd ethnic m inority c andidates, particularly for up grading, M asters a nd Specialist t raining, t o i ncrease t he pr oportion o f w omen w ith hi gh l evel qualifications. T raining opportunities will be equitably distributed:

Geographically

Between levels of service in the Province (Province, District, Commune)

Between curative and preventative/ health promotive fields of practice



22. Project training activities will be based on Training Needs Analyses (TNA), prioritized based on he alth ou tcomes of t he population served, an d d eveloped and i mplemented through t he Provincial and District Training Working Groups‟ participation in the following sequence of steps:

a. Identifying key communicable disease prevention, preparedness and control issues

b. Identifying training-related issues/ problems

c. Identifying key positions/ responsibilities

d. Identifying target staff and required knowledge attitudes, and skills

e. Determining “gaps”

f. Clarifying specific training needs

g. Reviewing available training packages

h. Selecting existing training packages or developing and testing new packages

i. Designing courses

j. Implementing training

k. Monitoring the training progress

l. Recording training content

m. Evaluating and validating training outcomes

n. Reporting on training

23. Topics for the training at Commune and District levels will be identified through analysis of the Project baseline health indicator estimates, participatory community needs analysis, and the outcomes of ongoing TNA. Training courses will include all or some of the following:

Training of Trainers including:

Training of Master Trainers

Training of District Trainers

Interactive methodology training for Professional Trainers

Interactive methodology training for community-based health promotion trainers

In-service short-course training may include courses related to:

Skills based training

Integrated Supervision

Methods for improving Quality of Care

Health Services Management

Financial Management



Project Management

Information and Communication Technology (ICT)

Laboratory Management and Haematology

Participatory Community Needs Assessment of Priorities and Resources for CDC

Health Promotion, Communication and Counselling

Audience Analysis for IEC Media Testing and Development

Community Mobilization and Village Health Worker Networks

Monitoring and Evaluation

Research Methods Using Existing Data (for implementing the baseline)

Communicable Diseases Diagnosis and Treatment

Other topics that address priority gaps in staff skills identified in the TNA

Key training areas likely to be identified in the TNA include:

Diarrhea

Pneumonia and other causes of cough

Malnutrition and anemia in women and children

Vector borne diseases (malaria, dengue, Japanese encephalitis, rabies)

Reproductive tract infections and sexually transmitted diseases

Adolescent reproductive health awareness.

Communication and counseling skills

Diagnosis and Treatment

Up-grading Training and Pre-service Training

24. Up-grading t raining a nd pre-service t raining will be pr ovided based o n pr iority n eeds to improve the skill levels of health staff and where lack of staff is a problem at health facilities in the most disadvantaged communities, particularly those in remote border areas. Preparatory courses and s cholarships will be pr ovided as needed, i ncluding for ethnic m inority c andidates and local school l eavers t o attend h ealth w orker t raining at provincial Secondary Medical Schools or Colleges. Theses s cholarships w ill c over l iving ex penses s uch as food an d ac commodation, uniforms, bo oks, travel between hom e an d school f or holidays, ex tra tuition an d pr eparatory courses if needed, and will supplement government subsidies for tuition.



Specialist Training

25. Laboratory technicians w ill be t rained i n ar eas o f h aematology and g eneral laboratory safety, management and hygiene. F or health service providers, training will be focused on rapid testing and other areas as identified. This training will take place in formal training courses, on-site training, workshops, clinical attachments and exchanges.

Post-graduate and Specialized Professional Training

26. A range of Masters Degree options, professional short-courses, attachments and study tour opportunities w ill b e i dentified for assessment an d selection by t he P rovincial Management Committees according to the provincial human resources (HR) p lan. Criteria will be developed to ensure that selection of candidates for scholarships is consistent with Project goals to increase the representation of EMGs and women in senior positions within the health sector.

Participatory Community Needs Analysis

27. Provincial, district a nd commune h ealth personnel and m embers o f Mass O rganizations and other community volunteers will be trained in participatory community needs analysis. Training will take place in the form of training workshops and field practice.

Training for community-based health promotion, BCC and community mobilization

28. Provincial, D istrict a nd C ommune l evel he alth workers a nd s elected m embers o f M ass Organizations w ill be t rained i n c ommunity-based h ealth pr omotion, primary he alth c are a nd communication s kills, t he d esign a nd i mplementation of v illage h ealth w orker net works, a nd audience a nalysis for h ealth pr omotion/ I EC m edia dev elopment a nd a udience t argeting. T his training will take place in the form of training workshops, study tours and field practice.

E. Selection Criteria

29. Selection criteria are established for each training activity according to the target group and the specific learning objectives, including:

Training must be relevant to the current duties of the participant; Trainees m ust b e av ailable for, an d agr ee t o par ticipate i n f ollow-up w orkplace

assessment as required; and Trainees must have the required academic background and language skills required to

succeed in the course.

F. Gender and Ethnic Minority Strategies

30. In addi tion, t he P roject t raining ac tivities ar e developed and i mplemented i n ac cordance with the Project Gender and Ethnic Minority Strategies. For training, this means:

Using appropriate locations and venues; Selecting appropriate times; Ensuring that the content and the materials for training are appropriate for specific ethnic

groups where indicated, are gender sensitive and promote gender equality; Ensuring where possible, at least equal representation of men and women among the

trainers and trainees; and Monitoring participation rates and providing gender training as required.



G. On-site Training

31. On-site training will be conducted whenever feasible to enable skills to be developed in an environment which is familiar to the participants, and within which they will be expected to apply their new skills and k nowledge. This is particularly important at district level where infrastructure and r esource l imitations demand t hat flexible a nd c reative o ptions b e d eveloped. T he on -site model will also be comprehensive, treating the workplace as the functioning whole. For example, in the laboratory departments of district hospitals, the whole department, including supervisors, will be in involved in the training.

H. Team Teaching

32. Cascade t raining, by w hich M aster T rainers t rain pr ovincial t rainers, w ho t rain district trainers, who then deliver t raining at commune level has the tendency to progressively di lute the quality of training skills and content. To address this, the Project will use a team teaching approach that has been successfully applied in CLV, whereby district trainers work in teams with provincial trainers, and T OT i s del ivered di rectly t o di strict t rainers. I n t his w ay a c ore group o f di strict trainers is developed, recognized, supported and provided with the necessary training references and equipment to sustain training capacities at lower levels.

I. Training Materials

33. Existing t raining materials in CLV which have formal MOH approval will be r eviewed and used wherever possible to avoid unnecessary duplication. I t i s l ikely that many of the currently available materials will be suitable as reference books and texts despite the innovations in teaching methods. Nonetheless, it is anticipated that the SBT approach will require a significant amount of time give the specifically prepared skills learning materials to be developed and submitted to MOH for approval.

J. Provincial Training Working Groups: Develop, deliver, manage and evaluate training

34. Provincial and district staff are em powered t hrough t heir par ticipation i n t he P rovincial Training W orking Groups (PTWG). All P TWG members, c omprising 5 0 percent males and 50 percent females, will have participated in an intensive Master Trainer training program focusing on the benefits of learner-centered approaches, including consideration of the needs of women.

PTWG Members: Senior clinical and preventive health managers and trainers from:

Provincial Preventive Medicine Centers Provincial and District Hospitals Provincial Reproductive Health/ MCH Centers Provincial Health Education Centers Provincial Secondary Medical Schools

Provincial Training Working Groups (PTWG) responsible for:

Training needs analysis of target groups Review of existing curricula and materials Use existing materials and/or develop new materials Content and methods consistent with MOH standards, policies and programs Training materials printed and distributed Master trainers provide TOT training for their provincial and district staff.



K. Training Monitoring, Evaluation and Validation

35. Participation registration forms will be provided to record essential information for preparing certificates and for reporting purposes. Periodic monitoring of training progress is conducted for all activities by gathering feedback from participants. T his information is used by providers to refine activities d uring i mplementation. Evaluation oc curs at t he end of each c ourse or ac tivity t o determine the achievement of learning objectives. This includes formative assessment results as well as p articipant and provider feedback, a nd det ermines the n eed for c ourse m odification. Validation of activities is conducted where appropriate, involving workplace summative assessment through follow-up interviews with, and feedback from, participants, their patients and clients, their direct supervisors and managers.

L. Training Records and Reporting

36. At t he en d o f e ach t raining ac tivity, t he c ourse pr ovider pr epares a ( i) t raining r ecord, comprising al l h andouts a nd c ourse n otes, pl us a c opy o f t he s chedule, a nd ( ii) t he t raining completion report, including a summary of learning outcomes, participant and presenter feedback, and recommendations for future activities. A database of training participants will be es tablished and maintained. A chievement o f t raining o bjectives a nd o utcomes i s r ecognized by the presentation o f P roject C ertificates t o s uccessful par ticipants, i f t hey a ttend 90 percent of t he training, and demonstrate achievement of the learning objectives.

M. Training Structure and Process

Sub-Component 2.2: Strengthening Systems for Human Resource Development

37. The P roject w ill s trengthen s ustainable s ystems f or t raining, s upervision, r eferral an d capacity-building t o i ncrease t he number and r etention of s killed h ealth s taff pr oviding qu ality clinical and preventive health services for communicable diseases control at provincial, district and commune levels in priority border districts in the 30 project provinces.

Provincial Training Working Groups: develop, deliver, manage and evaluate training

38. Members: Senior c linical a nd preventive h ealth s upervisors a nd trainers from p rovincial and district hospitals, preventive health/ health education centers, and secondary medical schools.

Stage One: Teaching Methods TOT for Master Trainers Stage One: Teaching Methods TOT for Master Trainers Master Tr ainers TOT u sing S kills Based T raining ( SBT) pr ovided by s enior national/

regional institute trainers, supported by specialist agencies (eg WHO), and Project TA Project training equipment provided

Stage Two: General TOT for Provincial and District Staff (based on TNA)

39. A c ore t eam o f c linical and preventive h ealth t rainers from D istrict a nd P rovincial l evels receive TOT for improved facilitator skills, as well as for planning and design of training courses.

Course modules may include: Course modules may include: Field Epidemiology (FE) TOT Behaviour Change Communication (BCC) TOT Data Management, Analysis and Reporting (DAR) TOT Laboratory Hygiene and Haematology Training TOT Clinical Diagnosis and Treatment TOT Health Services/ Project Management TOT



Participatory assessment of health promotion priorities and resources TOT Community based health promotion and communication techniques TOT Audience analysis and IEC/ BCC materials development TOT Monitoring and Evaluation TOT

Sub-component 2 .4: Capacity bu ilding of Provincial a nd D istrict Staff fo r C DC AND Health Services Delivery.

40. This c omponent will improve CDC s ervices for t he p oor, w omen, c hildren and e thnic minorities by: (a) s trengthening health care services in remote a nd ethnic minority communities; and (b) improving health behavior through increased knowledge, awareness, and participation in community-based surveillance, prevention and response activities for CDC.

District Training Working Groups: train in their districts and communes Members: Provincial and district trainers who have completed Project TOT

41. Provincial le vel: tw o Preventive Medicine Center t rainers; District le vel: one out reach worker/ mobile team member from each Project district. Training takes place in the form of training workshops, study tours and field practice. 20-30 trainees in each province (majority female)

Stage Three: Training of District and Commune Health Staff (based on TNA) Health staff trained in FE (including FE TOT)

Health staff trained in BCC (including BCC TOT) Health staff trained in Data Analysis and Reporting (including TOT) Laboratory staff trained in Laboratory Hygiene/ Rapid Testing (including TOT) Clinical staff trained in Diagnosis and Treatment (including TOT) Provincial and District management staff trained in Project Management (including TOT) Participatory assessment of CDC priorities and resources (including TOT) Community based Behavior Change Communication techniques (including TOT) Audience analysis and IEC/ BCC materials development (including TOT) Monitoring and Evaluation (including TOT)

Additional Courses: provided by PTWGs and Short-term Technical Assistance (STA):

Health Systems Management Training General and Medical English Ethnic minority languages for CHS personnel Power Point software Felt-board presentation Equipment maintenance

Sub-component 2 .5: Targeted CDC Health Services for R ural Populations i n Border

districts

42. To contain t he s pread of e pidemic di seases at l ocal l evel, a nd r educe the b urden of common en demic di seases requires c ollaboration b etween a r ange of s ervice s ectors and community groups so t hat he alth is s een a s an i ssue of c ommunal c oncern and n ot s imply a technical i ssue for w orkers i nside the health s ystem. I n t he health s ystem t his i s promoted by developing s kills in community ne eds assessment, a nd i mproving o utreach ac tivities. At t he community l evel, ac tivities i nvolve m ass or ganizations, go vernment officers from v arious commune-level departments, and community volunteers and staff from Commune Health Stations



(CHS). S trengthening health services focuses on district and commune levels, but includes the strengthening of provincial training, management and supervision skills.

43. Project ac tivities w ill pr ovide the m eans for communities to be pr epared for and pr event common en demic, neglected diseases an d promote maternal and c hild h ealth a nd nutrition, through t he development o f IEC m essages for a r ange o f m edia t o complement t he t raining i n health promotion and communication skills for health workers, health volunteers and members of mass organizations and, to support activities at village level to improve awareness and practices for prevention and recognition of priority communicable diseases.

Stage Four: District Courses in Community-Based BCC and Community Mobilization

44. Training o n community-based health pr omotion, B CC techniques, a udience analysis f or development o f I EC m aterials a nd r elated m onitoring a nd s upervision ar e c onducted, w ith refresher c ourses a nd practice for e ffective use o f t he I EC m aterials. With s upport from t he Provincial and District Training Working Groups, District clinical and preventive health trainers will conduct t he district t raining c ourses, w hich i nclude advanced s kills pr actice and t echnical information for effective diagnosis and treatment of communicable diseases.

Course modules may include: Participatory needs analysis and community mobilization Community-based Behavior Change Communication Techniques Audience analysis for IEC materials development, audience targeting and use Community strategy development for CDC preparedness and prevention Setting up and managing community health volunteer (CHV) networks Recognition, diagnosis, care and treatment of common diseases

District Level Training Methodology

45. Provincial a nd district trainers w ho c omplete T OT courses c oordinate and c onduct BCC and Community Mobilization courses as a team in their districts and communes. One district trainer in each province is also a member of the PTWG, linking Component 2.5 training activities to overall training r esources a nd s upport. Participatory ac tion or iented training m ethods i nclude brainstorming, drama, case study, small group discussion, role play and group exercise.

Participants: District and Commune level (25 persons per course: majority female and EMG)

46. Courses are conducted in selected Project communes and include participants from district and commune l evels who ar e trained t ogether i ncluding health staff, mass or ganizations, population collaborators, peoples‟ committees, and general community members as follows:

Each District:

Two District Health Staff One District Women's Union member One District National Program member

Each Commune:

Two Commune Health Staff Community H ealth V olunteer (CHV) (e.g. Women's U nion, R ed C ross, Y outh U nion,

Farmer‟s Union, Child Protection/ Care Committee, National Program Collaborator, etc)



III. GENERAL TRAINING SYSTEM

Master Trainer TOT General TOT Teaching Methods TOT

Training Equipment Field Epidemiology TOT

Behaviour Change Communication TOT

Training Materials Information & Communication Technology TOT

Laboratory Hygiene and Haematology TOT

Clinical Diagnosis and Treatment TOT

Monitoring & Evaluation TOT

Provincial & District Trainers Skills Training & TOT In-service Training Courses

Field Epidemiology TOT

Behaviour Change Communication TOT

Training Equipment TOT Data Management, Analysis & Reporting

Laboratory Hygiene and Rapid Testing TOT

Training Materials Clinical Diagnosis & Treatment TOT

Monitoring & Evaluation TOT

District & Commune Health Staff Skills Training In-Service Training Courses

Field Epidemiology (short course)

Volunteers and Community Members

Behaviour Change Communication

Data Management, Analysis & Reporting

Training Equipment Laboratory Hygiene and Rapid Testing

Training Materials Clinical Diagnosis and Treatment

Monitoring & Evaluation

IEC Materials Community Health Volunteers

Students

Additional Training courses – provided by Project STA

General and Medical English

Ethnic minority languages

SBT techniques

Power Point software

Felt-board presentation

Equipment maintenance


Appendix 10: Training Systems Development Framework – Draft Final Consultant Report April 2010 Page 14

ANNEX 1 - INDICATIVE LIST OF TRAINING ACTIVITIES

(Combined Estimates for Three Countries: Cambodia, Lao PDR and Viet Nam)

Training Course Number of

Course Duration Participants in each course Objective/ Outputs Location

Person Months

(estimate)

1 Regional Workshop to Design the Baseline

1 Workshop Year 1

5 days 30 persons (senior MOH managers, and PMU/ PPMU officers

Agree common criteria for baseline studies of contiguous districts endorsed by MOHs in CLV

Phnom Penh, Vientiane, or Hanoi

5

2 Regional Workshop on Knowledge Management

1 workshop

Year 1

3 days 30 persons (from MOHs, RCU, National Institutes)

RCU Khowledge Management program transferred to MBDS website

Phnom Penh, Vientiane, or Hanoi

3

3 Research Methods using existing data

30 courses

Year 1

5 days x 2 times

10 persons (health managers from each target districts and province)

300 managers with skills in data management , analysis & reporting for improved quality of health services for CDC

Province 100

4 Training on Information and Communication Technology (ICT)

30 courses/

Year 1

2 wks (part time over 2 months

10 persons

(health officers from target districts and provinces

300 managers with increased skills in use and application of ICT for CDC

Province 100

5 Study tour on CDC Preparedness, Surveillance and Response Systems

1 Study Tour

Year 1

10 days 5 persons (selected PHD officers and PMU / PPMU officers in each CLV)

15 persons with increased understanding of best practice in preparedness, surveillance and response

Other countries in the Region (Thailand China)

5

6 Provincial Workshops to plan implementation of the baseline

30 workshops

Year 1

5 days 10 persons (health officers from PHDs in target provinces

300 managers/ health officers develop agreed plans for conducting and compiling baseline

Province 50

7 Cluster workshops for integration of health services at district level

3

Workshops Year 1

5 days 25 persons

(PHD health officers in each target cluster of provinces)

75 managers/ health officers with common understanding for integration of health services at district level

Province 12.5





Person Months

(estimate)

8 Project Management Procurement, Planning and Monitoring for Results, Financial Management, and Project Implementation

3 courses in each CLV country

Year 1

2 weeks 22 persons (6 MOH officers, PMU staff and 2 PPMU staff from each target province)

660 persons with increased skills in ADB procurement process and in using performance indicators, monitoring inputs, outputs, outcomes, and evaluation

Phnom Penh,

Vientiane,

Ha Noi

330

9 Orientation Course on Advisory Support

1

Year 1

5 days 25 persons (staff from Universities and National Institutes that will take responsibility for supporting Provincial Training

25 teachers/ researchers trained to provide quality support to PHDs and hospitals in target provinces and districts

Phnom Penh,

Vientiane,

Ha Noi

4

10 Masters TOT: Adult Teaching Methods for Master Trainers

9 courses

Year 1

5 days x 2 times

25 persons (staff from: Provincial preventive medicine, RH MCH, HE Centers, Provincial and District Hospitals)

225 provincial and district staff trained to provide leadership in Skills Based Training (SBT)

30 project provinces

75

11 General TOT: Adult Teaching Methods for Core Trainers; from 30 provinces and 100 districts

15 / year

Project Years

1 & 3

5 days x 2 times

25 staff with training and supervisory responsibilities

1500 provincial and district clinical and preventive health staff trained to provide SBT in-service training

30 project provinces

500

12 Training of Provincial and District Staff: in Field Epidemiology; Behavior Change Communication; Data Mgt, Analysis and Reporting; Laboratory Hygiene, Safety & Testing; Clinical Diagnosis, Treatment and Infection Control; Leadership/Mgt, Financial Management, Quality Assurance, Management Information Systems and Monitoring & Evaluation

30 Year 2

90 Year 3

120 Yr 4 – 5

2 weeks 25 staff from provincial and district level, selected based on Training Needs Assessment

6000 provincial and district staff trained or retrained to provide improved quality of health care and CDC in target provinces

Districts or Provinces

3000

13 Training of Commune Health Center staff: in Field

30 Year 2

90 Year 3 120

2 weeks 25 staff from CHS, selected based on

6000 CHS staff trained or retrained to provide improved

Districts 3000





Person Months

(estimate)

Epidemiology, Behavior Change Communication, Information and Communication Technology, Data Management, Analysis and Reporting, Laboratory Hygiene and Rapid Testing, Recognition, Clinical Diagnosis and Treatment, Infection Control; Health Services Management; and Monitoring and Evaluation

Year 4-5

Training Needs Assessment

quality of health care and CDC in target provinces and districts

14 Training in Supportive Supervision

8 Year 2

8 Year 4

2 weeks 25 supervisors (staff from Provincial Health Departments, and selected districts)

200 supervisors trained and retrained in supervision for quality improvement

Provinces 200

15 Training of New Village Health Workers (VHW)

15 / Yr Project Years 2-5

3 months 25 persons selected by their community to become VHW

1500 new VHW on community-based surveillance, BCC and community mobilization

CHS or District 4500

16 Refresher Training of Village Health Workers (VHW)

30 / Yr Project Years 2-5

1 month 25 VHW from target provinces

3000 VHW retrained to provide improved community-based surveillance, BCC and community mobilization

CHS or District 3000

17 Cluster Study Tour on Community Based Disease Surveillance, Behavior Change Communication Techniques and Community Mobilization for CDC

3

Years 2-4

10 days 30 persons

(supervisors with CDC responsibilities from each target district and province

90 persons with increased understanding and awareness of successful CDC strategies used in each CLV cluster

Selected provinces and/or clusters in each CLV

30

18 Ethnic Minority Language and Culture Training

100

Years 2-5

10 days 25 persons (staff from 1000 CHS in remote ethnic minority areas)

1000 staff with increased capacity to communicate effectively with ethnic minority patients / clients

Province 830

19 Preparatory Course for Ethnic Minority Candidates

120 Year 1

240 Year 2

480 Year

1 year 1 person (nominated by community of remote mountainous Communes in target provinces)

840 ethnic minority students with skills needed to join in Pre-service training to become health workers)

Provincial Ethnic Minority Schools

10220





Person Months

(estimate)

3 – 5

20 Pre-service training 120 Year 1

240 Year 2

480 Year

3 – 5

2 – 3 years 1 person (nominated by community of remote mountainous Communes in target provinces)

840 new staff trained to secondary or college level to staff CHS in mountainous areas of target provinces)

Province (Secondary Medical Schools or Colleges in CLV)

10220

21 Upgrading Training

150 Year 1

300 Year 2 - 4

2 years 1 person (staff from District, Province or Commune selected based on priority needs)

450 staff with upgraded qualifications and skills to provide improved quality CDC

Colleges or Universities in CLV

20440

22 Foundation Course to prepare for Masters and Specialty Training

2 / year

Years 1 – 3

6 months 25 persons (2 PHD/ hospital managers from target provinces)

180 managers with capacity to enroll and participate successfully in Masters training

National or Regional training Institution or Province

32400

23 Specialty Training

(e. g. Field Epidemiology

(12 month Course)

3 courses

Years 2-4

1 year

(3 modules of 3 wks of class room follow by 3 months of field work

10 persons (staff from Province, District or Commune level selected based on priority needs)

300 staff with advanced qualifications and skills to provide improved quality CDC

Regional and National Institutes in CLV

3650

24 Specialty Training

(e.g. Formal Field Epidemiology Training Program [FETP] Course)

2 FETP Courses

Years 2-3

Years 4-5

2 years 1 person

(4 health officers/ hospital staff from target provinces and districts)

120 staff with advanced qualifications and skills to provide improved quality CDC

Universities, National Institutes in CLV

87600

25 Masters in Public Health (MPH) 1 in Project Years 3-4

1 in Project Years 4-5

2 years 1 person (2 PHD/ hospital managers from each target province)

120 managers with increased capacity to effectively manage health services for CDC

National Uni. in collaboration with international Uni.

87600

26 General and Medical English 60 courses 8 weeks (part-time over 8

25 persons (8 health officers from PHD and

240 persons (staff from provincial, district levels selected

Province or 448





Person Months

(estimate)

Language Training

Years 2-3 months hospitals in target provinces

based on priority needs

District

27 Equipment Maintenance Training

60 courses

Years 1-5

1 – 5 days 25 persons (clerical and technical staff from Provincial Health Departments (PHD) and hospitals in target provinces, districts and communes)

1500 PHD and hospital staff with increased skills in operating equipment, cleaning it, and routine maintenance

Province or District

375

APPENDIX 11:

ECONOMIC AND FINANCIAL

ANALYSIS


Appendix 11: Economic and Financial Analysis– Final Consultant Report April 2010 Page i

TABLE OF CONTENTS

ABBREVIATIONS ......................................................................................................................... II

I. OVERVIEW OF THE STUDY ................................................................................................. 1

II. PROJECT AND ITS RATIONALE .......................................................................................... 1

A. Macroeconomic Context Review and Outlook ................................................................... 1

B. Communicable Diseases Control in CLV countries: A Summary Review ........................... 3

C. Key Constraints and Demand Analysis .............................................................................. 6

D. Project Rationale ............................................................................................................... 7

III. ECONOMIC JUSTIFICATION ............................................................................................ 9

A. Project Grant and Loan Determination ............................................................................... 9

B. Project Benefits ................................................................................................................ 10

IV. PROJECT BENEFICIARIES AND SOCIAL AND POVERTY IMPACTS............................ 11

A. Direct and Indirect Beneficiaries....................................................................................... 11

B. Social and Poverty Impact ............................................................................................... 12

V. FINANCIAL ANALYSIS ........................................................................................................ 13

A. Overview of Financial Analysis of CDC2 .......................................................................... 13

B. Project Recurrent Costs and the Trends in Health Sectors of CLV countries ................... 13

C. Counterpart Funds Arrangements .................................................................................... 16

VI. FINANCIAL EVALUATION AND FINANCIAL RISK ASSESSMENT ................................. 17

VII. CONSULTANT‟S CONCLUSION AND RECOMMENDATIONS........................................ 19

TABLES Table 1: Population Characteristics of all Provinces Proposed for CDC2 ................................... 12 Table 2. CDC2 Recurrent Costs Projection Allocated Over Five Years ...................................... 14 Table 3. Recurrent Costs Allocated for Health Sector from 2005-2009 ...................................... 14 CHARTS Chart 1. Recurrent Costs from State Budget for Health sector and Trends ................................. 15 Chart 2. GDPs in CLV countries and Trends .............................................................................. 15


Appendix 11: Economic and Financial Analysis– Final Consultant Report April 2010 Page ii

ABBREVIATIONS

ADB Asian Development Bank AFD Agence Francaise de Development AHI Avian and Human Influenza APSED

Asia Pacific Strategy for Emerging Diseases

ARI Acute Respiratory Infection AusAID Australian Agency for International Development BCC Behaviour Change Communication BTC Belgian Technical Cooperation CD Communicable Disease CDC Communicable Diseases Control CDHS Cambodia Demographic Health Survey CDHS Cambodia Demographic and Health Survey CHS Commune Health Station CHW Community Health Worker CLV Cambodia, Lao PDR and Viet Nam COPE Client Oriented Provider Efficient (Quality of Care) DALY Disability Adjusted Life Years DD Diarrheal Diseases DF Dengue Fever DFID United Kingdom Department for International Development DHF Dengue Hemorrhagic Fever DHP Department of Hygiene and Prevention EMDP Ethnic Minority Development Plan EMG Ethnic Minority Group EPI Expanded Program on Immunization FETP Field Epidemiology Training Program GAP Gender Action Plan GDPM General Department of Preventive Medicine GDPMEH General Department of Preventive Medicine and Environmental Health GMS Greater Mekong Sub-region HC Health Centre HCFP Health Care Funds for the Poor HCMC Ho Chi Minh City HEF Health Equity Funds HIHE National Institute for Hygiene and Epidemiology HSSP Health Systems Support Program IEC Information, Education and Communication


Appendix 11: Economic and Financial Analysis– Final Consultant Report April 2010 Page iii

IHR International Health Regulations IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate (number of deaths of children < 1/ 1000 live births) INGO International Non-governmental Organization IVM Integrated Vector Management JFPR Japanese Fund for Poverty Reduction M&E Monitoring and Evaluation MBDS Mekong Basin Disease Surveillance MCH Maternal and Child Health MDG Millennium Development Goal MMR Maternal Mortality Ratio (number of maternal deaths/ 100,000 live births) MOH Ministry of Health MPI Ministry of Planning and Investment NCHDSC National Centre for HIV/AIDS, Dermatology, and Sexually Transmitted

Diseases Control NCLE National Centre for Laboratory and Epidemiology NCMPE National Centre for Malariology, Parasitology and Entomology NCPEMC National Centre for Parasitology, entomology and Malaria Control NGO Non-governmental Organization NIMPE National Institute for Malaria, Parasitology, and Entomology NIPH National Institute of Public Health NSEDP6 6th National Socio-economic Development Plan NTD Neglected Tropical Diseases O&M Operation and Maintenance PHC Primary Health Care PHD Provincial Health Department PMO Project Management Office PMU Project Management Unit PPC Provincial People‟s Committee PPMC Provincial Preventive Medicine Centre PSC Provincial Steering Committee PTWG Provincial Training Working Group QOC Quality of Care RCAPE Regional Country Assistance Program Evaluation RCSP Regional Cooperation Strategy and Program RCU Regional Coordination Unit RETA Regional Technical Assistance RPG Regional Public Goods RPPTA Regional Project Preparation Technical Assistance RRP Report and Recommendation of the President


Appendix 11: Economic and Financial Analysis– Final Consultant Report April 2010 Page iv

S&R Surveillance and Response SARS Severe Acute Respiratory Syndrome SBT Skills Based Training SEDP Socio-economic Development Plan SMS Secondary Medical School STA Short Term Technical Assistance STH Soil Transmitted Helminths STI Sexually Transmitted Infections SWAp Sector-wide Approach TA Technical Assistance TB Tuberculosis TOT Training of Trainer TWG Training Working Group UNICEF United Nations Children‟s Fund VAAC Viet Nam Administration of HIV/AIDS Control VHW Village Health Worker WB World Bank WHO World Health Organization WU Women‟s Union YU Youth Union


Appendix 11: Economic and Financial Analysis– Final Consultant Report April 2010 Page 1

I. OVERVIEW OF THE STUDY

1. The Consultant, Mr. Hai Thanh Nguyen has retained by the Cardno Acil Pty. Ltd. (Cardno) over the period from September 2009 to January 2010, to carry out a financial due diligence (FDD) analysis and economic analysis of the proposed Second Communicable Disease Control Project (CDC2) (PPTA No 7279 REG). The Terms of Reference are given in Annex 1 of Appendix 12. The Consultant has carried out several studies1 and this Economic and Financial Analysis report covers only the economic and financial analysis and gives the findings of the study and provides recommendations.

2. This study has been carried out in accordance with guidance in ADB‟s Guidelines for the Economic Analysis of Projects, 1997; ADB‟s Handbook for the Economic Analysis of Health Sector Projects, 2000; and ADB‟s ERD Technical Note 6, 2003. Information from previous studies, especially the CDC1‟s PPTA, was also incoporated in this report with references. Based on this analysis, it is confirmed that the Project is economically and financially viable and sustainable. It notes that a number of financial risks associated with the project have been also identified together with Consultant‟s proposed mitigations. These mitigations should be strictly implemented by the EAs together with those mitigations proposed for the financial management aspects as discussed in Appendix 12.

3. Since CDC2 is the second phase of CDC1, it was the intention of the Consultant to update the Economic and Financial Analysis of CDC1 for CDC2, but it is not an optimal solution at this stage, as the benefits of CDC2 cannot be valued. Thus it is not practical to use cost effectiveness methodology in this economic analysis. The Consultant has not used the alternative project designs methodology to justify this design through discussions on: (i) the variation in the combination of project components; (ii) the range of intervention modalities; (iii) different types of inputs; and (iv) different types of institutional arrangements and different scenarios for the timing and phasing of the project, if possible. From these, the optimal design is indicated and justified.

II. PROJECT AND ITS RATIONALE

A. Macroeconomic Context Review and Outlook

4. The global economic crisis 2007-2008 has impacted substaintially on the economies of the three CLV countries and the GMS ecomony as a whole. From the end of 2008, with adequate interventions to the economy in each country and support from and cooperation with the international community, the economies of these CLV countries have been improved postitively, even though there is room for improvement. Cambodia has recorded double-digit economic growth over 4 years (from 2004-2007), averaging 11.1 percent. Nonetheless, this growth has been narrowly based and concentrated in the garment, tourism, and construction sectors, leaving the economy vulnerable to external shocks. Domestic liquidity has been rising rapidly. In 2007, the budget‟s current balance showed a healthy surplus, while overall there was a budget deficit of approximately 2 percent of gross domestic product (GDP). That continued an improving trend from the last few years. Inflation has accelerated rapidly, from 6.4 percent (year on year) at end-September 2007 to 18.7 percent at end-January 2008. While no official figures have been released since, it is likely that inflation has continued to rise, fuelled by rapid credit expansion and rising food and energy prices. GDP per capita rose from around $297 in 1995 to about $594 in

1 (i) Fiduciary Financial Assessment; (ii) Cost estimates and Project Financing Plans; (iii) Project Procurement Plans; (iv) Economic and Financial Analysis; (v) External Assistance Coordination



2007, and the incidence of poverty declined from over 45 percent in 1994 to 35 percent in 2004. There are indications that the poverty rate has declined by now to around 30 percent. Rural poverty remains stubbornly high at 40 percent, and in addition, rural income distribution inequality rose from around 27 percent in 1994 to 33 percent in 2004 2

5. In Lao PDR, economic performance has been impressive over the past 5 years. Real GDP growth averaged 7.3 percent from 2003 to 2008, reflecting favorable mining, hydropower, commercial agriculture, and tourism activities. Per capita incomes climbed to $840 in 2008 from $581 in 2006 owing to growth and exchange rate appreciation. Lao PDR has relatively high external current account deficits, averaging 15 percent of GDP during 2004–2008 and possibly higher percentage for 2009-2010, which have been financed through concessionary loan inflows and foreign direct investment (FDI).

6. Overall, the effects of the global crisis on the Lao PDR economy are envisaged to be relatively lower than in other Asian economies because of its shallow domestic financial sector and the limited degree of enterprise and financial sector exposure to overseas sources of financing. Impacts of the global economic crisis will slow near-term economic growth to a still respectable 5.5 percent in 2009 because of falling global commodity prices, a reduction in FDI, and the knock-on effects to tourism and retail sales from weaker performance in neighboring economies. Over the medium term, growth should rebound to 6.5 percent–7.5 percent per annum as the country exploits its competitive advantage as a low-cost source of mineral resources, hydropower, commercial agriculture products, and tourism services3. Overall Poverty incidence of the country is currently less than 30 percent while rural poverty, especially in remote areas, remains much higher. The 2006 Lao Poverty Assessment reports that of the four major ethno linguistic groups, the Mon-Khmer is the poorest group, with a headcount of 55 percent, followed by the Hmong-Iu Mien (45 percent), the Chine-Tibet (40 percent) and the Lao-Tai (28 percent).

7. Viet Nam has been one of the fastest growing economies in Asia for the last two decades, with real gross domestic product (GDP) growth averaging 8.0 percent annually in 2003–2007. In 2007, real GDP grew by 8.5 percent. GDP per capita at current prices increased from $441 in 2002 to $818 in 2007. GDP of 2008 grew 6.23 percent and that of 2009 is estimated to grow by only 5.2 percent (current price). In recent years, however, growth in aggregate demand has outpaced growth in aggregate supply. Both internal and external macroeconomic imbalances have emerged because of a number of reasons4. High inflation from 2004-20085 was caused, not only by the excessively rapid growth of aggregate demand in 2007, but also by rising world commodity prices (especially for energy and food) in 2007 and the first half of 2008 and supply-side shocks in late 2007 and early 2008 (including outbreaks of livestock epidemics, an unusually harsh winter in northern provinces, and floods in the central provinces).

8. Viet Nam has achieved a recognized effort in poverty reduction from 1998 to date. From a country poverty rate of 34.7 percent in 1998, it was reduced to 16 percent in 2006 and 14.8 percent in 2007. However, a high poverty rate has remained in rural areas (on average: 44.9 percent in 1998, 20.4 percent in 2006) especially in Northern Midland and Mountains and Central Region and Central Highland regions where most of the the Ethnic Minorities are living (poverty

2 Asian Development Bank: Country Operations Business Plan (2008-2011), October 2008 3 Asian Development Bank: Country Strategy and Program Midterm Review, Lao PDR 2007-2011 4 While expansionary monetary and fiscal policies and extensive borrowing and spending by state-owned enterprises (SOEs) have fuelled growth of aggregate demand, aggregate supply has been constrained by infrastructure bottlenecks, relatively low efficiency of public investment, and increasingly acute shortages of skilled labor. 5 Average annual inflation jumped from 1.8% in 1999–2003 to 7.9% in 2004–2007, accelerating in late 2007 and the first half of 2008. Period-average inflation reached 20.3% in January-June 2008.



rate: 32.3 percent and 22.3 percent and 28.6 percent on year 2006 respectively in these three most difficult regions)6.

B. Communicable Diseases Control in CLV countries: A Summary Review7

9. Communicable diseases do not stop at borders. Emerging and re-emerging diseases such as Dengue Fever (DF), Dengue Hemorrhagic Fever (DHF), Severe Acute Respiratory Syndrome (SARS), Avian and Human Influenza (AHI), H1N1 Pandemic Influenza (H1N1), and other zoonoses are increasingly becoming priority public health concerns, highlighting the importance of regional cooperation in communicable diseases control (CDC).

10. Although these newly emerging diseases have not caused major fatalities compared to malaria, tuberculosis (TB), acute respiratory infections (ARI) diarrhea diseases (DD), and other more common infectious diseases, the evident economic impact and the potential for a regional or global pandemic are making AHI, H1N1, HIV/AIDS (and previously SARS) high priorities among national and global health systems and international health institutions. This is particularly so because early recognition and referral at the community level is required to avert these emerging diseases that have high cases of fatality and potential for a rapid epidemic. In areas with targeted support, surveillance, preparedness and response have been expanded to the community level, although sustaining effective community participation is an on-going challenge.

11. Nonetheless, it is ordinary endemic diseases such as ARI, DD and parasitic infections that continue to exact a heavy toll on the population, in particular children. Public funding for primary health care (PHC) and child survival programs is inadequate, and local public health systems have limited capacity to reach remote populations. Even where sufficient coverage is achieved, it does not imply good quality of care is available.

12. According to the WHO, ARI, DD, dengue and malaria are the most common causes of morbidity in Cambodia, while malaria, ARI and road accidents cause the most deaths. HIV/AIDS is not in the top five, but may be masked by ARI, TB or even road accidents. In Lao PDR, malaria, pneumonia, and gastrointestinal problems cause the most morbidity and mortality. In Viet Nam, which has better overall health indicators, pneumonia, acute pharangitis, and ARI are the common causes of morbidity and mortality, while intracranial injury, road transport accidents, and pneumonia are common causes of mortality. There is potential that these new diseases will absorb limited resources at the expense of addressing the neglected tropical diseases (NTDS).8 There is a potential danger that new diseases will absorb a considerable level of commitment, staff time, and funding at the cost of addressing common illnesses and NTDs.9

13. Dengue fever (DF) and DHF are the most important vector-borne diseases in the GMS, in terms of morbidity and mortality, especially for children less than 15 years of age. In Viet Nam, in the past five years, there have been approximately 50,000 to 90,000 new cases per year and relatively high mortality (0.1 percent). A similarly severe situation has emerged in Cambodia and Lao PDR. Although the disease is traditionally urban, it has progressively spread to rural villages where breeding of the vector mosquito Aedes aegypti has become substantial10.

6 Sources: GOS of Viet Nam 7 Sources: Situation Analysis Report of James Mielke, team member of CDC2 consultant team. 8 www.wpro.who.int Country Health Profiles, Cambodia Heath Information System (2007-2008) 9 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 10 Asian Development Bank, 2008. CDC1 Regional Dengue Technical Forum Report, Viet Nam

http://www.wpro.who.int/



14. Although there is no specific treatment for dengue, experience has shown that mortality can be considerably reduced by standard case management, which depends on access to care, especially during an epidemic. Early recognition and prompt control of dengue outbreaks or epidemics is important for control of dengue. This requires effective surveillance, including early warning, good data management, regular information exchange and epidemic preparedness plans that can be operationalized. For control to be effective, programs should organize their work with a focus on inter-epidemic periods as well as on epidemics. Appropriate linkages are needed with integrated disease surveillance programs at national and sub-national levels.11

15. Schistosomiasis, mainly soil-transmitted Helminthiasis, Lymphatic Filariasis, food-borne Trematodiasis and Cestodiasis are among the important Neglected Tropical Diseases (NTDs) affecting primarily the poor and marginalized populations in the GMS. The effective treatment of these infections is known to increase work capacity and productivity and is important to maintain good nutritional status, especially in women of child bearing age, resulting in higher birth weights and lower infant morality rates.

16. In collaboration with ADB and other partners, the GMS countries have made significant progress in the control of many of these diseases, particularly in the administration of Preventive Chemotherapy (PCT) in the form of Mass Drug Administrations (MDA). However, there is still a need for improving coverage, and effectively monitoring the coverage and impact of interventions. It is also important to synchronize elimination efforts in the GMS countries and monitor cross border transmission of infection.12 A draft strategic plan for control and elimination of NTD in the region was developed by WHO, together with ADB and other partners, in March 2009.

17. Access to and by qualified health workers is a key issue for many border populations. Both public and private sector healthcare provision decreases as population density falls. Surveys show that the poor, in particular women and children, and ethnic minority groups (EMG) typically receive the lowest coverage of prevention and care services due to their remoteness, language barriers and the low number of trained outreach health staff.13

18. Despite the considerable advances in road construction across the GMS borders, many border communities and other remote areas in these countries are still beyond the reach of conventional health facilities and rely on networks of community health workers, volunteers, and village drug stores for primary care. Community-based activities are typically more challenging, but represent the only long term solution to controlling common endemic diseases, such as dengue. Reaching these populations require innovative strategies which build on lessons learned in the region, such as multipurpose outreach workers and community-based programs that can be adapted and tested locally.14

19. Surveys confirm that the poor and EMGs receive the lowest coverage because of remoteness, language barriers and the low number of health staff from EMGs. Table 1 of the Situation Analysis report (Appendix 4) indicates that coverage indicators for access to routine preventive and curative health services in CLV are still low or sub-optimal.

20. Achievement of sufficient coverage does not necessarily imply that good quality care is available. Human resources are the key to good health services. Health facilities, drugs, supplies

11ibid 12 Asian Development Bank, 2009. Background Information, First GMS-CDC Technical Forum on Control and Elimination of Parasitic Diseases in the Mekong Sub-region. Forum 13 Asian Development Bank, 2005. RRP. Regional Communicable Diseases Control Project 14 Asian Development Bank, 2007. Proposed Asian Development Fund Grant: Lao People’s Democratic Republic: Health System Development Project



and equipment are also important, but they can achieve nothing without effective health workers to staff the facilities and deliver services to those who need them. Human resource, financial and supply constraints, and the general lack of consumer understanding of what constitutes good health care are continuing challenges, particularly in the remote areas. The rise of the private sector, while greatly helping to improve coverage, further raises the risk of reduced quality of care, over-prescription with possible medical consequences, and financial burden. Reliable data on the quality of heath service, public or private, is also difficult to track.

21. Common Challenges in National Health Systems - There are many common issues in the CLV health systems that affect CDC, including human resource constraints, the management of health services, and the affordability and financing of health services. CDC must also cope with specific challenges including: (i) integration of disease control programs in PHC; (ii) staff constraints for preventive care; (iii) standard setting and regulation; and (iv) regional surveillance and response. A challenge is to decentralize CDC to the provinces and to reduce the overlap of training, laboratory services and supervision. Of critical importance in CLV is the development of competent provincial planning, budgeting, management and monitoring capacity, with the provinces having responsibility and authority for health sector performance.15

22. The foundational concepts of primary health care (PHC) and the district health system toward achieving health for all remain highly relevant in all three CLV countries, and form the central approach to their national health policies today. However, support for PHC has, for a variety of reasons, been increasingly replaced by a more selective approach focusing on diseases and sub-sectors, and increasingly organized through vertical programs for swifter impact.

23. Vertical programs are established for malaria, tuberculosis, HIV/AIDS, and the expanded program on immunization (EPI). There were also prominent programs for child survival focusing on ARI and DD control, followed by the introduction of tools for the Integrated Management of Childhood Diseases (IMCI), and recently, a new regional strategy for child survival. However, vertical systems continue to pose challenges to integrating CDC into national health systems that are fragmented by these separate, top-down structures.

24. CDC tends to be fragmented and donor-driven, causing projects to be implemented in isolation, resulting in further fragmentation, repetition, and lack of sustainability of interventions. Surveillance is particularly complicated by the use of several separate systems for prioritized diseases that receive financial and technical support from international organizations. Many people, especially in remote regions, use private healthcare providers, and therefore a significant amount of CDC information is not recorded in the existing surveillance systems. Furthermore, health services often lack minimum standards against which performance can be measured. Health sector planning, financing, and aid coordination remain major challenges with limited accountability and authority at the local level.

25. Human Resources Development - GMS countries also face different challenges in human resource development (HRD). Because of these, as well as diverse languages and cultures, the normal tendency is to favor national education, training and health programs. Regional initiatives in health, for example, do not fit easily and seamlessly across borders due to the vertical structures that separate disease programs in national health systems. There are a number of areas where sub-regional cooperation in HRD is logical and urgently needed to address: (i) health

15 Asian Development Bank, 2005. RRP. GMS Regional Communicable Diseases Control Project



and social problems associated with mobile populations, including CDC; (ii) the rights of migrant and guest workers; and (iii) the trafficking of women and children.

26. Experience in CDC1 indicates that training efforts are often shallow, and have limited means to assess skills development. Training needs to be more practical and less theoretical, more hands-on and experiential, using adult learning methodologies and materials. Training processes also need to be closely monitored at implementation and supervisory levels to ensure quality, and at central and senior levels to ensure sustainability and continuing relevance.16

27. While health workers are widely distributed throughout every level of the health care system, mal-distributions and chronic shortages exist, and the staff that are available are often inadequately trained to provide the quality of health care needed. The governments of CLV have all set goals to train increased numbers of health personnel, and to improve the quality of their training, training curricula and training materials, and to strengthen the capacity of trainers, in order to bridge the gap between the quantity of students and the quality of their education.

28. Health Management - With the move toward decentralization, provincial health authorities in CLV countries are assuming increasing responsibility. Managerial roles are changing and uncertain, and managers often lack the financial resources, information, training and experience to carry out their new responsibilities effectively. Managers at the central level are reluctant to give up their authority, or unsure how to do so without abdicating their own obligations. The willingness of provincial health departments to exercise their authority reflects their continuing dependence on national subsidies. The need to make informed decisions at provincial levels will increase the need for more sophisticated data processing and analysis. Provincial authorities have limited capacity in health system development and improving services to reach the poor.

C. Key Constraints and Demand Analysis

29. As discussed under Section B above, there are a number of constraints for CDC including but not limited to: (i) relatively quick development (especially in Viet Nam) that may impact negatively on environement at certain levels; (ii) poverty (nutrition problems, low level of CDC awareness, knowledge of diseases, etc.); (iii) primary health care (government system, staffing, equipment and facilities, supplies, etc.); (iv) human resouces for heath; and (v) health managemnt in each CLV countries and in GMS as a whole.

30. In addition to the above, the budget allocated from public expenditures for surveillance and response (S&R) and regional coorporation at province and district levels continues to be very limited. Cross border cooperation at district and commune levels has been relatively weak, while there is only limited cooperation between provinces in CLV countries. All provinces and districts we have met recently confirmed that they have constraints on budgets for these important activities17.

31. Investment demand, as very roughly estimated by the Consultant, for CDC is very high in CLV countries in general and along the economic corridors in particular. More than $350 million is needed. There is evidence of huge demand for investment in both capital investment (civil works, equipment, vehicles etc) and support for recurrent costs especially for operation and maintainance of invested equipment, per diem for travel, communication, etc. As discussed

16 AusAID, 2003. Primary Health Care for Women and Children Project Evaluation, Viet Nam 17 National Annual budget for provinces and districts, do not have any budget line for cross border activities to discuss communicable diseases issues.



above, it is important to reconfirm that in project border provinces and districts, there should be a budget line allocated from public expenditure supporting various meetings to discuss and share experience of CDC between provinces and districts that have a common border.

32. With a total of about $51 million grant and loan funds for three countries, 29 provinces, 102 districts, CDC2 cannot cover all of the huge demands summarized above. The optimal solution is that CDC2 be used an additional investment to supplement other ongoing and pipelined projects of both donors and governments of CLV countries. Under this approach, a number of key areas are selected to be considered for funding and the “key words” for these are: „ linkage to economic corridor’, ‘border province and district focus’; ‘surveillance and response’; ‘regional cooperation’; ‘the poor and EMGs focus’. These “key words” then become short guiding principles for the Consultant Team to propose project areas (three clusters), project components (2) and sub-components (10), and project activities (various).

D. Project Rationale

33. Since 1992, the Asian Development Bank (ADB) has supported the Greater Mekong Subregion (GMS) Economic Cooperation Program to enhance cooperation between Cambodia, Lao PDR, Myanmar, Thailand, Viet Nam, and China (specifically Yunnan Province). Areas of focus include: strengthening infrastructure linkages; facilitating cross-border trade, investment and tourism; enhancing private sector participation and competitiveness; developing human resources and skills competencies; protecting the environment; and promoting sustainable use of shared natural resources.

34. However, it has become increasingly evident that the benefits of regional economic integration, including increased economic activities and job opportunities across borders, as well as „common use‟ of health facilities, are accompanied by undesired side effects, such as: the spread of HIV/AIDS and other communicable diseases; increased drug trafficking; increased illegal labour migration and related issues of human trafficking and child labour; environmental degradation; escalating land prices causing farmers to become landless; and increasing traffic accidents. There is also concern that integration may be worsening the income distribution in these countries as it is leading to an expansion of the formal sector, at the cost of the informal sector where most of the poor are engaged.18

35. To address these issues, ADB supported the development of the Greater Mekong Subregion (GMS) Regional Communicable Diseases Control (CDC) Project (referred to as „CDC1‟) with USD38.75 million funding for a project over four years to support CDC in CLV countries19. CDC1 has made good progress during 4 years and there is a very high level of awareness across sectors within government and the community at large of the issues relating to communicable diseases and their impacts. CDC1 was completed in December 2009

36. The CLV countries have made considerable progress in improving the health of their populations over the past decades, and are making major efforts to put in place strong policy frameworks and primary health care (PHC) systems. To achieve health-related MDGs requires providing PHC to remote populations suffering from a high burden of infectious and reproductive diseases, and improving the affordability and quality of health care. By strengthening cross-border 18 Asian Development Bank, 2001. Moving the Poverty Agenda Forward in Asia and the Pacific: The Long-term Strategic Framework for the Asian Development Bank (2001-2015) 19 The Project is supported by the Governments of the participating countries, the Asian Development Bank (ADB), and the World Health Organization (WHO). The project aimed to: (i) strengthen national surveillance and response systems; (ii) improve CDC for vulnerable groups; and (iii) strengthen regional collaboration in CDC



cooperation on disease surveillance and response systems the costs associated with outbreaks will be reduced.

E. The Scope of Project

37. The CDC2 Project will use the experience of CDC1 as a basis on which to develop CDC2 and to contribute to the further development of communicable diseases control (CDC) in the GMS. The Project will focus on cross border cooperation for communicable diseases control and prevention, and will address CDC issues associated with cross border traffic and population movements and impacts on border populations, which have been rapidly accelerating, enabled by the GMS economic corridors and subsidiary road networks. In recent years, globalization has transformed borders from barriers to bridges, and this transformation has shifted attention to cross-border matters that localities have in common. Regional economic developments, catalytic events and their economic impact, and high-level political commitment to attaining Millennium Development Goals (MDGs) have generated strong support for regional cooperation across health sectors. The current GMS setting favours a regional approach to CDC that can significantly improve the health of the poor in Cambodia, Lao PDR and Viet Nam (the CLV countries).

38. Activities under the project are pro-poor, focusing on rural and remote populations in the project districts of CLV border areas, where many ethnic groups and the poorest reside. Women and children will be the major beneficiaries of the primary health care (PHC) and community-based interventions, including community based CDC surveillance and responses in these border districts.

39. The project will be built around the three strategic pillars that were developed by ADB in CDC1:



(iii) Pillar 3: Cross border (ground) collaborations and health services.

(i) Components The Project has two components:

(i) strengthening regional cooperation in communicable disease control, and (ii) strengthening national surveillance, response and health systems.

(ii) Impact and Outcomes

40. Impact Statement. The overall project impact will be improved health for the populations in the project provinces in the border region, which will assist the Ministries of Health in Cambodia, Laos and Vietnam (CLV) to achieve MDGs 4, 5 and 6 and by reducing the spread of emerging and neglected communicable diseases thereby reducing morbidity and mortality, in particular among children, and the economic cost of these diseases.

41. Outcomes. The expected project outcomes will be improved regional security through:




(ii) Strengthened regional and MOH‟s technical capacity for surveillance and response, following WHO guidelines for implementation of the IHR and APSED with timely responses to epidemics in provinces with common borders that are likely to have a major impact on public health and the economy in the region;

(iii) Increased capacity of national, provincial and district health services in results based management and technical capability with integrated CDC and health services particularly underserved populations who have a high disease burden neglected tropical diseases(NTDs) and are at risk from newly emerging diseases(EIDs;


42. The Project will be implemented over a period of 5 years, commencing in July 2010 and will be adjusted yearly on the basis of Annual Operating Plans (AOPs) developed at the provincial level, and approved by the national steering committees (SC).

III. ECONOMIC JUSTIFICATION

A. Project Grant and Loan Determination

43. In determining the proposed grant and loan funds for CLV countries in CDC2, the following factors were considered: (i) this is not a leading investment but a supplementary one to support the existing and pipelined investments in health sector in general and in CDC in CLV countries in particular; (ii) even though demand is high, this investment is targeted to be spent for border districts and provinces rather than to be centralized at the national level (three „clusters‟ are proposed to be formed under CDC2 along the borders between Viet Nam and Lao and Cambodia from the North to the South [refer to the Project map]); and (iii) the poor and vulnable groups in these investment clusters should have the chance to receive more direct support from the project. Total proposed cost from ADB is $50.5 including $25 million soft loan funds, $2.8 million grant funds for Viet Nam, $10.6 million and $11.6 million grant funds for Cambodia and Lao. In addition to ADB funds, total counterpart fund in cash and in kind contributed by the three CLV countries is $4.3 million equivalent20.

44. Since this report was written ADB have advised that an additional 1 million grant funds would be available for Lao PDR, plus an additional 8 million of loan funds would be available for civil works for Preventative Medicine Centres in the Project Provinces.

45. The cost estimates for Technical Assistance and operation of the Regional Coordination Unit (RCU) include relevant costs for consulting services to be based in Viet Nam in an RCU office. The total cost for this TA/RCU is $ 5.6 million for a 5-year implementation with a detailed breakdown of costs in Annex 4 of Appendix 6. Lao PDR and Cambodia will contribute to this pool fund $ 1.4 million each and Viet Nam will contribute a sum of $2.8 million from ADB‟s grant fund.

46. Alternative project designs were considered carefully before coming to this design with two components: (i) Strengthening Regional Coorporation in CDC with four subcomponents; and (ii) Strengthening National Surveilance and Response Systems; with six subcomponents to respond two key aspects of CDC in GMS: regional cooperation and national surveillance and response systems. CDC2 is not restricted to a single modality of intervention but combines two

20 Details can be seen in Appendix 6.



modalities in one including health facilities and the outreach people involved in CDC. This combined modality of intervention continues the good experience from CDC1 and findings of the Consultant which prove that the effectiveness of the national S&R system and regional cooperation in CDC could be improved substaintially if a more flexible support can be given to the current systems in CLV countries in both capital investments (vehicles, lap equipment) and incremental costs (fuel, per diem, various supplies, emergency fund, etc.).

47. The type of inputs of CDC2 emergency response remains the same as in CDC1 except that emergency funds will be available at three levels (national, province and district)21 with the majority of project operational funds allocated at local levels. An important baseline survey is included to build up baseline information on communicable dieases in the project areas together with other relevant information which will help improve the planing, monitoring and evaluation of project activities. In addition, some funds will be provided directly to the commune/village level in the form of block grants to support community initiatives.

48. The arrangement of an institutional system to manage and deliver the services of CDC2 was considered and two alternatives were discussed for Cambodia. Firstly there is the potential for contracting an NGO to implement this project; secondly CDC2 can be placed, as CDC1, in the national heath system. As a final proposal, it was agreed that it is best if CDC2 is designed as part of the national health system, because it will cost more to use an NGO22 and there are no convincing reasons that CDC2 will not work smoothly in the Cambodian national health system as experienced from CDC1. In contrast, in Lao and Viet Nam, governments are not ready to contract out substantial public health services to an NGO, thus this is not an alternative. Hence the proposed design relies on the current national health systems of CLV countries to operate CDC2. The three MOHs are selected to work as the executing agencies for CDC2, while the Communicable Diseases Control Department (Cambodia), Department of Finance and Planning (Lao) and General Department of Preventive Medicine and Environmental Health (Viet Nam) are designated to serve as the national implementing agencies as in CDC1.

49. Timing and phasing of CDC2 were considered and the Consultant proposes CDC2 should commence from July/August 2010 and be completed by June/July 2015 (5 year project life). Prompt action and retroactive financing are proposed so as to ensure the continuity between CDC1 and CDC2 and speed up project implementation (see Section IV of Appendix 8). There are no reasons to justify phasing this project into smaller periods of implementation. B. Project Benefits

50. Economic benefits will accrue from: reduced health care costs; gains in labor productivity and educational achievements as a result of decreased incidence and severity of illness; and reduced population growth as a result of better access to family planning. In addition, gains and investments in women‟s health will have additional positive impacts on reducing the country‟s population growth rate; improving the health and welfare of children and families; reducing health costs; and contributing to poverty reduction. As confirmed elsewhere, it is impossible to value these economic benefits but direct and indirect beneficiaries and social and poverty impacts are discussed under Section IV to justify that substantial economic benefits are given by this project to the GMS countries.

21 In CDC1, there is only a fund at national level. 22 NGOs are contracting by MOH in Cambodia to support RGoL in operational districts. Remuneration and per diem for NGO staff are higher than Government staff and they cannot reply on the existing facilities of national public health system thus it will cost more if contract them.



IV. PROJECT BENEFICIARIES AND SOCIAL AND POVERTY IMPACTS

A. Direct and Indirect Beneficiaries

51. The project will provide significant benefits for the poorest groups in the project areas, including: (i) improved health care services to women, children, disadvantaged ethnic groups, the poor, and those who live in remote areas; (ii) an increase in the number of deliveries done at hospitals and health centers; and (iii) an increase in the use of health services and health care facilities by the poor. It is estimated that 30% of the population in the CLV‟s project areas will directly benefit from the project services through various interventions as summarized in Box 1 below:

Box 1. Summary of Activities that will Directly Benefit Populations Health staff in CDC2

People from national to commune/village levels will be trained in various subjects related to CDC and project management through formal training courses, workshops, study tours, fellowships;

Villages from village level will benefit from „Healthy Village activities‟ implemented and monitored in selected villages;

Health staff at district health centers will benefit from project direct supports such as per diem, fuel and telephone cards, supplies;

Students and teachers will benefit from the community Initiatives that support local schools for S&R and Community CDC;

Local people will benefit from community initiatives that support local remote communities for Environmental Cleanup programs ( for dengue Control);

Householder in communes/villages will benefit from community initiatives which support village rainwater jar protection initiatives (for dengue control).

52. In terms of indirect beneficiaries, the project will benefit at least 6,6 million people who live in the nominated CDC2 project districts within the economic corridors and in some cases associated with border crossings, and of whom more than 50 percent live below or close to the poverty line. Some further information can be seen in Table 1.

53. Ethnic minorities are confirmed as a significant proportion of the total number of project beneficiaries, comprising a total 28.2 % of the population of all border districts in provinces currently nominated by governments for inclusion in the project (some of which have no minority populations). The poor and vulnerable groups (approximately 5 million people) will benefit from the project's focus on border areas and its commitment to train local health workers and community volunteers, using a PHC approach with mobile clinics, outreach services, and improved service delivery at the health centres and referral hospitals.



Table 1: Population Characteristics of all Provinces Proposed for CDC2

Population


Project provinces

5 1,797,419 9 2,187,716 15 22,420,579 29 26,405,714

Border districts

17 650,564 33 1,311,955 53 4,692,013 102 6,609,532


13.8% 83,752 29.2% 383,565 29.7% 1,394,451 28.2% 1,861,768

Source: CDC2 PPTA Team with a note that ethnic minority data was not available for some provinces,

B. Social and Poverty Impact

54. CDC2 will make three major economic contributions to the GMS subregion. The project will support national survaillance and response systems and cross border cooperation in CLV countries and assist cooperation with neighbouring countries of PCR, Thailand and Myanmar. Its social economic and poverty impacts will be:

55. Reduction of economic risk of major communicable disease outbreaks: By strengthening CDC response capacity at provincial levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the subregion. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue. 23 The sudden and deadly outbreak of SARS early in 2003 provided a good lesson. By mid 2003, SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world. Apart from the direct costs of intensive medical care and control interventions, SARS caused widespread social disruption and economic losses. Schools, hospitals, and some borders were closed and thousands of people were placed in quarantine. International travel to affected areas fell sharply by 50-70 percent. Hotel occupancy dropped by more than 60 percent. Businesses, particularly in tourism-related areas, failed, while some large production facilities were forced to suspend operations when cases appeared among workers24.

56. Increased sustainability of national investment to eradicate endemic infectious diseases: Emerging epidemic diseases such as Dengue and the group of parasitic diseases (such as Filiariasis, Schistosomiasis, and Helminthiasis and food-borne Trematodiasis and Cestodiasis) referred to as neglected tropical diseases (NTDs) pose significant cross-border risks. This issue of NTDs is less well understood as many NTDs are not included among notifiable diseases and tend to be endemic to specific areas. However, NTDs span borders in the GMS. The increasing population mobility arising from increasing economic integration in the GMR means that there are growing risks of parasitic diseases moving into new populations via human

23 World Health Organization, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html 24 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15




contacts. National investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border. 25

57. Poverty reduction by improving the health of border populations: NTDs are endemic in most border areas of GMS and are associated with poverty and poor environmental sanitation and poor health services. The effective treatment of these infections is known to increase work capacity and productivity. Without treatment, prevention and eradication programs, these diseases disable and eventually kill unknown thousands of people every year. Hookworm, for example, causes anaemia, which endangers the lives of unknown thousands of women in the GMR border regions and contributes to high maternal mortality rates in these areas. The development of unknown thousands of children in these areas is affected by intestinal parasites.26

V. FINANCIAL ANALYSIS

A. Overview of Financial Analysis of CDC2

58. The financial analysis of this project has as an objective to assess the financial sustainability of the proposed CDC2. Since this is a non-revenue generating investment, financial analysis will only include the preparation of projected incremental recurrent costs together with an assessment of the GoV‟s capacity to absorb these costs and any debt service obligations associated with them. This methodology is different from conventional financial analysis for a business project.

59. Specifically, CDC2 recurrent costs will be compared with the public recurrent costs spending in the health sector in CLV countries to see if the proposed recurrent costs of the project will be a burden for MOHs or not in terms of timely and sufficient arragement. The capacity of MOHs to „receive‟ these recurrent costs and spend them will also be assessed and in the case of Viet Nam, the current external debt of GoV will be checked to ensure that this proposed loan fund is sustainable for GoV to borrow and repay27. Finally, counterpart fund arragements, including those for operation and maintainance, will be reviewed, especially those of Viet Nam, in terms of availability and timely allocation and delivery.

B. Project Recurrent Costs and the Trends in Health Sectors of CLV countries

60. Under CDC2, project recurrent costs include, but are not limited to, cost for operation and maintainance of vehicles and equipment financed by the project, supplementary supplies for the surveilance and response system. A summary of financial projection for recurrent costs of the loan and grants is presented in Table 2. Careful budget planning will be required to ensure financial sustainability including due attention to keep pace with inflation. In addition, Table 3 presents a summary of recurrent public expenditures the CLV governments allocated for the heath sector from 2005- 200928.

25 Country Reports presented at the The First GMS-CDC Technical Forum on the Control and Elimination of NTDs in the Mekong Sub-Region October 21-22, 2009 26 Presentation by the Global Network for Neglected Tropical Diseases The First GMS-CDC Technical Forum on the Control and Elimination of NTDs in the Mekong Sub-Region October 21-22, 2009 27 In CDC2, Viet Nam will receive a preferential loan funds from ADB while Cambodia and Lao will have grant funds. 28 Sources: CDC2 calculation and MOHs of CLV countries.



Table 2. CDC2 Recurrent Costs Projection Allocated Over Five Years29 Unit: $1,000

Project year CLV countries

Total Cost Cambodia Viet Nam (*) Lao PDR

Year 1 70 229 63 246

Year 2 279 1,116 364 1,488

Year 3 237 789 297 1,151

Year 4 237 719 297 1,151

Year 5 230 636 289 1,119 Total 1,052 3,490 1,310 5,155

(*) Including interest during project implementation period Table 3. Recurrent Costs Allocated for Health Sector from 2005-200930

Unit: $1,000

Fiscal Year of Cambodia and

Viet Nam

CLV countries

Cambodia Viet Nam (central state budget only)

Lao PDR Fiscal Year Amount

2005 56,125 101,933 2004-2005 22,796 2006 69,008 112,603 2005-2006 18,539 2007 84,230 123,293 2006-2007 18,882 2008 106,488 105,651 2007-2008 23,037 2009 125,963 131,681 2008-2009 37,337

61. Information from Table 1 and Table 2 indicates that project recurrent costs accounted for a very minor percentage of the total average recurrent costs for health sector from 2005-2009, respectively 1.09 percent, 0.24 percent and 0.61 percent in Lao PDR, Cambodia and Viet Nam31. Thus these should not be a major concern for CDC2 in terms of timely and sufficient arrangement of these costs for project purposes. Based on information collected and analysis, Chart 1 below provides the trends of projected recurrent costs after 2009. The graphs mostly rise from 2005 to 2010 and continue the same trends with a reasonable slope except for a fall in Viet Nam and Cambodia in the period 2007-2008 (probably because of the global economic crisis). Thus these graphs, together with the figures in Table 2 prove that the CLV governments have been increasing their state budget for recurrent costs in public health sector.

29 Source: CDC2 project design- Appendix 6 30 Sources: MOHs and Ministries of Finance in Lao and Viet Nam, Ministry of Economy and Finance in Cambodia 31 In Viet Nam, the figures of state public recurrent cost for health sector from 2005-2009 are only those of the central level, not yet the local level



Chart 1. Recurrent Costs from State Budget for Health sector and Trends

Chart 2. GDPs in CLV countries and Trends

62. In CLV countries, from 2005-2009, recurrent costs for health sector have accounted for an average of about 0.51 percent; 1 percent and 0.16 percent of GDP in Cambodia, Lao and Viet Nam respectively. The trends of GDP in CLV countries are also presented in Chart 2 for visible comparison w ith t he t rends of state budget recurrent spending f or health sectors presented i n Chart 1 . The graph shows that the GDP l ines and the public health recurrent cost l ines of the three CLV countries from 2005-2009 and after this period are going relatively parallel, indicating a sustained linkage between GDP and public expenditure for health sector in these three CDC2 countries.



C. Counterpart Funds Arrangements

63. In Cambodia and Lao PDR, these two countries have had difficulty in the arrangement of counterpart funds for donor funded projects, and probably for other domestic projects and programs. However, most counterpart funding in CDC2 is designed as an in-kind countribution ($ 0.706 million in Cambodia and $ 0.856 million in Lao). The cash contribution of CDC2 accounts form a very small proportion of project cost and total budget expenditure of the two MOHs (less than 0.2 percent of average state public expenditure for the period from 2005 to 2009). Specifically, since these financings from ADB are non refundable then both RGoC and GoL are exempted from the main kinds of taxes such as VAT, import tax, special consumption, if any, for vehicles and laboratory equipment and other goods purchased under the project. Thus both MOHs will not need to arrange large amounts of counterpart funds in cash for CDC232. From the information provided, it can be assumed that both MOHs can still arrange sufficient in-kind and in cash contributions in a timely fashion for the activities of CDC2.

64. In Viet Nam, MOH‟s overall financial position is well defined and stable in the GoV‟s system. This is an expenditure agency which is responsible to ensure the most effective, efficient and timely uses of every Dong allocated to it from the State budget. The importance of the health sector is now fully recognized by the GoV, and ranked as one of the top development priorities of the country. In general, the Central GoV has tried to allocate annually enough incremental recurrent costs for the operation of MOH and the implementation of its projects. Under this proposed CDC2, with a total of $ 3,490 million over 5 years (on average $ 0.697 million per year including cost for loan interest) which accounts for only around 0.61 percent of the total average annual state budget allocated for health sector in the period 2005-2009 for the central level (see Table 2), the availability of counterpart fund arrangements for the Project is not a matter of major concern.

65. Unlike MOH at the central level, provincial governments at the local level usually fail to collect enough revenue from different local sources for their budget, to balance it and make timely allocation to their own agencies, including DOHs. It is clearly defined in the State Budget Law that counterpart fund arrangements for the decentralized projects are the responsibility of the Provincial People‟s Comittee (PPC). Due to very limited local budgets, PPCs are often unable to provide counterpart funds for project activities on a timely basis in spite of their written commitment. This has resulted in delays in implementation of projects. Evidence of such occurrences are plentiful among donor-funded projects, including those of ADB. With the exception of some big cities such as Ha Noi and Ho Chi Minh City and a few better-off provinces, almost all provinces, especially mountainous provinces, have to request the central GoV for annual budget support. This “committed but unable to timely deliver in full” situation at provincial level leads to the requirement for MOH to arrange counterpart funding for project provinces under CDC233.

66. Fund arrangements for operation and maintainance (O&M) of equipment provided by CDC2 in CLV countries is another important aspect. As mentioned in Appendix 12, there have been some concerns about O&M, not only in CDC1, but also in other projects and programs of CLV countries. Examination of results in three project provinces of CDC1 indicated that annual

32 It notes that for goods and services purchased in domestic market, CDC2 has to pay valued added tax (VAT) from the counterpart fund allocated. 33 Similar arrangements were placed in other several projects and this follows GoV‟s guidance in Decision No 210/2006/QD-TTg date 12/9/2006 and Decision No. 27/2008/QD-TTg date 05/02/2008 of the Prime Minister.



spending for O&M purposes is a minor proportion of state budget for health sector of each province – only 8 percent and 7 percent in Kampot and Takeo provinces (Cambodia)34, about 12 percent in Champasak (Lao).35 This compares with Nghe An province (Viet Nam), where the situation is more positive with around 16.5 percent-25.6 percent of the budget spent on O&M during the period from 2005-200936. Field trips to these provinces also confirm that there is room for improvement in operation of the equipment provided by CDC1 and other projects (see picture 1 and 2)37. This should be a concern for CDC2 and a committment should be required, not only from MOHs, but also from the Chairmen/Governors of project provinces for improvement of O&M in CDC2 as a condition for loan/grant negotiations.

67. Based on the analysis above, it is confirmed that the MOHs can ensure the availability of the recurrent costs for CDC2 in sufficient quantity during project life and beyond. However, special attention should be given to O&M, not only of equipment provided by the donor funded projects but also by the governments through various projects and programs.

VI. FINANCIAL EVALUATION AND FINANCIAL RISK ASSESSMENT

68. Financial evaluation is an assessment of whether the proposed Project is financially viable or not. It is noted that methodology for financial evaluation of this CDC2 as a non revenue generating Project is different from any commercial projects38. The Consultant normally relies on the financial sustainability to evaluate Project‟s financial viability. In addition, a number of key financial and operating ratios are tested under various scenarios as described below.

69. Overview of the financial risks under the project39: CDC2 is not only subject to the specific risks of the project but also to external risks from the economy. However these risks are deemed to be low and will be reduced by the adopted mitigation measures. Overall, regulatory and institutional risks for CDC2 are minimal. The Goverments of the three countries have shown strong commitment to the Project. Accounting and reporting systems, and the capacity of the health sector in planning and financial management will be strengthened and improved by the 34 Sources: Chief accountant and Deputy Chief accountant of PHDs of Kampot and Takeo provinces, date 16 and 17 November 2009. 35 Discussion with the Director of Champasack provincial PHD on 26 October 2009. 36 Information provided by PHD of Nghe An, October 2009. 37 For example, in border gate with Thailand of Phonthong district, the staff of quarantine office has not been able to operate the thermometer after two months provided by Champasack PHD (see the Picture 1 above). 38 Traditional financial evaluation of an commercial project relies primarily on a comparison between the FIRR and WACC which respectively represents financial benefits and financial costs, if the FIRR exceeds the WACC the project is deemed to be f inancially viable. 39 The risks in financial management are identified and discussed in Appendix 17.

Pic.1: Medical bag provided by PHD to the Vang Tao border gate Quarantine Office

Pic.2: Medical board of the Vang Tao border gate Quarantine Office- Champasack- Lao PDR



Project. Government‟s recent efforts on hamonize national procedures with those of donors have eased previous difficulties for not only project but also sector funding (i.e. in Cambodia and Viet Nam). Therefore, the overall external risk to the financial sustainability of CDC2 is deemed to be minimal. No quantitative analysis was carried out to examine the sensitivity of key financial indicators to adverse changes in key variables40. There is some financial risk due to project costs and potential delays which may cause difficulties in achieving outcomes and outputs. Accordingly, efforts have been made in project design and implementation to avoid such delays as discussed below.

70. Delays in project implementation: There are several reasons which may cause delay in CDC2 implementation, including but not limited to: (i) lack of experience of the project provinces for implementation of a donor funded project; (ii) continuing low quality of human resources to implement the project both at central and provincial levels; (iii) centralization of project procurement works at the national IA level (such as in Viet Nam CDC1); (iv) delays in planning and budgeting and consequently tranfering funds from central level to project provinces; and (v) too many project provinces located separately in three far away regions participating in the Project (the case of Viet Nam), etc.41A two year delay of the project may cause difficulties in achieving project outputs and outcomes. Substantial delay was found in CDC1 during 2006-2007 while an acceleration happened in 2008-2009. Based on this experience, efforts must be made in project design and implementation to avoid such delay. At this stage, however, it is not envisaged that there will be a two-year delay in implementation. On the other hand, a one-year delay may occur if any EA under this CDC2 fails in implementation of procurement works on time and this could be the case in Viet Nam when the procurement capacity of CDC1 (GDPMEH) remains weak.

71. However, these „delay‟ risks are considered to be low because MOHs‟ implementation capacity has improved through recent implementation of a number of major health projects funded by ADB and by other donors. The Governments have shown strong commitment to addressing constraints in current administrative procedures inside and outside MOHs. In order to further mitigate this risk, more efforts on harmonization and simplification of regulations are needed. The quality and capacity of human resources to implement the Project will be given special attention and technical assistance will accelerate the project implementation progress. Project support for training (in Project procedures for planning, ADB procurement procedures, project accounting, and financial management for central and provincial project staff, decentralizing almost minor procurement works to project provinces), as well as good monitoring and supervision, are critical factors for successful implementation of CDC2. Given these actions, the risk of delays in implementing the Project should be significantly reduced.

72. Expenditure higher than projected: Usually, projects are most sensitive to delays associated with corresponding cost increases. The current global financial crisis has impacted negatively on donor-funded projects, especially for civil works activities, and caused many problems for implementation42. The period 2007-2008 was the worst time for projects in terms of price escalations, which sometimes reached a level as high as 17.6 percent in Lao, 19.7 percent

40 Because this is a non productive project thus the FIRR and NPV are not calculated. 41 In Viet Nam, there are two sources of funds under this Project, ADB loan fund and counterpart fund. At least 91 key fund spenders including 1 PMU, 20 PIUs and 70 districts in 21 cities and provinces will be involved in disbursement. Such large numbers of agencies will lead to higher risk in fund management, more complicated disbursement arrangements and consequently more delay in implementation. 42 Costs for civil works construction increased substantially led to many constructors breach the signed lump sum contracts or delay their works indefinitely.



in Cambodia and 23 percent in VIE43, or higher because of inflation. There is, however, no evidence of major excalations in expenditures under other activities in ADB and WB funded projects including CDC1. However, lessons have been learnt from this experience in preparation for future occurrences. Special attention has been given during the design phase to project costs to ensure they are realistic.

73. Project Cost Overrun: The cost estimates for CDC2 were carefully formulated following ADB‟s guidelines as specifically discussed in the Technical Note “Preparation and Presentation of Cost Estimates for Projects financed by Asian Development Bank”, April 2008, to ensure that the Project will not be overestimated and consequently not overrun during implementation. It is confirmed that no cost overrun is envisaged because: (i) activities selected for CDC2 are very selective and based on experience of CDC1 and on the priorities of MOHs and ADB, (ii) very tight mechanisms of the CLV governments on planning, budgeting, payment control and inspection of implementation are in place; and (iii) no evidence of significant cost overrun was found in CDC1 and other projects that the Consultant visited.

VII. CONSULTANT’S CONCLUSION AND RECOMMENDATIONS

74. The economic and financial analysis and evaluation conducted confirm that the project is economically and financially sustainable and viable. However, there are a number of risk mitigation actions which should be taken immediately after loan/grant negotiations and during project implementation, including: (i) improvement of project human resources quality; (ii) ensuring the availability of the project staff and consultants who participate in the project; (iii) devising stronger decentralization of procurement to the provicial level should be done; and (iv) a sound capacity building plan in order to help mitigate any financial risk associated with CDC2.

75. To ensure communities and schools will most benefit from community initiative budgets as designed under Component 2, a participatory planning process should be used in the targeted communes/villages through community consultations. The consultants should support PMUs/PIUs to ensure this really happens at the local level before any budget can be disbursed.

43 Source: ADB estimated and provided in November 2009.

APPENDIX 12:

FIDUCIARY FINANCIAL

ANALYSIS REPORT


Appendix 12: Fiduciary Financial Analysis Report – Final Consultant Report April 2010 Page i

CONTENTS

ACRONYMS.............................................................................................................................. II

I. OVERVIEW ........................................................................................................................ 1

II. FINANCIAL MANAGEMENT ASSESSMENT (FMA) ......................................................... 2

A. Introduction ............................................................................................................................... 2

B. Project Executing Agency and Implementing Agencies ........................................................... 2

B.1. Executing Agencies and Project Management Units (PMUs) .......................................... 2

B.2. Provincial Project Implementation Units (PPIUs) .............................................................. 3

C. Staffing of MOHs in the Three Countries .................................................................................. 3

D. Accounting Policies Applied ...................................................................................................... 6

D.1. Accounting Policy in MOHs ............................................................................................... 6

D.2. Accounting Policy in Projects under MOHs ...................................................................... 6

D.3. Accounting Policy for the proposed CDC2 ........................................................................ 7

E. Safeguard over Assets.............................................................................................................. 8

F. Internal Control and External Audits ......................................................................................... 8

F.1. Internal Control .................................................................................................................. 8

F.2. External Audits ................................................................................................................ 10

G. Reporting System ................................................................................................................ 12

III. KEY RECOMMENDATIONS ........................................................................................ 13

A. For CLV ................................................................................................................................... 13

B. For each participating country ................................................................................................ 13

IV. APPENDICES............................................................................................................... 14

Annex 1 - Terms of Reference of the Consultant ........................................................................... 15

Annex 2 - List of Agencies and People Met ................................................................................... 16

Annex 3 - List of Key Reference Documents ................................................................................. 18


Appendix 12: Fiduciary Financial Analysis Report – Final Consultant Report April 2010 Page ii

ACRONYMS ADB Asian Development Bank AI Avian Influenza AOP Annual Operation Plan CA CDC

Chief Accountant Communicable Disease Control

CDC1 Communicable Disease Control Project No.1 CDC2 Communicable Disease Control Project No. 2 CDCD Communicable Disease Control Department, Cambodia CLV countries Cambodia – Lao PDR - Viet Nam DHP Department of Hygiene and Prevention, Lao PDR DOH Department of Health (Viet Nam) DPF Department of Planning and Finance (Viet Nam and Lao) EA Executing Agency FGIA First Generation Imprest Account GDPMEH General Department of Preventive Medicine and Environmental

Health GMS Greater Mekong Region GoL Government of Lao PDR GoV Government of Viet Nam HSSP Health Sector Support Program, Cambodia IA Implementing Agency L2280 ADB funded Preventive Health System Support Project MEF Ministry of Economy and Finance (Cambodia) MOF Ministry of Finance NIMPE National Institute of Malariology, Parasitology and Entomology O&M Operation and Maintenance ODA Official Development Assistance Para. Paragraph PCR Project Completion Report PPIU Project Implementation Unit PMU Project Management Unit PMC Preventive Medicine Center (in provinces of Viet Nam) PPC Provincial People’s Committee RCU Regional Coordination Unit RGoC Royal Government of Cambodia SGIA Second Generation Imprest Account SOE Statement of Expenditures ST State Treasury VAS Vietnamese Accounting Standards W/A Withdrawal Application


Appendix 12: Fiduciary Financial Analysis Report – Final Consultant Report April 2010 Page 1

I. OVERVIEW

1. The Consultant, Mr. Hai Thanh Nguyen was retained by the Cardno Acil Pty Ltd (Cardno) over period from September 2009 to January 2010 to carry out a financial due diligence (FDD) analysis and economic analysis of the proposed Second Greater Mekong Sub-region Communicable Diseases Control Project (CDC2) (PPTA No 7279 REG). The Terms of Reference are detailed in Annex 1. The Consultant has carried out several studies1 and this Financial Management Assessment (Fiduciary Assessment) report covers only the fiduciary assessment works, gives the findings of the study and provides recommendations. The technical justifications for the Project have been described and analysed elsewhere. This report is concerned with the Financial Management Assessment for the Project Loan and Grants in the CLVs (hereafter known as the Project). The Consultant would like to thank the officials and staff of the Ministry of Health (MOH) (in particular those from three CDC1 projects in three countries), ADB officers in Viet Nam Resident Mission (VRM) and staff in the Manila office for their help and assistance in carrying out the study. A list of people and agencies met is provided in Annex 2.

2. This study has been carried out in accordance with ADB’s Manual-Financial Management and Analysis of Projects and Financial Due Diligence: A Methodology Note (ADB, September 2008). The Consultant studied financial management in six projects included in CDC1 (two projects in each country) to draw lessons for CDC2 and findings from previous similar reports (if any). ADB/WB’s financial management related studies are used in support of the assessments. A list of reference documents is provided in Annex 3.

3. The proposed CDC2 Project financed by ADB includes a project loan of US$ 25 million2 for Viet Nam and two grants valuing US$ 10.6 million for Cambodia and US$ 11.6 million for Lao PDR and a grant fund of about US$3.5 million for the Regional Coordination Unit. The Government of Lao (GoL), Goverment of Viet Nam (GoV) and Government of Cambodia (GoC) will contribute in cash and in-kind counterpart funds of US$0.706 million, US$0.856 million, US$2.704 million respectively equivalent. The Project has two key components including: (i) Strengthening Regional Cooperation in Communicable Disease Control; and (ii) Strengthening National Capacity in Communicable Disease Control for a period from 2010-2015 in the three countries.

4. Based on this fiduciary assessment, it is confirmed that the three MOHs of the participating countries have capacity to ensure the effective and appropriate project financial management.

1 (i) Fiduciary Financial Assessment; (ii) Cost estimates and Project Financing Plans; (iii) Project Procurement Plans; (iv) Economic and Financial Analysis; (v) External Assistance Coordination 2 This is a conventional loan from ADF and will have a 32-year term, including a grace period of 8 years, and an interest rate of 1% during the grace period and 1.5% per annum thereafter



II. FINANCIAL MANAGEMENT ASSESSMENT (FMA)3

A. Introduction

5. This FMA review MOHs’ systems for financial management accounting, reporting, auditing and internal controls. MOHs’ disbursement and cash flow management arrangements are also part of the FMA. The FMA should not be considered to be an external audit. It is a review designed to determine whether or not the MOH and its National Institutes and Provincial Departments are considered capable of implementing the financial management arrangements for CDC2, and have adequate systems for recording all transactions and balances, supporting the preparation of regular and reliable financial statements, safeguarding the entity’s assets, and are subjected to audit (of a substance and form acceptable to ADB). Issues or weaknesses identified during the FMA will be taken into consideration either through project design or the development of project implementation arrangements. MOHs are all non revenue-earning executing agencies in the public sector. ADB expects sound financial policies, adequate accounting records, proper internal control systems, timely reporting to management, and sound and timely auditing.

B. Project Executing Agency and Implementing Agencies

B.1. Executing Agencies and Project Management Units (PMUs)

6. In Cambodia the MOH will be the Executing Agency (EA) and CDC2, as with CDC1, will be implemented through the Second Health Sector Support Program (HSSP2) for national health sector development. HSSP2 will be the Project Administrator for the EA. The Communicable Disease Control Deparment (CDCD), through the Project Management Office (PMO), will be the implementing agency (IA), together with six other IAs.

7. In Lao PDR the Department of Planning and Budgeting (DPB) under MOH will administer CDC2. The Department of Hygiene and Prevention (DHP) will be the coordinating National Implementing Agency (NIA). Nine project provinces will participate in this Project as Provincial Implementing Agencies (PIA). Some central medical institutes will also participate as contractors to provide technical supports to the Project.

8. In Viet Nam the MOH will be responsible for overall project management and guidance as the EA. The General Department of Preventive Medicine and Health Environment (GDPMHE) will be the coordinating IA and the Department of Planning and Finance (DPF) will be involved in terms of financial management.

9. Generally, the CDCD in Cambodia, the DPB in Lao PDR and the GDPMHE in Viet Nam will be the lead departments of this Project and will be responsible to the respective Ministers of Ministries of Health in the CLVs for the quality, effectiveness and efficiency of Project implementation within the allocated funds.

3 Also called as Fiduciary Financial Assessment



10. Findings from previous studies and CDC1 confirm that the three MOHs in CLV, with their assigned coordinating departments, have acceptable experience with donor-funded projects, including ADB and WB.

11. Because CDC2 follows on from CDC1, it is proposed that three Project Management Units (PMUs) in CLV for CDC2 will be the same as those for CDC1, and will be located in Phnom Penh, Vientiane and Hanoi. Each PMU is to be headed by a Project Director and will be responsible for the overall project management. It is noted that in Cambodia, the HSSP and CDC Department are serving as the PMU.

B.2. Provincial Project Implementation Units (PPIUs)

12. In CLV, the Provincial Health Department (PHD) (in Cambodia and Lao PDR) and Provincial Department of Health- PDH (in Viet Nam) will work as the IA to implement project in their provinces. Each PHD/PDH will have a small PPIU including three key positions as Project Manager, Technical Coordinator and Accountant. These government permanent staff will receive per diems when travelling for CDC2 work and in addition, they will receive monthly incentives from the Project. In Lao and Viet Nam, an accountant should be contracted from the market, as per CDC1 arrangements. In all CLV countries, lack of understanding and experience of ADB procedures, noncompetitive salaries and allowances, and staff workloads have been constraints for CDC1 implementation. In Viet Nam, in addition, long bureaucratic delays caused in provincial departments are an emerging issues that need to be addressed not only in this CDC2 but also other donor funded projects.

C. Staffing of MOHs in the Three Countries

13. At MOH level in Cambodia, the CDC Department has a total staff of 64 who are deployed in four different units. As the CDCD is purely a technical department, it does not have a financial management unit. It has good experience in implementing at least three projects including two pooled fund projects financed by WB and various donors (HSSP1 and HSSP2) and ADB (CDC1). The HSSP2 (2009-2013) is currently located within CDCD and it’s Finance Unit has eight staff, to be strengthened by four additional accounting assistants next month. Information gathered indicates that these staff members are well qualified, and the four key members (one Chief Financial Management Officer, two Senior Financial Officers and one Financial Officer) are competent and have acceptable command of English.

14. At MOH level in Lao PDR, CDC1 is under the management of the Department of Planning and Finance (DPF) of MOH. DPF has reasonable experience in implementing externally funded projects, and is implementing two ADB funded projects (HSDP2 and CDC1). Presently (November 2009), DPF’s five functional units (Statistics and Planning; Budgeting; Properties Management; Health Insurance; and, Administration) have a total of 26 staff, including one with post-graduate qualifications and 17 considered by MOH as high-level staff in technical/professional categories. The remaining are classified as middle- and low-level staff (8 people). Findings from other DPF projects financed by WB and ADB4 indicate that DPF project management capability is acceptable, and its departmental heads are relatively supportive and active. DPF has strongly relied on international consultants to implement projects assigned to them, as ADB once commented, thus this should be gradually changed in upcoming ADB

4 Including but not limited to: CDC1, L2180-VIE, PPTA 7029-VIE, etc.



projects, such as CDC2 and the Health Human Resources Development Program. There is no reason not to place CDC2 under the overall management of this deparment.

15. At MOH level in Viet Nam, the first observation is Viet Nam’s MOH staff, specifically those from the DPF, are very busy with their daily work and this could be a concern in terms of supporting projects under MOH. However, after discussions with two ADB projects and officials and staff of the DPF of MOH and cross checks with relevant departments of MPI and MOF, it is confirmed that no evidence of significal delays has been found recently in annual planning, budgeting, bid appraisal and assistance to MOH’s leaders in gaining approval of bid results from Viet Nam’s MOH. DPF staff have considerable experience with donors’ procedures on consultant recruitment and procurement of goods after having involved in several ADB and WB funded projects. This experience would be helpful for DPF in appraising procurement plans of the forthcoming CDC2 project. In summary, DPF is well organized and has good experience in implementating ODA loan project including those funded by ADB.

16. The General Deparment of Preventive Medicine and Environmental Health (GDPMEH) consist of about 120 officials and staff divided in 6 key units including the planning and finance one (PFU). The PFU is staffed with 13 persons and one leader of the GDPMEH (Mr. Nam) is assigned to manage the operation of this unit. The head of this unit (Dr. Mai Anh) is the Deputy Director of the L2180 and the Deputy Head (Mrs. Hoa) also works as the Chief Accountant of the same project. It is understood that they are very busy from several project assignments.

17. This Department has had experience in implementing two ADB projects, one WB project and nine other donor funded projects so far. From 01 August 2009, MOH assigned the GDPMEH to review and approve bid results proposed by projects belonging to it. There are concerns with regards to possible procurement delay in CDC2 because of the delay in establishing the procurement practices of the L2180 and CDC1 even though two leaders of this Department are assigned as the Project Directors and in addition, Dr. Nguyen Huy Nga, General Director of GDPMEH directly manages procurement team of the L2180.

18. At project level in Cambodia, all staff in the PMO of CDC1 are engaged on contractual basis and the CDC1 has only two accountants and one accounting assistant, all work full time5. With its work volume CDC1 is clearly operating under constraint with only two regular accounting staff. It is essential that CDC2 has an additional assistant accountant to assist with the work load .

19. At provincial level, each PPIU has an accountant who, according to the PMU staff and the consultant’s observations during field trip, has to handle a heavy workload that include tasks from PHD, HSSP2, CDC1, and possibly one or two other projects. Such heavy workloads can easily lead to delays and errors in performance. In each PPIU, three positions, including the Project Accountant, receive an incentive payment level of $180/month. CDC2 should continue this model of financing.

20. At project level in Lao PDR, in spite of substantial achievements made in project implementation, there are still several improvements that need to be attended to in terms of financial management. The MTR of ADB was of the view that after the hiring of the accounting firm ASA to carry out accounting services, there has been significant improvements in financial

5 Presently the accountant receives a salary of $600/month and the accounting assistant gets $400/month while the average salary level for government staff is $120-$150/month. These are acceptable payment.



management. Discussions with the Project Accountant reveal that the three people assigned to work full time have been able to handle effectively all matters relating to financial management. This practice of engaging accounting staff from external sources should be continued under CDC2, given the fact that in Lao PDR, there is a shortage of qualified accountants in the market.

21. The Project Accountant has reported that accountants assigned to 15 project provinces of the CDC1 have yet to satisfy the requirements of the Project with regard to financial management, quality report and other aspects. Only three out of 15 staff are able to use email to communicate with the Project Accountant, and in general interactions with these staff have been rather difficult. It should however be mentioned that accounting staff among the participating National Institutes in Vientianne (two) are of an acceptable standard.

22. The SAO Audit Report of 2007-2008 raised several issues relating to financial management of PPIU at provincial level, including, but not limited to, property management, use of project funds and procurement. There had been training for accounting staff. But since 2/2008 no training course/seminars for accouting staff of PPIUs have been held due to a lack of funding. This is clearly a constraint on capacity building and also improvement in quality of project financial management. These are issues that need to be addressed under CDC2, especially if all these staff are engaged on contractual basis there is no guarantee that they will be available to work for CDC2.

23. At project level in Viet Nam, although GoV policy6 allows EAs of ODA projects to outsource the Chief Accountant from the market, MOH is likely to prefer filling this post with its own full time permanent staff and this prevents CDC1, Loan 2180 and other projects under MOH from having Chief Accountants who are of a high quality, have good English language skills and have sufficient time to spend on the projects. Almost all Chief Accountants are tasked on projects in addition to their normal duties, and may only spend up to 50 percent of their time on project work. This situation has resulted in in dealing with project matters, and delays cause adverse impacts on project implementation progress generally and need to be addressed in the startup phase of CDC2.

24. Financial analyses of WB funded project TF 053774 and ADB funded project PPTA 7029 VIE,7 expressed concerns as to the low level of English language competency of Chief Accountants of ODA funded projects in Viet Nam in general, including those working in MOH. There are presently few Chief Accountants who can speak English at an acceptable level8. This deficiency effects their ability to review withdrawal applications and leads to a dependency of staff who have a command of English working in the project. A question here is that if the Chief Accountant’s command of English is poor, how can she/he verify the quality of these documents before submitting to MOF and the donors?

25. Low government salary norms have impacted negatively on recruitment of good accountants for a long time. CDC1 has two accounting posts which carry a salary of US$1,200/ month, and, according to the Chief Accountant, these posts are for the two key accounting staff. If CDC2 cannot continue paying this level of salary (or at least around $500-700/month) these two staff will certainly seek alternative employment elsewhere as the current level of 6 Decision No.3/2007/TT-BKH dated 12 March 2007 “Guidance on functions, responsibilities and organization of Project Management Unit of ODA Projects, Projects” 7 Preparing the Support for Health Human Resources Sector Development Program (HHRSDP) 8 Two CAs of the CDC1 and L2180, both, have very limited competence in English



government salary (as per QD61) is too low to retain their services (less than $300/month for a qualified person with considerable experience).

26. Findings from interviews of finance staff of CDC1 in Nghe An and Quang Tri were very positive. Both Chief Accountants are highly experienced and they also enjoy the support of trained accounting staff from PMCs. CDC2’s financial management may be based entirely on the existing system. However, as there is no guanrantee that accounting services in new provinces, if any, will also be of high quality, it is therefore necessary to have a training program appropriate for CDC2 accounting staff. Training on financial management procedures of this Project Loan at the beginning for finance staff of DOHs with participation of staff from provincial State Treasury and staff from provincial Department of Finance is recommended to partly build capacity for both project staff and the the associated national institute staff.

D. Accounting Policies Applied

D.1. Accounting Policy in MOHs

27. MOHs are required by the Governments of CLV to comply with the accounting system issued by Ministry of Finance and Economy on 27 December 2007 (Cambodia), State Budget Accounting System (Lao PDR), and Accounting Standards for the public services agencies (Decision 19/2006 of MOF, Viet Nam). Each MOH implements their Government’s accounting policies and procedures to ensure that cost allocations to the various funding sources can readily be identified. This system allows for the proper recording of project financial transactions, including the allocation of expenditures to the respective cost components, disbursement categories, and sources of funds. Controls are in place concerning the preparation and approval of transactions. The systems used are adequate to properly account for and report on project activities and disbursement categories. No concerns were identified with regard to possible wrong transactions and accounting practices relating to expenditures and funds, and the policies and procedures are considered appropriate for use in CDC2.

D.2. Accounting Policy in Projects under MOHs

28. In Cambodia, projects and programs must all follow common implementation procedures determined by RGoC as reflected in the Standard Operating Procedures (August 2005) as amended from time to time. Other implentation handbooks contain greater details, including the Financial Management Manual (FMM) (September 2005). The FMM spells out clearly and in simple language accounting procedures, financial management and disbursement procedures which are convenient for referencing and implementing. On the basis of these documents and procedures, HSSP2 has prepared the Financial Policices & Procedures Manual (FPPM), January 2009. This FPPM has also been applied to CDC1. In general, the Consultant is of the view that the accounting policy under HSSP2/CDC1 is acceptable to meet the requirements of ADB and can be continued to be applied to CDC2.

29. In Lao PDR, a Manual for Project Accounting (code 1012/MOF) was issued by Ministry of Finance on 26 June 1998, and, based on this Manual, CDC1 and other projects have developed their own accounting systems. Observation at the CDC1 Finance Unit indicates that the current accounting system of CDC1 should be acceptable for CDC2. There is a concern



that under CDC1, all original supporting documents are requested to be sent to and stored in the PMU. The PPIUs can keep a set of photocopied documents. This raises three issues: (i) it is costly to mail documents from provincial level to the central level for storing in MOH; (ii) with the original documents at the central office, it is difficult to check or inspect works at the provincial level when the neeed arises; and (iii) the provincial level staff would rightly feel that they have less ownership of the Project when all supporting documents produced by them have to be sent to the central office while, in terms of development of financial management decentralization these should remain with them. It is noted that the PIM of CDC1 should be updated for use in CDC2.

30. In Viet Nam, CDC1 has used the accounting system for Administrative and Service Units9. The Project Director has full authority to execute all transactions under a project. The Chief Accountant delegates authorities to her finance accounting staff to record transactions. Project management staff, as authorized by the Project Director, order and monitor all procurement of goods and services, and all payments are prepared by accounting staff. Bank reconciliation is prepared by accounting staff and approved firstly by the Chief Accountant and then the Project Director.

31. Projects in MOH normally use a computerized accounting system which means it should be easy to reconcile the general ledger at PMU and subsidiary ledgers at PPIUs, if the system is designed to do so. All the accounting and supporting documents are retained by the Project at both central and local levels on a permanent basis.

32. CDC1’s Audit Reports for 2008 and 2009, prepared by the AASC, revealed minor concern in terms of accounting practices at both PMU and PPIUs. L2180’s Audit Reports for 2007 and 2008 repeatedly recommended that coordination between PMU and PPIUs in financial and accounting activities should be improved. Hands-on training courses should be undertaken during the Project start-up period for the accountants of PPIUs, as well as the dissemination of a Project-specific and user-friendly financial management manual will certainly help improve this situation, especially as CDC2 will be engaged with 15 PPIUs.

D.3. Accounting Policy for the proposed CDC2

33. Accounting policy for CDC2 should have the same arrangements for CDC1 because the current systems under CDC1 in all three countries have been working well. For the Project Grant in Cambodia, the accounting system for HSSP2 is applied for CDC1 and this should be maintained with no major change for CDC2. In Lao PDR, although the audit report of the SAO recommended that a double entry accounting system should be applied at provincial level, the Consultant assumes that there should be a flexibility for PPIU to use a single entry accounting method if using the double entry books make them less confident (PPIUs have been using single entry method as confirmed from Consultant’s field trip to Champasak and Attapeu in October 2009). For CDC2 in Viet Nam, the accounting system for administrative and service units will be applied.

9 This is an accounting system designed by GoV for administrative and service units and issued in conjunction with Decision No 19/2006/ QD-BTC dated 30 June 2006 of MOF



E. Safeguard over Assets

34. Fixed asset management at MOH level in the CLV countries was found to be acceptable by the Consultant. Each department has a register which records names, serial numbers and brief notes on the status of the assets. Each asset is attached with a label. MOH implements an annual fixed assets review and updates of this register. The current value of the fixed assets (after deduction of depreciation) are reflected in accounting books at MOH’s head office. Similarly, findings at HSSP2, CDC1 in Cambodia, HSDP2, CDC1 in Lao and CDC1, L2180 and PPTA 7029 VIE’s Consultant Report indicate that they have been able to manage their fixed assets satisfactorily.

35. In the project provinces, the assets are basically well managed. In Cambodia and Viet Nam, the Consultant did not find any significant issues relating to asset management while in Lao PDR, the Audit Report by SAO raised 11 issues on the management of assets procured under the Project (Item 2.8 of Audit reports). CDC2 will have to pay attention to these matter and ensure that solutions are put in place as outlined in Section III of this report.

36. Operation and Maintainance (O&M) of equipment and other assets provided by donor- and Government-funded projects are important issues. With increasingly large investments in this sector scheduled for the period 2009-2015, due attention should be given to these, especially at the provincial level. In Viet Nam (Quang Tri) and Lao PDR (Champasak and Attapeu provinces), delay in delivery of equipment procured to support operation in the provinces has somewhat lessened the effectiveness of such investments.

F. Internal Control and External Audits

F.1. Internal Control

37. Internal Control at MOHs of the CLVs: Findings from previous studies of WB and ADB conducted during preparation of the project design for the health sector in these countries, including CDC1, confirmed that the internal control system at MOHs level was modelled and has been regularly updated in accordance with guidance in the Government’s Accounting System in each country.This should be acceptable to ADB.

38. Internal control at PMU level in Cambodia: The audit report by PWC for 2006-2007 highlighted several deficiencies in internal control system10. Updates on changes gathered from the 2008 Audit Report by PWC indicated a number of positive developments in the PMU. Apart from the deficiencies mentioned above, observations by consultant at PMU show that basically, accounting records are well maintained, reports are well prepared, and withdrawal applications are reviewed at three separate levels within the Project (Accountant, Senior Financial Management Officer, Chief Finance Officer) before signing by the Project Director.

39. Internal control at PMU level in Lao PDR: Findings from discussions with the Project Accountant, Accounting Consultant and related staff indicate that CDC1’s internal control

10 (i) There should be prompt liquidation of advances; (ii) Only authorized staff should issue cheques; (iii) Improve on cost efficiency; (iv) Controls on purchasing, monitoring and evaluation should be improved; (v) Noncompliance with procurement guidelines; etc.



system is acceptable. However, there should be additional delegation of document signing duties for SGIA from MOF to MOH. Presently signing duties rest with the Minister (or, in his absence, the Secretary of State) after documents have been prepared, reviewed and certified by six relating parties. The Consultant considers it is appropriate to keep the signatory at the Project Director level in order to lessen the paper work and to increase delegation of tasks relating to financial control (in Viet Nam and Cambodia, these documents, including those concerning withdrawals of funds from ADB, do not require the Minister’s signature).

40. Internal control at PMU level in Viet Nam: The Consultant conducted two reviews of internal control systems of the CDC1 and L2180 and results were relatively positive. Under CDC1, the internal control system was found acceptable but could be done better if the Project strengthened the following issues: (i) ensure more regular independent reviews: internal auditors11 should regularly review and evaluate the system of internal controls to determine whether it is functioning effectively as planned (e.g. internal auditors' findings and recommendations should be submitted to senior management for action); and (ii) all IT systems/accounting software to be regularly (daily if possible) backed up and procedures established to restore data and/or software following any operational disruption and emergency procedures will be available to provide business continuity following loss of IT systems.

41. Although there are currently no individual job descriptions for individual staff of the Accounting Unit, except a summary in the labor contract, the Consultant finds this arrangement not acceptable and Terms of Reference should be developed and include, as a minimum, the following information: (i) who reports to whom; (ii) when to implement what; (iii) what is the streamline of documents within the Unit and to other relevant bodies; and (iv) where and how to file accounting documents.

42. Under the L2180, the internal control system was found generally acceptable. The Consultant has however noted certain issues that need attention. After March 2009, the PMU issued a “Duties Assignment for Officials and Staff of PMU” document approved by the Project Director without any date and issuance number, and this has not been updated so far (e.g. names of various new staff have not been included). It includes a short job discription for each of 5412 diferent people involved in this PMU (officials from various MOH’s departments assigned to support the project, consultants, contracted staff), but no information could be found on how much time each person can work for the Project; this is a very important issue.

43. In reviewing a writen document provided by the Deputy Director of PMU on staffing, the Consultant observed that: (i) it would not be feasible that the Project Director Mr. Nguyen Huy Nga could spend up to 70 percent of his time on this Project given that he is the Director General of the GDPMEH - a very busy position and wellknown nationally and by the international community; (ii) it is therefore questionable as to his ability to ensure timely decision and approval of matters relating to day-to-day project activities, especially those relating to procurement at the PMU which require his direct and special attention while Mr. Nga is extremely busy; and (iii) among five staff of Accounting/ Disbursement Unit of PMU, three are very newly recruited (9/2009). This lack of experience among staff may impact negatively on operational quality of the internal control system. CDC2 would be well advised to be mindful of this matter.

11 Those may be assigned from the GDPMEH and/or Department of Planning and Finance of MOH 12 In fact, from project management view, this big figure of staffing partly indicates that there has been room for improvement in the operation of this PMU.



The Accountant of Kampot’s PHD with a pool of supporting documents- 16 Nov.2009

44. The quality of accounting practices and, particularly, the internal control systems at provincial level vary from province to province in each CLV country. Regarding the implementing agencies in three countries, it was found that the quality of accounting work is good in Nghe An and Quang Tri Provinces and NIMPE (Viet Nam). Accounting books and supporting documents are very well maintained. It was very positive that in Quang Tri Province, annual financial report is displayed publicly in the administration office of PMC within one month from the close of the financial year. Meanwhile, in Lao PDR, at provincial level, the SAO 2007-2008 Report highlighted a number of rather minor issues that must be attended to in regard to internal control systems. IT practices for accounting staff should be given a high attention; for example, in Champasak and Attapeu, the accountants have used computers to prepare accounting books and reports but there is no back up system which may lead to a serious risk in loss of information.

45. In Cambodia, except the information gathered from the PMU Accountant and from 2007 Audit Report by PWC which refers to a case that a cashier countersigned a check – an elementary error in accounting practices, and accounting documents are not filed and maintained well in PHDs of Kampot and Takeo (see the picture below), the Consultant found that internal control system of CDC1 at provincial level (i.e. Kampot and Takeo provinces where the Consultant could visit) is acceptable to be continued in CDC2.

F.2. External Audits

46. External Control by the State Treasury: In Viet Nam and Lao PDR, expenditures incurred by the Project are subject to control by State Treasury (ST) regardless of whether they are ADB funded or counterpart funded, while in Cambodia this is not the case. In Viet Nam, this Agency is delegated authority by MOF to review and confirm any payment from PMU to beneficiary(ies). This authority is strictly followed and reflected in the current regulations of GoV on state budget management. MOF only accepts to reimburse any payment which was verified and confirmed (or will be verified and confirmed later) by the ST. In general, this procedures compliance is a kind of external audit. The STs of Hanoi City and the provinces are in charge of controlling payments for the PMU in Hanoi and PPIUs in provinces respectively. While this control helps PMU strictly follow GoV procedures, sometimes it leads to delays in the disbursement process.

47. There are concerns from donors, GoV and project management units on long delays caused by the State Treasury in Viet Nam, especially at provincial level, in checking payment dossiers



submitted to them13. Lack of qualified staff and poor understanding of donor funded projects/ programs are key reasons for delays, among a number of other reasons. This should be considered as a risk for not only CDC2 but also other projects/ programs. Howewer, the level of risk is low and this risk is considered as “minor” and under control. Findings from CDC1 indicate that relatively smooth cooperation between this Project and Ba Dinh District State Treasury, and between PMCs (i.e. Nghe An and Quang Tri) and Provincial State Treasuries have been maintained, and this will be beneficial to the proposed CDC2.

48. In Lao PDR, the State Treasury Department of MOF reviews the request for fund replenishment from the IA to the SGIA before issuing the payment voucher for the Bank of Lao to transfer funds to PMU. The PMU confirms that there is no major delays from this Agency.

49. External Audit: It is mandatory that ADB funded projects in MOHs of CLV have annual financial accounts be audited by external independant auditors acceptable to ADB, EAs and the Ministry of Finance14. There is a concern regarding the level of understanding of external auditors in Viet Nam and Lao PDR on donors’ procedures and their application in ODA projects15. The recruited auditors should have been aware that an ADB funded project must comply with ADB procurement procedures rather than those of Viet Nam and Lao PDR, and any references to Viet Nam, Lao PDR bidding laws are irrelevant in this case, and in addition such references may cause confusion for project implementors.

50. Terms of reference for the auditors of CDC2 in CLVs should provide clear instructions on what procedures to be applied to that Project. In Lao PDR, the auditor recommended that all PPIUs should apply a double entry accounting system and this reflects a lack of undertanding and flexibility of this Agency in project implementation as the capacity of accountants at province level in Lao PDR is still rather limited and they are using single entry accounting system developed in Excel MS software. This has been working well in CDC1’s project provinces of not only Lao PDR but also Cambodia .

51. Regarding the quality of audit works, the Consultant considers PWC’s audit report for the CDC1 is of good quality. Findings and recommendations are not only valuable for project implementation but also reveal a good understanding of processes and procedures in project implementation and a realistic view of implementation issues. SAO’s report for the CDC1 in Lao PDR contains valuable findings which detail and prove the competence and diligence of its staff. However, the AASC’s16 audit reports (not only for Loan 2180 and CDC1 but also for a number of other projects in other sectors, such as education sector17) do not provide much detailed nor helpful information for project implementers to improve their performance and management (refer to various audit reports prepared by them).

52. For the proposed CDC2, the PMUs and PPIUs will likely be able to maintain separate accounts of the loan funds, grant funds and counterpart funds. They are obligated to prepare annual

13 Refer to Report on Improvement of ODA Projects and Projects’ Payment and Disbursement Process under the TF No.053774 (WB) 14 In Cambodia it is the Ministry of Finance and Economy 15 For example in the 2008 audit report of ADB’s L1979-VIE prepared by the AASC (who also conducted audit service for the CDC1), under the item II.6 “Matters relating to bidding”, page 23-24, references are given to the Bidding Law of Viet Nam- not the one of ADB and the auditors used this Law as the base to assess procurement performance of PPIUs. 16 Full name of this firm is Auditing and accounting financial consultancy service company limited (AASC), operating in Vietnam 17 For example: L2298-VIE and L1979-VIE funded by ADB (see Fiduciary financial assessment report of ADB’s PPTA 7034-VIE)



financial reports and make these available to an independent external auditor acceptable to ADB, MOH and MOF. Details of requirements for external audits are presented in Appendix 8.

G. Reporting System

53. Three EAs have to submit quarterly reports to ADB and their concerned Government’s agencies. PMUs are assigned to do this on behalf of EAs. The quarterly reports should also include a summary financial accounts for the investment component, consisting of project expenditures during the year to date, and total expenditure to date. The quarterly reports should be submitted to ADB within one (1) month at the end of each quarter. PMU should be able to prepare relevant financial reports automatically from their financial accounting system, but some assistance will probably be required initially to ensure the reports are providing the necessary information and that all the information is correct. Reports by PMUs should provide separate information for the Project Grant/Loan. In addition to the obligation to submit audit reports of annual financial accounts (see detail in Appendix 8), it is noted that within six months of physical completion of the Project Grant/Loan, the PMU will submit to ADB a Project Completion Report (PCR). More detailed information of this PCR can be seen in Appendix 8.

54. In Cambodia, CDC1’s financial reports from PPIU to HSSP2 (PMO) and from HSSP to MOH are prepared and submitted following guidance in the Financial Policies and Procedures Manual (FPPM) of HSSP2, updated January 2009. A review by the Consultant indicates that there will need no changes to those current forms and submision arragements in CDC2.

55. In Lao PDR, the Consultant noted that even though working space of the CDC1 is relatively limited, accounting and supporting documents are kept in a well organized and good location which make reporting works more convenient. The ASA is responsible for preparing Monthly Financial Reports and submiting to the PMU (the Asistant Project Manager), for consolidating into the Project Quarterly Reports and submitted to ADB and MOH with technical support of the CDC1’s international consultant. This arrangement has been working smoothly, thus it could be maintained with no change in CDC2.

56. In Viet Nam, when visiting the GDPMEH and DPF offices, the Consultant noted that accounting and other documents are kept in a well organized and good location. It is also confirmed that these agencies have been able to prepare relevant reports and submit them to MOH and other relevant GoV authotiries in time. The accounting system includes guidance and templates to facilitate preparation of these reports (Decision No 19/2006/ QD-BTC). This helps ensure that information on planning, budgeting, fund notification, and actual costs inccured for each activity under the proposed project loan can be conveniently and timely extracted from MOH’s system for reporting and assessment purposes, if required.

57. GoV issued the Aligned Monitoring Tool (AMT) which provides templates for quarterly and annual reports acceptable to ADB18. The CDC2 Project Loan will have to follow this AMT to produce reports for submission to both ADB and GoV. For CDC2, PPIUs will need to submit quarterly and annual reports to the PMU, which in turn will incorporate these into the project progress reports. Reports from PPIUs are expected to provide a narrative discussion of progress made during the period, changes in the implementation schedule, problems or difficulties encountered, and the work to be carried out in the next period. However, it is regretable that AMT does not incorporate this function. This information, therefore, should be collected via consultant’s progress reports and ADB periodic supervision missions instead.

18 Decision No 803/2007/QD-BKH dated 30 July 2007 “On issuance of reporting mechanism on implementation ODA Projects and projects”



III. KEY RECOMMENDATIONS

A. For CLV

58. For CDC2, it is strongly recommeded, for both Cambodia and Viet Nam, to have stronger decentralization of project activities to project provinces and where appropriate, also the procurements of goods within the agreed thresholds. The central agencies (institutes, centers) should not be involved in implementation of project activities as the Implementing Agencies rather than only providing technical assistance services to both the PMU and PPIUs. Thus in the design of CDC2, quantity of works managed by these agencies should be reduced considerably in comparison with that of CDC1. This has been reflected in the project design of CDC2 proposed by the Consultant Team that these agencies should be providing technical assistance to CDC2 on a contract basis rather than as the IAs so as to: (i) reduce management and overhead costs; and (ii) strengthen capacity of these agencies through bidding procedures for jobs from CDC2.

59. It is recommended that in Lao PDR and Viet Nam, an updated Financial Management Manual for the CDC2 be prepared for training of all project finance staff and relevant key persons before the Project Loan / Grant becomes effective. This requirement should be made as a condition of loan effectiveness.

60. With a view to minimizing CDC2 implementation delays, training courses on ADB procurement and consultant recruitment procedures should be done by experienced experts using hands-on methods, and this should be one of the grant / loan effectiveness conditions. The Consultant also strongly notes that the PMU in Viet Nam should not assume that it is enough for their staff when they have chance to participate in an ADB annual procurement workshop for project staff in Viet Nam, because it is still a lack of detailed practical examples and situations in procurement of goods, civil works and consultants recruitments.

61. Given the fact that there were a number of problems in consultant recruitment in CDC1 which gave good experience for CDC219, it is recommended that all international consultants and some national consultants for CDC2 should be recruited by ADB as individual consultants thus they can quickly start working in the project. This will also give better chances for ADB to select the best consultants who are interested to work for the project20. The remaining pool of national consultants will be selected through firms using QCBS procedures (see the detailed proposal for these in Appendix 9).

62. It is recommended that CLV countries submit CVs of key CDC2 project staff to ADB before Grant / Loan negotiations. They should start assigning / recruiting of these postions, with the TORs outlined in Appendix 8. Contracts signed (in case of contracted staff) and/or assignment decisions signed by relevant authorities (in case of government staff), should be forwarded to ADB for endorsement before the effectiveness date of grant / loan.

B. For each participating country

63. In Cambodia, it is recommended that MOH should timely approve AOPs (i.e. in January every year) because evidence collected indicates that Kampot’s AOPs of 2007 and 2009 were

19 Including but not limited to (i) delay in recruitment because of various reasons; (ii) low fee rates in three CLVs as regulated by three governments which prevent PMUs to recruit high quality consultants; (iii) there are not many good international health consulting firms in the world. 20 Since the better consultants, the more expensive they are, the consulting firm may drop good consultants to have lower level consultants as to maximize the chance to win and benefit or they may not know who are the good consultants in the market to include in the proposal, etc.



approved by MOH in May 2007 and March 2009 respectively, which obviously delayed project implementation substantially.

64. In Lao PDR, using accounting services of the ASA (or other qualified company) should be continued for CDC2. However, the terms of reference for this assignment should be included, with training services for all PPIU accountants on financial management and accounting practices at the begining of CDC2 with some periodical repeated training. Using single entry accounting could be continued at provincial level, as it has appeared the most appropriate practice for them. Allowance for provincial accountants should be paid throughout the life of the Project.

65. The leaders of Minister of Health (Vice Minister) should not be involved in signing the withdrawal application of fund from MOF (FGIA) to MOH (SGIA) (see para 39 above). This arrangement will help simplify internal procedures in MOH, as part of administration reform.

66. In Viet Nam, to ensure that PMU will have qualified staff in important positions to work full time for the Project, the following positions must be full- time positions: (i) a PMU’s Deputy Director; (ii) an experienced Procurement Officer; and, (iii) a Chief Accountant and one experienced accountant. The proposed CVs of these positions should be submitted to ADB for endorsement as one of loan effectiveness conditions. These positions are proposed to be project consultants and a budget line for these position are included in project costs. Transparent staff recruitment procedures are also strongly recommended and the Outline Terms of Reference for these positions are attached in Appendix 8.

67. Written confirmation from MOH on provision of timely and adequate counterpart funds for Project Loan should be in place. It is recommended that MOH to arrange counterpart fund for project provinces.

68. It is recomended that the “Responsible Contract” between PMU and PPIUs in CDC1 should not be continued for CDC2. In the Consultant’s view, little value from this current arrangement has been added to project performance, and project implementation has been effected because of delays in preparation and signing these contracts. (an evidenced in Nghe An Province in that the Responsible contract of 2009 was only signed in March 2009- thus the project implementation was delayed at least three months);

69. ADB procedures for recruitment of external auditor should be strictly followed and TOR for them should be prepared with appropriate reference to ADB’s sample audit TOR in ADB website (http://www.adb.org/Documents/Guidelines/Financial/part071700.asp). Viet Nam’s PMU is strongly recommended not to use one auditing firm (i.e. AASC company) for more than 2 times and it is encouraged to use international auditing firms working in Viet Nam (for example E&Y, KPMG, PWC, etc.) in CDC2 rather than only one Vietnamese firm very frequently contracted by projects in GDPMEH.

IV. APPENDICES

Annex 1: Terms of Reference of the Consultant

Annex 2: List of People and Agencies met

Annex 3: List of Key Reference Documents

http://www.adb.org/Documents/Guidelines/Financial/part071700.asp



Annex 1 - Terms of Reference of the Consultant

i. The Regional Economist and Financial Analyst will have a master in economics or finance, and have at least 7 years of experience, including in project economic and financial analysis and preparing project cost estimates. The expert can be a national of Cambodia, Lao PDR or Viet Nam, and must be fluent in English. The expert will undertake a comprehensive review of CDC financing, including sources, funding, and funding gaps from partners and national and local budgets; and prepare the external coordination matrix;

ii. Review experiences with provincial CDC financing, and propose how this can be improved in a sustainable manner. Assess financial management capacity, propose fund-flow and disbursement arrangements;

iii. Prepare cost estimates for the Project outputs using standard tools. Prepare the final Project budget, and cost tables, disaggregated into investment and recurrent costs and local and foreign currency costs;

iv. Assess the financial capacity of provincial governments; and prepare an analysis of the financial sustainability of the Project, including recurrent costs associated with the Project;

v. Provide an economic justification for the Project in terms of investment compared to returns. Undertake an economic analysis, including potential poverty impact, in accordance with ADB's Guidelines for the Economic Analysis of Projects (1997).

vi. Contribute to the Final Report of the whole Consultant Team.



Annex 2 - List of Agencies and People Met

Cambodia

1. Ministry of Health of Cambodia (MOH): - Dr. Cha Meng Chour, Deputy Director General of CDC Department 2. Project Management Unit of ADB’s Communicable Disease Control Grant Project and

HSSP2 (under MOH) - Dr. Uy Veng Ky, Executive Administrator, HSSP2 - Mr. Thuy Sovanna, Project Accountant, CDC1 - The International Procurement Officer (lead), HSSP2 - Mr. Krang Makol, Financial Management Officer, HSSP 2 3. Kampot Province - Dr. Lao Vanna, Deputy Director of PHD - M.A. Heng Chantha, CDC1 Chief, PHD staff - Mr. Hem Sithan, Chief Accountant of PHD/ Accountant of CDC1 - Mr. Khoun Ath, Quarantine staff at Prek Chak International checkpoint border 4. Takeo Province - Dr. Hem Sareth, PHD Director - Dr. Tum Kim Ly, Chief of Technical Bureau - Dr. Sir Sam Ol, Dengue Program - Mr. Sep Kea, Accountant

Lao PDR

5. Project Management Unit of the CDC 1 Project (under MOH) - Dr. Somphone Phangmanixay, Deputy Project Director - Ms Phonesavanh Phanthaly, Assistant Project Manager - Mr. Phonesackda Dethoasavong, Project Accountant 6. Project Management Unit of the HSDP2 Project (under MOH) - Thomas Agnes, Project Planning Specialist - Brad Schwartz, Economist - Mr. Boun Hou, Procurement Officer of HSDP2 (in charge of procurement of goods for CDC1) 7. Provinces - Ms Khampho Chaleunvong, Director of PHD, Champasak province - Mr. Souban Head of District Health Office (DHO), Khong District- Champasak - San Thana, Project Accountant in Champasak - The Deputy Director of PHD, Attapeu province

Viet Nam

8. Asian Development Bank (ADB) - Mr. Vincent De Wit, Principal Health Specialist, SSD, Southeast Asia Department 9. Ministry of Health of Viet Nam (MOH): - Mrs Nguyen Mai An, Specialist of Department of Planning and Finance 10. Ministry of Finance of Viet Nam



- Mrs. Nguyen Lan Huong, Chief of Bilateral Unit of Department of Debt Management and External Finance

11. Project Management Unit of ADB’s Communicable Disease Control Grant Project (under MOH)

- Mrs. Le Thu Huyen, Chief Accountant - Mrs. Do Thu Mai, Accountant - Mr. Pham Hung, Procurement Officer (lead) 12. Project Management Unit of the Preventive Health Support Project (L2180) - Mrs. Luong Mai Anh, Deputy Director - Mrs. Nguyen Le Hoa, Chief Accountant 13. PPIUs of Quang Tri and Nghe An (CDC1) - Mr. Tran Kim Phung, Deputy Director of Quang Tri Health Department - Mr. Phung Xuan Ty, Director of Quang Tri Preventive Medicine Center (PMC) - Mr. Cao Lu Hoang, Chief accountant of PMC - Ton Nu Thi Thu Ha, Accountant, Quang Tri PPIU - Dr. Tuan, Deputy Director of Huong Hoa Preventive Medicine Center - Mr Pham Van Thanh, Director of Nghe An Health Department - Nguyen Thi Hong Tham, CDC1 Chief Accountant



Annex 3 - List of Key Reference Documents

1. Financial Management and Analysis of Projects, ADB, 1997 and updated version

2. Financial Due Diligence: A Methodology Note (ADB, September 2008)

3. Final Report on Improvement of ODA Projects and Projects’ Payment and Disbursement Process of Viet Nam (WB funded study) ( Mr. Nguyen Thanh Hai and Mr. Thang Pham Ngoc)

4. Report and Recommendations to Presidents of Loan 2180, CDC1 (ADB’s website)

5. Audit Report of Loan 2180-VIE and CDC1 (year 2007, 2008) (AASC Jsc. Viet Nam)

6. Audit Report of CDC1 (year 2007, 2008) (SAO, Lao)

7. Audit Report of CDC1 (year 2007, 2008) (PWC, Cambodia)

8. A number of Aide Memoires from Supervision Missions, MTR of CDC1

9. Draft Cost Estimates of the Health Human Resources Development PPTA in Lao (ADB provided)

10. Trust Fund for Forests, Ministry of Agriculture and Rural Development: Fiduciary Risk Assessment Report of KPMG Finland;

11. Business Analysis & Valuation: Plepu. Healy. Bernard

12. Applied Corporate Finance: A User’s Manual (Aswath Damodaran)

13. Other relevant ADB’s Guidelines and other various documents.

APPENDIX 13:

SOCIAL ANALYSIS

REPORT


Appendix 13: Social Analysis Report –Final Consultant Report April 2010 Page i

TABLE OF CONTENTS

I. INTRODUCTION ........................................................................................................... 1

II. ETHNIC MINORITIES .................................................................................................... 5

A. Ethnic Minorities in the Greater Mekong Sub-region ................................................... 5

B. Ethnic Minorities in Cambodia .................................................................................... 8

C. Ethnic Minorities in Lao PDR .................................................................................... 13

D. Ethnic Minorities in Viet Nam .................................................................................... 18

III. CDC ISSUES FOR MIGRANT WORKERS IN THE GMS ......................................... 25

A. Background .............................................................................................................. 25

B. Population Mobility in the GMS ................................................................................. 28

C. The GMS Labor Migration Study .............................................................................. 29

D. Study of Health of Undocumented GMS Migrants Residing in Thailand.................... 32

E. The Svay Reing, Cambodia Migrant Health Survey .................................................. 34

IV. CDC GENDER ANALYSIS ....................................................................................... 36

A. Introduction .............................................................................................................. 36

B. Gender and Vulnerability to Communicable Diseases .............................................. 37

V. CONCLUSION AND RECOMMENDATIONS ............................................................... 46

A. Lessons Learned From CDC1 .................................................................................. 46

B. Social Mainstreaming Strategy for CDC2 ................................................................. 48

TABLES Table 1. Population and the Proportion of Ethnic Minority Groups, Cambodia, Lao PDR and Viet Nam ....................................................................................... 5

Table 2. Population of Project Provinces Proposed for CDC2 ............................................... 6

Table 3. Ethnicity in CDC2 Project Provinces and Districts, Cambodia ................................. 9

Table 4. Poverty Estimates (2001) in Provinces Proposed for the Project, Cambodia ........ 11

Table 5. Characteristics of Ethnic Groups in Lao PDR ....................................................... 14

Table 6. Ethnic Minority Populations in Proposed Project Provinces and Border Districts, Lao PDR ................................................................................................... 15

Table 7. Proposed Project Provinces and Border Districts, Viet Nam .................................. 19


Appendix 13: Social Analysis Report –Final Consultant Report April 2010 Page ii

Table 8. Poverty Rates and the Poverty Gap, Viet Nam ..................................................... 22

Table 9. Ethnic Variation in Poverty Measures, 2006, Viet Nam ......................................... 22

Table 10. Cross-border Vehicle Traffic: Phangthong Local border with China (near Sing District town), 2001-2002 ......................................................................... 27

Table 11. Border Traffic Recorded for Luangnamtha, 1999-2003 ....................................... 27

Table 12. Estimated Numbers of Adults Living with HIV in Thailand, Cambodia and Viet Nam...................................................................................... 40

Table 13. Maternal Mortality Rates 2001-2009 and MDGs in Cambodia, Lao PDR and Viet Nam ..................................................................................... 41

FIGURES Figure 1. Mortality Rates by Nationality, 1998-2006 ............................................................ 33

Figure 2. Morbidity Rates by Diagnosis and Nationality, 2006 ............................................. 33

Figure 3. Health Staff in Proposed Project Provinces (district and provincial levels combined) by Sex in Cambodia, Lao PDR and Viet Nam ....... 43

Figure 4. Provincial Health Staff in Proposed Project Provinces by Country, Sex and Qualification ............................................................................................ 43

Figure 5. District Health Staff in Proposed Project Provinces by Country, Sex and Qualification ............................................................................................ 44

BOXES Box 1. Ethnic Minority Issues in North East Cambodia ....................................................... 13

Box 2. Case Study from Northwest Lao PDR ..................................................................... 17

Box 3. Ethnic Minority Poverty in Viet Nam ........................................................................ 24

Box 4. The Case of Lao PDR ............................................................................................. 41

Box 5. An Equal Opportunities Approach to Health Sector Employment ............................ 45

MAPS Map 1. Economic Corridors in the Greater Mekong Subregion ............................................. 1

Map 2. CDC2 Project Clusters in the Greater Mekong Sub-region (still being produced) ..... 3

Map 3. Migration Trends in the Greater Mekong Sub-region .............................................. 31

ANNEXES Annex 1. Social Analysis Supporting Maps 50


Appendix 13: Social Analysis Report –Final Consultant Report April 2010 Page iii

ACRONYMS


AI Avian Influenza

CD Communicable Disease

CDC Communicable Disease Control

CDC1 Greater Mekong Subregion Regional Communicable Diseases Control Project

CDC2 Second Greater Mekong Subregion Regional Communicable Diseases Control Project

CPR Contraceptive Prevalence Rates

DALY Disability Adjusted Life Years

DHF Dengue Hemorrhagic Fever

EID Emerging Infectious Disease


GAP Gender Action Plan

GMS Greater Mekong Sub-region

HIV Human Immunodeficiency Virus

IDPD Indigenous People Development Plan


IMC Inter-Ministerial Committee

IOM International Organization for Migration

INGO International Non-Government Organization

LICADHO Cambodian League for the Promotion and Defence of Human Rights



MDG Millennium Development Goal

MMR Maternal Morbidity Ratio


MRD Ministry of Rural Development


Appendix 13: Social Analysis Report –Final Consultant Report April 2010 Page iv

NGO Non Government Organization

NTD Neglected Tropical Disease


RPPTA Regional Project Preparation Technical Assistance

RTI Reproductive Tract Infection

SARS Severe Acute Respiratory Syndrome

STI Sexually Transmitted Infection

TB Tuberculosis

UNDP United Nations Development Program


VLSS Viet Nam Living Standards Survey

VSS Viet Nam Social Security

VVF Vesico Vaginal Fistula


Appendix 13: Social Analysis Report – Final Consultant Report April 2010 Page 1

APPENDIX 13 – SOCIAL ANALYSIS REPORT

I. INTRODUCTION

1. Since the 1990s a network of roads has been upgraded or constructed as part of the Greater Mekong Sub-region (GMS) strategy for regional integration which began in 1992. (Map 1 shows the six major regional corridors of GMS). The GMS strategy has promoted closer economic ties and economic cooperation among the six countries that share the Mekong River. The Asian Development Bank (ADB) has been the lead agency in both initiating inter-country consultations and financing transportation and energy infrastructure.

Map 1. Economic Corridors in the Greater Mekong Subregion

2. Greater connectivity has resulted in rapidly accelerating flows of people and goods across borders. New roads have attracted new labor intensive developments (plantations, casinos, resorts, logging, dams, mines, ecotourism projects) bringing both benefits and communicable disease control (CDC) consequences. There is no reliable data on the numbers of people crossing border to work because the borders are so porous and many migrants are undocumented and working in the informal economy. These population movements are driving rapid social change in border provinces, particularly in localities



where the populations were previously sparse and isolated, mainly comprising ethnic minority groups (EMGs).

3. The expansion of transport networks exposes those in previously remote and isolated communities to a world where their life skills do not easily transfer and where few support mechanisms are available for coping with emerging socio-economic shocks, potentially placing them into conditions of landless poverty and pushing many of them to move in search of better opportunities. Construction and other development projects have led to large scale displacement and resettlement of local communities, especially ethnic minority populations, leading to the migration of those who have lost their land and other sources of livelihood, or who are relocated to land where they cannot make a living, or where they experience psychosocial dislocation.

4. The Project focus is on three cluster border regions (Map 2) of Cambodia, Lao PDR and Viet Nam (CLV), with common national and international borders, in areas where recently constructed or upgraded roads form part of the GMS economic corridors. These are areas in which the rapid social change created by increased connectivity has major health implications for both national and regional CDC. So far there is very limited data on the social and associated epidemiological impacts in CLV districts adjacent to 26 international border crossings that are directly or indirectly associated with the GMS economic corridors. 1

1 The most detailed studies to date was supported by Rockefeller Foundation in 2003 to examine the social and health impacts of Highway 17 and its border crossings from PRC and Thailand in north-eastern Luangnamtha Province in Lao PDR. This road is linked but not integral to the north-south corridor Lyttleton, Chris et. al.. 2004. Watermelons, bars and trucks: dangerous intersections in Northwest Lao PDR: An ethnographic study of social change and health vulnerability along the road through Muang Sing and Muang Long. Lao Institute for Cultural Research, and Macquarie University, Australia. Another ADB –sponsored study is informative but out of date, as it does not capture the rapid economic growth on GMS corridors since 2000: Chantavanich, Supang et. al. 2000. Mobility And Hiv/Aids In The Greater Mekong Subregion. Asian Research Center for Migration Institute of Asian Studies Chulalongkorn University Bangkok, Thailand in consortium with World Vision Australia and Macfarlane Burnet Centre for Medical Research under TA 5881 REG: Preventing HIV/AIDS Among Mobile Populations in the Greater Mekong Subregion Asian Development Bank (ADB) United Nations Development Program (UNDP)



Map 2. CDC2 Project Clusters in the Greater Mekong Sub-region



5. By strengthening CDC response capacity at provincial and district levels in border provinces of GMS, the Project will enable rapid response to disease outbreaks, particularly outbreaks of new and emerging diseases that have the potential to inflect major damage on the economies of the subregion. New diseases have been emerging at the unprecedented rate of one a year for the last two decades, and this trend is certain to continue. 2 The sudden and deadly outbreak of Severe Acute Respiratory Syndrome (SARS) early in 2003 provides a lesson. By mid 2003 SARS had infected more than 6,500 people worldwide, and illustrates the importance that a severe new disease can assume in a closely interdependent and highly mobile world.3

6. Significant cross-border risks arise from emerging epidemic diseases such as Dengue but also the group of parasitic diseases referred to as neglected tropical diseases (NTDs). The issue of NTDs is less well understood as a cross-border CDC issue because many NTDS are not included among notifiable diseases and tend to be endemic to specific areas. However, NTDs span borders in the GMS. The increasing population mobility arising from increasing economic integration in the GMS means that there are growing risks of parasitic diseases moving into new populations via human contacts. National investments to eradicate NTDs cannot be sustained unless matching efforts are made across the border. 4

7. NTDs are endemic in most border communities of GMS and are associated with poverty and poor environmental sanitation and limited availability or access health services in the remote areas. The effective treatment of these infections is known to increase individuals work capacity and productivity. Without treatment, prevention and eradication programs, these diseases disable and eventually kill unknown thousands of people every year. Hookworm, for example, causes anaemia, which endangers the lives of unknown thousands of women in the GMS border regions and contributes to high morbidity and maternal mortality rates in these areas. The development of unknown thousands of children in these areas is affected by intestinal parasites.5

8. This social analysis examines the situation of two vulnerable groups in the context of the Project locations, ethnic minorities and cross-border labor migrants. Poverty is not analysed separately because border populations in Lao PDR and Viet Nam have the highest poverty rates, while in Cambodia where poverty is more widespread, ethnic minorities in border provinces are among the poorest people.

9. While gender is a cross cutting issue in consideration of migrants and ethnic minorities, this social analysis reviews gender issues specifically in relation to CDC. CDC gender issues are now fairly well understood in relation to HIV and other sexually transmitted diseases (which has so far been the highest priority for CDC on cross border transport corridors), but gender is less well understood in relation to other communicable diseases. Recent research on gender and CDC in the CLV region shows that gender is a significant variable in understanding vulnerability and for planning responses to communicable diseases and that insufficient attention is given to women.6

10. The concluding section of this analysis relates the findings for these three social considerations to the Project, its two components and expected results.

2 World Health Organisation, 2003. SARS: Lessons from a new disease. http://www.who.int/whr/2003/chapter5/en/index.html. 3 Asian Development Bank, 2003. SARS: Economic Impacts and Implications Economic Research Division, Policy Brief No. 15 4 Country Reports presented at the First GMS-CDC Technical Forum on the Control and Elimination of NTDs in the Mekong

Sub-Region October 21-22, 2009 5 Presentation by the Global Network for Neglected Tropical Diseases The First GMS-CDC Technical Forum on the Control

and Elimination of NTDs in the Mekong Sub-Region October 21-22, 2009 6 ASEAN + 3 disseminated the findings of the studies at a regional workshop on gender and social issues related to emerging

infection diseases on 13-14 October 2009 under the auspices of the Lao PDR Ministry of Health. Publication is forthcoming.




II. ETHNIC MINORITIES

A. Ethnic Minorities in the Greater Mekong Sub-region

11. Ethnic Minorities in the population: A regional project to address CDC in the border regions of GMS must necessarily focus on EMGs. These are mainly trans-border highland peoples whose traditional territories long predate the establishment of modern states in the subregion. They live in the foothills and highlands of the forested mountain cordillera on the borders of the six countries of the subregion. Many of these groups live in all three countries and are socially, linguistically and culturally linked to groups on the other side of the border. Although most ethnic minorities may be classified as members of four major linguistic groups, they do not classify themselves this way. Over time and under different historical circumstances they have developed many distinct identities, languages and customs.7 Although collectively they are national minorities, in some border provinces and districts they collectively form a majority of the population.

12. Table 1 shows the proportion EMG in the population of each Project country. Although EMGs comprise small minority of the population of Cambodia and Viet Nam, they comprise significant proportion of the population in Lao PDR in the districts of the Project provinces close to the borders between PRC Yunnan province, Myanmar and northern Thailand.

Table 1. Population and the Proportion of Ethnic Minority Groups, Cambodia, Lao PDR and Viet Nam

CAMBODIA LAO PDR VIET NAM

Population (million) 14.0 6.0 86.2

Ethnic Minority Groups, % of population

4% 44% 14%

Source: Source: Asian Development Bank, 2009, Key Indicators for Asia and the Pacific

13. Table 2 indicates the overall numerical importance of EMGs for the border provinces recommended for the Second GMS Regional Communicable Diseases Control Project (CDC2). These aggregated figures include the populations of districts and in some cases provincial towns, where there are few ethnic minorities. If it were possible to disaggregate rural from urban district populations, the proportion of EMGs would be considerably higher overall. In the provincial cluster in southern Cambodia and Viet Nam there are very few EMGs, which also reduces the proportion of EMGs in the provinces and districts for Cambodia.

7 Khampheng Thipmuntali (1999) provides an example showing how the Tai Lue have developed different identities in China

and in Lao PDR, where they are known by different names in different districts. see his chapter “The Tai Lue of Muang Sing” in Grant Evans (ed.) Laos Culture and Society. Silkworm Books.



Table 2. Population of Project Provinces Proposed for CDC2

Population

CAMBODIA LAO PDR VIET NAM TOTAL

# Population # Population # Population # Population

Project provinces

5 1,797,419 9 2,187,716 15 22,420,579 29 26,405,714

Border districts

17 650,564 33 1,311,531 52 4,692,013 102 6,609,108


13.8% 83,752 29.2% 383,565 29.7% 1,394,451 28.2% 1,861,768

Source: Population data gathered for CDC2 project preparation see Annex 1

14. Disadvantage and Poverty: In all three Project countries EMGs have higher levels of poverty, lower education participation rates, lower literacy rates and higher communicable disease burdens than the majority populations (this is explained further in the following country sections on Cambodia, Lao PDR and Viet Nam). Many similar historical, cultural, environmental and policy factors have contributed to the disparities between EMGs and majority ethnic groups. EMGs once lived (and many still live) live in remote, inaccessible locations in small hamlets in remote mountainous regions far from modern health and education services and with limited economic integration into market economies. Road-building has ended that isolation in most border areas. EMGs speak minority languages which may restrict their access to information. Unless they have had at least a primary school education, they do not speak, read or write majority language. Many have religious and cultural traditions that differ from and are misunderstood by majority populations. Some groups are stigmatized as „backward‟ or „primitive‟.

15. Traditional livelihoods: For thousands of years EMGs in mountainous border regions of GMS have practiced shifting or swidden subsistence agriculture (sometimes negatively referred to as „slash and burn‟ agriculture). Throughout Asia and the Pacific this mode of cultivation represents human economic adaptation to highland environmental conditions. Where there is low population density and large areas of forest, the practice is not harmful to the environment. However, when territories within which shifting cultivation is practiced becomes too small, the environmental impacts of shifting agriculture may be negative. However, it should be emphasized that impact is considerably less than the environmental impact of commercial logging or forest clearance for plantations.

16. Some EMGs have traditionally cultivated opium as a subsidiary crop for centuries as their main source of cash, but are now being targeted for drug eradication. In many cases opium eradication increases poverty among EMGs, when efforts to provide them with new sources of cash income fail. Road building is opening up mountainous areas, resulting in intensified competition for land, as well as for forest resources. The traditional domains of many EMGs are shrinking as highland areas are allocated for logging, plantations, hydropower dams and mining. As these areas become more accessible with new roads, migrant settlers from the lowlands and across borders are migrating to these areas.



Traditionally EMGs held their lands under customary tenure, which has now has limited or no recognition in modern national law. Without legal title to their land they are easily displaced.

17. State policies and actions frequently deprive EMGs of their traditional lands: in the name of watershed an environmental protection and conservation; to make way for logging concessions, other forest industries and hydropower dams; to facilitate opium eradication; or following policy to „modernize and integrate‟ integrate EMGs into the mainstream by relocating them closer to government health and education service centers. These are real dilemmas for governments in the GMS; if they encourage assimilation strategies such as compulsory relocation they are criticized by scholars and international NGOs, however, if governments ignore remote populations of EMGs they are also criticised. These have been difficult political issues for Cambodia and especially Lao PDR and Viet Nam in the past.8 These sensitivities may have created some political resistance to considering the particularly severe social and health impacts of economic integration in GMS.

18. Voluntary and informal relocation: In addition to formal relocation programs, many EMGs are voluntarily and informally relocating their settlements near to new roads, hoping for economic advantages by doing so. However with lower levels of education and knowledge of modern skills, and limited exposure to market economies, they are more likely to become low-paid day laborers than to become more prosperous, although there are some examples of success among EMGs who have made this transition.

19. Ethnic Minorities as tourist attractions: EMGs are often featured in tourism promotion and tourist activities and it is assumed that tourism will mainly bring them economic benefits9. However this assumption is questionable as cultural exploitation can occur. For example featuring EMGs as curiosities tends to reinforce their marginal social status and national cultural prejudices. Another example is commercial appropriation of EMG traditional arts and crafts by business operators for mass production. The author of this report observed most goods on sale as „handicrafts‟ in the popular tourist night market in the tourism centre of Luang Prabang in Lao PDR are actually produced in small and medium-sized factories by paid workers who may or may or may not be belong to EMGs. Many of these same items may be seen for sale in curio/handicraft shops in Bangkok, Hanoi, Vientiane and other cities in the GMS region.

20. Rapid integration: In summary, most EMGs in GMS border areas can no longer be thought of simply in terms of being disadvantaged due to isolation; they are becoming increasingly and rapidly integrated into national and regional economic processes and the associated processes of social change. This transformation is largely a result of new roads opening up previously isolated areas, attracting not only investment in mines, plantations, dams, logging and other enterprises, with growing numbers of national and international cross-border migrants. In most cases, EMGs are beginning this process of integration from a very disadvantaged position.

8 For example United Nations Declarations and Covenants such as the Declaration on Rights of Indigenous Peoples and the

United Nations International Covenant on Civil and Political Rights and, in particular the International Covenant on Economic, Social and Cultural Rights, which states that all peoples have the right of self-determination by virtue of which they “freely determine their political status and freely pursue their economic, social and cultural development”. (Part one, Article one, 1966) have led some state governments oppose use of the term “peoples” in regards to EMGs because they fear its association with international boundaries the right of secession, even independent statehood. Those states would prefer the terms “tribes” or “populations”, which do not have those associations. Study guide: The Rights of Indigenous Peoples. University of Minnesota Human Rights Centre, 2008

9 Asian Development Bank, Proposed Grant to the Lao People’s Democratic Republic and Loan to the Socialist Republic of Viet Nam: Greater Mekong Subregion Sustainable Tourism Development Project. Project Number: 38015 RRP, September 2008, p 12.

http://www1.umn.edu/humanrts/instree/b3ccpr.htm

http://www1.umn.edu/humanrts/instree/b2esc.htm



http://www1.umn.edu/humanrts/edumat/studyguides/indigenous.html#self

http://www1.umn.edu/humanrts/hrcenter.htm



21. Health issues. Several recent studies suggest that EMG populations living near regional economic corridors bear a disproportion burden of the health costs of the rapid social and economic changes created by these developments.10 For example, when EMGs whose customary habitat is in high mountain areas move to lower altitudes, they are exposed to malaria, to which they have little acquired resistance, so in the early phase of relocation to lower altitudes there have been high mortality rates from malaria, as well as morbidity resulting from exposure to other water-born and environmentally-related infectious diseases. 11 Those who live close to rapidly developing hubs on transport corridor areas are particularly vulnerable to recruitment into the sexual services industry, to cross border human trafficking. Under these circumstances they become vulnerable to infection with HIV and other sexually transmitted diseases (see footnote 5 for reference to a detailed case study).

22. There are no comprehensive national or regional data comparing CDC incidence and prevalence among EMGs compared with majority populations in CLV, although some information can be inferred from provincial data. Surveillance data does not include ethnicity when it is collated at national level and often also at provincial levels, though it is collected at health centre levels. Therefore most epidemiological data, unless based on special surveys, is not ethnically sensitive. However, the disparities are highlighted in country specific data showing that provinces with high infant and child mortality rates also have high concentrations of EMGs, and that EMGs have lower education and literacy rates as well as poverty rates in the three countries. EMGs are more likely have a higher burden of infectious diseases than mainstream populations due to poverty, malnutrition and other factors outlined above, and due to lack of knowledge of prevention, access to health services.

23. Some EMGs may only use heath services (when they are available) as a last resort. This may be because of lack of experience but also reflects anxiety about modern health services, as well as the expense of accessing them. In all societies people‟s beliefs about health have cultural underpinnings. EMGs have had less exposure than most people to modern scientific knowledge about the cause of diseases, and less opportunity to learn about the value of vaccination, vector control and other measures.

24. Programs aiming to promote behavior change (for example, building and using latrines, drinking boiled water, removing disease vector breeding sites, hand-washing, using bed nets, and acceptance of vaccination) are mainly designed for the mainstream population and do not take account of the varied circumstances, behavior and need to use culturally relevant modes of communication in EMG villages.

B. Ethnic Minorities in Cambodia

25. Cambodia is a multi-ethnic society with a majority of population as ethnic Khmer. The Khmer majority occupies the central areas of Cambodia and the banks of the Mekong, while EMGs mainly live in foothills and high mountain areas, with the exception of the lake-dwelling Muslim Cham. Minority groups include Vietnamese and Chinese as well as EMG populations and comprise about 4% of the population based on the 1998 census. Most EMGs live in the north-eastern upland border provinces of Mondulkiri, Ratanakiri, Stung, Treng and Kratie.

26. Government Policy: Cambodia established an Inter-Ministerial Committee (IMC) for Highland Peoples Development in 1994, with support from the United Nations Development 10 Cited in Cornford, Jonathon and Nathaniel Matthews, 2008. Hidden Costs: the Underside of economic transformation in the

Greater Mekong Subregion. Oxfam, Australia. Broken Lives: Trafficking in Human Beings in the Lao PDR. Manila 11 See the evidence for this and the discussion of the impact on Akha people in two border districts of Luangnamtha, Lao PDR

in Lyttleton, C. et. al., 2004 Watermelons, bars and trucks: Dangerous Intersection in Northwest Lao PDR. Institute for Cultural Research of Lao and Macquarie University.



Program (UNDP). The IMC secretariat is based in the Ministry of Rural Development (MRD) and includes representation from the Ministry of Health (MOH). The IMC selected the north-eastern pr ovinces (Ratanakiri, M ondulkiri, S tung Treng, and K ratie) as priority areas for development be cause of t he l arge nu mber of h ighlanders and d iversity in t he e thnic populations. R ecently, t he G overnment c reated t he D epartment of Ethnic Minorities Development under MRD to follow up IMC recommendations.

27. Table 3 shows the ethnic minority p opulation recorded i n t he 20 08 c ensus; these populations were identified as „minority language speakers‟.

Table 3. Ethnicity in CDC2 Project Provinces and Districts, Cambodia

PROVINCE BORDER DISTRICT

POPULATION MINORITY LANGUAGE SPEAKERS IDENTIFIED IN 2008 CENSUS

PROPORTION IN DISTRICT

Mondulkiri Kaev Seima

21,712 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Kuoy, Phnong, Stieng, Ra Ong, Kroal, Mel, Kcuch, others

48.30%

Kaoh Nheaek

17,182 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Kreung, Phnong, Stieng, Tampoon, Kroal, Raadear, Thmoon, others

46.90%

Ou Reang

4,460 Vietnamese, Chaaraay, Kaaveat, Phnong, Stieng, Tampoon, others

74.20%

Kaev Seima

21,712 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Kuoy, Phnong, Stieng, Ra Ong, Kroal, Mel, Kcuch, others

48.30%

Rattankiri Andoung Meas

10,710 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Kuoy, Phnong , Stieng, Souch, others

87.50%

Ou Ya Dav

16,966 Vietnamese, Lao, Chaaraay, Chaam Kaaveat,Klueng, Kuoy, Krueng, Phnong, Proav, Tumpoon, Others

81.20%

Ta Veaeng

6,029 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Krueng, Lon, Phnong, Proav, Tumpoon, Others

93.60%

Veun Sai

16,996 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Klueng, Kuoy, Krueng, Lon, Proav, Tumpoon, Ra Ong, Suoy, Others

96.80%

Stung Treng

Siem Pang

19,518 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Lon, Ro Ong, Other.

22.60%

Stueng Traeng

32,978 Vietnamese, Lao, Chaaraay, Chaam, Kaaveat, Klueng, Krueng, Phnong, Proav, Tumpoon, Stieng, Ro Ong, Raadear, Thmoon, S'OUCH, Other.

3.20%

Thala Barivat

32,425 Vietnamese, Lao, Chaaraay, Chaam Kaaveat, Klueng, Kuoy, Krueng , Phnong, Tumpoon, Other.

0.65%

Kampot Banteay Meas

84,724 Vietnamese, Chaaraay, Chaam, Kaaveat6 Klueng, Stieng, Ro Ong, S'OUCH, KCHRUK, Other

0.25%




POPULATION MINORITY LANGUAGE SPEAKERS IDENTIFIED IN 2008 CENSUS

PROPORTION IN DISTRICT

Kampong Trach

109,170 Vietnamese, Lao, Chaaraay,Chaam, Kaaveat, Phnong,Stieng Ro Ong ,S'OUCH,KCHRUK, Other

0.13%

Takeo Angkor Borei

46,874 Vietnamese, Lao, Chaaraay, Chaam, Kaaveat, Klueng ,Stieng, Ro Ong , Raadear Other 1.85%

Borei Cholsar

26,400 Vietnamese, Chaaraay, Chaam, Kaaveat Lon, Stieng, S'OUCH1 2.86%

Kiri Vong

99,005 Vietnamese, Lao, Chaaraay, Chaam, Kaaveat ,Klueng, Kuoy Krueng 1 Stieng, Ro Ong ,S'OUCH Other 0.36%

Kaoh Andaet

48,675 Vietnamese, Chaaraay, Chaam, Klueng ,Ro Ong, Other 0.86%

Source: Preliminary Census Data, Ministry of Health, Cambodia 2008

28. This data includes Vietnamese, w ho f or t he pur poses of t his analysis are not regarded as EMGs under the ADB definition, being mainly refugees or more recent cross-border migrant labor a nd settlers. T he w ay the dat a w as collected i n t he c ensus did n ot permit calculation of the proportion of EMGs as defined in this analysis. However all minority language groups can be considered vulnerable in terms of their relative economic situations and access to services.

29. An AD B-sponsored s tudy (2002) notes that t he ethnic minorities of C ambodia a re likely to be significantly under enumerated, as some members of minority groups prefer not to disclose their ethnic identity.12 The study comments that despite the guarantees of EMG rights in the Cambodian Constitution and the existence of the IMC, the Government does not appear t o h ave an ac tive pol icy toward e thnic minorities and t hat many c onstraints l imit access by ethnic minorities to government services. It also comments that of all minorities, ethnic Vietnamese have the most problematic status for social and historical reasons.

30. Ratanakiri s hares borders with L ao PDR a nd Viet N am, and M ondolkiri s hares a border with Viet Nam. The majority of EMGs live in these two border provinces and if it was possible to disaggregate urban and rural populations by ethnicity/language at district level, the proportion of minorities in the population would be higher. The territories of some EMGs go beyond the Cambodian border. For example, the Chaaraay in Ratanakiri, and the Phnong in Mondulkiri and, m ay be found r espectively in the provinces of Pleiku and Dalat in Viet Nam; t he K uy, p resent i n P reah V ihear ar e al so i n T hailand an d i n L ao P DR; and t he Kaaveat in Ratanakiri are closely related to EMGs in southern Lao PDR13. In Ratanakiri and Mondulkiri, EMGs are the majority of the population. Although EMGs are found in other than the other proposed provinces, they represent smaller proportions of district populations.

31. Poverty and E thnicity: Because p overty is so wi despread i n Ca mbodia and because EMGs comprise a relatively small proportion of the population, most poverty studies do n ot sp ecifically address EMG p overty issues.14 In i ts overall a nalysis, t he World B ank reports t hat the latest ( 2004) household s urvey finds t hat 3 5 percent of C ambodians live below the nat ional poverty line, down from an estimated 47 pe rcent a de cade earlier, and that the living standards of the population, including the poor, have improved between 1994 12 Plant, R., 2002. Indigenous Peoples/Ethnic Minorities and Poverty Reduction: Cambodia Environment and S ocial Safeguard Division, Regional and Sustainable Development Department Asian Development Bank, Manila, Philippines, June 2002 13 Borders, mainly those imposed by the French in 1903, artificially divided these groups and restricted their movements to an area that was previously free of administrative control. 14 World Bank, 2006, cited by Engers Anderval and Orjan Sjoberg in Poverty in rural Cambodia: The Differentiated Impact of Linkages, Inputs and Access to Land. Stockholm School of Economics.



and 2004. The rise in living standards has been more pronounced in urban areas, and among the richest quintile. The extreme poor (the bottom 20 percent who fall below the food poverty line) have experienced significantly slower growth in real consumption than the "normal" poor. Thus, the World Bank recommends that accelerated poverty reduction, by improving productivity and profitability in the rural economy, will require: (i) secure property rights to private land, particularly for smallholders; (ii) emphasis on small holder agriculture for both growth and poverty reduction; (iii) equitable access to common property resources as a critical source of income and security for the rural poor; (iv) increased investments in productivity-enhancing infrastructure; and, (v) improved human development and human capital, through the pro-poor delivery of basic services in education and health.15

32. Mapping by the World Food Program shows that disadvantage associated with poverty is particularly high in at commune levels with significant EMG populations16 even though this does not show in aggregated data for provinces by the government for inclusion in CDC2 (Table 4). Recent studies sponsored by the International Organisation for Migration (IOM) show that populations of Ratanakiiri and Mondulkiri have almost doubled in the past decade mainly due to in-migration from other provinces.17

Table 4. Poverty Estimates (2001) in Provinces Proposed for the Project, Cambodia

Province Poverty Rate

Poverty Gap

Poverty severity

% of Total Population

Poverty share %

Estimated number of poor (000‟s)

Ratanakiri 8.81 2.82 1.41 0.83 0.27 8.1

Mondol kiri 19.87 5.60 2.29 0.28 0.20 6.2

Stueng Treng

16.77 3.85 1.42 0.70 0.42 12.6

Takeo 15.22 4.29 1.92 7.05 3.89 117.9

Kampot 18.67 4.68 1.72 4.74 3.21 97.3 The United Nations World Food Programme (2002) Estimation of Poverty Rates at Commune-Level in Cambodia Using the Small-Area Estimation Technique to Obtain Reliable Estimates. Ministry of Planning.

33. According to the ADB-sponsored Participatory Poverty Assessment in Cambodia (2001), EMGs consulted in the upland provinces did not consider themselves poor because they lived in remote areas. They were most concerned about becoming poor as the result to loss of land to new settlers from the lowlands and the loss of forest resources, as these trends now threaten their traditional livelihoods. Communication and language barriers have now become issues for them.

34. Land allocation: In the past, periods of hardship and food shortage resulted from droughts, fires, and unusually heavy rains. These were occasional events. Recent studies of Ratanakiri and Mondolkiri Provinces provide a detailed account of the impacts on EMGs of loss of land and forestry resources due to logging, dams and plantations and their increased exposure to natural disasters.18 Today these include loss of land, restriction of forest use due

15 World Bank, 2006. Cambodia - Halving poverty by 2015 - poverty assessment. 16 United Nations World Food Programme, 2003.Mapping Poverty, Malnutrition, Educational Need, and Vulnerability to Natural Disasters in Cambodia. Ministry of Planning, Royal Government of Cambodia 17 Haynes Sumaylo, K. K., 2009. Mapping Vulnerability to Natural Hazards In Rattanakirii. International Organization for

Migration (IOM), Mission in Cambodia. Thuon T. & Haynes Sumaylo K. K., 2009. Mapping Vulnerability to Natural Hazards In Mondulkiri. International Organization for Migration (IOM), Mission in Cambodia

18 Haynes, Thuon T. & Haynes 2009, previously cited.



to conservation regulations, loss of forest resources due to land concession for logging and plantations are ongoing situations, and the breakdown of social cohesion. These changes are pushing the EMG communities interviewed in the ADB poverty assessment in these provinces into what they consider to be poverty. International Non-Government Organization (INGO) health providers working with EMGs in border provinces told members of the team preparing this project proposal that large-scale land confiscation, along with a large influx of small farmers was marginalising and impoverishing EMGs with associated impacts on their health and risks of becoming infected with communicable diseases.

35. On the issue of land alienation, the Cambodian League For The Promotion and Defence Of Human Rights (LICADHO) cites evidence of abuse of social land concessions, a legal mechanism ostensibly to transfer private state land for social purposes to the poor who lack land for residential and/or family farming purposes, of no more than 10,000 hectares.19 Its study asserts that small and large land concessions continue to be granted in unlawful secrecy, sometimes in sizes far exceeding the legal limit. It cites evidence from reports such as that of Miloon Kothari, the UN Special Rapporteur on Housing Rights, 2005, a 2008 report by Amnesty International on forced evictions in Cambodia, a Global Witness report on Cambodia‟s extractive industries and the report of the UN Special Representative, Dr Yash Ghai to Cambodia in December 2007 on land and housing rights issues. Although these claims are refuted by the government, the evidence seems compelling.

36. Most of the documented cases in the LICADHO report refer to valuable peri-urban and lowlands areas of the country, but in relation to concessions in excess of the legal limits, it refers to cases in upland border provinces with significant EMG populations, such as a 100,852 hectare concession in Stung Treng province, and 19,900 and a 199,999 hectare concessions in Mondulkiri province to private companies.

19 The Cambodian League For The Promotion and Defense Of Human Rights (LICADHO), 2009. Land Grabbing and Poverty in Cambodia: The Myth of Development.



Box 1. Ethnic Minority Issues in North East Cambodia

According to a 2006 report by CARE international20 in the five highland provinces of North East Cambodia there are over 100,000 EMG people belonging to over 10 ethnic groups. Most people live in remote villages with very poor or no access to health or educational services and extremely limited access to commercial activities.

In Ratanakiri EMGs together make up around 65 percent of the 115,000 population of the province; the balance of the population is made up of Lao, Vietnamese and Chinese (15 percent), and Khmer (20 percent) based on 1998 census data. These proportions however, are rapidly changing due to the implementation of the Royal Government of Cambodia‟s economic development strategy for the north east, the Triangle Development Plan. This strategy actively encourages migration from other regions to develop resources in traditional ethnic minority areas. Recent populations moving into these two provinces are Khmer and Chinese who have mainly settled along the rivers, roads and in urban areas.

Ethnic groups of this area speak their own languages and practice their own religions. Few speak or understand Khmer, Cambodia‟s official national language, and those that do, have limited competence. Orthographies for some (but not all) of the more widely spoken Indigenous languages, based on the Khmer alphabet, have recently been approved. The lack of mainstream language skills of most Indigenous people compounds their marginalization. These peoples are mainly agriculturalists growing dry land rice using shifting cultivation; however they are increasing cultivation of cash crops such as cashew, coffee and soybean. In contrast, the ethnic Khmer, who constitute “mainstream” society, live in the towns or along the main roads where they are prominent in business, trading and government service.

An issue of immediate and growing significance directly impacting on the way of life of Indigenous people is that of land alienation. Enormous pressure is being placed on ethnic minority communities to sell land for private investment and the development of commercial agricultural crops. Concessions for logging and plantations continue to be granted over huge areas of Indigenous lands and land sales are often coerced. It has been noted that the villages most affected by land alienation are those where social cohesion has eroded the most. The increasing disruption caused by these activities threatens the very existence of many communities, and if left unabated will lead to increased poverty and further marginalization.

37. Health care for the poor: The Ministry of Health‟s Health Strategic Plan 208-2015 includes provision for health service fee exemptions for the poor through various mechanisms. The role of Health Equity Fund schemes is to provide access to health services and to protect the poor from catastrophic health expenditures. The role of Community Based Health Insurance is to provide a risk-pooling mechanism for informal-sector workers who live above the poverty line. Social Health Insurance provides universal coverage to wage earners employed in the formal sector. The strategic objective is to bring all pre-payment schemes under a common Social Health Insurance umbrella. However it is unclear whether EMGs know about these entitlements.

C. Ethnic Minorities in Lao PDR

38. Lao PDR is a multi-ethnic state comprising at least 49 distinct ethnic groups. The 2005 census of Population and Housing uses ethno-linguistic classification (Table 5). Based on this definition, the nation‟s population comprised 66 percent of the Lao-Tai ethno-linguistic group. However, the Lao are the largest ethno linguistic group in only eight of the 18 provinces (Attapeu, Champasack, Khammuane, Saravan, Savannakhet, Vientiane City,

20 Jan Noorlander, 2002. The Highland Community Education Program CARE Cambodia. Land Alienation from Indigenous Minority Communities in Ratanakiri, NGO Forum, Nov 2004; Workshop to Seek Strategies to Prevent Indigenous Land Alienation, NGO Forum in Collaboration with CARE, Ratanakiri, 2005



Vientiane P rovince an d X iengkhouang). T he ot her t hree ethno-linguistic groups a re classified as Austro-Asiatic (32 ethnic groups are 23 percent of the population), Hmong-Yu Mien ( two e thnic groups are 7. 4% of t he popu lation), and t he S ino-Tibetan ( seven e thnic groups are 2.7 percent of the population).

Table 5. Characteristics of Ethnic Groups in Lao PDR

Groups Sub-groups a/

% of Total Pop‟n

b/ Summary Characteristics a/

Lao-Tai (Tai-Kadai, Lao Loum)

Lao & Tai groups, Lue, Phou Tay

64.9

Live mostly along the well-connected Mekong corridor along the Thai border or in Northern lowlands; settled cultivators with or urban dwellers;

Mon-Khmer (Austro-Asiatic, Lao Theun)

Khmou, Lamet, Katang, Makong, Brao, Ta Oy, Katu

22.6

Found in highland areas in the North and Central South, and smaller groups (Khmou) in the Northern lowlands; the most diverse ethnic group, shifting cultivators; fairly assimilated due to hundreds of years of interaction with Lao-Tai, some communities live in isolation as hunter-gatherers

Sino-Tibetan (Lao Soum)

Akha, Lahu, Sila 2.8 Live mainly in poorly-connected upland areas

in the North; shifting cultivators; Hmong Mien (also Miao-Yao, Lao Soum)

Hmong groups, Yao, Huoay

8.5 Live mainly in mid- and upland areas in the North; Hmong as largest subgroup; mainly shifting cultivators.

Sources: Draft Lao People's Democratic Republic Health Sector Development Program 12 June 2009 a/ World Bank. 2006. Lao PDR: Poverty Assessment Report - From Valleys to Hilltops—15 Years of Poverty Reduction; Gender Resource Information and Development Center. 2005. Lao PDR Gender Profile b/ Lao Population and Housing Census 2005

39. Government P olicy: In Lao P DR a ll people a re c onsidered equal u nder t he constitution, irrespective of ethnic background. Ethnic groups are conventionally divided into three m ajor groups, based on what is or was their typical location. These are lowland Lao (Lao Lo um), m idland Lao ( Lao T heung) a nd upland o r h igher a ltitude Lao (Lao Sung). Although t here ar e v arious ethnic groups within t he l owland Lao, on ly the upl and a nd midland Laos are considered EMGs. The Government prefers the use of the term “smaller ethnic groups” to “ethnic minority groups”.

40. Table 6 shows the proportion of smaller ethnic groups in the provinces and border districts proposed for inclusion in the Project provinces. EMGs are highly represented in all the l ocations except i n three di stricts in Khammuane, t wo d istricts of Saravane, a nd f our district of Champasak.



Table 6. Ethnic Minority Populations in Proposed Project Provinces and Border Districts, Lao PDR

PROVINCE BORDER DISTRICT POPULATION SMALLER ETHNIC

GROUPS IN DISTRICTS Phongsaly Phongsaly 24,908 94.7% May 23,902 64.6% Samphanh 28,140 90.8% Boon neua 22,022 69.9% Nhot ou 59.6% Boon tai 69.2% Luangnamtha Namtha 50,125 44.9% 55.8% Long 33,361 69.5% Oudomxay Namor 37,393 72.2% Bokeo Huoixai 63,487 16.4% Tonpheung 28,518 36.6% Meung 13,480 36.0% Khammuane Thakhek 3.6% 42,353 2.7% Hinboon 0.4% 43.5% Nakai Saravane 92.8% Lakonepheng 42,450 8.7% Khongxedone 1.1% Samuoi 14,615 78.4% Sekong Kaleum 98.4% Dukcheung 19,281 95.0% Champasak Pakse 0.7% Phontong 91,695 2.0% Champasack 0.7% Sukhumma 56,875 10.6% Moonlapamok 77,979 1.5% Attapeu Snamxay 30,596 61.7% 19,222 83.1% Phouvong 10,924 95.5% Source: Preliminary census data, Lao PDR 2008

41. Poverty and Ethnicity: Overall poverty incidence in Lao PDR fell from 45 percent in 1992–1993 t o 3 0 pe rcent by 20 02–2003. The sharp r eduction i n po verty incidence was associated w ith c onsecutive y ears of s trong e conomic growth, ac hievement of r ice s elf-sufficiency, and increased cross-border trade. However, poverty levels differ between urban and rural areas, and r egionally across the country. O verall, m inority groups show



substantially higher poverty headcount rates than the majority Lao-Tai. The 2006 Lao Poverty Assessment reports that of the four major ethno linguistic groups, the Mon-Khmer is the poorest group, with a headcount of 55 percent, followed by the Hmong-Iu Mien (45 percent), the Chine-Tibet (40 percent) and the Lao-Tai (28 percent).

42. Land allocation: Since 1982 the Government has pursued policies in relation to the development of EMGs that allocated specific plots of land to each midland and highland EMG household. Titling and resettlement meant that, in effect, many EMGs lost their historical customary rights to the territories they occupied but acquired legal rights to land. The aim of this policy was to give EMG farmers, particularly those in the northeast, incentives to practice permanent cultivation and to deter shifting cultivation. As part of this initiative the government also pursued a policy of relocation and resettlement of upland villages to land in lower altitudes or to lowlands. In 1991 the government reiterated commitment to the maintenance of ethnic identities and the economic development of all groups, but when the „new economic mechanism‟ was adopted, it reaffirmed commitment to encouraging transition from subsistence to a market economy which included the progressive abandoning of „slash and burn‟ agricultural practices.

43. In 1992 Government acknowledged that challenges arising from these policies targeting EMGs have been insufficient preparation of both resettling and host communities and inadequate resources and experience to support the policy. Many, if not most resettled EMGs, encountered serious hardship in adapting to environments and new farming practices. Many became poorer than they had been before, and most experienced cultural and social dislocation and marginalization as a result of intensified contact with other sections of the population and new social and economic influences. In some rapidly developing transport corridor areas, the titling of land had unfortunate consequences in increasing poverty and landlessness when members of EMGs were persuaded to sell land to settlers coming into these areas. Government endorses the need for close attention – including analysis of the specific sociocultural situation of each EMG population – to be included in the design of development projects, to ensure that EMGs benefit.

44. The policy of the government of Lao PDR on shifting cultivation was enunciated at the Sixth Party Congress in 1996: "Shifting cultivation (also known as slash-and-burn agriculture) is a problem the Government wants to address. Peoples whose livelihoods depend on shifting cultivation must be settled in areas where they can be allocated land to earn a living". Shifting cultivation is perceived, not always correctly, as a major cause of deforestation and erosion and forestry is a major source of government revenue. Opium reduction in Lao PDR is an integral part of the worldwide 'war on drugs' but also because opium cultivation is a form of slash-and-burn agriculture, opium eradication is consistent with, and supportive of, national policies on shifting cultivation. As opium cultivation decreases, however, the consumption of widely available and cheap methamphetamine (yaba) increases.

45. Resettlement initiatives linked to rural development, have made sedentisation an integral part of a process that not only requires leaving a territory but the transformation of a whole way of life even though there is no official policy of resettlement, embodied in state decrees or laws.21 Resettlement is mainly the product of the government rural development policy of creating "focal zones". Resettlement or "village consolidation" of highland villages in the lowlands (or along arterial roads leading to the lowlands) is considered essential to an "area-focused development approach". Focal zones involve the provision of essential services (roads, electricity, schools, medical facilities, etc) as well as the development of

21 Evrard, O. and Goudineau, Y. (2004) “Planned resettlement, unexpected migrations and cultural trauma: the political management of rural mobility and interethnic relationships in Laos” Development and Change 34(5)



paddy land, livestock-raising, etc, in selected areas22. It is based on the assumption that is it more cost effective to bring highland villagers to lowland services than to extend the same services to remote areas. The approach has generally been supported by major international organizations such as FAO and the World Bank, at least until quite recently23.

Box 2. Case Study from Northwest Lao PDR

A study in 200224 of the impact of Route 17B (which connects to the north South and northwest GMR economic corridors) through Luangnamtha Province in northwest Lao PDR found its impact on local populations has been profound. The two districts connected by Route 17B, Muang Sing and Muang Long districts are ethnically very diverse with 15 ethnic groups of whom the Tai Lue and Tai Neua, though a minority, have been the most politically and economically powerful. The most populous ethnic group is the Akha, with about 46% of the population of Muang Sing and 58% of Muang Long.

The road has brought a wide range of social and material changes have taken place throughout the lowlands and highlands of the two districts that the road bisects. In the first instance, the road has opened opportunities for a huge influx of people and goods. Numerous trucks travel from China to the port of Xiengkok ferrying goods to and from Thailand. Traders, investors and agricultural laborers are moving into the two districts utilising the road‟s transport efficiency as an incentive to produce goods for sale back in China. In-migration has the most impact on issues of material and social livelihood. But it is not just transit vehicles or in-migrants that are catalysts of social change.

The road has played a significant role in demographic changes that are fundamentally transforming the social fabric in this region. Ethnic groups that have for centuries lived in the mid and upper slopes of the mountains flanking the valleys are quickly moving down to be near the road and the market opportunities it symbolically and materially represents. The end result is an increasing integration of people from different cultural backgrounds engaging in market enterprise and negotiating new forms of social competencies in the lowlands near the road. The study found that relocated highlanders are increasingly providing lowlanders with a pool of dependent, cheap and labor, and young women are very vulnerable to recruitment into the sex trade. This is largely because relocated people are allocated low quality non-irrigable land and are economically compelled to engage in daily wage labor and other servile occupations in order to survive.

46. Health impacts of relocation: Movements of highland EMGs to lower altitudes as a result of voluntary and involuntary resettlement has had a snowballing effect resulting in the depopulation of whole highland areas. A survey of 67 displaced villages in six provinces in which serious problems of relocation were identified, including devastating epidemics (particularly from malaria), as well as loss of assets, debt accumulation, rice deficits, intensified competition for land, and lack of government resources to provide assistance to relocated communities. 25 These problems were confirmed by a number of other studies.26

22 National Poverty Eradication Campaign (NPEP): A Comprehensive Approach to Growth and Development, Eighth Round Table Meeting, September, 2003, Vientiane. 23 Baird, I.G. and Shoemaker, B, 2007. „Unsettling Experiences: Internal Resettlement and International Aid Agencies in Laos‟. In Development and Change 38(5): 865–888. 24 Lyttleton, C. et. al., 2004 Watermelons, bars and trucks: Dangerous Intersection in Northwest Lao PDR. Institute for Cultural

Research of Lao and Macquarie University. 25 United Nations Development Programme (UNDP), 1997. Basic Needs for Resettled Communities in the Lao PDR. UNDP Vientiane 26 Gebert, R. 1995. Socio-economic baseline survey. Muang Sing: GTZ Integrated Food Security Programme. Cohen, P.T. 2000a. "Lue across borders: pilgrimage and the Muang Sing reliquary in Northern Lao PDR. In G.Evans, C. Hutton and Kuah-Khun Eng (eds.) Where China Meets Southeast Asia: Social and Cultural Change in the Border Region. Singapore: Institute of Southeast Asian Studies. Cohen, P.T., 2000. "Resettlement, opium and labour dependence: Akha-Tai relations in Northern Laos", Development and Change, 31:179-200. Romagny, L. and Daviau, S. 2003. Synthesis of Reports on Resettlement inLong District, Luang Namtha province, Lao PDR. Action Contre La Faim mission in Lao PDR. Lyttleton, C. 2005. "Market-bound: relocation and disjunction in northwest Lao PDR". In Toyota, M., Jatrana, S., and Yeoh, B., 2003 (eds.) Migration and Health in Asia. Routledge. Alton, C. and Houmphanh Rattanavong, 2004. Service Delivery and Resettlement: Options for Development Planning, unpublished report, UNDP: Lao PDR, Vientiane. McCaskill D. and K. Kampe (eds.) 1997. Development or Domestication: Indigenous Peoples of Southeast Asia Chiang Mai: Silkworm Press.



47. While there has been improvement in control of recognized disease vectors, the damaging impact of rapid social change among people with limited experience with market economies and of wider social integration continues to have negative effects. While some families might improve economically, most do not. Poverty and exploitation are clear consequences of voluntary and involuntary relocation. The National Poverty Eradication Program (2003:45) which surveyed a large number of districts reported: “In the villages where overall income had increased, it was found that increases in production were being realized by only a few families”.

48. Data on Ethnicity and Health: Data on sex and ethnicity is recorded in health centres and hospitals but is not reflected in most national epidemiological data. Information on ethnic differences in health status is patchy. In the north of the country, ethnicity and location of villages have been found to have a significant effect on health knowledge and utilisation among women. The importance of ethnicity can be seen in relation to contraceptive prevalence rates (CPR) in the Northern provinces. In 2006 the PHCEP Household Survey found that the highest CPR (82 percent) was in Sayaburi where 75 percent of the population are Lao Tai, and the lowest CPR (30 percent) was in Phonsaly where 80 percent of the population are from ethnic groups. The CPR among the Sino-Tibet and Hmong-Iu Mien was less than half the CPR among the Lao-Tai in the north (28 percent, 33 percent and 68 percent respectively).

49. Health care for the poor: The MOH is currently considering how to address high out of pocket expenditure on health. Various „free services‟ scenarios have been costed and are under consideration for future implementation. In addition, Health Equity Funds, which provide free health services to the very poor, are being piloted in different parts of the country.

50. Village location and access to health services determines the difficulty of the terrain that has to be traversed to reach a health facility, which, in turn, affects the financial and other costs associated with accessing services. The 2006 PHCEP Household Survey found an association between village location (i.e. whether a village was urban, rural with a road, or rural with no road) and CPR in the Northern provinces. The CPR in urban areas was 67 percent compared to only 41 percent in rural areas with no roads.

51. Ethnic Composition of the Heath workforce27: Individuals from the Lao-Tai ethno linguistic group comprise 91 percent of the workforce; 7 percent are Mon Khmer; 2 percent are Hmong-Iu Mien; and 0.1 percent are Chine-Tibet.28 Knowing the ethnic composition of the health workforce can indicate whether there are factors at work that act as a barrier to entry to the health workforce by specific ethno-linguistic groups, and therefore whether equal opportunities commitments are being fulfilled. In some regions where there are large concentrations of smaller ethno-linguistic groups, and few Lao-Tai speakers, the provision of culturally appropriate health services illustrates the need to increase the number of health staff from the smaller ethnic groups working within the health system.

D. Ethnic Minorities in Viet Nam

52. Ethnicity and Population: In Viet Nam the majority “Viet” or “Kinh” people comprise 86 percent of the population of approximately 84 million. The “Hoa” or Chinese are a significant but generally prosperous minority who for the purposes of this discussion will be considered as part of the ethnic majority population. The lowland EMGs consist mainly of Khmer Krom, the original population of the Mekong Delta. Most EMGs belong to the

27 This section categorizes ethnic groups into four ethno-linguistic categories in line with the National Assembly Notification No.

213 (as reported in the newspaper Pasason on 4th February 2009). The notification authorises use of this classification. 28 MOH 2008, cited in the gender analysis from the HSDP, 2009



category of the population of Viet Nam referred to by the French as „Montagnards‟ during the colonial era, who historically inhabited the upland and high mountain areas bordering China, Cambodia a nd Lao P DR. The 53 of ficially recognized E MGs in V iet N am c omprise approximately 14.0 percent of the total population.29 62 percent of Viet Nam‟s EMGs inhabit high mountains plateaus and hillsides, while 27 percent live lower hilly areas.

53. Government Policy: The Government policy is that Viet Nam is a united nation of all ethnic groups in which al l c itizens are equal, i rrespective of ethnicity. Policy orientation is generally towards assimilation and creation of a unitary national identity. The Government is committed t o c reating f avorable c onditions for E MGs to develop a nd advance t oward mainstream so ciety. Ho wever, t he G overnment of ficially acknowledges pr inciples of respecting t he in terests, t raditional cultures, l anguages, c ustoms, and be liefs of al l e thnic groups. I t recognizes that socioeconomic policies and development programs should take into consideration the special characteristics of the r egions and ethnic groups, particularly ethnic minorities. Many studies30 show EMGs are significantly unequal in most measures of social development. EMGs are comparatively low in indicators of economic advancement. Eighty-seven p ercent of e thnic minority women i n r ural areas are s elf-employed i n agriculture and the same group is the least likely to be in wage employment

54. Government policy has encouraged population relocation into mountainous r egions leading to significant changes in the population composition of these regions. For example, Kinh people ac counted f or f ive p ercent of t he t otal po pulation in the C entral H ighlands in 1945, 50 percent in 1975, and more than 70 percent at present. Kinh people have become the m ajority inhabitants in s ome ar eas previously dominated by ethnic minorities. T hese demographic trends and the resulting pressure on lands and natural resources have created some tensions and disturbance in the Central Highlands.

55. Table 7 shows the pr oportion of e thnic minority p opulations in pr oposed P roject provinces and border districts.

Table 7. Proposed Project Provinces and Border Districts, Viet Nam


DISTRICT POPULATION

ETHNIC MINORITY GROUPS IN DISTRICT

ETHNIC MINORITIES (%)

Dien Bien 52,052 61.50% 92.50% Dien Bien 50.60% Son La

Moc Chau

152,028 Thai, H‟mong, dao, muong, xinhmun, kho mu, nhang, laha, Tay 71.70%

Yen Chau 67,234 Thai, H‟Mong, Dao, Xinh mun, Kho mu 76.30%

Mai Son 72.20%

85.10% Sop Cop 39,039 Thai, H‟Mong, muong, Khomu, Laos 99.80% 29 Official classifications are not considered satisfactory by some EMGs as well by some anthropologists, because some people classified as a single group are actually more culturally and linguistically diverse that the official classification implies. 30 Sources for this section include the draft report on Ethnic Minority Poverty In Viet Nam, World Bank, September 2009. Imai, Katsushi and Raghav Gaiha, 2007. P overty, Inequality and E thnic Minorities in Vietnam. Brooks World Poverty Institute WPI Working P aper 10, U niversity of Manchester. Asian D evelopment B ank, 200 2. Indigenous P eoples / E thnic M inorities a nd Poverty Reduction - Viet Nam. Manila, Philippines. van de Walle, D. and Gunewardena, D.,2001. Sources of ethnic inequality in Viet Nam, Journal of Development Economics, 65, 177-207.




DISTRICT POPULATION



Thanh Hoa Muong Lat 33,314 Muong, Thai, H‟Mong, , Dao, Khomu 95.40% Quan Hoa 43,995 Muong, Thai, H‟Mong, Khomu 90.80% Quan Son 35,355 Muong, Thai, H‟Mong 90.70% Thuong Xuan 60.10% Nghe An Que Phong 63,543 Thai, Tho, Kho mu, Hmong, 90.10% Ky Son 69,412 Thai, Kho Mu, Hmong 95.00% Tuong Duong 69,159 Thai, Kho Mu, Hmong, O Du, 90.60% 72.50% Anh Son 102,049 Thai 7.60% 0.80% Ha Tinh 0.80% Vu Quang 33,809 0.00% Huong Khe 107,001 Chut, Muong 1.00% Quang Tri Huong Hoa 55,234 Van Kieu, Pa Co 46.80% 75.60% Quang Nam

Nam Giang 86.00% Tay Giang 15,625 Ca Tu 95.50% Dak Lak Ea Sup 60,284 Thai, Muong, Dao, Tay, Gia rai 40.40%

Buon Don 61,318Thai, Muong, Dao, Tay, Hmong, Cham, Kho me, Bana, Gia rai, Ede 46.20%

Dak Nong

Cu Jut 88,204 Mnong, Nung, Tay. Hmong, Dao, Ede, Ma, , Muong 50.20%

Dak Mil 0.00% 51,702 Mno 19.00%

Tuy Duc 34,694 Mnong, Nung, Tay. Hmong, Dao, Thai, Ede, Chines, Muong 49.10%

Binh Phuoc Phuoc Long 202,462 Kho me, Stieng 14.70%

Loc Ninh 109,775 Tay, chines, Khome, muong, nung, Cham, Stieng 16.50%

Bu Dop 51,232 Tay, chines, Kho me, muong, nung, Stieng 17.10%

Tay Ninh

Tan Bien 90,586 Kho me, Cham, Thai, Muong, Tay, nung 2.30%

Tan Chau 121,215 Muong, Thai, Dao, Tay, Cham, Kho Me, Stieng, other 5.6%




DISTRICT POPULATION



Chau Thanh 129,447 Kho me, Cham, Thai, Muong, Tay, nung 1.70%

Ben Cau 65,003 Khome, Thai 0.20% 153,387 Chinese 0.20% An Giang Chau Doc 118,950 0.00% An Phu 190,931 Chinese 3.60% Tan Chau 184,129 Cham and Chinese 6.50% Tinh Bien Kho Me 29.60% Tri Ton 127,280 Kho me and Chinese 38.50% Dong Thap Tan Hong 90,792 0.00% Hong Ngu 225,569 0.00% Kien Gang Kien Luong 104,188 Kho Me, Chinese 17.00% Long An 44,946

Vinh Hung 46,286 0.13% Moc Hoa 76,000 0.77% Duc Hue 69,510 0.07% Thanh Hoa 55,753 0.10% Source: Health Provincial Report, Viet Nam 2009

56. Poverty a nd Ethnicity: In V iet N am EMGs are much p oorer t han t he ethnic majorities; poverty h as de clined among ethnic majority g roups w hereas t he economic condition of EMGs has stagnated (Table 8). More research has been done on ethnicity and poverty in V iet N am that in ot her c ountries of t he s ub-region be cause E MGs are much poorer than the ethnic majority Kinh and Hoa; the poverty headcount ratio was 64.3 percent in 2002, almost three times larger than that of the ethnic majorities (22.3 percent) and this fact needs to be explained.31

31 Draft report on Ethnic Minority Poverty In Vietnam, World Bank, September 2009.



Table 8. Poverty Rates and the Poverty Gap, Viet Nam32

Ethnic Category 1993 (%) 1998 (%) 2002 (%)

Poverty rate Kinh and Hoa Ethnic Minorities

53.9 86.4

31.1 75.2

23.1 69.3

Food Poverty Kinh and Hoa Ethnic Minorities

20.8 52.0

10.6 41.8

6.5 41.4

Poverty Gap Kinh and Hoa Ethnic Minorities

16.0 34.7

7.1 24.2

4.7 22.8

57. Table 9 shows more recent calculations of ethnic variation in poverty33. The analysts note that are insufficient observations in the Viet Nam Living Standards Survey (VHLSS) to estimate statistics for most ethnic groups individually, so have adapted categorizations from other sources34 to identify 6 ethnic categories to examine the disparities. It shows that some ethnic categories, in particular the Other Northern Uplands and Central Highland minorities are considerably poorer in expenditure terms than the Tay, Thai, Muong, and Nung, who are in term poorer than the Khmer and Cham.35 Many of the poorest ethnic minorities live in the highlands, particularly in border areas.

Table 9. Ethnic Variation in Poverty Measures, 2006, Viet Nam

Ethnic Category Poverty headcount (%) Poverty Gap

Kinh and Hoa 13.4 2.7

Khmer and Cham (lowlands) 34.6 5.8

Tay-Thai-Muang-Nung 45.2 11.1

Other northern upland EMGs 72.5 26.1

Central Highlands EMGs 73.6 25.7

Others 50.1 23.5 58. Livelihood of Ethnic Minorities: Programs have been in place for resettlement of ethnic minorities, and over the past decades some 3.14 million so-called „nomadic‟ people have been settled. So far there is little evidence that relocation into fixed settlement areas has improved the well being of EMGs. In many highland border localities, extensive forestry plantations now occupy land once used for upland rice cultivation and the populations who formerly utilized this land now face hardship and relative disadvantage in new locations and social and economic settings. In the northern region of Vietnam, programs to discourage shifting cultivation have faced many challenges. Despite provincial government efforts, most EMGS living in fixed settlements still practice their accustomed livelihood based on shifting

32 Vietnam Development Report on Poverty, 2004. Join Donor Report to the Viet Nam Consultative Groups Meeting, Hanoi,

December, 2003. 33 From a draft background paper by Baulch et. al. on poverty and ethnicity for the World Bank 2008-09 Vietnam Poverty

Update report 34 Baulch, B., Pham, H., and Reilly, B. (2008) „Decomposing the ethnic gap in Vietnam, 1993 to 2004‟, Manuscript submitted to Oxford Economic Papers 35 The analysts, Baulch et. al. note that these poverty headcounts for these four ethnic categories are statistically different from

one another at the 1 % level. This is not the case for the residual „Other category‟ which contains just 28 households.



cultivation, while a smaller proportion continue be nomadic, moving their settlements as they clear and cultivate new areas of land for planting. 36

59. Education: School enrollment rates for ethnic minorities are rising overall, but remain low for some groups, particularly minorities living in the Central and Northern Highlands. Primary school enrollment rates for ethnic minorities have stabilized at about 80 percent (approximately 12 percentage points lower than among Kinh and Chinese). Gaps are larger for secondary education. These gaps are attributed to poor infrastructure and accessibility, language and cultural barriers, limited quality of teachers, low suitability of the curriculum, and the perception that returns to education are low. Many ethnic minority children entering primary school face a language barrier. Of the 334 primary schools surveyed in the Viet Nam Living Standards Survey (VLSS) of 1998, only 10 provided some courses in an ethnic minority language. The quality of education in remote areas is also a concern. In highland areas, up to 50 percent of teachers are not fully trained.

60. Gender disparity: The literacy rate in 2002 for Kinh women was 92 percent, while the rate is 70 Thai women and 22 percent Hmong women, respectively. Education participation rates are lower among EMG girls and there are low literacy and education levels among EMG women. According to one survey, around one-fifth of ethnic minority young women reported never having attended school. Among 15-to-17 year olds, ethnic minority girls lag behind Kinh and Chinese girls by 10 percentage points, and behind Kinh and Chinese, or ethnic minority boys, by 13 percentage points. Enrollment rates for boys are equal for both Kinh/Chinese and ethnic minorities. While the percentage of school age children engaged in income generating activities fell nationally between 1997 and 2004 as more children stayed longer in school, ethnic minority girls in rural areas were more likely than other girls or their male counterparts to have worked. Gender disparities in education appear limited to certain ethnic groups. For example, in lower secondary school there appear to be more Nung, Chinese, Muong, and Tay girls enrolled than boys, while the opposite is true for Khmer, Xo-dang, and Hmong.

61. Health: A Ministry of Health survey in 2003 shows health indicators lag behind for ethnic minorities.37 Most provinces with high infant and child mortality rates also have high concentrations of ethnic people. Childbirth without prenatal care is a high as 60 percent among ethnic minorities, as compared to 30 percent for the Kinh population. Family planning remains a sensitive issue among ethnic minority groups. The infant and child mortality rates among EMGs in the Northern Mountains border regions are twice the rates of the majority Kinh in the Red River Delta region, while the maternal mortality rate was nine times higher. There is a shortage of qualified ethnic health care professionals who can bridge the language and culture gap in the provision of health services in certain geographic areas. Despite the availability of health care, 63 percent of Northern Mountain ethnic minority groups and 75 percent of central region ethnic groups give birth alone without trained health assistants; 98 percent of people in Viet Nam live in communes that have access to a commune health center, but only 59 percent live in communes where the commune health center has a medical doctor.

62. The proportion of EMGs living in communes where the commune health center has a medical doctor is only 30 percent, as compared to 63 percent for Kinh or Chinese people. There are striking gaps in malnutrition between the majority population and ethnic groups in mountainous areas. Approximately 23 percent of all ethnic minority children are underweight for their age. This proportion is even higher among ethnic people in the Northern Highlands

36 ADB (Asian Development Bank) (2002) Indigenous Peoples / Ethnic Minorities and Poverty Reduction - Viet Nam. Manila,

Philippines. 37 Viet Nam Ministry of Health National Health Survey, 2001–02, Ministry of Health report 2003.



(34 percent), and in the central coast and the Central Highlands (45 percent). Malnutrition is also more severe among these groups.

Box 3. Ethnic Minority Poverty in Viet Nam

A recent paper on ethnic minority poverty in Viet Nam for the World Bank‟s 2008-09 Vietnam Poverty Update points out that the scale and depth of ethnic minority poverty in Vietnam presents one of the major challenges to Vietnam achieving the targets for poverty reduction set out in the Socio-Economic Development Plan, as well as the Millennium Development Goals.

Ethnic minority poverty in Vietnam is multi-dimensional and increases cumulatively with the life course. This is the results of a complex interplay of several overlapping layers of disadvantage which start in utero and continue until adult life. Counter-acting such disadvantages requires multiple interventions coordinated across a number of sectors, which pose complex implementation challenges in Viet Nam‟s multi-layered system of government. Nonetheless, there are certain initiatives in the nutrition and education sectors (e.g., the bio-fortification of staple foods, provision of nutritional supplements to women of child bearing age in mountainous areas, the development of weekly boarding schools, and the extension of simple conditional cash transfer/scholarship programs) that are relatively simple to implement and which would make an important difference to the life chances of ethnic minority children.

Counter-acting the disadvantages which ethnic minority people face later in their life, especially improving their rural livelihoods and access to wage employment is more complex. In the agriculture and forestry sectors, extension systems which are sensitive to the farming systems and tenure practices of the different minorities require development. Improving infrastructure in the remote villages in which the smaller and more disadvantaged ethnic groups live, also has its role to play in improving the returns they receive to their assets. However, given the extensive investments which have been made here in recent years, the importance of further investments in infrastructure should not be overstated. In the wage employment field, further work is needed exploring the extent to which ethnic minority workers experience „unequal treatment‟, or whether their clear inability to access wage jobs outside the public sector is a function of their education (combined, perhaps, with „educational screening‟), networks and Vietnamese language ability. Finally, the importance of promoting growth that is geographically broad and socially inclusive is essential. Without a more equitable pattern of growth, the current disparities between the majority Kinh and Hoa and ethnic minorities are sure to continue growing.

Ethnic minorities have benefited less from interventions to promote economic growth than other groups. EMGs relocated on registered land as sedentary cultivators have generally remained poor or became poorer or even suffering from hunger and many returned to shifting cultivation. ADB (2002)38 comments that the capacity of EMGs to make full use of the Government‟s investment in resettlement programs has been low and that the program itself had many inadequacies. The ADB‟s Viet Nam Poverty Assessment (2006) found poverty continues to be strongly related to ethnicity. In 2004, only 13.5 percent of Kinh and Chinese were poor, while 60.7 percent of the ethnic minorities lived below the poverty line. The gap was even bigger in terms of food poverty. There was almost no food poverty among Kinh and Chinese (3.5 percent), while 34.2 percent of ethnic minorities were classified as food poor. While minorities living in the Mekong Delta have experienced a steady decline in poverty and have lowest rate of ethnic minority poverty of all regions, poverty has been increasing among ethnic minority groups living in the Central Highlands despite government action to achieve equitable development.

63. Health Care Funds for the Poor: Poverty, as well as remoteness in some cases, is a significant barrier for EMGs in Viet Nam to access health care. The government allocated funds annually to the provincial HCFP to support the provision of health care services to the poor, including ethnic minorities in mountainous provinces.39 However, experience in the

38 ADB (Asian Development Bank, 2002, Indigenous Peoples / Ethnic Minorities and Poverty Reduction - Viet Nam. Manila,

Philippines. 39 These funds originally could be used to support the purchase of health insurance cards or to directly reimburse providers of

health services to beneficiaries. Beginning in 2006, provinces are generally required to use the health insurance



Central Highlands and elsewhere has identified a number of weaknesses and constraints in implementation. These include problems related to: (i) awareness of beneficiaries concerning entitlements and requirements; (ii) distribution and replacement of health insurance cards; (iii) limits on coverage of health services and indirect costs such as transport and food; (iv) awareness and motivation of health care staff in providing covered services; (v) limited capacity of health care facilities and Viet Nam Social Security (VSS) to process reimbursement claims under the program; and (vi) general weaknesses in management and monitoring40.

64. The maps included in Annex 1 further illustrate, in a visual form, the geographic distribution of EMG in the GMS as well as the issues that impact on the their livelihoods as detailed in Section II above.

III. CDC ISSUES FOR MIGRANT WORKERS IN THE GMS

A. Background

65. The process of economic integration in GMS has contributed to greatly increased flows of people as well as goods across borders. Increasing attention under the GMS Program has also been given to other sectors: human resource development, tourism, the environment, investment and trade with initiatives to resolving policy, regulatory and other non-physical barriers to the cross-border traffic, complementing investment in transportation infrastructure.

66. There has always been population mobility among the countries of the GMS but the nature and size of the flows are now very different. In the past, borders changed in conflicts between small states and through colonial interventions from the 18 th century, and ethnic minority groups living in border areas moved freely in the region. From the mid-70s to early 90, most GMS countries became more isolated and there were significantly reduced cross-border movements, with the exception of the continuous movements into Thailand of displaced persons and refugees.

67. Over the past decade or more, much of the GMS has experienced a double transition: from subsistence farming to more diversified economies, and from command economies to more open, market-based economies.

68. While greater integration has contributed to the subregion becoming an internationally recognised growth area, there have also been costs. The roads have had impacts on the environment of the sub-region from the uplands to plains to coastal areas affecting people‟s livelihoods, particularly the three-quarters still living in rural areas, where they lead subsistence or semi-subsistence agricultural lifestyles.

69. One recent trend has been the opening up of remote provinces. For example recent studies by the International Organisation for Migration indicate the impacts of opening up remote in Cambodia to commercial enterprises. In Ratanakiri (bordered by Viet Nam and Lao PDR), the provincial population grew from 94,243 to 149,997 between 1998 and 2008, with 88 percent of the population residing in rural areas; the population grew nearly 60 percent in ten years. Similarly, in neighbouring Mondulkiri province, there has been an 80

mechanism. Proposed revisions to Decision 139 include certain changes in the definition of target groups, but the net effect of these changes is expected to be an increase in the number of eligible beneficiaries.

40 Project Preparation Draft Final Report: August 18, 2007, Project Number: VIE 4855 Proposed Loan Socialist Republic of Viet Nam: Health Care in the South Central Coast Region



percent population growth in the last five years. In both cases the change is mainly due to the influx of Khmer populations into the province.41

70. It has not been possible within the scope of this Regional Project Preparation Technical Assistance (RPPTA) to do a detailed or quantified study of population movements facilitated by the GMS economic corridors or their CDC impact; however observations from the RPPTA team field visits in October 2009 in Lao PDR provide some indications of the issues and potential impacts.

71. Example of mobility from North-western Lao PDR: In Bokeo Province in the area known as „the golden triangle‟ where Lao PDR, Thailand and Myanmar border one another on the Mekong River, a very big casino has opened, although construction is ongoing. It has been financed by private investment China, reportedly from Macao. An associated hotel, shopping mall and staff quarters have been completed, and work is beginning nearby on a big resort complex which will include villas, canals and golf courses. The road between the provincial centre of Bokeo and the development is being upgraded, reportedly with private investment from China. This road connects to the economic corridor through to Luangnamtha Province and Yunnan Province in China. Along this road, which mainly follows the Mekong River flats, are hundreds – perhaps thousands – of hectares of plantations producing vegetables and maize. The plantations are reportedly leased and operated by Chinese companies.

72. In Luangnamtha Province, which border and is linked to Bokeo province by the North South economic corridor, a new border crossing has been opened at Boten (Namtha district). A casino and several hotels have been built on the Lao PDR border and there is a very large market place comprising hundreds of small Chinese-owned shops selling goods from China and Thailand, and accepting only Thai and Chinese currency. On the highway between the provincial centre and this border crossing (there is another in Sing district with similar development), there are hundreds of plantations, mainly rubber but some of timber trees. Most of those close to the road are smallholder plantations, supplied by a Chinese company, further from the road, there are reportedly thousands of hectares of large-scale rubber plantation under management of a Chinese company.

73. The response to these developments among government officials interviewed was positive; the provinces had been backwaters but were now booming. However one concern they raised was the health impact of labor migration which they thought might be inevitable, given the scale of investments and the potential labour demand. Already it is rumoured that labor from Myanmar is being employed on private investments in Bokeo.

74. It seems unlikely these provinces will be able to supply the demand which must grow for construction workers, agricultural labourers and rubber tappers from their own local populations. It seems likely that the cross-border scenario developing in these provinces is one in which labor will be recruited from EMGs within the two provinces and others in northern Lao PDR, from Myanmar. Skilled workers and business managers will come from China. Tourists will come mainly from China and Thailand.

75. The risk recognised by local officials was particularly Human Immunodeficiency Virus (HIV) and other sexually transmitted infections (STIs), as the sex industry flourishes under these conditions and that human trafficking could become a greater issue42. However there will be significantly increased risks from new and emerging infectious diseases including 41 Haynes Sumaylo, K. K., 2009. Mapping Vulnerability to Natural Hazards In Rattanakirii. International Organization for Migration (IOM), Mission in Cambodia. Thuon T. & Haynes Sumaylo K. K., 2009. Mapping Vulnerability to Natural Hazards In Mondulkiri. International Organization for Migration (IOM), Mission in Cambodia. 42 See: Asian Development Bank, 2009. Broken Lives: Trafficking in Human Beings in the Lao PDR. Manila



influenzas, Dengue, Japanese Encephalitis and Malaria, as well as the neglected tropical diseases associated with poverty and poor environmental hygiene. These issues have been partly addressed in the four studies summarised below.

76. In 2003 a study 43 was conducted in this region, on the social and health impact of the upgrading of route 17B that connects the border districts of Sing and Long and Namtha in Luangnamtha (and the neighbouring province of Bokeo) with the North South GMS Corridor. It documents extensive long and short term migration of Chinese into Luangnamtha as traders and business operator and technical advisers on plantations. Attractions include cheaper land and business spin-offs from Chinese-owned construction, plantation, casinos and hotels, and marketplaces. Unskilled labor was being locally recruited, mainly from EMGs. Table 10 from this study presents border crossing data on vehicles crossing to and from a crossing in Sing district, showing the national disparity of movements between Lao and China.

Table 10. Cross-border Vehicle Traffic: Phangthong Local border with China (near Sing District town), 2001-

2002

Type of Vehicle Lao Vehicles going to China Chinese Vehicles entering Muang Sing

Trucks 212 2,065

Buses 574 2,063

Motor cycles and Tuktuks 2,932 1,133

Total 3670 5,211

77. Table 11 from the study shows the movement of people and vehicles in statistics also make clear the highly volatile nature of such movement. As SARS struck the region in early-mid 2003 the number of travellers dropped noticeably at the international border point (Boten) but less obviously at the local entry points into Sing district (Pangthong and Ban Mom).

Table 11. Border Traffic Recorded for Luangnamtha, 1999-2003

People Crossing 1998 1999 2001 2002 2003

Boten International crossing (Namtha)

Entry (all foreigners)

13,433 17,396 21,785 22,452 15,799

Exit (Lao) 6405 3482 5088 5419 4745

Pangthong Local crossing (Sing)

Entry (Chinese) 8,281 15,803 14,747 14,552

Exit (Lao only) 10,352 7,924 11,696 15,035

Sopla River Crossing (Sing)

Entry (Chinese 10,838 12,739 10,636 7,889 10,507

Exit 59 52

43 Lyttleton, C. et. al., 2004 Watermelons, bars and trucks: Dangerous Intersection in Northwest Lao PDR. Institute for Cultural

Research of Lao and Macquarie University.



People Crossing 1998 1999 2001 2002 2003

Ban Mom

Entry (Chinese) 2,067

Exit 1,251

VEHICLES

Boten

Entry (all foreigners) 1,660 1,872 1,911 1,520 1,270

Exit 3,074 2,629 2,794 2,974 3,788

Phangthong

Entry (Chinese) 3,670 5,211 4,399 3,961

Exit 3,581 3,670 3,364 3,325

Sopla (boats)

Entry (Chinese) 1,319 1,645 1,389 1,194 1,286

Exit 10 9

Ban Mom

Entry (Chinese) 464

Exit 49

78. The following sections summarise information from four migration studies in GMS.

B. Population Mobility in the GMS

79. A study of population mobility between Lao PDR, Myanmar, Viet Nam, Thailand and Yunnan Province of PRC 44 found that since the late 1990s most migrants crossing borders in the region have been responding to economic incentives. Each country, except Myanmar, has increasing rural to urban population flows. Each country has flows to border sites, as well as to remote construction or mining sites. These internal flows may include seasonal labour, trading, travel to markets and festivals, tourism, and service and transport industry workers, plus uniformed and state officials as well as private sector personnel.

80. Transnational population movements include much the same groups as the internal movements with both emigration and immigration occurring in each country. Thailand receives most of this emigration from Myanmar and in total has almost a million migrant workers in the country, with numbers having marginally decreased since the financial crisis. Viet Nam has many thousands of workers in Cambodia and abroad, with the number of documented workers going abroad projected to rise sharply. Cambodia has had many thousands of workers in Thailand and a few thousand in Malaysia. Even Lao PDR has possibly tens of thousands of workers from China and Viet Nam, mostly documented, but this is more than matched by emigration to Thailand, with as many as 100,000 undocumented migrants annually.

44 Chantavanich, Supang et. al., 2000. Mobility and HIV/AIDS In The Greater Mekong Subregion. Asian Research Center for Migration Institute of Asian Studies Chulalongkorn University Bangkok, Thailand in consortium with World Vision Australia and Macfarlane Burnet Centre for Medical Research under TA 5881 REG: Preventing HIV/AIDS Among Mobile Populations in the Greater Mekong Subregion Asian Development Bank (ADB) United Nations Development Program (UNDP)



81. The m anufacturing, se rvice, a griculture, f isheries and c onstruction sectors attract many unskilled w orkers. Other mobile po pulations include t ransport w orkers, t raders, businessmen and sales representatives, fishers and seafarers. State and uniformed officials are constantly on the move, and they may also cross borders or travel overseas. Thailand, where the economy has been booming for decades attracted many Cross-border migrants; its border is porous, with little difficulty in crossing, from Lao PDR, Myanmar and Cambodia. Once across the border migrants are readily employed in a range of low-paying jobs, but for many their illegal status, language difficulties, and low awareness of their new surroundings places them in a precarious position.

82. The opening of c ross-border t rade and t ourism has revitalised many border t owns and settlements. These border crossing points are m eeting places of t housands of mobile and migrant po pulations, namely, t ransport w orkers, t raders, t ourists and v isitors, b order police and military personnel, service and entertainment workers etc. They are destinations for some, and transit points for others, whether classified as mobile populations or migrant workers.45

83. Men pr obably number s ignificantly higher a mong mobile pop ulations and migrant workers, although the number of women migrants is increasing and, in some migration flows, their numbers can be equal to, or higher than, that of male migrants. In urban settings in particular, there are m any opportunities for women in factories as garment workers, in the expanding service and entertainment industry, as housemaids or as sales clerks. They also find work in construction and agriculture. Some women accompany their husbands or family members but many migrate al one or w ith f riends. T his latter gr oup is susceptible t o difficulties during travel and at the workplace. They may be sexually or physically abused or be confined to the workplace. Working in difficult conditions, women can be induced into sex work when offers are made to them.

C. The GMS Labor Migration Study

84. This following section summarizes some of the key findings on migration and health from a study of migration in the GMS46:

Overall economic growth has failed to reduce gaps between rural and urban areas, and greater economic i ntegration h as not na rrowed t he gaps between m ore industrialized and l ess industrialized c ountries, w ith T hailand, V ietnam, and Y unnan showing the biggest proportionate gains with regards to trade, investment and economic growth.

The G DP of e ach G MS c ountry is increasingly earned i n u rban o r pe ri-urban industrial areas or from t ourism ( largely based in or n ear ma jor G MS cities), notwithstanding t he f act t hat a large pr oportion of t he G MS population (ranging f rom approximately 50 percent in Thailand to over 80 percent in ot her countries in the sub-region) is still e ngaged i n low-earning ag ricultural ac tivities. H owever, f armers are increasingly becoming a source of low-wage labor in the rapidly expanding construction, service and manufacturing sectors in booming urban and semi-urban areas.

While most migration i s r ural to urban w ithin n ational b orders the e merging transnational trend for the sub-region is intra-regional cross-border migration, most of it involving u ndocumented and l ow-skilled m igrants and m anaged through an i nformal

45 Since this study was undertaken new casinos have opened in Bokeo province of Lao PDR, on the borders of Thailand and

Myanmar, and in Luangnamtha, Lao PDR on the border with PCR. 46 Caouette, T., Sciortino, R., Guest, P., Feinstein, A., 2006. Labor Migration in the Greater Mekong Sub-region. Rockefeller Foundation‟s Southeast Asia Regional Program (SEARP). Map 2 is from this source.



network of f amily, f riends and brokers.8 I nterviews, how ever of ficial do cumentation generally does not exist, and quoted figures are often inconsistent (see Map 3).

GMS countries have become closely connected to each other through cross-border labor migration f lows. Each of them has become, to different degrees, sending, transit, and de stination c ountries for workers from th e s ub-region. T he gr owing i ntra-regional flows have been m ainly irregular, but this may soon change as GMS countries embark on officially exporting workers to ensure an economic boost of foreign remittances and a better management of migration f lows. A notable s ignal o f this change was the signing by Th ailand of bi lateral agr eements with La o P DR (2002), Cambodia ( 2003) a nd Myanmar (2003) t o import 10 0,000 w orkers from e ach c ountry, with t he logistics subcontracted to labor recruiting agencies overseen by government institutions.

Not only do migrants travel to neighbouring countries as a final destination, they also use t hem as transit countries before goi ng to o ther c ountries within the s ub-region or elsewhere. V iet N am i s a gateway for m igrants from China t o C ambodia an d L aos. Myanmar, Laos and Cambodia are i n turn t ransit countries for migrants f rom Viet Nam and China making their way to Thailand. For a small proportion of migrants to Thailand, Thailand is also a t ransit point t o Myanmar, Macao, Hong Kong, Singapore and ot her countries.

The di fferent s tages of i ndustrialization of c ountries in t he G MS a lso c reate a differentiated sub-regional labor market: Thailand faces a labor shortage in certain low-skilled sectors, while Laos, Cambodia and Myanmar face an unskilled labor surplus due to rural poverty, underdeveloped infrastructure and low or poor-quality education.

Women g enerally are at a d isadvantage. T he process of feminization of poverty in the r egion, w ith two-thirds of t he poo r i n r ural a reas and i n new urban settings being women, is leading to a growing feminization of both the work force in emerging industries and of migration f lows, w ith an increasing number of w omen migrating internally and abroad in occupations where they are paid lower wages, experience greater exploitation, and have l ess legal protection c ompared to their male counterparts. Women are also more v ulnerable t o t rafficking, n ot only for s exual purposes, bu t a lso f or servitude i n domestic work and sweatshop labor.



Map 3. Migration Trends in the Greater Mekong Sub-region

85. Aside from the fact that unregulated migration exposes migrants to many socioeconomic and legal risks, and that statelessness and trafficking compound irregularity, migrants face many great health risks. Data from Thailand shows that there is high incidence of communicable diseases among GMS migrant workers. Many arrive with pre-existing infectious conditions, while most are vulnerable to acquiring infectious and parasitic diseases from living in insanitary environments. For example in Thailand, which has the largest and best documented inflow of migrants in the GMS, malaria is the main cause of death among migrants, with a growing number of other mosquito-borne diseases such as dengue fever and lymphatic filariasis. Cholera and especially tuberculosis are prevalent and on the rise among migrant workers, thus forming a renewed threat to the Thai population.

86. According to Thailand‟s 2004 registration data, tuberculosis was the disease with the highest prevalence among tested migrants, with 5,300 out of the 9,500 sick applicants found infected. Other significant health hazards include diseases related to malnutrition such as beriberi, skin and eye infections, and sexual and reproductive health problems. However, migrants make little use of health services in host countries, due to language problems, registration status issues, fears of arrest, and the attitude of providers.



87. There i s growing e vidence t hat rather t han bringing t he H IV t o the de stination country, migrants become v ulnerable t o c ontracting H IV du ring t ransit a nd o n a rrival, eventually carrying it back to t heir h ome c ommunities on return. T hailand as the c ountry worst hit by the epidemic in the GMS, with an estimated adult HIV prevalence of 1.4 percent by the end of 2005, is a likely source of infection for migrants from countries with a lower prevalence rate (see footnote 1).

88. Conclusions of the GMS Labor Migration study relevant to Project are the following:

New approaches to migration policy and interventions require accurate information. While there is now more research attention to migration, there remain serious knowledge gaps and inadequacies. The volume and scope of migration in the GMS may be growing, but statistical and other quantitative data that would allow monitoring and assessment of this trend is minimal, and for some countries almost non-existent.

Efforts of the Asia Development Bank and the World Bank, the major donors to GMS countries, are needed to promote facilitation and regulation of migration in the sub-region by employing n ot only s ocial, b ut also economic a rguments to a dvocate pr otection of migrant labor.

Stronger, r eceiving e conomies could c ontribute more t o r educing t he w idening disparities across countries are that drives both regulated and unregulated migration.

D. Study of Health of Undocumented GMS Migrants Residing in Thailand

89. A s tudy of h ealth an d mortality differentials of migrants from M yanmar, L aos and Cambodia47 found that undocumented migrants typically live in unhygienic and poor sanitary condition. A lack of k nowledge, l imited access to h ealth se rvices and mobility condition intensify migrant‟s vulnerability to health problems and mortality. Major causes of sickness among these migrants were acute diarrhea, malaria and pyrexia with unknown origin. Major causes of death a mong Myanmar m igrants are m alaria, pne umonia, tuberculosis, leptospirosis and s uicide w hile pneumonia, tuberculosis, hepatitis, meningitis and t etanus are c auses of d eath a mong C ambodian migrants. A major c ause of de ath a mong L ao migrants is pneumonia. Results from the vital registration revealed that majority of Myanmar and C ambodian migrants died f rom communicable d iseases (CDs) but t he m ortality rate from CDs was lower among Lao migrants.

90. The D epartment of D isease C ontrol, M inistry of P ublic Health, T hailand has conducted an nual s urveillance t o monitor s pecific cause of s ickness and de ath a mong migrant workers, cross border and foreigners in Thailand since 1996 to the present. These data show that migrant morbidity and mortality have r isen f rom 16,578 to 31,205 patients annually during the last decade. In 2006, 31,205 migrants and cross border and f oreigner patients attended hospitals. Mortality rates are around 0.14. Of these, 22,047 were migrant workers and 2,841 c ross border and foreigners patients aged 15-44 years. 72.26 percent were f rom Myanmar followed by Cambodia, Laos, China, Malaysia and Vietnam. Myanmar and Cambodian migrants tend to have higher case fatality rate w hen compared with Laos migrants and native Thai people (Figure 1).

47 Srivirojana, N. and Punpuing S. 2009. Health and mortality differentials among Myanmar, Laos, and Cambodian migrants in Thailand. http://paa2009.princeton.edu/download.aspx?submissionId=91913

http://paa2009.princeton.edu/download.aspx?submissionId=91913



Figure 1. Mortality Rates by Nationality, 1998-2006

91. The major causes of morbidity among migrants were acute diarrhea, malaria, pyrexia of unknown origin, hemorrhagic conjunctivitis, pneumonia, sexually transmitted diseases, food poisoning, tuberculosis, dengue hemorrhagic fever and dysentery. Malaria, pneumonia and tuberculosis are major causes of death among migrants from Myanmar and Cambodian migrants while major concern among migrants Lao PDR is only pneumonia (Figure 2).

Figure 2. Morbidity Rates by Diagnosis and Nationality, 2006

0

10

20

30

40

50

60

Acutediarrhoea

Malaria Pyrexia ofunknown origin

HaemorrhagicConjunctivitis

Pneumonia Food poisoning Sexuallytransmitted

diseases

Percentage

ThaiMyanmarLaosCambodia

0.53

0.43

0.12

0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.13

0.00

1.07

0.29

0.52

0.20

0.35

0.09 0.07

0.68

0.70

0.260.18 0.200.24

0.74

0.64 0.480.42

0.12

0.080.090.11

0.160.160.13

0

0.2

0.4

0.6

0.8

1

1.2

1998 1999 2000 2001 2002 2003 2004 2005 2006

Case fata

lity

rate

/100 p

ers

on Myanmar

Laos

C ambodia

Thai



53

3

13

0.7 1.2

23

37

10

27

9

18 18

9

20

10

20

30

40

50

60

Pneumonia Malaria Tuberculosis Hypatitis Meiningitis

Perc

enta

ge

ThaiMyanmarCambodiaLaos

92. The study concluded that the health status of migrants from Myanmar, Laos and Cambodian to Thailand is evidence of their marginalizion and inadequate access to health services, both in their origin countries and in Thailand.

E. The Svay Reing, Cambodia Migrant Health Survey

93. This study was conducted by the International Organization for Migration near the Bavet-Mocbai cross-border point, which became an international border crossing in 2005. More than 850 people go through this cross border point every day. On August 2008, Samrong-Samor, another cross-border point near the study site, was opened as an international border crossing area.

94. Cambodia follows the general GMS pattern of internal migration in that movement is mainly rural to urban, but there are also significant population movements from internal rural areas to border areas. Lack of employment opportunities, increasing landlessness and poverty in rural areas are driving this internal migration, while the push factors are often linked to incentives prompting international migration. Cambodia has recently opened its doors to regular labor migration. The government is actively promoting labour migration policies and programmes to improve labour migration management. However, many workers continue to choose irregular channels, mainly because of the cost and time associated with regular migration and general distrust toward the bureaucratic procedures involved.

95. Most of the cross border migration is from Cambodia to Thailand. As of 2005, there were 104,789 registered Cambodian labour migrants in Thailand, representing approximately 13 percent of the total number of legal migrant workers in that country. While the majority of migrants to Thailand move voluntarily, trafficking from Cambodia to Thailand and to other countries is a problem.

96. Cambodia is a destination country for both labour and other types of migrants, some of who have settled permanently, primarily from Viet Nam and China. Vietnamese emigrants are by far the biggest migrant group in Cambodia. It is difficult to estimate the exact numbers; however, the Asian Migrant Centre (2002) estimated that there are more than one million Vietnamese migrants in Cambodia.

97. A serious issue is the trafficking of women and girls from Viet Nam to Cambodia into the sex industry, and is the major pattern of trafficking; however trafficking from and within Cambodia is also a concern. Women and children are trafficked internally and to neighbouring countries such as Thailand, China, Malaysia and Viet Nam to work as



domestic workers, beggars, or i n the sex industry. Cambodian m en are m ore likely to be trafficked to labor in the construction and fishing industries. Due to the clandestine nature of trafficking, it is difficult to make accurate estimates of the number of victims involved.

98. The s urvey as sessed k nowledge of epidemic risks and a ttitudes and p ractices for prevention. I t w as ba sed o n 83 0 i ndividual interviews i n 20 08 in the C ambodia – Vietnam cross-border districts of Chantrea and Svay Teap in Svay Rieng province. The respondents consisted of migrants employed within the formal sector (garment factories and casinos) and others working i n the i nformal s ector - Cambodian r eturnees and Vietnamese m igrants in Cambodia. Key findings were:

Knowledge

Respondents had some knowledge of communicable diseases, particularly HIV/AIDS and Avian Influenza (AI). About eight out of 10 respondents considered that they or their families could be at r isk from t hese di seases; t he m inority who w ere not c oncerned thought they could protect themselves or were not at risk because they were healthy and strong.

Television, r adio a nd physicians w ere r egarded as the be st s ources of he alth information. T he v ery low ranking o f he alth w orkers and information, e ducation a nd communication ( IEC) materials indicates that migrants the bot h f ormal a nd informal sectors in these ar eas have l ittle co ntact wi th government h ealth service p roviders, o r that t hese s ervice pr oviders do not have effective pr ograms for public information o n CDC. Of t hose w ho ha d be en gi ven i nformation, a round t wo-thirds received i t f rom employer c ompanies and non gov ernment or ganizations (NGOs). About 2 0 pe rcent obtained s ome i nformation f rom Government he ath s taff o r c ommunity officials. Language was the most commonly identified barrier to receiving health information.

A v ery high p roportion of migrants believed t hat h ygiene i s the k ey to maintaining good health but showed limited understanding of hygiene. 94 percent of the respondents claimed they washed their hands before eating, while around 63 percent said they used soap w hen w ashing their hands. M easures to pr event of i nfection m entioned were washing one‟s hands after coming in contact with an infected person and avoiding close contact with an infected person. Misconceptions of how to avoid AI were common.

Health Seeking Behaviour

Trust w as identified as the major factor in c hoosing h ealth se rvice p roviders. Cambodian r eturnees were t he m ost c oncerned a bout c ost and l ocation. M igrants working in the formal sector were more l ikely to have sought health care compared to those in the informal sector primarily because they had better access to health services. Respondents said the pl aces they would go t o if s ick w ere, i n o rder of f requency: i ) government hospital; ii) government health centre; i ii) private doctor; iv) pharmacy; and iv) p rivate cli nic. However, actual t reatment sought during the past 12 m onths was, in order of frequency: i) pharmacies; ii) government hospital; iii) government health centres; iv) private doctors; and v) relatives; signifying a tendency to practice self-medication.

Being unable to pay for treatment was the most frequently cited barrier to accessing health s ervices among t he C ambodian r espondents and t he s econd most f requently cited barrier among t he V ietnamese r espondents. M ost a lso f eared l oss of income by taking time off work to visit a health service provider. The irregular hours and weekly or monthly rotations of casino and garment workers do not coincide with the opening hours



of many public and private sector health facilities. The fact that pharmacies are open longer than health facilities may be the reason for their popularity.

F. Implications of These Studies for CDC2

99. Provincial health service providers, in cooperation with other government agencies and NGOs need to include strategies for improving the health status of migrants in the province, especially those who are poor and have high risks of becoming infected by CDs.

100. Provincial health strategies, plan and budgets need to be based on better information on the situation, location and flow of migrants in each province.

101. The comprehensive baseline study proposed for CDC2 should be designed to capture this information and update it regularly for ongoing planning, activities and monitoring and evaluation (M&E).

102. The IOM, which is already working on migration and health issues and policy in the GMS would be the most appropriate technical adviser and sub-contractor for collecting information on migration issues in the comprehensive baseline study and could be considered for funding under CDC2.

103. Legal issues are dealt with at national levels and ADB should include the health and welfare of migrants in its policy dialog with the governments of GMS.

IV. CDC GENDER ANALYSIS

A. Introduction

104. There are two main gender challenges to be addressed in CDC. 48

105. Gender and health needs: The first challenge is to encourage health policy and services that recognize the differences in the health needs of men and women. Women and girls have specific health needs as a result of their biological differences with men. In the health system in CLV, women‟s specific biological needs are recognized to a greater or lesser extent in the provision of maternal and reproductive health services, and in the associated health policy, plans and budgets. However, men and women also have different degrees of vulnerability to infectious diseases, depending on how they are exposed. Men and women have different roles in the management of their households and in productive and livelihood activities which can affect their specific disease vulnerability. Further, there are differences between the sexes in their access to information. Women are often less well informed than men on the sources of communicable diseases and how to prevent them.

106. Gender equity in health services: The second challenge is to encourage gender equity in health sector staffing that leads to better health outcomes for women and men. Gender relations (the social and cultural rules that influence relationship between men and women) influence the roles of women and men role. In CLV, women have different social statuses to that of men which vary with class and culture. Gender differences in status and power affect women‟s career opportunities in the health professions. Women are concentrated in service delivery jobs and greatly under-represented at decision-making levels. Those in senior positions are more likely to be men. This difference is not just an equity issue. When women‟s perspectives are not represented in senior management, it is less likely that practical and effective gender-sensitive policies will be developed. At the

48 This report owes much to the work and analysis of Cathy Green, ADB Social Development and Gender Technical Adviser for the Lao PDR MOH Health Systems Development Project ADB Grant 0079-LAO., 2009.



same time community based health services need equal or greater numbers of women staff and community workers to address women‟s specific health needs. Inequity is closely linked to women‟s roles as wives and mothers. Highly qualified women are m ore l ikely to ho ld positions in towns and cities because of their husband‟s jobs and their children‟s educational needs.

107. The following analysis examines these issues more closely at regional and national levels.

B. Gender and Vulnerability to Communicable Diseases

108. Gender is a significant CDC variable: Recent research on gender and CDC in the CLV region shows than gender is a significant variable in understanding the spread of, and planning response to, communicable diseases. Gender differences in disease rates can be interpreted i n b oth t he c ontext of b iological differences between m en an d w omen (sex differences), and t he di fferences b etween al so t he di vision of household an d e conomic tasks be tween m en and w omen a nd pow er r elations between m en and w omen ( gender differences).49

109. Emerging i nfectious d iseases ( EIDs): Relevance of g ender di saggregated dat a and ge nder a nalysis i n e pidemiology h as been most r ecently de monstrated f or C LV b y recent AusAID a nd ASEAN-sponsored s tudies of ge nder v ariables in A I and Dengue Hemorrhagic Fever (DHF). The studies concluded that gender sensitivity will make national and r egional i nitiatives for he alth I EC strategies and o perations more c ost-effective a nd efficient.50

Dengue. The s tudy found women and children ar e more vulnerable, b ecause t hey spend more time in the household compound area where Aedes Aegypi mosquitoes are most likely to breed in proximity to human beings. Women of reproductive age may also be m ore b iologically vulnerable t o t he h emorrhagic form of t he d isease than m en, although t his issue n eeds f urther evidence-based r esearch. M en a re m ore l ikely to understand the source of the disease. Avian Influenza: The study found women are at greater risk of AI than men because

of their roles in routine small-scale poultry farming commonly found in CLV. The ASEAN study in Cambodia and Viet Nam shows that women‟s role in poultry production is most frequently concentrated on feeding, cleaning, marketing birds, which makes them more vulnerable to infection than men, whose role is more likely to be slaughtering live birds and plucking them. But male children are m ore l ikely than female children to play with birds and in areas where birds are kept, and therefore have greater risk of infection. It was found that it was generally well understood by men and women that sick birds may infect hu mans, b ut w ays to reduce r isk of infection t ends to be poo rly understood, especially by women.

110. The need to convince women of disease risks is the major finding of the ASEAN study, because women are much more likely than men, in the countries studied: to manage household f inances; and to exercise c onsiderable decision making au thority on ho usehold matters, including management and expenditure. The study found gender differences in how 49 Differences b etween m ales a nd f emales ar ise b ecause of biological dif ferences a nd as a c onsequence of gender-based roles, beha viour and p ower. The dis tinction between t hese t wo concepts is im portant, i t is not alw ays eas y t o at tribute differences in disease processes uniquely to either sex or gender, s ince sex and gender are not independent of one another. WHO. 2007. Addressing sex and gender in epidemic-prone infectious diseases. Geneva. 50 ASEAN + 3 disseminated the findings of the studies at a regional workshop on gender and social issues related to emerging

infection diseases on 13-14 October 2009 under the auspices of the Lao PDR Ministry of Health. Publication is forthcoming.



information was received. W omen w ere m ore l ikely than men t o r eceive i nformation on infectious d iseases (whether c omplete o r i ncomplete, ac curate or i naccurate,) f rom television, radio, pamphlets, and health centres than men, but more men said they found the information they received useful. Discussions at a workshop on the ASEAN study indicated that public health campaigns (such as the “three cleans” in Lao PDR) may not give women enough u seful i nformation be cause m any women d o n ot u nderstand t hat t he A edes mosquito prefers clean water for breeding and has a short breeding cycle. The larvae are commonly f ound in c ontainers for drinking w ater, h ousehold pl ants, and for c ollecting rainwater. Similarly women associate AI r isk with s ick birds, not with the poultry droppings they clean up, which are likely to harbor the virus.51

111. Malaria: Biological differences between men and women have a bearing on how they experience m alaria. Women ar e m ore v ulnerable t o malarial infection t han non-pregnant women or men.52 Malaria is associated with anemia in pregnant women and the presence of parasites in the pl acenta. This impairs fetal growth, and contributes to m aternal and neo-natal mortality and morbidity.

112. The 2009 gender strategy paper for the Lao PDR HSDP refers to the assumption that malaria p revalence i s higher a mong men t han w omen due t o t heir gr eater exposure t o mosquitoes. For example, in contexts where men are involved in forest-based activity, men may wear fewer clothes when working outdoors, and stay in the forest longer than women, which increase their exposure. Yet there is some evidence to suggest that prevalence rates may be similar for both men and women. Because women are less likely to seek treatment than men, t heir malaria may go undetected. T he paper c ites four case s tudies of gender differentials in malaria.53

A s tudy in S ri L anka reported s lightly higher r ates of malaria a mong men t han women. A lthough s leeping patterns, occupation and c lothing differences between m en and women could account for the higher rate of malaria among men, the study explained that numerous women in the community refused to be examined because the health staff involved in the case detection were predominantly male.

A study in Thailand compared the clinical prevalence of malaria and the prevalence of malaria in communities. While the study found parasite rates within communities to be equal, men were six times more likely than women to seek care at the health care clinic.

A s tudy of t he A kha people, w ho live i n t he hi ghlands of Thailand, M yanmar, Lao PDR and China, where men and women sleep in different parts of the house. If only one net i s distributed for the family, social ranking or perceptions of vulnerability to malaria can determine who has access to it.

The 2006 P HCEP Household Survey in Lao PDR found that in seven of t he eight northern pr ovinces (Oudomxay is the exception) t here w as an i nverse r elationship between women‟s knowledge of malaria prevention and the ethnic minority composition of the population: in other words the hi gher the proportion of ethnic groups living in a province, the lower a woman‟s knowledge of malaria prevention. In Sayaburi where 75 percent of the pop ulation a re Lao T ai, 9 7 percent of w omen k new about malaria prevention. In contrast, i n Phonsaly where 80 percent of t he population is from ethnic groups, only 64 percent of women knew about malaria prevention and it may be inferred

51 ASEAN plus Three Workshops on Gender and Emerging Infectious Diseases and Knowledge Attitudes and Practice studies of emerging infectious diseases, Luang Prabang, Lao PDR, 13-16 October 2009 52 Women who are pregnant for the first t ime experience a higher frequency and density of infection, while during subsequent

pregnancies their vulnerability is the same as non-pregnant women. 53 References are from WHO, 2005, Integrating Poverty and Gender into Health Programs – Module on Malaria, WHO WIPRO (pp. 22-23).



from this finding than they have generally low awareness of how to prevent other communicable diseases. Differences in women‟s knowledge of malaria prevention in the north may relate to socio-cultural differences between the different ethnic groups, or to other factors such as differences in the supply of health services. However, in 2006, both provinces had relatively equal access to community based health providers and to drugs: over 80 percent of villages in Sayaburi and Phonsaly had Village Health Volunteers, who have a remit for health education, and villages in both provinces had almost equal access to a supply of drugs (69 percent and 67 percent respectively).

113. Pulmonary Tuberculosis: Research shows that in most low-income countries, twice as many men are notified with tuberculosis (TB) as women. However, the assumption that men are more vulnerable may lead to under-notification of TB in women, as has been suggested by studies from Viet Nam showing that women with pulmonary TB are diagnosed on average two weeks later than men and that men were more frequently given sputum examinations than women.8 TB is a leading infectious cause of death among women. Annually, about three-quarters of a million women die of TB, and over three million contract the disease, accounting for about 17 million Disability Adjusted Life Years (DALY). As tuberculosis affects women mainly in their economically and reproductively active years, the impact of the disease is also strongly felt by their children and families. The mortality, incidence, and DALY indicators do not reflect this hidden burden of social impact.54

114. Reproductive tract infections: The 2009 gender strategy paper for the Lao PDR HSDP cites a study on the financing, provision and utilization of reproductive health services in rural China.55 The study focused on five rural counties in Yunnan Province (which shares borders with Lao PDR and Viet Nam) and gathered information on reproductive health services, utilisation, payments, government financing and morbidity. Among the results was the finding that reproductive tract infections (RTIs) were commonplace, but that women seldom sought treatment due to a combination of poor service provision, embarrassment, lack of information, and fear of high costs. By 2009, advocacy efforts began to focus on ensuring that a focus on RTIs was incorporated in the national essential package of health care (the China Basic Service Package).

115. Gender and HIV: Gender is a key variable in relation to the prevention of HIV and other sexually transmitted diseases. In CLV the proportion of women who are HIV positive has increased and is increasing. According to the Report of the United Nations Commission on AIDS in Asia (2008), the trend is typical of a pattern throughout Asia. 56 Although three out of four adults living with HIV in Asia are men, the proportion of women has risen gradually throughout the region – from 19 percent in the region overall in 2000 to 24 percent in 2007. In Cambodia, more than 43 percent of new infections were among married women, and more than one third of all new infections were from mother to child.57 Table 12 shows comparative data from Thailand, which has the most generalised epidemic in the GMS and Asia, and CLV. Thailand made some progress in reducing HIV infection rates but the rates have increased in bordering Cambodia and Lao PDR, as well as in Viet Nam.

54 World Health Organisation, 2009. http://www.who.int/tb/challenges/gender/en/ 55 The study was conducted by the Kunming Medical College, Shanghai Medical University, ABT Associates and the UK

Institute of Development Studies over the period 1994-96 with funding from the Ford Foundation 55 Kieu Van, Nguyen, 2009. „Children: the forgotten victims of HIV‟. Viet Nam News, November 27, p. 14

Deleted: ¶



Table 12. Estimated Numbers of Adults Living with HIV in Thailand, Cambodia and Viet Nam

Indicator (Aged 15 years and over, thousands)

Thailand Cambodia Lao PDR Viet Nam

Year of estimate 2001 2007 2001 2007 2001 2007 2001 2007

Estimated number of adults per thousand living with HIV

650.0 600.0 93.0 270.0 0.5 1.3 37.0 76.0

Estimated number of adult women living with HIV

240.0 250.0 10.0 54.0 1.1 5.4 0.5 1.3


116. Border crossing towns are HIV hot spots: There is no comprehensive comparative gender sensitive data on HIV epidemiology in border crossing areas, or inventory of HIV prevention and treatment activities in border towns in CLV. The study of population mobility and HIV in the GMS previously cited has shown a disparity exists between men and women in the norms of sexual behaviour in CLV; women are expected to be monogamous in marriage and to abstain from sex before marriage, while there is a general acceptance of “informal” polygamy and patronage of brothels among married and unmarried men. Most of the new cases among women result from infection transmitted by husbands or boyfriends who were themselves infected during paid sex or through injecting drugs. The Report says that, at a conservative estimate, the number of women at risk being infected by an infected husband or regular (non-commercial) intimate partner could number more than 50 million in Asia, thus „generalising‟ the epidemic.

117. Neglected tropical diseases: Neglected tropical diseases (including Schistosomiasis, mainly soil-transmitted Helmithiasis, Lymphatic Filariasis, food-borne Trematodiasis and Cestodiasis) are affecting primarily the poor and marginalized populations in the GMS. The effective treatment is important to maintain good nutritional status, especially in women of child bearing age, resulting in higher birth weights and lower infant mortality rates. One of the few studies of gender differences in the incidence of parasitic infections found that overall rates of infection were high in both sexes, but higher in males than females, however the sample was based on persons admitted to hospital, which is likely to have skewed the data towards males. 58

118. Communicable disease and maternal health: Women suffering from infectious diseases and malnutrition are more likely to have complications of childbirth and to die in childbirth. Their babies are also more likely to die and their other children to suffer ill health. One of the major health issues in Lao and Cambodia and some areas of Viet Nam is maternal mortality. Reduction of the maternal mortality rate is a Millennium Development Goal and Table 13 shows the comparative ratios for CLV.

58 Nacher M; Singhasivanon P; Treeprasertsuk S; Silamchamroon U; Phumratanaprapin W; Fontanet A L; Looareesuwan S.,

2003. “Gender differences in the prevalences of human infection with intestinal helminths on the Thai-Burmese border.” Annals of tropical medicine and parasitology 2003;97(4):433-5.



Table 13. Maternal Mortality Rates 2001-2009 and MDGs in Cambodia, Lao PDR and Viet Nam

Maternal mortality ratio

2001 2005 2008-2009 Projected 2010-2015

MDGs 2015

Cambodia 437 472 400 140 140

Lao PDR 530 405 461 250 185

Viet Nam 95 85 83 60 62


119. These are aggregate figures and do not show geographic or ethnic differences. They cannot be compared with poverty data, or epidemiological data for communicable disease rates because the data is rarely disaggregated by age and gender. High maternal mortality is associated with many factors, including poverty, infectious disease and lack of health services. Among poor women, maternal mortality and morbidity is severely exacerbated by communicable diseases. For example, women with chronic malaria and hookworm are likely to be anemic, and at risk of post partum hemorrhage. Tetanus kills many mothers and babies, and many other more chronic infections also contribute to maternal and infant mortality. Women who are malnourished are more vulnerable to infectious disease.

120. Short maternal stature (stunting) is a risk factor for obstructed labor. In 2006 it was estimated that approximately 40 percent of Lao children were stunted. Stunting is an outcome of long-term inadequate food intake, which is linked to poverty, and is thought to be a particular problem in remote highland areas of the country.

Box 4. The Case of Lao PDR

The official national maternal mortality ratio (MMR) in Lao PDR is 405/100,000 live births.59 This figure translates into 800 maternal deaths per year, or two deaths a day. For every maternal death, it is estimated that another 20 women suffer morbidity as a result of a pregnancy or delivery complication. Some types of morbidity can result in drastic and life-changing conditions such as vesico vaginal fistula (VVF). If left untreated VVF can result in serious stigma and social exclusion.

By far the majority of women in Lao PDR (85 percent) give birth at home,60 with the majority of these births assisted by family members or friends. It is estimated that only 23 percent of women received any form of skilled attendance during delivery in 2005. This figure masks very significant rural-urban differences. UNFPA, for example, estimates that skilled attendance ranges from 11.6 percent in rural areas to 63.4 percent in urban areas.

In the northern border provinces only 15 percent of women gave birth in a hospital or health centre in 2006, an increase from 9.5 percent in 2004.61 Although this increase is positive, there is still a very long way to go to improve maternal health care in this part of the country. It is likely that many maternal emergencies in the north do not receive appropriate care. Indeed, according to the 2005 census, the MMR is almost twice as high for women living in remote rural areas with no roads.62 This means that mountainous parts of the Northern provinces63 are likely to have a MMR that equates with some of the highest ratios in the world.64

59 This compares with a ratio of 660/100,000 cited in key UN documents. 60 Lao PDR Reproductive Health Survey, 2005. 61 MOH, 2006, PHCEP 2006 Household Survey, December. 62 MOH, 2009b, Skilled Birth Attendance Development Plan: Lao PDR 2008-2012. February. 63 Access to emergency obstetric care services can reduce maternal mortality by up to 70%. Family planning can reduce maternal deaths by 25-40% and skilled birth attendance by 13-33%. 64 Cathy Green, 2009.Gender Analysis and Strategy for the ADB Lao PDR MOH Health Systems Development Project.



To conclude that poverty rather than gender is the key determinant of health care utilisation is to ignore women‟s additional reproductive needs for health care so women can be expected to use health services more often than men. From a „women‟s health needs‟ perspective, the findings show that the very poorest women have unacceptably low access to essential maternal and reproductive health services.

121. Poverty and socio-cultural differences may also be important. For example, high infant mortality rates in ethnic group communities may influence decisions about birth spacing. However, understanding of how gender, poverty and ethnicity intersect in specific locations is limited. It is probable that language barriers act as a significant barrier to access to birth spacing information and supplies in non-Lao Tai communities. Language barriers may prevent women from using static health facilities, the services of outreach workers, or benefiting from community based health education and messages relayed via mass media. Strategies for overcoming language barriers need to be given higher priority within policy and programmes.

122. Gender, health and culture: Gender relations in cultural contexts have been examined in various micro studies and social assessments supported by development agencies and NGOs, usually related to specific rural development projects. There has been no systematic comparison of cultural differences in gender relations between the diverse ethnic groups of CLV, and indeed in a situation of rapid social and cultural change, such comparison would be very difficult to make.

123. Gender relations vary with culture. Women in Lao-Tai ethnic groups have a generally matrifocal social system, in which at least one daughter is likely to inherit family assets. Lao-Tai and Khmu women are active in small business activities, even including long-distance trading in the North-western region65. In Viet Nam, where women are as active as men are in the economy, and often manage family businesses or farms and household finances, the prevailing cultural ideology is that women should defer to men, and that men are more entitled to exercise authority in all forms of decision-making. According to cultural norms, men have the right to discipline women, including the use of violence, but women should not discipline men.66

124. Although among mainstream cultures in CLV women often manage household finances, they typically give men a share of household cash as „going out‟ money for socializing and drinking that they do not usually allocate to themselves. Green comments that access to and control over household financial resources has a major effect on women‟s utilization of health services in other low-income countries, and yet the evidence for this is weak in Lao PDR. Accordingly, recognizing that poverty status may differ within a household is important when programs to improve health access for the poor are designed. 67

65 Walker, Andrew, 1999. „Women, Space and History: Long Distance Trading in Northwestern Laos.‟ In Grant Evans (ed.) Laos

Culture and Society. Silkworm Book. 66 Huong, Minh. 2009. Women and Confucianism: Ancient rules requiring women to obey men undercut new laws. Viet Nam

News. November 25, p.5 67 Green, Cathy, with Khamtanh Bounmany, 2009.Gender Analysis and Strategy for the ADB Lao PDR MOH Health Systems

Development Project.



Figure 3. Health Staff in Proposed Project Provinces (district and provincial levels combined) by Sex in

Cambodia, Lao PDR and Viet Nam

Source: Ministries of Health, Cambodia, Lao PDR and Viet Nam

125. When assessing the male/female staffing levels in the health sector in the 3 countries Figure 4 i llustrated a higher number of females employed in the sector in both Vietnam and Laos but no t in C ambodia. When disaggregated by qualification an d l ocality, disparities become more evident. Figure 4 shows the qualification level of provincial health staff in the proposed Project provinces in Cambodia, Lao PDR and Viet Nam. Those with degrees and higher de grees i nclude doctors, d entists, radiographers and l aboratory managers. T hose with lower de grees include nurses, midwives a nd paramedical s taff an d l aboratory technicians. Cambodia has a high disproportion of females to males among staff with both higher an d l ower l evels of qualifications. I n c ontrast, L ao P DR h as only a sli ghtly lower portion of females with higher qualifications, but a h igher proportion o f f emales with lower qualifications. Viet Nam shows the same pattern. Well qualified women better represented in professional provincial positions in the provinces because the service and ad ministrative centres are in towns Married women generally follow their husbands in job postings rather than the reverse.

Figure 4. Provincial Health Staff in Proposed Project Provinces by Country, Sex and Qualification



126. At district levels of t he h ealth se rvices the d isparity is m ore m arked (Figure 5). Proportionately more women work in district health services, but they are less qualified than men. Women q ualified to ho ld senior positions may be di scouraged f rom taking posts at district le vel unless their hus bands also ha ve posts t here. A ccordingly, f emale h ealth workers at district level are more likely to be from the district. Overall, few district level staff of both sexes have hi gher qu alifications. I n Lao PDR t here ar e no s taff w ith h igher qualifications at district level in the proposed Project provinces. The difference between Lao PDR and Viet Nam is likely to be because district towns are larger and more developed than those in Lao, with more employment opportunities.

Figure 5. District Health Staff in Proposed Project Provinces by Country, Sex and Qualification

127. The few female s taff w ith h igher qu alifications at district l evel in La o PDR i s of particular concern. For this proposed Project district, there were no female doctors at district level, although there are women doctors at district level in some other provinces. Lao PDR is the onl y Project c ountry for w hich t here h as been a s ystematic study of ge nder an d ethnicity in health services staffing. An analysis of 2008 health workforce data in Lao PDR revealed that women comprise the majority of the health workforce. Nursing and midwifery jobs are ma inly h eld by women, a nd women are w ell r epresented a mong laboratory a nd pharmacy staff. However, there are proportionately more women than men in positions for which fewer qualifications are required to gain entry, so women are more likely than men to be in lower level and low paid jobs. 68

128. As well as a concentration of female health workers in low paid and low level jobs, the Lao P DR gender anal ysis found there was a t rend to early departure f rom the h ealth workforce of female health workers and few women in senior health management positions outside c entral l evel. It a lso noted the low representation of smaller ethnic groups at every level of the health sector. It noted both equity and efficiency arguments for promoting equal opportunities policies within the Lao PDR health workforce.

68 Green, Cathy, with Khamtanh Bounmany, 2009.Gender Analysis and Strategy for the ADB Lao PDR MOH Health Systems

Development Project.



Box 5. An Equal Opportunities Approach to Health Sector Employment69

Flexible contracts: being able to work part-time may fit better with women‟s other responsibilities such as child care or caring for elderly parents.

„Flexi-time‟: organising shift-work in a way that enables women to participate in the health workforce is important. In addition, for workers in administrative or management positions, flexible working hours can sometimes enable women to better manage their working and domestic responsibilities.

Targeted incentives: incentives systems that aim, for example, to promote rural working, need to recognise that „push and pull‟ factors may be different for men and women, and for older and younger women. For example, women may be more interested than men in whether appropriate and secure accommodation is available than financial incentives. Older women who no longer have dependent children may be more interested and perhaps more able than younger women to take on a posting to a remote area if the right incentives were provided.

Promotion requirements: these need to be achievable by both men and women. For example, linking promotion to a requirement of long-term overseas training may discriminate against women who lack scope to leave their families for long periods. Similarly, linking promotion to an unbroken service record (e.g. no career breaks taken to care for children) would discriminate against women.

Career development opportunities: training and other skills-enhancement opportunities need to offered on an equal basis to men and women. Assumptions that women have no time to participate in career development opportunities tend to be common in the health sector and may determine who is and who is not included on a training short-list.

Pay and conditions: comparison of the median earnings of women in full-time employment compared to men would determine if there is a gender pay gap in the health sector in Lao PDR.70 However, it is also important to determine whether pay and conditions of employment are equal for comparable jobs (e.g. jobs requiring similar skills, effort and responsibility). As far as is known neither of these analyses have been carried out in Lao PDR to date.

Workplace safety and culture: ensuring that workers are protected from verbal or physical abuse, bullying or other discriminatory behaviour within the workplace is essential. Little is currently known in Lao PDR about the affect of workplace culture and practices on male and female health workers at different levels

129. No gender disaggregated data was available for village health workers (VHWs) in CLV. In all three countries VHWs are either paid a small stipend, or in some provinces in Lao PDR earn money from the sale of medicines and condoms under the drug revolving fund. Payments to VHWs often come from donor projects and are therefore unsustainable. In some communes in Viet Nam, VHWs are paid by the Commune Peoples Committee. Anecdotal evidence suggests women are underrepresented among VHWs, particularly in ethnic minority communities, with the possible exception of Cambodia where it is said to be policy to appoint VHWs of both sexes in every village. The reason why men tend to predominate among VHWs is likely to be because local governments mainly comprise males, and because males are considered to be in greater need of paid or partly paid work, and because most men, especially older men, have higher social status than most women.

69 Green, C., 2009, Equity Analysis of Health Workforce in Lao PDR, in Technical Assistance Inception Report to Ministry of

Health, Health Systems Development Project. 70 Green, previously cited, who prepared these recommendations, notes that although informative, this information would not

reveal differences in rates of pay for comparable jobs (i.e. jobs requiring similar skills, effort and responsibility). Pay medians are affected by the different patterns of work by men and women (e.g. the proportion of men and women in different occupations, their length of time in jobs etc).



130. There is a need to ensure that the gender balance is tipped in favour of women in the training and appointment of VHWs because women have more reproductive health issues than men do, and are unlikely to discuss these issues with male health workers. Women are also key targets for CDC, having major responsibilities for caring for children, the sick and the elderly, for preparing food and for household sanitation and handing.

131. Gender and community health promotion: The 2007 Lao PDR National Growth and Poverty Eradication Strategy recognises the importance of promoting stronger female participation in local level planning and decision-making, including in the arena of health. To date, women‟s active participation in local level decision-making bodies, including Village Health Committees, has been limited. In many places women‟s involvement on village committees is limited to the participation of a single Lao Women‟s Union (LWU) representative. The same is true of Viet Nam and Cambodia, according to discussions with provincial health personnel. Women are particularly underrepresented, according to these sources, in EMG communities. Village Health Committees need external capacity building support to enable them to function more effectively, to include representation of women, and to represent the concerns and needs of the community at large, and lobby effectively for improvements in service delivery. Special attention to building the capacity of female members will be needed since they may have less experience of working to influence change at local level.

V. CONCLUSION AND RECOMMENDATIONS

A. Lessons Learned From CDC1

132. Indigenous People Development Plan (IPDP) and provisions for vulnerable groups: Although CDC1 contained provision for country IPDPs, these were not done nor was the generic IPDP in the RRP and provision in the PAM implemented. Most of the localities selected for implementation of CDC1 were not in border areas and did not have significant EMG populations, and in those that did, no special provisions were included in project activities.

133. Currently, provincial and district health authorities in CLV face a number of challenges in addressing CDC in vulnerable rural border populations mainly comprising EMGs. Typically they cite the constraints of distance and accessibility to the typically mountainous terrain in most border areas. But district health offices (working with the district hospitals and health centres) also lack the resources to provide outreach services. Budgetary allocations are insufficient for fuel and to cover incentive payments or travel allowances to health staff. There may be staff shortages. Often there is no adequate transportation for outreach activities, such as trail bikes that can travel on rough tracks, or in some instances, boats to reach villages without road or track access.

134. Generally, border people are expected to get themselves to health centres when they need services. At district level, health staff experience frustration when they attempt to reach a rural border population and find many of the target population are absent from their villages, or else located in areas that health staff cannot reach.71 In some projects, according to the ADB gender and social safeguards adviser in the Viet Nam Resident Mission, it has been found that people living in scattered locations can be reached on market days when they come together. But in general, the planning of the limited outreach programs that do exist in border districts is not sufficiently flexible to match the annual activity cycles of minority peoples to ensure that outreach activities occur when they people are in their main village. 71 Based on discussions with district health staff in Bokeo, Luangnamtha, Champasak and Attapeu districts in

Lao PDR and in Tay Ninh, Quang Tri, and Nge An provinces, Viet Nam



135. Border populations in many provinces often speak different languages from the majority of the population. Those who have attended school may speak the majority language, but adults (particularly women) do not, and are unlikely to read and write in the national language. They have different customs and beliefs to the mainstream populations of the country, which is likely to influence their perceptions of illness and health. Few health workers are from minority groups because of their generally lower levels of education. Where village health volunteers are engaged in the district health service, they are predominantly male. Accordingly, there are challenges in communicating information on CDC effectively, especially to women who are key targets for CDC information.

136. Gender Provisions: Although CDC1 contained provision for country Gender Action Plans (GAPs) these were not done nor was the generic GAP in the RRP and provision in the PAM implemented, although some efforts were made to tabulate training beneficiaries by sex. The data shows that women were well represented in district level training activities, as might be expected because most district level health workers in CLV are women, although women are less likely than men to hold senior management or technical/clinical positions at district level Since there was no baseline, it was difficult to interpret these data.

137. The generic gender action plan for CDC1 was not applied or mainstreamed into project activities because the relevance of the requirements to CDC was not understood by the PMUs and because they were unable to find suitably qualified national consultants to provide advice on developing and implementing the GAPs. Nor were there budgeted outputs for gender specific activities.

138. The relevance of gender analysis to CDC1 was poorly understood by the Project Management Units (PMUs) and not communicated to the participating provinces and institutes. A key lesson is that more evidence-based research is needed on gender issues in emerging and neglected diseases to demonstrate to health policy and planning agency staff that gender variables are relevant to CDC. Routine surveillance by health centers and hospitals includes information on patients by sex, ethnicity and age but gender disaggregation and gender analysis is rarely if ever applied when data is collated by the provincial and national levels of government.

139. More disaggregated epidemiological data is needed to improve the focus of prevention and control measures. Discussions with MOH staff in CLV indicated that where gender disaggregated data is collected, it is done to satisfy donor requirements, not because the information is considered of useful, nor is it analysed at national level for its relevance to CDC control and response. Despite these important variables, MOH staff, including the clinical staff of health institutes have difficulty in understanding why gender is a relevant consideration in CDC and why, for example CDC is an issue in addressing the high MMR/IMR in border areas.

140. Another issue is HIV surveillance. At present HIV surveillance in CLV appears to focus on “at-risk groups” such as female entertainment service workers, men who have sex with men, users of injected drugs, and transient male workers in the transport and construction industry. The gradual „feminization‟ of HIV suggests that the surveillance approach must be widened so that all sexually active men and women understand: the risk of HIV and other STIs; how to prevent infection; and that testing and counselling is available. Anecdotal evidence from health staff in Bokeo Province of Lao PDR confirmed this consideration. They said when voluntary testing was widely promoted, most of those who came for testing were “housewives” and a high proportion were found to be HIV positive.

141. Migrants were identified as a vulnerable group in CDCI, but no specific actions were included in the project design to address migrant health. Provincial health service providers,



in cooperation with other government agencies and NGOs, need to include strategies for improving the health status of migrants in the province, especially those who are poor and have high risks of becoming infected with communicable diseases. Provincial health strategies, plans and budgets need to be based on better information on the situation, location and flow of migrants in each province. The comprehensive baseline study proposed for CDC2 will be designed to capture this information and update it regularly for ongoing planning, activities and M&E. The IOM, which is already working on migration and health issues and policy in the GMS would be the an appropriate technical adviser and sub-contractor for collecting information on migration issues in the comprehensive baseline study and could be considered for funding under CDC2. Legal issues concerning the rights of migrants are dealt with at national levels, and ADB should include the health and welfare of migrants in its policy dialogue with the governments of GMS.

B. Social Mainstreaming Strategy for CDC2

142. Summary Ethnic Minorities Development Plan:72 The project design gives highest priority to supporting CDC activities in districts of Provinces that have contiguous borders with and common CDC issues in CLV; in this way EMG CDC issues will be mainstreamed in the Project. Table 2 shows the proportion of EMGs in Project provinces for be targeted in CDC2.

143. A key feature of Component 1 is a comprehensive baseline survey designed to guide the provincial and district CDC cluster strategies for cross-border cooperation. This will identify EMG communities in border districts and identify their needs in more detail, and will assist to plan harmonised cross-border activities to improve CDC in these communities. An international consultant Social anthropologist with relevant GMS experience will advise on specific research activities on EMGs for the baseline and on the development of more appropriate ethnic and gender sensitive strategies for engagement and communication with linguistic/ethnic groups in the participating districts. The consultant will lead a team, working with national institutes for social and cultural research.

144. In Component 2, CDC2 will provide outreach to underserved populations. Support will be given to districts to plan integrated village-based primary health care program based on national „healthy village‟ criteria for environmental sanitation and coordination of government services to support achievement of these criteria, including health care funds for the poor. Existing maternal and child health (MCH) services in rural areas will be strengthened to increase communicable disease prevention capacity, by increasing outreach services to border communities. The focus of activities and priorities will be determined by the district‟s comprehensive baseline study and will be tailored accordingly, with gender and cultural sensitivity, to the specific needs of each district. National women‟s organizations will be provided with support to promote women‟s participation (which is currently weak), MCH activities, immunization, healthy village concepts and associated CDC project activities at community level.

145. The interventions, depending on the needs assessments derived from baseline data may include: i) Mobile clinics, with provision of vehicles, trail bikes, boats and equipment for conducting outreach programs for vaccination, checkups of children under five years old, antenatal care, family planning and HIV and STI awareness, hookworm treatment, vitamin supplements, tetanus immunization, malaria treatment and bed nets, dengue vector eradication and other measures relevant to local CDC situations; i) IEC training package to retrain health volunteers and health workers using participatory, culturally and gender sensitive methods to raise community awareness on prevention of communicable diseases

72 An ethnic minority development plan is provided as an Appendix for the RRP for CDC2



and environmental sanitation; and iii) provision of water and sanitation facilities where needs and additional donor funding permits.

146. The baseline will enable on-going monitoring and evaluation of project benefits and outcomes for improving engagement with and reduction of CDCs among EMG populations in Project provinces.

147. Summary of Gender Action Plan:73 All Project interventions at the district level will be gender sensitive and will focus on women and children. To ensure the gender issues identified in the analysis are mainstreamed into these activities it is proposed to adapt the Manual For Gender And Health Equity Training for Provincial Health Staff Lao PDR (jointly prepared by the Lao Women‟s Union Of The Ministry Of Health and the ADB-funded MOH Health Systems Development Project, September 2009) for use in Cambodia, Lao PDR, and Viet Nam. The manual is evidence-based and will have to be adapted for the situations in each country, translated into national languages, and also incorporated into other training plans and materials to ensure it is mainstreamed.

148. The Project will engage an international gender / public health specialist to coordinate and ensure the technical quality of this activity and three national gender / public health specialists to develop the national editions of the manual. The international gender specialist will work in close consultation with the Project training specialist. The national consultant gender specialists will research and prepare evidence-based training materials (which will be translated into national languages) on gender issues in public health, with an emphasis on CDC for mainstreaming into all training activities.

73 A summary gender action plan has been prepared as a separate appendix for the RRP for CDC2



Annex 1 – Social Analysis Supporting Maps

APPENDIX 14:

ETHNIC MINORITY DEVELOPMENT PLAN


Appendix 14: Ethnic Minority Development Plan – Final Consultant Report April 2010 Page 1

APPENDIX 14 - ETHNIC MINORITY DEVELOPMENT PLAN

I. BACKGROUND AND JUSTIFICATION 1. Ethnic minority groups (EMGs) in the Greater Mekong Sub-region (GMS) are mainly trans-border highland peoples whose traditional territories long predate the establishment of modern states in the sub-region. They live in the foothills and highlands of the forested mountain cordillera on the borders of the six countries of the sub-region. Some of these groups live in all six countries, while many are found on adjacent borders of Cambodia, Lao PDR and Viet Nam, and are culturally and linguistically linked across borders. Although collectively they are national minorities, in some border provinces and districts they collectively form a majority of the population. A detailed analysis of issues with country profiles is provided in the Social Analysis Appendix. 2. EMGs are ‘indigenous people’ in the sense of the ADB working definition. ADB Policy on Indigenous Peoples, 1998, defined indigenous people as those with specific social or cultural identity distinct from the dominant or mainstream society that makes them vulnerable to being disadvantaged in the process of development. The ADB Safeguard Policy Statement, June 2009 states that the objectives of Indigenous people safeguards are: To design and implement projects in a way that fosters full respect for Indigenous Peoples’ identity, dignity, human rights, livelihood systems, and cultural uniqueness as defined by the Indigenous Peoples themselves so that they: (i) receive culturally appropriate social and economic benefits; (ii) do not suffer adverse impacts as a result of projects; and (iii) can participate actively in projects that affect them. It states that the term Indigenous Peoples is used in a generic sense to refer to a distinct, vulnerable, social and cultural group possessing the following characteristics in varying degrees: (i) self-identification as members of a distinct indigenous cultural group and recognition of this identity by others; (ii) collective attachment to geographically distinct habitats or ancestral territories in the project area and to the natural resources in these habitats and territories; (iii) customary cultural, economic, social, or political institutions that are separate from those of the dominant society and culture; and (iv) a distinct language, often different from the official language of the country or region. In considering these characteristics, national legislation, customary law, and any international conventions to which the country is a party will be taken into account. A group that has lost collective attachment to geographically distinct habitats or ancestral territories in the project area because of forced severance remains eligible for coverage under this policy. 3. A regional project to address communicable disease control (CDC) in the border regions of the GMS must necessarily focus on EMGs. EMGs once lived (and some still live) in remote, inaccessible locations, in small hamlets in remote mountainous regions, far from modern health and education services and with limited economic integration into market economies. Road-building has ended that isolation in most border areas. 4. In all three Project countries (Cambodia, Lao PDR and Viet Nam [CLV]), EMGs have higher levels of poverty, higher maternal, infant and child mortality rates, and communicable disease burdens than majority populations, and much lower vaccination coverage, use of health services, education participation rates, and literacy rates than majority populations. Many similar historical, cultural, environmental and policy factors have contributed to the disparities between EMGs and majority ethnic groups. (For a detailed analysis, see the country chapter on Cambodia, Lao PDR and Vietnam in the Social Analysis Appendix). Low health status and high incidence and prevalence of communicable diseases is closely associated with poverty. 5. In Lao PDR smaller ethnic groups have substantially higher poverty headcount rates than the majority Lao-Tai. The 2006 Lao Poverty Assessment reports that of the four major ethno linguistic groups, the Mon-Khmer is the poorest group, with a headcount of 55 percent, followed by the Hmong-Iu Mien (45 percent), the Chine-Tibet (40 percent) and the Lao-Tai (28 percent).



6. In Viet Nam EMGs are much poorer than the ethnic majorities; with a poverty headcount ratio of 64.3 percent in 2002, almost three times larger than that of the ethnic majorities (22.3 percent). Poverty has declined rapidly among ethnic majority groups whereas the economic condition of EMGs has stagnated and for this reason more research has been done on ethnicity and poverty in Viet Nam that in other countries of the sub-region. 7. In Cambodia ethnic variables in poverty have not been documented, however small studies show high poverty among EMGS. 8. EMG populations living near regional economic corridors bear a disproportion burden of the health costs of the rapid social and economic changes created by these developments. Relocation and/or resettlement of EMGs have been supported by governments and donors in CLV for various reasons. In some provinces, movements of highland EMGs to lower altitudes as a result of voluntary and involuntary resettlement has had a chain migration effect, resulting in the depopulation of whole highland areas.1 9. When EMGs whose customary habitat is in high mountain areas move to lower altitudes, they are exposed to malaria, to which they have little acquired resistance, so in the early phase of relocation to lower altitudes there has been high mortality rates from malaria, as well as morbidity resulting from exposure to other water-born and environmentally-related infectious diseases. 10. A survey2 of 67 displaced villages in six provinces of Lao PDR found there has been devastating epidemics (particularly from malaria), as well as loss of assets, debt accumulation, rice deficits, intensified competition for land, and lack of government resources to provide assistance to relocated communities. 11. EMG populations who suffer from food deficit and malnutrition are more vulnerable to contracting new and emerging infectious diseases, and those who live close to rapidly developing hubs on transport corridor areas are particularly vulnerable to recruitment into sexual services industry, to cross border human trafficking. Under these circumstances they become vulnerable to infection with HIV and other sexually transmitted diseases. 12. Some EMGs may only use heath services (when they are available) as a last resort. This may be because of lack of experience but also reflects anxiety about modern health services as well as the expense of accessing them. In every society, people’s beliefs about health have cultural underpinnings. In the case of EMGs, they have had less exposure than most people to modern scientific knowledge about the cause of diseases, and less opportunity to learn about the value of vaccination, vector control and other measures. Programs aiming to promote behavior change (for example, building and using latrines, drinking boiled water, removing disease vector breeding sites, hygienic management of animals, hand-washing, using bed nets, and acceptance of vaccination) are mainly designed for the mainstream population and do not take account of the cultural differences in behavior and need to use culturally relevant modes of communication in EMG villages. 1 Gebert, R. 1995. Socio-economic baseline survey. Muang Sing: GTZ Integrated Food Security Programme. Cohen, P.T. 2000a.

"Lue across borders: pilgrimage and the Muang Sing reliquary in Northern Lao PDR. In G.Evans, C. Hutton and Kuah-Khun Eng (eds.) Where China Meets Southeast Asia: Social and Cultural Change in the Border Region. Singapore: Institute of Southeast Asian Studies. Cohen, P.T., 2000. "Resettlement, opium and labour dependence: Akha-Tai relations in Northern Laos", Development and Change, 31:179-200. Romagny, L. and Daviau, S. 2003. Synthesis of Reports on Resettlement inLong District, Luang Namtha province, Lao PDR. Action Contre La Faim mission in Lao PDR. Lyttleton, C. 2005. "Market-bound: relocation and disjunction in northwest Lao PDR". In Toyota, M., Jatrana, S., and Yeoh, B., 2003 (eds.) Migration and Health in Asia. Routledge. Alton, C. and Houmphanh Rattanavong, 2004. Service Delivery and Resettlement: Options for Development Planning, unpublished report, UNDP: Lao PDR, Vientiane. McCaskill D. and K. Kampe (eds.) 1997. Development or Domestication: Indigenous Peoples of Southeast Asia Chiang Mai: Silkworm Press. 2 United Nations Development Programme (UNDP), 1997. Basic Needs for Resettled Communities in the Lao PDR. UNDP

Vientiane



13. In summary, most EMGs in GMS border areas can no longer be thought of simply in terms of disadvantage due to isolation; they are becoming increasingly less isolated, more disease prone, more marginalized while being rapidly integrated into national and regional economic processes and the associated processes of social change. This transformation is largely a result of new roads opening up previously isolated areas, attracting not only investment in mines, plantations, dams, logging and other enterprises growing numbers of national and international cross-border migrants. In most cases, EMGs are beginning this process of integration from a very disadvantaged position. 14. Although EMGs are more likely have a higher burden of infectious diseases than mainstream populations due to factors outlined above, there are no comprehensive national or regional data comparing CDC incidence and prevalence among EMGs compared with majority populations in CLV, although some information can be inferred from provincial data. The disparities are highlighted in country specific data showing that provinces with high infant and child mortality rates also have high concentrations of EMGs. Surveillance data does not include ethnicity when it is collated at national and often also at provincial levels, though this data is collected by health centers and hospitals. Therefore, most epidemiological data, unless based on special surveys, is not ethnically sensitive.

II. LESSONS LEARNED FROM CDC1 15. Although CDC1 contained provision for country Ethnic Minority Development Plans (EMDP), these were not done, nor was the generic EMDP in the Report and Recommendations to the President (RRP) and provisions in the Project Administration Memorandum (PAM) implemented. Most of the localities selected for implementation of CDC1 were not in border districts (although 73 percent or 19 out of 26 provinces were on the border of CLV). Most of these districts did not have significant EMG populations and in those that did, no special provisions for engaging them were included in project activities. 16. Currently, Provincial and district health authorities in CLV face a number of challenges in addressing CDC in vulnerable rural border populations mainly comprising EMGs. Typically they cite the constraints of distance and accessibility to the typically mountainous terrain in most border areas. But district health offices (working with the district hospitals and health centres) also lack the resources to provide outreach services. Budgetary allocations are insufficient for fuel and to cover incentive payments or travel allowances to health staff. There may be staff shortages. Often there is no adequate transportation for outreach activities, such as trail bikes that can travel on rough tracks, or in some instances, boats to reach villages near rivers but without road or track access. 17. Generally, border people are expected to get themselves to health centres when they need services. At district level, health staff experience frustration when they attempt to reach a rural border populations and find many of the target population are absent from their villages, or else located in areas that health staff cannot reach.3 In some health projects in Viet Nam, according to the ADB gender and social safeguards adviser in the Viet Nam Resident Mission, it has been found that people living in scattered locations can be reached on market days when they come together. But in general, district health department planning and budgeting cannot match health outreach to the agricultural cycles of border communities. The limited outreach programs that do exist in border districts is not sufficiently flexible to match the annual activity cycles of minority peoples, to ensure that outreach activities occur when they people are in their main village.

3 Based on discussions with district health staff in Bokeo, Luangnamtha, Champasak and Attapeu districts in Lao PDR and in Tay

Ninh, Quang Tri, and Nge An provinces, Viet Nam



18. Border populations in many provinces often speak different languages from the majority of the population. Those who have attended school may speak the majority language, but adults (particularly women) do not, and are unlikely to read and write in the national language. They have different customs and beliefs to the mainstream populations of the country, which is likely to influence their perceptions of illness and health. Few health workers are from minority groups because of their generally lower levels of education. Where village health volunteers are engaged in the district health service, they are predominantly male, except in Cambodia where it is policy to appoint one health worker of each sex. Accordingly, there are challenges in communicating information on CDC effectively, especially to women who are key targets for CDC information.

III. SELECTION OF PROJECT PROVINCES 19. Table 1 shows the population of the provinces and border districts currently nominated by the MOHs of CLV.

Table 1: Population Characteristics of all Provinces Proposed for CDC2

Population

CAMBODIA LAO PDR VIET NAM TOTAL

# Population # Population # Population # Population

Project

provinces

5 1,797,419 9 2,187,716 15 22,420,579 29 26,405,714

Border

districts

17 650,564 33 1,311,955 53 4,758,013 103 6,675,532

Ethnic

Minority

Groups, %

of border

district

population

13.8% 83,752 29.3% 383,972 29.9% 1,424,451 28.3% 1,892,175

Source: Population data gathered for CDC2 project preparation see Appendix X: Ethnic minority data was no available for some provinces,

20. More detailed data on the population of the proposed provinces in CLV is shown in Tables 2, 3, and 4. These data are based on preliminary census report, or, in the case of Viet Nam, Provincial population reports. The term used in the census for ethnic minorities in each country is used in the tables.



Table 2: Population Characteristics of Provinces Proposed for Project Inclusion in Cambodia

PROVINCE BORDER DISTRICT POPULATION

PROPORTION

SPEAKING MINORITY

LANDGUAGES IN

DISTRICT

Mondulkiri

Kaev Seima 21,712 48.3%

Kaoh Nheaek 17,182

46.9%

Ou Reang 4,460

74.2%

Pech Chreada

10,392

70.1%

Rattankiri

Andoung Meas 10,365 87.5%

Ou Ya Dav 16,420 81.2%

Ta Veaeng 5,835 93.6%

Veun Sai 16,449 96.8%

Stung Treng

Siem Pang 18,323 22.6%

Stueng Traeng 30,959 3.20%

Thala Barivat 30,439 0.65%

Kampot Banteay Meas 83,022 0.25%

Kampong Trach 85,776 0.13%

Takeo

Angkor Borei 46,261 1.85%

Borei Cholsar 26,055 2.86%

Kiri Vong 97,711 0.36%

Kaoh Andaet 48,039 0.86%

Source: 2008 Preliminary Census Data, Ministry of Planning. The minority language speakers included Vietnamese.



Table 3: Population Characteristics of Provinces Proposed for Project Inclusion in Lao PDR


POPULATION PROPORTION OF SMALLER

ETHNIC GROUPS IN DISTRICT

Phongsaly

Phongsaly 24,908 94.7%

May 23,902 64.6%

Samphanh 28,140 90.8%

Boon neua 22,022 69.9%

Nhot ou 29,236 59.6%

Boon tai 19,066 69.2%

Luangnamtha

Namtha 50,125 44.9%

Sing 36,140 55.8%

Long 33,361 69.5%

Oudomxay

Namor

37,393 72.2%

Bokeo

Huoixai 63,487 16.4%

Tonpheung 28,518 36.6%

Meung 13,480 36.0%

Khammuane

Thakhek 93,153 3.6%

Nongbok 42,353 2.7%

Hinboon 68,674 0.4%

Bualapha 28,809 43.5%

Nakai 23,087 37.8%

Saravane

Lakonepheng 42,450 8.7%

Khongxedone 58,524 1.1%

Samuoi 14,615 78.4%

Sekong

Kaleum 12,445 98.4%

Dukcheung 19,281 95.0%




POPULATION PROPORTION OF SMALLER

ETHNIC GROUPS IN DISTRICT

Champasak

Pakse 86,535 0.7%

Phontong 91,695 2.0%

Champasack 58,825 0.7%

Sukhumma 56,875 10.6%

Moonlapamok 42,184 11.4%

Khong 77,979 1.5%

Attapue

Snamxay 30,596 61.7%

Sanxay 19,222 83.1%

Phouvong 10,924 95.5%

Source: Preliminary census data 2008



Table 4: Population Characteristics of Provinces Proposed for Project Inclusion in Viet Nam

PROVINCE BORDER DISTRICT DISTRICT POPULATION PROPORTION OF ETHNIC

GROUPS IN DISTRICT

Dien Bien

052 61.5%

92.5%

Dien Bien 50.6%

Son La 99.8%

85.1%

Mai Son 72.2%

Yen Chau 76.3%

Moc Chau 71.7%

Thanh Hoa

95.4%

90.8%

90.7%

60.1%

95.0%

90.6%

90.1%

72.5%

Anh Son 7.6%

Thanh Chuong 251,152 0.8%

Ha Tinh

0.8% Khe 1.0%

0.0%

46.8%

75.6%

Quang Nam

Tay Giang 15,625 95.5%

Nam Giang 20,519 86.0%

Dak Lak Buon Don 46.2%

40.4%

Cu Jut 50.2%

Dak Mil 84,367 0.0%

Dak Song 51,702 19.0%

Tuy Duc 34,694 49.1%

Binh Phuoc

17.1%

Loc Ninh 14.7%

Tan Bien 90,586 2.3%

Chau Thanh 129,447 1.7%

Ben Cau 65,003 0.2%

Trang Bang 153,387 0.2%

An Giang

An Phu 190,931 3.6%

Chau Doc 118,950 0.0% Tinh Bien 125,337 29.6%

Tri Ton 127,280 38.5%



PROVINCE BORDER DISTRICT DISTRICT POPULATION PROPORTION OF ETHNIC

GROUPS IN DISTRICT

Dong Thap

0.0%

0.0% Kien Gang

Kien Luong 104,188 17.0%

Long An

Duc Hue 0.07%

Thanh Hoa 0.10%

Moc Hoa 76,000 0.77%

Vinh Hung 46,286 0.13%

Tan Hung 44,946 0.09%

Source: Provincial reports, MOH, 2009

21. These provinces are preferred for inclusion in the Project by the MOHs of CLV, and some do not have “matching’ cross border provinces in CLV (see map 2) In some of these, such those on the Mekong Delta borders of Viet Nam and Cambodia, communication across the border is long established and m ore s atisfactory s urveillance and r esponse pr ocesses a ppear t o h ave been es tablished, a nd t he pr esence o f significant v ulnerable populations h as no t be en demonstrated. 22. It is re commended that ADB consider discussing possible reconsideration o f some of the proposed Project provinces in its policy dialog with the governments of CLV to maximize the impact and sustainability of the Project objectives. The project objective is to reduce the risk of communicable disease o utbreaks s preading across borders, t o m aximize t he s ustainability of investments i n di sease c ontrol o n two sides o f a border, and t o i mprove t he health s tatus of vulnerable gr oups i n b order ar eas w ith high c ommunicable disease b urdens through a public health approach. A key factor for success will the selection of relevant regional localities. 23. It is recommended that the Project focuses on three clusters of provinces and districts in CDC (see Map 2). In these clusters all provinces are on the border. The priority inclusion criteria for Project districts should be: (i) shared border with another GMS country; (ii) opened up by the economic corridors and associated roads and development activities over the past decade; and, (ii) s ignificant pr oportions of EMGs or ot her demonstrably v ulnerable populations. D istricts meeting these criteria should be given highest priority for strengthening surveillance, response and prevention activities, including community based training and capacity building activities.

IV. ETHNIC MINORITIES DEVELOPMENT PLAN 24. The P roject d esign gi ves hi ghest pr iority t o s upporting C DC ac tivities i n di stricts o f Provinces that have contiguous borders with and common CDC issues in CLV; in this way EMG CDC issues will be mainstreamed in the Project. 25. Component 1: A key feature is the proposed comprehensive baseline survey designed to guide the provincial and district CDC cluster strategies for cross-border cooperation. This will identify EMG c ommunities i n border districts and i dentify t heir n eeds i n m ore d etail, and w ill assist t o pl an h armonised c ross-border ac tivities t o i mprove C DC i n t hese c ommunities. An international c onsultant S ocial Anthropologist w ith r elevant G MS ex perience w ill adv ise o n specific research ac tivities on EMGs f or t he bas eline an d on t he development of more appropriate ethnic a nd gender s ensitive s trategies for e ngagement and c ommunication and capacity building with linguistic/ethnic groups in the participating districts. The consultant will lead a team, working with national institutes for social and cultural research in CLV. 26. In Component 2 the Project provinces and districts will provide outreach to underserved populations. Support will be given to districts to plan integrated village-based primary health care



program based on national ‘healthy village’ criteria for environmental sanitation and coordination of government services to support achievement of these criteria, including health care funds for the poor. Existing MCH services in rural areas will be strengthened to increase communicable disease prevention capacity, by increasing outreach services to border communities. The focus of activities and priorities will be determined by the district’s comprehensive baseline study and will be tailored accordingly, with gender and cultural sensitivity, to the specific needs of each district. National women’s organizations will be provided with support to promote women’s participation (which is currently weak), MCH activities, immunization, healthy village concepts and associated CDC project activities at community level. 27. The interventions, depending on the needs assessments derived from baseline data may include: (i) mobile clinics, with provision of vehicles, trail bikes, boats and equipment for conducting outreach programs for vaccination, checkups of children under 5 years old, antenatal care, family planning and HIV and STI awareness, hookworm treatment, vitamin supplements, tetanus immunization, malaria treatment and bed nets, dengue vector eradication and other measure relevant to local CDC situations; (ii) IEC training package to retrain health volunteers and health workers using participatory, culturally and gender sensitive methods to raise community awareness on prevention of communicable diseases and environmental sanitation; (iii) engagement with local schools as part of community surveillance and environmental sanitation programs for vector control; and (iv) provision of water and sanitation facilities where needs and additional donor funding permits. 28. The baseline will enable on-going monitoring and evaluation of project benefits and outcomes for improving engagement with and reduction of CDCs among EMG populations in Project provinces.

APPENDIX 15:

GENDER ACTION PLAN


Appendix 15: Gender Action Plan – Final Consultant Report April 2010 Page 1

APPENDIX 15 – GENDER ACTION PLAN

I. STRATEGIC ISSUES 1. There are two main gender challenges to be addressed in communicable disease control (CDC). A. Gender and Health Needs 2. The first challenge is to encourage health policy and services that recognize the differences in the health needs of men and women. Women and girls have specific health needs as a result of their biological differences with men. In the health systems of Cambodia, Lao PDR and Vietnam (CLV), women’s specific biological needs are recognized to a greater or lesser extent in the provision of maternal and reproductive health services, and in the associated health policy, plans and budgets. However, men and women also have different degrees of vulnerability to infectious diseases, depending on how they are exposed. Men and women have different roles in the management of their households and in productive and livelihood activities which can affect their specific disease vulnerability. Further, there are differences between the sexes in their access to information. Women are often less well informed than men on the sources of communicable disease and how to prevent them. Gender is a significant CDC variable. Recent research on gender and CDC in the CLV region shows that gender is a significant variable in understanding the spread and planning response to communicable diseases. Gender differences in disease rates can be interpreted in both the context of biological differences between men and women (sex differences), and the differences between the division of household and economic tasks between men and women and power relations between men and women (gender differences). B. Gender Equity in Health Services 3. The second challenge is to encourage gender equity in health sector staffing that leads to better health outcomes for women and men. Gender relations (the social and cultural rules that influence relationship between men and women) influence the roles of women and men role. In CLV, women have different social statuses to that of men, which vary with class and culture. Gender differences in status and power affect women’s career opportunities in health professions. Women are concentrated in service delivery jobs and greatly under-represented at decision-making levels. Those in senior positions are more likely to be men. More women than men are employed in provincial and district health services in Lao PDR and Viet Nam and the proportions are similar; women are more equitably represented at provincial level in terms of their qualifications but few women doctors work at district levels. In Cambodia, men predominate in the health sector workforce at all levels in the proposed Project provinces. Gender disparity is not just an equity issue. When women’s perspectives are not represented in senior management, it is less likely that practical and effective gender-sensitive policies will be developed. At the same time community based health services need equal or greater numbers of women staff and community workers to address women’s specific health needs. Inequity is closely linked to women’s roles as wives and mothers. Highly qualified women are more likely to hold positions in towns and cities because of their husband’s jobs and their children’s educational needs. 4. A detailed analysis of gender issues in the Project is provided in Chapter IV of the Social Analysis Paper (Appendix 13).



COMPONENT 1: STRENGTHENING REGIONAL COOPERATION IN COMMUNICABLE DISEASE CONTROL

PROJECT OBJECTIVE GENDER ACTIVITIES TO BE MAINSTREAMED

TARGET OUTPUTS MEANS OF VERIFICATION

PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

Subcomponent 1.1 Compatible and coordinated strategies for CDC across borders

Subcomponent 1.2: Cross-border planning, monitoring and evaluation for CDC

i. Comprehensive baseline survey (CBS) is designed to guide the provincial and district strategies for cross-border cooperation.

a) Regional workshop to design the GBS defines the GBS objective for evidence-based gender planning.

MOHs, RCU, WHO, National research institutes, National women’s organizations.

Common criteria for baseline studies of contiguous districts endorsed by MOHs.

Workshop report, Baseline design.

WHO, MBDS

X

b) Technical advisory teams are appointed, includes gender focal point.

MOHs, WHO, National research institutes, National women’s organizations.

Gender sensitive technical advisory teams.

Baseline Implementation Plan.

WHO, IOM, MBDS

x

c) Provincial workshops to plan the implementation of the baseline defines data for gender disaggregation.

Provincial DOH technical advisory team, National research institutes, Provincial women’s organizations.

Gender sensitive plan for conducting and compiling baseline.

Baseline implementation plan.

WHO, MBDS

x

ii. Comprehensive baseline survey is completed for all border districts in the project areas.

Gender disaggregated baseline data on population, epidemiological characteristics, and health service needs of border villages identified.

MOH PMU, Provincial Departments of Health, Provincial women’s organizations,

Baselines provide analysis of CDC risks. Gender issues and needs and district health priorities.

Final baseline, Survey report.

WHO, MBDS

x X



Technical advisory team.

iii. Provincial and District multi-sector, long-term strategic plan of action for CDC.

Analysis of baseline data to design provincial and district plans of action on CDC that address specific needs and issues in each locality, including identified gender needs and issues.

Technical advisory team, Provincial women’s organizations, Provincial government agencies responsible for health, quarantine, agriculture, water and sanitation, police, and tourism.

Activities incorporated into gender sensitive provincial and district Annual operational plans (AOPs).

Provincial and District operational plans.

WHO MBDS

X X X X X

Subcomponent 1.3 Support for regional GMS CDC cluster implementation and coordination

Sub component 1.4 Regional knowledge management

i. “Clearing house” register of donor activities for CDC in the GMS.

RCU website incorporates register which identifies gender studies and projects.

RCU,MBDS, MOHs.

RCU Website in MBDS.

MBDS & RCU Websites.

MBDS X X X X X

ii. Collated comprehensive baseline data for GMS CDC2 provinces and districts.

RCU/MBDS websites incorporates gender disaggregated baseline summary results

RCU, MBDS, MOHs.

RCU /MBDS Websites.

MBDS & RCU Websites.

MBDS X

iii. Regional Technical forums are conducted annually.

Technical forums address CDC issues including gender dimensions in CDC 2 project areas.

MOH, RCU, MBDS.

Technical CDC information on MBDS website.

Forum reports.

MBDS, WHO

X X X X X



COMPONENT 2: STRENGTHENING NATIONAL SURVEILLANCE, RESPONSE AND HEALTH SYSTEMS

PROJECT OBJECTIVE

GENDER ACTIVITIES TO BE MAINSTREAMED


PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

Subcomponent 2.1: Strengthening institutional structures, partnerships, and policies

Subcomponent 2.2: Strengthening Systems for Human Resource Development.

i. Provincial training plans to strengthen diagnostic, surveillance and reporting capacity and improve gender equity and representation of EMGs.

a) Provincial training groups are formed for planning and managing all provincial CD training needs.

ADB CDC2 TA,

National CDC institutes,

Medical universities and colleges, Provincial and

District AOPs, Provincial and district women’s organizations.

Provincial training groups established.


Reporting,

EMG Action Plan,

Gender Strategy.

X X X X X

b) Analysis of gender and ethnic minority representation and roles in provincial health services.

ADB CDC2 TA,

PPIUs,

National women’s organizations,

National social research institutes.

Strategy and plan to improve gender and EMG equity in provincial, district and commune/village level health services.

Monitoring and Evaluation Reporting.

X X

c) Inter-provincial training working groups to advise on overall strategies and priories have gender focal points.

ADB CDC2 TA,

PPIUs,

Inter-provincial training working groups,

Provincial

GMS CDC provincial and district training priorities and activities planned.


Reporting, Inter-provincial meeting.

X X X X



PROJECT OBJECTIVE



PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

women’s organisations.

d) Provincial CDC steering committees and management committees have gender focal points, oversee provincial training programs, advise on priorities and approve training funds.

PPIUs supported by national institutes (as required).

Provincial training plans budgeted and implemented.


Reporting,

Steering Committees and Management Committees minutes.

X X X X X

ii. Provinces have gender and ethnic equity-based master training systems established.

a) Master training approach system harmonized in project provinces and districts.

ADB CDC2 TA,

MOHs,

PPIUs.

Master trainer system established.


Reporting.

WHO, MBDS.

X X

b) Evidence-based research on gender and CDC training materials developed in national languages.

National gender consultants,

International

gender specialists,

Provincial women’s organizations.

Gender Training Manual for CDC developed in national languages.

Training reports identify that gender issues are mainstreamed in training

c) Training of master trainers in skills based training includes gender training. Gender equity in selection of master trainers.

ADB CDC2 TA

PPIUs.

Gender Training Manual prescribes the gender criteria to be considered in selection.


Reporting.

X X

iii. Provincial human resource staffing and training plans

a) Gender and ethnic sensitive training needs

ADB CDC2 TA, Training plans include funded provisions for

Monitoring and X



PROJECT OBJECTIVE



PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

are maintained and updated.

analysis is conducted.

PPIUs,

National gender consultants,

Provincial women’s organizations.

gender and ethnic equity.

Evaluation

Reporting.

b) Review of existing gender training curricula and materials, adaptation of these or development new materials.

ADB CDC2 TA,

PPIUs,

MOHs.

Training materials are finalised , funded, printed and distributed.


Reporting.

X X

iv. Review IEC materials produced or planned by ASEAN+3, national institutes, donors, WHO, UNICEF, INGOs.

Identification of gender IEC and training materials that can be translated and shared in regional CDC2 project areas.

ADB CDC2 TA

MOHs.

Production and distribution plan for sharing IEC materials in GMS CDC funded from national CDC2 funds.


Reporting.

IEC Review report.

X X X X X

Review and adapt Lao PDR gender and health training manual.

National gender consultant and

international

gender specialists recruited.

Approach to mainstreaming gender in IEC material and messages is incorporated in Training Manual.

Consultants report prescribes the required gender adaptation to IEC material.

X

v. Provincial, district and commune/village level capacity for gender disaggregated surveillance and reporting and analysis is strengthened.

Gender sensitive training plans, materials and activities are approved by national authorities.

MOHs, PDOHs, Provincial and district women’s organizations.

Training plans finalised. Capacity assessment report.


Reporting.

X X X X X



PROJECT OBJECTIVE



PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

Subcomponent 2.3: Strengthen systems of surveillance, response, and preparedness.

i. Effective and equitable engagement and community with communication minority linguistic/ethnic groups

a) Provincial studies designed to guide engagement and communication with women and men minority linguistic/ethnic groups on CDC.

ADB CDC2 TA

National Universities/Institutes for social research.

Provincial and district women’s organisations.

Gender sensitive strategy for engagement and communication.

Study Reports. MBDS

IOM

X

b) GMS CDC Cluster workshops to harmonise strategy for gender sensitive engagement and communication with minority linguistic/ethnic groups.

ADB CDC2 TA

Provincial IAs

National Universities/Institutes for social research.

Provincial and district women’s organisations

Gender sensitive GMS CDC strategy for engagement and communication with minority linguistic/ethnic groups.

Workshop reports

X

c) Gender sensitive Provincial and district plans for engagement and communication with minority linguistic/ethnic groups.

ADB CDC2 TA,

Provincial and District AOPs,

National universities / institutes for social research,

Provincial and district women’s organizations.

National gender consultant and international gender specialists prepare community engagement strategy and train provincial and district staff on its introduction.

Provincial and District Operating Plans.

X X X X



PROJECT OBJECTIVE



PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

Subcomponent 2.4: Capacity building of provincial and district staff in CDC and health services delivery.

i. Capacity of provincial and district health staff and community-based health workers is strengthened.

Master trainers provide gender equitable and gender sensitive TOT on field epidemiology, clinical diagnosis and treatments, data management, analysis and reporting IEC and BCC.

Laboratory Specialist,

ADB CDC2 TA,

PPIUs,


Gender sensitive CDC training conducted on an ongoing basis in districts and communes/ villages.

Laboratory Specialist Report,


Reporting.

X X X X X

ii. Quality, timeliness and accuracy of reporting and analysis is strengthened.

a) Data management, analysis and reporting using ICT wherever feasible.

ADB CDC2 TA

PPIUs.

Efficient high quality gender sensitive and ethnically sensitive reporting and analysis.


X X X X X

b) All data is disaggregated by sex, ethnicity and age.

Subcomponent 2.5: Targeted communicable disease control and health services for rural populations in border districts.

i. GMS CDC 2 provincial and district AOPs to provide outreach to underserved populations.

GMS CDC cluster workshop to harmonise healthy village criteria based on district baseline data.

ADB CDC2 TA

PPIUs


Healthy village criteria agreed in GMS CDC cluster.

Workshop report.

X

ii. Provincial outreach program for underserved villages.

a) Provincial planning meeting to identify underserved border villages.

ADB CDC2 TA,

PPIUs,


Communes and villages in border districts receive CDC services.


X



PROJECT OBJECTIVE



PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

b) Formation of technical management committees within provincial and district level health departments to integrate vertical health programs.

ADB CDC2 TA,

PPIUs,


Integrated PHC services operating in Project districts.


X X

iii. Provincial MCH/PHC services are strengthened in border districts.

Provincial and district needs assessment for strengthened MCH/PHC.

ADB CDC2 TA,

PPIUs,


Procurement plan and action.

Field trip reports.

X

iv. District teams formed in all border districts.

Establishment of district teams working with a network of health centres, dispensaries and village health volunteers.

ADB CDC2 TA,

PPIUs,

Provincial and district women’s organizations

District teams have monthly work schedule.

Work schedule,

Field trip reports.

X

v. Mobile clinics are established for underserved communes and villages.

Provincial and district needs assessment for transportation and equipment.

ADB CDC2 TA

PPIUs


Procurement of transportation and equipment based on needs assessment of provinces and district.

Asset register,

Field trip reports.

X

Subcomponent 2.6: Support for national project implementation

i. Efficient and effective management of national project activities.

a) Design of detailed M&E framework includes gender disaggregated CDC data, gender objectives from the baseline and results-based

ADB CDC2 TA,

MOHs,

PPIUs, District management teams.

Effective and timely gender sensitive management of national project implementation.

TORs, Reporting, Monitoring and Evaluation.

X X X



PROJECT OBJECTIVE



PARTNERS IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

monitoring.

b) International gender specialist provides input to design.

MOHs,

PPIUs,

District management teams.

Gender action plan activities or criteria incorporated into provincial and district plans and M&E.

Consultants report with recommendations of M&E indicators to be incorporated into M&E Plan.

M&E Plan.

X X

c) Coordination of TA inputs to national and provincial project activities.

MOHs,

PPIUs,

District management teams.

Program of activities for TA inputs supported by the PPIU team and District management rteams.

Work plan for consultants.

X X X X X

APPENDIX 16:

RESULTS FRAMEWORK

ADB TA: 7279-REG: Second GMS Regional Communicable Diseases Control Project

Appendix 16: Results Framework for Communicable Diseases Control – Final Consultant Report April 2010 Page 1

APPENDIX 16. - RESULTS FRAMEWORK FOR COMMUNICABLE DISEASES CONTROL

PROJECT IMPACT

Improved Health in populations in the GMS border areas.

The overall project impact will be improved health for the populations in the project provinces in the border region, which will assist the Ministries of Health in Cambodia, Laos and Vietnam (CLV) to achieve MDGs 4, 5 and 6 by reducing the spread of emerging and neglected communicable diseases thereby reducing morbidity and mortality, in particular among children, and the economic cost of these diseases.

PROJECT OUTCOMES

Improved Regional Security through:

(i) Governments of GMS adopting a harmonized approach in the region, with established long-term multi-sector strategic national policies for prevention and emergency response to communicable diseases.

(ii) Strengthened regional and MOH’s technical capacity for surveillance and response, following WHO guidelines for implementation of the IHR and APSED with timely responses to epidemics in provinces with common borders that are likely to have a major impact on public health and the economy in the region.

(iii) Increased capacity of national provincial and district health services in results based management and technical capability with integrated CDC and health services for the underserved populations who have high disease burden due to neglected tropical diseases (NTD) and are at risk from newly emerging diseases (EIDs ).


COMPONENT 1: STRENGTHENING REGIONAL COOPERATION IN COMMUNICABLE DISEASE CONTROL

EXPECTED RESULT

(SPECFIC OUTCOMES)

ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

Subcomponent 1.1 Compatible and coordinated strategies for CDC across borders

i. Governments of GMS establish policies and strategies and approach to CDC (EIDs and NTDs) in three cross-border cluster areas.

a) Each country establishes a regional focal point in the MOH at national and provincial level.

MOHs PDOHs

Regional coordination focal points established in MOHs/PDOHs

Ministerial directive or decree

WHO, MBDS

X

b) Coordination and planning of linkages with national and regional health sector programs and projects.

MOHs, RCU

Longer term regional cooperation agreements.

Partnership agreements or MOUs signed.

WHO, MBDS.

X X X X X

ii GMS Regional countries agree to cooperate on CDC clusters.

a) Regional meeting to formalise agreement on cluster CDC activities in Cambodia , Lao PDR Vietnam are supported by ADB CDC2, and the Peoples Republic of China and Thailand with alternative funds.

MOHs, RCU

Regional steering committee and national steering committees roles and responsibilities reviewed and expanded.

Meeting reports, and signed MOUs.

WHO, MBDS

X X X X X



EXPECTED RESULT

(SPECFIC OUTCOMES)

ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

b) Provincial meetings to review and adopt formal agreements on CDC activities in each of the CLV countries

MOH PMUs, PHDs Provincial Steering committee meetings to review and clarify roles and responsibilities relating CDC2.

Meeting reports X X X X X

Subcomponent 1.2: Cross-border planning, monitoring and evaluation for CDC i. Comprehensive baseline survey

is designed to guide the cluster provincial and district CDC strategies and cross-border cooperation

a) Technical advisory teams are appointed for preparation of the baseline, including gender focal point

MOH PMUs, RCU, WHO IOM National research Institutes

Gender sensitive technical advisory teams established and functioning.

Baseline Implementation Plan

WHO IOM MBDS

X X

b) Regional workshops to design the baseline, including defined objective for evidence-based gender planning

MOH PMUs IOM National research Institutes, National Women’s Organizations

Common criteria for baseline studies of contiguous provinces and districts endorsed by MOHs

Workshop report Baseline design

WHO IOM MBDS

X

c) National and Provincial Training Workshops on Research Methodology

MOH PMUS and Provincial DOH Technical advisory team, National research Institutes.

Key provincial and central level health staff with skills to conduct research using existing data

Workshop report and follow-up workplace assessments

WHO, MBDS

x

d) National Workshop to plan the implementation of the baseline

MOH Technical advisory team National research Institutes.


Baseline implementation plan

WHO, MBDS x

e) Provincial workshops to plan the implementation of the baseline, with defined data for gender disaggregation.

Provincial DOH Technical advisory team National research Institutes. Provincial Women’s Organizations



WHO, X



EXPECTED RESULT

(SPECFIC OUTCOMES)

ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

f) Dissemination Workshops for Districts, and village communities to inform them the reason for the baseline survey.



x

g) Provision of computers, software and peripheral equipment for baseline data for each province.

MOH PMU, PPIUs and District Health office.

Training on Computers and IT equipment.

Project Asset register.

X

h) Software design. MOH, Technical advisory teams.

Common CDC Database for recording, analysis and M&E shared between provinces.

Baseline Implementation Plan.

X

ii. Comprehensive baseline survey is undertaken for all border districts in the project provinces.

Compilation of a baseline for all project border districts and provinces

MOH PMU, Provincial Departments of Health, Technical a Technical advisory team

Baseline provides analysis of CDC risks and through: (i) demographic analysis; (ii) district health services analysis; (iii) cross border traffic analysis, (iv) border quarantine service analysis (v) water and sanitation coverage analysis (vi) animal health services analysis and (vii) analysis of diagnostic capacity in district health centres.

Baseline data analysis reports

WHO

iii. Provincial and District multi-sector, long-term strategic plan of action for CDC activities in the border areas developed.

Analysis of baseline data to design provincial and district plans of action on CDC that address specific needs and issues in each locality, including identified gender needs and issues

Technical advisory team Provincial government agencies responsible for health, quarantine,

Activities incorporated into provincial and district Annual operational plans.

Provincial and District operational plans.

WHO

X



EXPECTED RESULT

(SPECFIC OUTCOMES)

ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

agriculture, water and sanitation, police, and tourism

iv. Identification of sentinel surveillance locations.

Sentinel surveillance data updates epidemiological and social indicators and information from baseline .

Provincial and District Departments of Health.

Baselines provide analysis of CDC risks through: (i) demographic analysis; (ii) district health service Activities incorporated into gender sensitive provincial and district annual operational plans (AOPs) Baseline data updated.

WHO, IOM X

v. District health departments harmonise their border district CDC priorities, plans and activities

Quarterly consultations and reviews of activities

Provincial and District Departments of Health Provincial Women’s Organizations

Monitoring and evaluation update

Baseline Database, Quarterly reports

X X X X X

vi. Multi-sector strategic and operational planning for national and regional CDC

a) National Multi-Sector Strategic and Operational planning workshops

MOH, MOE, MOA, MRD, …

X X X X X

b) Provincial Multi-Sector Strategic and Operational planning workshops

Provincial departments of health, education,

X X X X X

c) District Multi-Sector Strategic and Operational planning workshops

DOH, Local Schools, Dept Agriculture

X X X X X

vii. GMS CDC Provinces harmonise health services within a PHC framework.

a) GMS CDC cluster workshop on integration of health services at district level.

ADB CDC2 TA PPIUs.

Harmonised GMS CDC approach to PHC services at district level.

Inter-sector agencies

X X



EXPECTED RESULT

(SPECFIC OUTCOMES)

ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

b) Study Tours to provinces and districts with successful CDC and cross- border activities

X X X

c) Study tours to neighbour districts in Thailand and China with successful CDC and cross-border activities

MOHs, PDOHs of districts sharing a common border

X X

Subcomponent 1.3 Support for regional GMS CDC cluster implementation and coordination

viii. Efficient and effective management of GMS CDC project activities and other regional activities

a) National Workshop to develop a detailed M&E framework for GMS CDC project activities

ADB CDC2 TA MOH PMUs

Coordinated and harmonised GMS CDC project activities

Monitoring and Evaluation reports.

X X X

c) Provincial Workshops on detailed M&E Framework for GMS CDC2 Activities

Coordinated and harmonised GMS CDC project activities

Monitoring and Evaluation reports.

X

d) Support for establishing regional focal points in MOHs.

MOH PMUs.

Functional regional focal point in MOH.

Focal point office in MOH.

X

e) Coordination of regional TA inputs with specialized technical agencies and INGOS.

MOH, RCU Long and short term TA support agreements signed.

TA Contracts. ADB, WHO, INGOs

X X X X X

Sub component 1.4 Regional knowledge management

i. “Clearing house” register of donor activities for CDC in GMS established.

RCU website incorporates register, which includes gender studies and projects

RCU MBDS MOH PMUs

MBDS website RCU / MBDS Websites

MBDS X

ii. RCU knowledge management programme work collaboratively with MBDS

GMS Regional meeting RCU MBDS MOHs

RCU Website in MBDS

Project reports

X

iii. Collated comprehensive baseline data for GMS CDC2 provinces and districts

RCU /MBDS websites incorporates gender disaggregated baseline summary results

RCU MBDS MOH PMUs

RCU /MBDS Websites

MBDS & RCU Websites

X



EXPECTED RESULT

(SPECFIC OUTCOMES)

ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

iv. Project managers optimise IT in project management and information sharing

Training on optimising the use of IT for CDC2 project managers

ADB CDC2 TA MOH PMUs, RCU, MBDS

Project managers skilled in use of IT for information and communication

Project reports Website user information

X

v. Regional Technical forums are conducted annually

Technical forums address CDC issues, including gender dimensions in CDC2 project areas

MOH, RCU, MBDS

Technical CDC information on MBDS website

Forum reports

X X X X X

vi. Applied research that addresses programmatic issues and gaps and strengthens national operational research capacity for prevention and control of emerging and neglected endemic tropical diseases

a) Meetings of oversight committees to develop and disseminate criteria for selection of applied research proposals for CDC

National Institutes, Universities WHO, MOH MBDS

Selection criteria developed and disseminated

Selection criteria available

WHO, MBDS X X X X X

b) Review and select research proposals

National Institutes, Universities WHO, MOH MBDS

Grants awarded for applied research on innovative models to operationalise effective and sustainable cross-border CDC activities, including for: (i) reducing the risk of emerging diseases, (ii) strengthening early warning detention of outbreaks of emerging diseases, and (iii) addresses programmatic issues and gaps in NTD prevention, control and elimination, especially among underserved populations in remote and rural border areas

Applied research conducted to operationalize effective, sustainable cross-border CDC activities, and findings disseminated. Research prposals and reports.



COMPONENT 2: STRENGTHENING NATIONAL SURVEILLANCE, RESPONSE AND HEALTH SYSTEMS

EXPECTED RESULT (OUTCOMES)

ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

Subcomponent 2.1: Strengthening institutional structures, partnerships, and policies

i. Each country in GMS has a multi-sector national long-term strategic policy for emergency CDC response and prevention of communicable diseases following WHO guidelines for implementing the IHR.

a) A national multi-sector mechanism is established to define sectoral and departmental roles for emergency CDC response.

MOH PMUs, ADB CDC2 TA. National agencies responsible for health, quarantine, food safety agriculture, water and sanitation, police, tourism.

National CDC response policies

National policies Ministerial decrees and supportive legislation.

WHO, MBDS.

X X X X X

b) MOHs convene regular meetings for donors in the Health Sector to brief and engage them in CDC projects and activities.

MOH An informed Donor community willing to engage in the CDC and the health sector.

Donor meeting minutes.

WHO, MBDS and donors

X X X X X

Subcomponent 2.2: Strengthening Systems for Human Resource Development

i. National human resource development systems approach established and endorsed

National HR Task Force working group meeting to endorse the training systems development framework

ADB CDC2 TA MOH, National CDC Institutes Medical Universities and colleges,

National HRD Systems approach established and endorsed

MOH Circular confirming Training Systems Approach

WHO X X X X X

ii. Provincial training plans to strengthen diagnostic, surveillance and reporting capacity and improve gender equity and representation of EMGs

a) Provincial training groups are formed for planning and managing all provincial CD training needs.

ADB CDC2 TA National CDC Institutes Medical Universities and colleges, AND Provincial and District AOPs. Provincial and district women organizations

Provincial training groups established

Monitoring and Evaluation Reporting. EMG Action Plan. Gender Strategy.

WHO, MBDS X X X X X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

b) Analysis of gender and ethnic minority representation and roles in provincial health services

ADB CDC2 TA PPIU National Women’s Organisations, National social research Institute

Strategy and plan to improve gender and EMG equity in provincial, district and commune/village level health services


X X X X X

c) Inter-provincial training working groups advise on overall strategies and priories and have gender focal points.

ADB CDC2 TA PPIU Inter-provincial training working groups, provincial women’s organizations.

GMS CDC provincial training priorities and activities plan.

Monitoring and Evaluation Reporting. Interprovincial meeting.

X X X X X

d) Provincial CDC steering committees and management committee have gender focal points, oversee provincial training programs, advise on priorities and approve training funds.

PPIU, supported by national institutes (as required)

Provincial training plans funded and implemented.

Monitoring and Evaluation Reporting. Steering committees and Management committees’ minutes.

X X X X

iii. Provinces have gender and ethnic equity-based master training systems

a) Master training approach system harmonised in project provinces and districts; training procedures manual produced.

ADB CDC2 TA MOHs PPIU

Master trainer system established. and Project Training Procedures Manual produced and reviewed


WHO, MBDS, National Institutes.

X X X

b) Evidence-based research on gender, including review and adaptation of the Lao PDR gender and health training manual and CDC training materials developed in national languages,

National Gender Consultants, International gender specialists, provincial women’s organizations

Gender training guidelines for CDC developed in national languages and incorporated into the CDC Project Training Procedures Manual

Gender guidelines and manuals

X X X

c) Training of master trainers in skills based training, incorporating gender issues,

ADB CDC2 TA PPIU

Master trainer teams able to plan and implement skills based training in


X X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

and ensuring gender equity in selection of master trainers

project provinces

iv. Provincial human resource staffing and training plans are maintained and updated

a) Gender and ethnic sensitive training needs analysis is conducted

ADB CDC2 TA PPIU

Training plans include funded provisions for gender and ethnic equity


X X X X X

b) Review of existing training curricula and materials and adopt or develop new materials

ADB CDC2 TA PPIU MOHs

Training materials are finalised , funded, printed and distributed


X X X

c) Quarterly Provincial Training Working Group meetings to plan and up-date for training and staffing needs

ADB CDC2 TA PPIU MOHs, PTWGs

Provincial staffing and training plans maintained and up-dated taking into account national policies, health provider training needs and training resources availability, linkages across training programs, and priority participation of EMGs and women

Monitoring and Evaluation Reporting

X X X X X

v. Review IEC/ BCC and relevant training materials produced or planned by MOH, PHDs, ASEAN+3, National Institutes, donors, WHO, UNICEF, and INGOs

Identification of IEC/BCC and training materials that can be translated and shared, adapted and produced for use in project areas.

ADB CDC2 TA MOHs

Production and distribution plan for sharing gender sensitive IEC/ BCC materials in GMS CDC funded from national funds

Monitoring and Evaluation Reporting. IEC /BCC Review report.

X X X X X

vi. Provincial, district and commune/village level capacity for gender disaggregated surveillance and reporting is strengthened

a) Gender sensitive training plans, materials and activities are approved by national authorities

MOHs, PDOHs Provincial and district women’s organizations

Training plans finalised Capacity assessment report. Monitoring and Evaluation Reporting.

X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

b) Training curricula and supporting materials and aids procured and distributed

MOHs, PDOHs

Training curricula, with supporting training, learning and reference materials and aids for district and commune health workers in priority areas of CDC

Training Curricula and reference material

X

c) Training equipment needs are assessed and procurement plans developed

ADB CDC2 TA PPIU

Training equipment is funded, procured and provided based on needs assessment

Asset register. X X

Subcomponent 2.3: Strengthening systems of surveillance, response, and preparedness.

i. National policies for CDC incorporate the WHO ICD, IHR; the MBDS Action Plan for Mekong regional cooperation.

National Workshop to review of National Health surveillance strategies and plans to incorporate WHO ICD, IHR, MBDS Action plan.

ADB CDC2 TA Ministries of Health MBDS

MBDS Action Plan for Mekong regional cooperation and APSED in GMR

National surveillance policies and guidelines

WHO MBDS

X X

ii. Provincial and District surveillance plans based on the MBDS Action plan ‘seven core strategies’

Workshops to review Provincial Health strategies to incorporate MBDS Action plan

ADB CDC2 TA Provincial and district health departments

Project provinces plan and implement the seven core strategies

Provincial and district surveillance plans developed

WHO, MBDS X X

iii. Each province in the GMS CDC cluster has rapid response capacity

Needs assessment of provincial rapid response capacity

ADB CDC2 TA PPIU

Procurement of transport and equipment based on needs assessment

Reporting, Monitoring and Evaluation

X X X X X

iv. Effective and equitable engagement and community with appropriate communication strategy for minority linguistic/ethnic groups

a) Provincial studies designed to guide engagement and communication with women and men minority linguistic/ethnic groups on CDC.

ADB CDC2 TA National Universities/Institutes for social research. Provincial and district women’s organizations

Gender sensitive strategy for engagement and communication dissemination

Study Reports MBDS IOM, INGOs

X X X X X

b) GMS CDC workshops to harmonise strategy for engagement and communication with minority

ADB CDC2 TA PPIUs National Universities/Institut

Gender sensitive GMS CDC strategy for engagement and communication with minority linguistic/ethnic

Workshop reports X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

linguistic/ethnic groups es for social research. Provincial and district women’s organizations

groups.

c) Provincial and district plans for engagement and communication with minority linguistic/ethnic groups.

ADB CDC2 TA Provincial and District AOPs. National Universities/Institutes for social research. Provincial and district women’s organizations

Provincial and District operating plans

X X X X

Subcomponent 2.4: Capacity building of provincial and district staff in CDC and health services

i. Capacity of provincial and district health staff and community-based health workers is strengthened.

a) Master trainers provide gender equitable and gender sensitive TOT for provincial, district and commune/health centre clinical and preventive health trainers, based on Training Needs Analysis

ADB CDC2 TA PPIU Inter-provincial provincial and district training working groups and specialist trainers

CDC TOT training conducted on an ongoing basis in districts and communes/ villages

Workplace Assessments, monitoring and evaluation reporting.

X X X X

b) Provincial and district trainers able to conduct training needs analyses, plan, design, develop, deliver and evaluate skills based training (SBT) materials and courses for health workers at district and commune/ village levels on an on-going basis

ADB CDC2 TA PPIU Inter-provincial provincial and district training working groups

Competent and skilled health personnel able to deliver improved health services at district commune and village levels

Workplace Assessments, monitoring and evaluation reporting

X X X X X

c) Training curricula, with supporting training, learning and reference materials and

ADB CDC2 TA PPIU Inter-provincial

Training curricula, with supporting training, learning and reference

Workplace Assessments, monitoring and

X X X X X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

aids, for district and commune level health workers in priority areas of CDC identified and revised according to trainees needs analysis

provincial and district training working groups

materials and aids, for district and commune health workers in priority areas of CDC available and used

evaluation reporting

ii. Diagnostic, treatment, laboratory and referral services strengthened at national provincial, district and commune levels

a) Assessment of laboratory services in project provinces and districts

ADB CDC2 TA PPIU

Standardisation and O&M based on Assessment.

Workplace Assessments Monitoring and Evaluation Reporting.

X X X

b) Provision of equipment and supplies based on the assessed needs.

ADB CDC2 TA Provincial IA

Equipment included in the procurement plan.

Procurement plan and asset register.

X X

c) Laboratory technical and equipment maintenance training based on the assessed needs

ADB CDC2 TA PPIU

Improved diagnostic capacity at provincial district and commune levels.

Training Report. X X X X

d) Development and implementation of provincial and district health equipment maintenance plans for recurrent budget provision support to the various levels of service delivery

ADB CDC2 TA PPIU

Selected district hospitals and commune health stations equipped to standards consistent with providing appropriate quality laboratory, transport and training equipment and supplies

Workplace Assessments Monitoring and Evaluation Reporting.

X X X X

iii. Quality, timeliness and accuracy of reporting and analysis is strengthened

a) Data management, analysis and reporting using ICT wherever feasible; all data disaggregated by sex, ethnicity and age

ADB CDC2 TA PPIU

Efficient high quality reporting and analysis


X X

b) Provision of computers, software and peripheral equipment.

MOH PMU, ADB CDC2 TA PPIU.

Computers and QA systems operating.

Asset register X X X X X

c) Design of surveillance reporting software.

ADB CDC2 TA PPIU.

Computers and Surveillance systems operating.

Periodic Surveillance reports.

X

d) Training on use of surveillance ADB CDC2 TA Staff confident in use of Work place X X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

reporting software, and use of IT for communication

PPIU Provincial and district TWGs

the Surveillance computerised system.

assessments Training report

iv. Professionals from each project province selected, prepared and able to complete appropriate post-graduate, up-grading or specialised training

Preparatory foundation and bridging courses provided as needed, and with priority given to EMG and women candidates

ADB CDC2 TA PPIUs PTWGS, DTWGS, Provincial Steering Committees

Candidates with sufficient language and other bridging skills to succeed in post-graduate, upgrading, and specialist training

Training report Secondary Medical Schools, Colleges, National Institutes

x x x

Subcomponent 2.5: Targeted communicable disease control services and training activities for rural populations in border districts.

i. GMS CDC provincial and district AOPS to provide outreach to underserved populations

a) GMS CDC Cluster workshop to harmonise healthy village criteria based on district baseline data, including other sectors to be involved (e.g. local schools, water and sanitation, agriculture, private sector…)

MOH PMUs, ADB CDC2 TA PPIU Provincial and district women’s organizations

Healthy village criteria agreed in selected GMS CDC provinces, districts and villages

Workshop report WHO, INGOs X X X X X

b) Strategies developed for community based CDC and health promotion activities, through training workshops and study tours to other provinces for commune health staff, and community health workers and other volunteers

MOH PMUs, ADB CDC2 TA PPIU Provincial and district women’s organizations and other community volunteers

Appropriate and effective systems established for sustainable community-based surveillance, rapid response and risk mitigation activities in selected project districts, building on existing models and strategies, and in accordance with MOH guidelines for primary health care

Reporting on Monitoring and Evaluation

X X X

ii. Provincial Outreach program for underserved villages

a) Provincial planning meeting to identify underserved border villages

ADB CDC2 TA PPIU Provincial and district women’s organizations

Communes and villages in border districts receive CDC services

Quarterly Reporting, Monitoring and Evaluation

INGOs X X X X X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

b) Formation of technical management committees within provincial and district level health departments to integrate vertical health programs.

ADB CDC2 TA PPIU. Provincial and district women’s organizations

X X

iii. Provincial MCH/PHC services are strengthened in border districts

a) Provincial and district needs assessment for strengthened MCH/PHC

ADB CDC2 TA PPIUs PTWGs, DTWGS Provincial and district women’s organizations

Training plan and procurement plan developed and implemented, based on needs assessments

Reporting, Monitoring and Evaluation

X X X X X

b) Provincial and district training working groups plan, deliver and monitor training courses and refresher training courses for district and commune level health staff and community volunteers, according to the provincial training plan

ADB CDC2 TA

PPIUs,

PTWGS, DTWGs

Appropriate and effective delivery of clinical services, and CDC health promotion media delivered by competent and skilled personnel at province, district and commune levels, including Community Health Workers with the skills and capacity to advise and support activities to promote healthy behaviours for CDC at village level

Work place assessments

Training report

X X X X

c) Effective supervisory and monitoring support for district and commune health centre staff

ADB CDC2 TA PPIUs

PTWGs, DTWGS

Work place assessments Training report

X X X X X

iv. Up-grading and pre-service training to improve skill levels of health staff and where lack of staff is a problem at health

Preparatory courses and scholarships provided as needed, including for EMG and women candidates and local school leavers

ADB CDC2 TA PPIUs PTWGS, DTWGS, Provincial Steering

Improved quality and

retention of staff at health

facilities in the most

disadvantaged areas, with

Staff assessment reports

Secondary Medical Schools, local

X X X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

facilities in the most disadvantaged, rural border areas

to attend health worker training at provincial secondary medical schools or local colleges

Committees priority given to women

and EMG candidates to

increase the proportion of

women and members of

EMGS with high level

qualifications

Colleges

v. District teams formed in all border districts.

Establishment of district teams working with a network of health centres, dispensaries and village health volunteers.

ADB CDC2 TA PPIU. Provincial and district women’s organizations

Field reports. Monthly reports

INGOS X X

vi. Mobile clinics are established for underserved communes and villages

Provincial and district needs assessment for transportation and equipment

ADB CDC2 TA PPIU Provincial and district women’s organizations

Procurement of transportation and equipment based on needs assessment of provinces and district.

Field reports. Monthly reports

X

Subcomponent 2.6: Support for national project implementation

i. Efficient and effective management of national project activities

a) Project management training, based on TNA

ADB CDC2 TA MOH PMUs Provincial and District PIUs

Effective and timely management of national project implementation

TORs, Reporting, Monitoring and Evaluation

WHO x x x x x

b) Design of detailed M&E framework

ADB CDC2 TA MOH PMUs PPIUs and District PIUs



WHO X X X

c) Management support for national and provincial project activities

ADB CDC2 TA MOH PMUs PPIUs and District PIUs



X X X X X

d) Coordination of TA inputs to national and provincial project

PMU consultants work schedules




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

activities and quarterly reports

ii. Efficient and effective multi-sector coordination and management of project activities

a) The National Project Steering Committee is (NSC) responsible for overall strategic coordination of the project, review of policies and progress and share lessons learned within each province, review financial reports, monitoring, reporting, agree on inter-provincial strategies and plans and approve activities and expenditures

ADB CDC2 TA MOH MOF, MOE, MOA, etc PPIUs, Provincial Political Authority, eg People’s Committees, Governors

The MOH approves all new training curricula and equipment purchases and provides policy and strategic guidance on CDC and PHC issues to ensure that project implementation conforms to existing MOH guidelines and thereby compliments current practices in the health system

Steering committee meeting minutes

X X X X X

b) The Project Technical Management Committee (PTMC) has a central management and supervision role. The PTMC meets quarterly for Project-wide operational management to agree n inter-provincial strategies and plans, and to share lessons learned within each province.

ADB CDC2 TA, Provincial People’s Committees PDOHs

Technical Management Committee meeting minutes

X X X X X

c) Inter-departmental Provincial DOH Steering Committees (PSCs) ) chaired by the local political authority are the key provincial decision-making mechanism, in partnership with the project districts as required, to agree on detailed implementation schedules and methods, and to resolve local

ADB CDC2 TA PDOH, various Departments, Provincial, People’s Committees, or Governors PPIUs

Reports on progress provided to the provincial Director of Health, who represents on the National Steering Committee (NSC)

Inter-

departmental

provincial

committee

meeting minutes.

X X X X X




ACTIVITIES

RESPONSIBILITIES

PRODUCT (OUTPUTS)

MEANS OF

VERIFICATION

PARTNERS

IN CDC2

TIMEFRAME 2010-2015

1 2 3 4 5

issues.

d) Provincial Technical Management Committees (PTMCs) follow-up on the management of the detailed implementation schedules and methods, plans and progress, review of financial reports, monitoring and reporting on Project activities

ADB CDC2 TA PDOH, Provincial, People’s Committees, or Governors PPIUs

Provincial Technical management committee minutes.

X X X X X

e) Multi-sector district technical management committee (DTMCs) guide and monitor the community-based primary health care and CDC activities

ADB CDC2 TA DDOH, DDOE, DDOA, etc District People’s Committees, WU, NGOs, etc

District Multi-sectoral technical management committee minutes.

X X X X X

ADB TA REG: Second GSM Regional Communicable Diseases Control Project

Expenditure CategoryBase Cost % $('1000) %

1 Civil Works2 Laboratory and Office Equipment 312 3.3% 472 5% 945 3.7% 1,729 3.8%3 Vehicles 700 7.5% 829 8% 2,503 9.8% 4,032 8.9%4 System Development 697 7.5% 672 7% 928 3.6% 2,297 5.1%5 Training, workshop, fellowships 2,146 23.0% 2,136 21% 3,382 13.2% 7,664 17.0%6 Commutity Mobilization 3,463 37.1% 3,959 39% 13,803 53.9% 21,225 47.0%7 Consulting services 723 7.8% 667 7% 1,000 3.9% 2,390 5.3%8 Project Management 389 4.2% 423 4% 702 2.7% 1,514 3.4%9 Recurrent Costs 893 9.6% 1,083 11% 2,350 9.2% 4,326 9.6%

Total 9,323 100% 10,241 100% 25,613 100% 45,177 100%

COMPONENT ONE

1.1Compatible and coordinated strategies for

CDC across borders 101.0 1.1% 66.8 0.7% 141.0 0.6% 308.8 0.7%

1.2Cross-border planning, monitoring and

evaluation for CDC 709.5 7.6% 803.3 7.8% 1,554.5 6.1% 3,067.3 6.8%1.3 Regional knowledge management 152.0 1.6% 163.0 1.6% 174.0 0.7% 489.0 1.1%

1.4Support for regional GMS CDC cluster

implementation and coordination. 49.0 0.5% 52.0 0.5% 120.0 0.5% 221.0 0.5%Total Component One 1,011.5 10.9% 1,085.1 10.6% 1,989.5 7.8% 4,086.1 9.0%

COMPONENT TWO

2.1Strengthening institutional structures,

partnerships, and policies. 30.0 0.3% 19.3 0.2% 19.0 0.1% 68.3 0.2%

2.2 Strengthening Systems for HRD 476.0 5.1% 602.4 5.9% 952.0 3.7% 2,030.4 4.5%

2.3Strengthening systems of surveillance,

response, and preparedness 1,559.0 16.7% 1,718.3 16.8% 3,151.0 12.3% 6,428.3 14.2%

2.4Capacity Building of Provincial and District

staff for CDC 1,786.0 19.2% 1,805.5 17.6% 3,046.0 11.9% 6,637.5 14.7%

2.5Targeted CDC and training activitives for

rural populations in border districts 1,501.0 16.1% 1,829.2 17.9% 9,388.0 36.7% 12,718.2 28.2%

2.6Support for national project

implementation 2,959.0 31.7% 3,181.2 31.1% 7,068.0 27.6% 13,208.2 29.2%Total Component One 8,311.0 89.1% 9,155.9 89.4% 23,624.0 92.2% 41,090.9 91.0%

TOTAL COMPONENTS 1 & 2 9,323 100% 10,241 100% 25,614 100% 45,177.0 100%

Summary of Base Cost Estimates by Expenditure by Component/Subcomponent and Country ($Thousand)

TOTAL - CLV

Appendix 17 - Table 3 - Second GMS Regional CDC Project: Summary of Base Cost Estimates by Expenditure Category and Country (Thousands)

Appendix 17: CLV Provincial Population Profiles by Cluster - Final Consultant Report April 2010 Page 3


National and

Project Provinces Pro

ject

Pro

vin

ces

Bo

rder

Dis

tric

ts

Po

or

Dis

tric

ts

Poor as

a % of

Border

Dist. Po

p. I

n

Bo

rder

Dis

tric

ts

EMG

Po

p. i

n

Bo

rder

Dis

tric

ts

EMG

as

a %

of

Bo

rder

Po

p.

No

.

Co

mm

un

es

No

. Po

or

Co

mm

un

es

Po

or

Co

mm

un

es a

s a

% o

f

No

. Vill

age

s

No

. Po

or

villa

ges

Po

or

Vill

. as

a %

of

all

villa

ges.

Cambodia 5 17 NA 605,564 83,752 13.8% 119 NA 707 NALao PDR 9 33 16 48.5% 1,311,531 383,565 29.2% NA NA 2762 961 34.8%Vietnam 15 52 11 21.2% 4,692,013 1,394,451 29.7% 768 259 33.7% 8152 NATOTAL 29 102 27 6,609,108 1,861,768 28.2% 887 259 11,621 961

LAO PDRPhongsaly 1 6 3 50.0% 147,274 110,593 75.1% NA 491 266 54.2%Luangnamtha 1 3 1 33.3% 119,626 65,863 55.1% NA 265 85 32.1%Oudomxay 1 1 1 100% 37,393 26,999 72.2% NA 93 80 86.0%Bokeo 1 3 1 33.3% 105,485 25,732 24.4% NA 219 25 11.4%Khammuane 1 5 2 40.0% 256,076 25,997 10.2% NA 528 124 23.5%Total Lao PDR 5 18 8 44.4% 665,854 255,184 38.3% 1,596 580 36.3%

VIETNAMDien Bien 1 3 1 33.3% 211,692 175,198 82.8% 50 27 54.0% 745 NASon La 1 5 1 20.0% 520,611 404,852 77.8% 93 26 28.0% 1,467 NAThanh Hoa 1 4 4 100% 195,760 153,752 78.5% 57 37 64.9% 448 NANghe An 1 6 3 50.0% 623,749 245,338 39.3% 127 57 44.9% 1,371 NAHa Tinh 1 3 0 0% 257,457 2,037 0.8% 66 13 19.7% 809 NATotal Vietnam 5 21 9 42.9% 1,809,269 981,177 54.2% 393 160 40.7% 4,840 TOTAL CLUSTER 1 10 39 17 43.6% 2,475,123 1,236,361 50.0% 393 160 6,436 580

CAMBODIARatanak Kiri 1 4 NA 50,701 45,238 89.2% 22 0.0% 109 NAStung Treng 1 3 NA 84,921 5,673 6.7% 20 0.0% 98 NAMondul Kiri 1 4 NA 55,094 30,087 54.6% 17 0.0% 88 NATotal Cambodia 3 11 190,716 80,998 42.5% 59 0.0% 295

LAO PDRSaravane 1 4 2 50.0% 139,116 37,631 27.1% NA 313 69 22.0%Sekong 1 2 2 100% 31,726 30,559 96.3% NA 179 153 85.5%Champasak 1 6 2 33.3% 414,093 14,891 3.6% NA 540 79 14.6%Attapeu 1 3 2 66.7% 60,742 45,300 74.6% NA 134 80 59.7%Total Lao PDR 4 15 8 53.3% 645,677 128,381 19.9% - 1,166 381 32.7%

VIETNAMQuang Tri 1 2 1 50.0% 83253 47,036 56.5% 36 23 63.9% 291 NAQuang Nam 1 2 1 50.0% 36144 32,567 90.1% 19 17 89.5% 133 NADak Lak 1 2 0 0% 121,602 52,662 43.3% 17 5 29.4% 170 NADak Nong 1 4 0 0% 258,967 89,374 34.5% 44 4 9.1% 477 NABinh Phuoc 1 3 0 0% 363,469 56,516 15.5% 48 12 25.0% 341 NATotal Vietnam 5 13 2 15.4% 863,435 278,155 32.2% 164 61 37.2% 1,412 TOTAL CLUSTER 2 12 39 10 1,699,828 487,534 28.7% 223 61 2,873 381

CAMBODIATakeo 1 4 NA 220,954 2,396 1.1% 29 NA 255 NAKampot 1 2 NA 193,894 358 0.2% 31 NA 157 NATotal Cambodia 2 6 414,848 2,754 0.7% 60 412

VIETNAMTay Ninh 1 5 0 0% 559,638 11,545 2.1% 57 15 26.3% 563 NALong An 1 5 0 0% 292,495 790 0.3% 57 2 3.5% 287 NADong Thap 1 2 0 0% 316,361 0 0.0% 20 5 25.0% 199 NAAn Giang 1 5 0 0% 746,627 105,023 14.1% 64 11 17.2% 715 NAKien Giang 1 1 0 0% 104,188 17,761 17.0% 13 5 38.5% 136 NATotal Vietnam 5 18 0 0% 2,019,309 135,119 6.7% 211 38 18.0% 1,900

TOTAL Cluster 3 7 24 0 0 2,434,157 137,873 271 38 2,312

CLUSTER 3

CLUSTER 2

District Level

APPENDIX 17 - Table 1 - CDC2 PROVINCIAL AND DISTRICT POPULATION PROFILES BY CLUSTERS

CLUSTER 1

Commune Level Village Level

Appendix 17: CLV Provincial Population Profiles by Cluster. - Final Consultant Report April 2010 Page 1


TOTAL CLV 29 102 27 6,609,108 1,861,768 28.2% 887 259 11,621 961



No.

Persons%

No.

Persons%

No.

Persons%

No.

Persons%

No.

Persons%

No.

Persons%

No.

Persons%

No.

Persons%

Cambodia 5 17 605,564 83,752 13.8% 844 537 63.6% 307 36.4% 1,878 881 46.9% 997 53.1% 1,293 860 66.5% 433 33.5% 4,015 2,278 56.7% 1,737 43.3%

LAO PDR 9 33 1,311,531 383,565 29.2% 3,619 1,349 37.3% 2,270 62.7% 4,348 1,942 44.7% 2,406 55.3% 1,586 785 49.5% 801 50.5% 9,553 4,076 42.7% 5,477 57.3%

Vietnam 15 52 4,692,013 1,394,451 29.7% 9,927 4,614 46.5% 5,313 53.5% 7,905 3,533 44.7% 4,372 55.3% 3,025 1,297 42.9% 1,728 57.1% 20,857 9,444 45.3% 11,413 54.7%

TOTAL CLV 29 102 6,609,108 1,861,768 28.2% 14,390 6,500 45.2% 7,890 54.8% 14,131 6,356 45.0% 7,775 55.0% 5,904 2,942 49.8% 2,962 50.2% 34,425 15,798 45.9% 18,627 54.1%

Communty Health Centres

F

EMG

Po

p. i

n

Bo

rder

Dis

tric

ts

EMG

as

a %

of

Bo

rder

Po

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Annex 17 - Table 2 - CDC2 - CLV HEALTH STAFF IN PROJECT PROVINCES AND DISTRICTS

District Office and Hospital TOTAL AT ALL LEVELS

Project

Countries

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APPENDIX 18: EXTERNAL ASSISTANCE

ADB TA – REG: Second GMS Regional Communicable Diseases Control Project

Appendix 18: External Assistance to the Sector– Final Consultant Report April 2010 Page 2

EXTERNAL ASSISTANCE

Table A3.1: Donor Coordination Matrix Core Area of the proposed CDC2

Specific Areas of the proposed CDC2

Support from ADB Support from Other Donors1

Strengthening Regional Cooperation in CDC

Compatible and coordinated strategies for CDC across borders

Cross border planning, monitoring and evaluation for CDC

Regional Knowledge Management

Support for Regional GMS CDC Implementation and coordination

CAM: CDC1

LAO: CDC1

VIE: CDC1

Strengthening National Surveillance, Response and Health Systems

Strengthening institutional structures, partnerships and policies

CAM: N/A

LAO: Health Sector Development Program

(Project and Program Grants) VIE:

Health Human Resources Sector Development Program (proposed);

Health Care in the South Central Coast Region Project

CAM: Health System Support Project

(AFD);Strengthening Health System (BTC); Vaccination Strengthening Program (GAVI); Scaling up Tuberculosis Program (GFATM);

Second Health Sector Support Program (WB); Health Sector Support Project (WB)

LAO: Institutionalization of NDP (SIDA); Health Service Improvement Project (WB); LAO 809-G11-H (GFATM)

VIE: Upgrading of Community Health Services in

Hoa Binh Province (BTC); Health Sector Capacity Support Project (EC); Northern Upland Health Support Project (WB);

Northern Central Coast Region project (WB)

1 Commitment from donor only, not included counterpart funds from the recipient countries



Core Area of the proposed CDC2



Strengthening systems for Human Resource Development

CAM: N/A

LAO: Health Sector Development Program

(Project and Program Grants) VIE:

Health Human Resources Sector Development Program (proposed)

CAM: Strengthening Health System (BTC); Second Health Sector Support Program (WB); Avian and Human Influenza Control and

Preparedness Emergency Project (WB) LAO:

Project for Human Resources Development of Nursing/Midwifery (JICA);

VIE: Vietnam Avian & Human Influenza Project

(EC); Health Sector Capacity Support Project (EC);

Human Resources Development (Netherlands); Mekong Regional Health Support Project (WB);

Strengthening systems of surveillance, response and preparedness

CAM: CDC1

LAO: CDC1 Health System Development Project

VIE: CDC1; Preventive Health System Support

Project; HIV/AIDS prevention for youth project

CAM: Vaccination Strengthening Program (GAVI) GFATM’s projects.

LAO: Avian and Human Influenza Control and

Preparedness Project (WB); All GFATM’s projects

VIE: HIV/AIDS Prevention Project (WB) Projects of the GFATM and USAID



Core Area of the proposed CDC2



Capacity building of provincial and district staff for CDC and health services

CAM: CDC1

LAO: CDC1; Health System Development Project


Project;

CAM: Health System Support Project (AFD); Vaccination Strengthening Program (GAVI);

Scaling up Tuberculosis Programs of 2006-2011 and 2008-2012 (GFATM);

Scaling up HIV/AIDS Programs of 2006-2011 and 2009-2013 (GFATM);

Strengthening Maternal and Child Health Program (UNDFA)

LAO: LAO 607-G08 H; LAO 708 G10-T (GFATM)

VIE: Vietnam Avian & Human Influenza Project

(EC); Strengthening Basic Health Care System in Disadvantaged Provinces (GAVI);

Northern Upland Health Support Project (WB) Targeted communicable disease control and training activities for rural populations in border districts

CAM: CDC1

LAO: CDC1


Project

CAM: GFATM’s projects in malaria and TB.

LAO: Communicable disease control, health system

development, human resource planning, child and adolescent health (WHO)

GFATM’s projects VIE:

Vietnam Avian & Human Influenza Project (EC); Strengthening Basic Health Care System in Disadvantaged Provinces (GAVI)

ADB = Asian Development Bank, BTC = Belgian Technical Cooperation, CDC1= Communicable Diseases Control Project, CHT = College of Health Technology, DOP = D epartment o f Organization and P ersonnel, HSDP = Health S ystem D evelopment P roject, J ICA = J apan I nternational C ooperation A gency, Lux Dev = Lu x Development, MNCH = Maternal Neonatal and Child Health, PHC = primary health care, PHCEP = Primary Health Care Expansion Project, PHCCU = Primary Health Care C oordination Units, SBA = Skilled B irth A ttendant, TBA = t raditional b irth a ttendant, UNFPA = United Nations Population Fund, UHS = U niversity of H ealth Sciences, VHV = village health volunteer, WHO = World Health Organization.



Table A3.2: Major External Assistance to the Health Sector, 2005-2014 ($ million)

CAMBODIA External Agency Project Start End Total Commitment

Asian Development Bank GMS-Communicable Disease Control Program (CDC1) Strengthening National Surveillance and Response System; Improving CDC for Vulnerable Groups; Strengthening Regional Cooperation in Communicable Disease Control

2006 2010 9.00

Agence Française de Développement (AFD)

Health System Support Project Internal Contracting System for 5 Operational Districts; Supporting Community Based Insurance system; Supporting Capacity Building for PHD, ODs and HCs

2009 2013 10.00

Belgium Technical Cooperation (BTC)

Strengthening Health System Contracting System (SOA); Support for Health Equity Fund; Incentive system support for health staff

2009 2011 3.90

Global Agency for Vaccines and Immunization (GAVI)

Vaccination Strengthening Program Strengthening Community Participation: VHVs and TBAs; Capacity building for Central Department/MoH; Capacity building for Provincial, District and Health Centre staff; Strengthening Monitoring System and Outreach services of immunization Programs.

2008 2015 8.46

Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)

HIV/AIDS Prevention, Home based Care and ARV treatment 2005 2011 36.50

Scaling up Malaria Program School health promotion; Malaria Community BCC; Malaria Case Management and Treatment; Bed Net distribution

2005 2011 9.85

Scaling up Malaria Program: School health promotion; Malaria Community BCC; Malaria Case Management and Treatment; Bed Net distribution

2009 2014 44.00

Scaling up HIV/AIDS Program BCC for HIV/AIDS Prevention; Capacity building for health staff; Home based Care and ARV treatment

2006 2011 34.90



External Agency Project Start End Total Commitment

Scaling up Tuberculosis ProgramImproving Co mmunity DO Ts; Capacity buil ding for health s taff; BCC in the community for TB awareness

2006 2011 4.50

Health System Strengthening Strengthening Capac ity o f Healt h s taff r egarding P lanning, Monitoring and Evaluation, Provincial and District Coordination.

2006 2011 5.00

Scaling up Malaria Program School health promotion; Malaria Community BCC; Malaria Case Management and Treatment; Bed Net distribution

2008 2012 13.10

Scaling up HIV/AIDS Program: BCC f or HIV/AIDS Prevention; Capacity building for heal th staff; Home based Care and ARV treatment

2009 2013 23.85

Scaling up Tuberculosis ProgramImproving Co mmunity DO Ts; Capacity buil ding for health s taff; BCC in the community for TB awareness

2009 2013 8.70

United Nations Children’s Fund (UNICEF)

Strengthening Child Health Program Strengthening Capac ity o f Co mmunity V HVs and T BAs; Strengthening P lanning, M onitoring and E valuation system of Health centre, OD and PHD.

2009 2013 6.35

United Nations Population Fund (UNFPA)

Strengthening Maternal and Child Health Program Capacity Building for health staff; Training for VHVs and TBAs; Provide IEC materials and health equipments; Health Equity fund support for Maternal Health Services

2009 2013 2.40

USAID Maternal/Child Health and Reproductive Health Service 2009 2013 40.00

PATH/USAID Procure Vaccines; Capacity building for Health staff on TB, IMCI, RH, BCC; Scaling up Nat ional Nut rition Program; Scaling up National

and Provincial CDC Program; Improving National Reproductive Health Program

2007 2015 40.50

World Bank Second Health Sector Support Program Strengthening Health Service Delivery; Improving Health

2008 2014 110.00



External Agency Project Start End Total Commitment Financing; Strengthening Human Resources; Strengthening Health System Stewardship Functions

Health Sector Support Project Improved Delivery of Health Services; Improved Programs Addressing Public Health Priorities; Strengthening Institutional Capacity

2002 2010 31.84

Avian and Human Influenza Control and Preparedness Emergency Project Animal Health Systems; Human Health Systems; Behavior Change, Health Education, and Community Action; Strengthening Management Systems, including Institutional and Legal Frameworks, and M&E

2008 2011 11.00

Total

453.85



LAO PDR



2006 2010 6.00

Health System Development Project Improving PHC delivery; strengthening capacity in health system development

2007 2011 13.00

Health Sector Development Program (Project and Program Grants) Strengthen planning and financing; Increased access to MNCH care; Improved of Health Human Resources for Health

2009 2013 20.00

Agence Française de Développement

Support to the Health Sector 2007 2012 10.30

Global Agency for Vaccines and Immunization

Expanded Program on Immunization 2008 2011 5.50

Global Fund to Fight AIDS, Tuberculosis and Malaria

Lao-405-G04-H - Scaling up the fight against HIV/AIDS/STI, TB an Malaria in the Lao P.D.R. (HIV/AIDS Component) Maintain a low sero-prevalence through preventing transmission of the infection among highly vulnerable groups.

2005 2010 7.75

Lao-405-G05-M - Scaling up the fight against HIV/AIDS/STI, TB an Malaria in the Lao P.D.R. (Malaria Component) Scale up the existing malaria program (Round 1) and seek to ensure access to and use of insecticide-treated bed nets (ITNs) in remote areas and rapid diagnosis and treatment of falciparum malaria cases.

2005 2010 14.50

Lao-405-G06-T - Scaling up the fight against HIV/AIDS/STI, TB and Malaria in the Lao P.D.R." (TB Component) Improve the quality of and access to TB services including DOTS with the aim of reducing transmission, prevalence, and mortality caused by TB.

2005 2010 3.62




Lao-407-G07-M - Ensuring the quality of anti-malarial and other Drugs in the Lao PDR Improve the quality of medicines for malaria at health facilities and to reduce the use of counterfeit and substandard anti-malarials and related antibiotics.

2007 2011 3.63

Lao-607-G08-H - Scaling up HIV and AIDS Prevention, Care and Treatment in Lao PDR scaling up HIV Counseling and testing in 11 priority provinces; care, support and treatment for people with AIDS; scaling up a comprehensive package of interventions for sex workers; improving surveillance and management of HIV; and expanding blood safety to 100% of the provinces.

2007 2011 7.93

Lao-708-G10-T - Reducing the TB burden in Lao PDR October 2008 – 2013 To sustain and optimize the quality of DOTS and go beyond 70/85 targets; To adapt DOTS to respond to MDR-TB and TB-HIV, TB in children and other vulnerable groups; To ensure equitable access to quality TB cares for all people with TB; To strengthen the management capacity of the National TB Program

2008 2013 10.91

Lao-708-G09-M - Sustaining Malaria Control in Lao PDR, focusing on Malaria vulnerable population through multisectorial approach Improving access to early diagnosis and appropriate treatment for malaria for population at risk by maintaining 80% coverage of all villages in the designated 47 poorest districts.

2008 2013 24.63

LAO-809-G11-H - Scaling up HIV and AIDS Prevention, Care and Treatment in Lao PDR Develop a more cohesive and cost effective supply system and regulatory system for HIV/AIDS, tuberculosis and anti-malaria drugs

2009 2014 23.49

Japan International Cooperation Agency

Medical Education and Research for Sithathirath Hospital 2007 2011 2.60

Capacity Development for Sector-Wide Cooperation in Health 2006 2010 1.30




Project for Human Resources Development of Nursing/Midwifery 2006 2010 2.70

Government of Luxembourg Health Information System 2006 2011 12.50

SIDA Institutionalization of NDP 2006 2009 1.30

United Nations Children’s Fund Health and Nutrition 2008 2011 5.20

United Nations Population Fund Support MCH Activity 2007 2011 3.50

Support to Strengthen Health System 2007 2011 0.90

Strengthen IEC/BCC 2008 2011 0.80

World Bank Avian and Human Influenza Control and Preparedness Project Animal Health; Human Health - Surveillance and Response; Human Health - Curative Services; Information, Education and Communication; Program Coordination and Regulatory Framework

2006 2010 13.55

Health Service Improvement Project improving the quality and utilization of health services; strengthening institutional capacity for health services provision; and improving the equity, efficiency and sustainability of healthcare financing.

2006 2011 15.00

World Health Organization Communicable disease control, health system development, human resource planning, child and adolescent health 2007 2009 2.70

Total

213.30



VIET NAM



2006 2010 15.00

HIV/AIDS prevention for youth project Leadership and strategy support for HIV prevention; National mass media program for behavior change; Community-based HIV-prevention for youth

2006 2011 20.00

Preventive Health System Support Project Upgrading preventive health centers in 46 provinces and four national institutes; Training in CDC, laboratory techniques; Surveillance system capacity building in 17 Province

2006 2012 40.00

Health Care in the South Central Coast Region Project Improved planning and budgeting skills in provincial health teams; Upgrading facilities and equipment in district hospitals; Workforce training; Improved quality of care

2008 2013 72.00

Nutrition (2 projects) Nutritious food for 6-24 month old children in poor areas (6 provinces, $2 million); Vitamin A and de-worming distributions – expanding age range and addition of deworming (18 provinces, $1 million)

2006 2010 3.00

Health Human Resources Sector Development Program Loan has two parts: (i) policy based, funds released based on policy actions; (ii) project based, focused on training of human resources, planning and management at the central level and management in the service delivery setting.

2010 2014 70.00

Belgium Technical Cooperation (BTC)

Upgrading of Community Health Services in Hoa Binh Province Accessibility and quality of basic health services in Hoa Binh Province improved; Health policy-making capabilities enhanced

2006 2010 3.90

European Commission Health Care Support to the Poor of the Northern Uplands and Central Highlands (HEMA Project) To ensure the provision of high quality preventive, curative and promotive care in the mountainous, minority areas of Lai Chau, Dien Bien, Son La, Gia Lai and Kon Tum provinces.

2006 2010 26.00




Vietnam Avian & Human Influenza Project (VAHIP) via a Multi-donor Trust Fund administered by World Bank Support t he H uman R esource D evelopment); C apacity B uilding t o respond the Avian Flu Epidemic; Training for DH and Communal levels

2007 2010 12.00

Health Sector Capacity Support Project (SCSP) Strengthen c apacity o f c entral M oH, p rovincial D oH and k ey sectoral stakeholders in health i n the areas of : ( i) sector policy ( including health financing), p lanning and bud geting; (ii) management an d r egulation, including P FM; ( iii) c oordination; and ( iv) de livery of q uality he alth services (with m ain f ocus on p rimary health care and pr eventive medicines).

2009 2012 18.50

GAVI Alliance Strengthening B asic H ealth C are S ystem in D isadvantaged Provinces, P hase-I Training to VHWs & CHWs; Monitoring & supervision of VHWs & CHWs; Strengthening planning and management capacity; Basic equipment kits & allowances for VHWs & CHWs; MOH capacity building

2007 2010 16.28

Embassy of Finland Avian Influenza (Grant) Contribution to UN Program to fight Avian Influenza 2005 2010 8.45

Water supply and sanitation in small towns Building water supply and sanitation schemes 2004 2013 44.20

Germany GTZ Join German cooperation project TC (GTZ-DEDCIM-InWEnt) + FC (KfW) 5 Provinces (Yen Bai, Phu Yen, Thanh Hoa, Thai Binh and Nghe An) 1. Capacity development of Health personnel in: Management of provincial and district health systems; Curative services delivery; Preventive Health service; Hospital (asset) management and MHIS; Waste Management 2. Strengthen the stewardship role of MOH

2008 2013 7.15

Germany KfW Join G erman cooperation p roject TC (GTZ-DEDCIM- InWEnt) + FC (KfW) 5 Provinces (Yen Bai, Phu Yen, Thanh Hoa, Thai Binh and N ghe An) Medical an d ge neral e quipment; C omprehensive s upport o n I T s ystem (hard and soft ware); Training for medical/technical & management staff of the hospital system

2008 2013 23.01

Netherlands National Targeted Programs TB Control (Euro 8 million) Human Resources Development (Euro 11.5 million) Safe Motherhood I nitiative, c overing 1 4 N orthern a nd C entral

2008 2011 41.86



External Agency Project Start End Total Commitment Mountainous provinces (Euro 6.7 million)

Special Innovate Interventions HIV/AIDS, Harm Reduction (Euro 4 million)

Community Based Social Support Networks for HIV widows and children (Euro 1.5 million)

2008 2011 7.15

World Bank HIV/AIDS Prevention Project Provincial implementation of HIV/AIDS action plans; National HIV/AIDS policy and program; Project management at CPMU & PPMUs

2005 2011 38.50

Mekong Regional Health Support Project Protecting the poor and near poor; Curative care quality and capacity; Preventive Health; Human Resources Development; Project management, Monitoring and Evaluation

2006 2012 85.00

Vietnam Avian Influenza control and preparedness project Human Influenza control in the Agricultural sector ($17.2m); Influenza Prevention and Pandemic Preparedness in the Health Sector ($16m); OPI integration & coordination, result M&E, Project management ($4.8m)

2007 2010 38.00

Northern Upland Health Support Project (NUP) Health Network Strengthening; Capacity Strengthening; HCFP contribution; Health facility strengthening; Project management

2008 2014 66.00

Northern Central Coast Region Project Provincial Health Support with the demand and supply side interventions; Pilot results based financing model; Support governance and management roles at central level; Project management, monitoring and evaluation

2009 2014 62.00

UNFPA Safe Motherhood Initiative UN-Kon Tum joint project VINAFPA-UNFPA s trengthening t he ac cessibility and quality of

reproductive health care project Maternal and Child Health project Program - Sixth Country Program (CP6) Program - Seventh Country Program (CP7)

2006 2010 39.10

UNAIDS Overall po licy, monitoring and e valuation, pa rtnerships and coordination of the HIV response

Strategic information, knowledge sharing and accountability, support to c oordination o f na tional e fforts, par tnerships bu ilding, a dvocacy,

2007 2010 3.00



External Agency Project Start End Total Commitment and monitoring and evaluation, including estimation of national prevalence and projection of demographic impact

Global Fund for AIDS TB and Malaria

ROUND 1 TB Reaching Tuberculosis Patients Among High-Risk Groups, Remote Populations and People Living with HIV and AIDS 2006 2011 10.00

ROUND 6 TB Support to Mid-Term Development Plan for TB in Viet Nam 2008 2012 10.60

ROUND 6 HIV: Strengthening HIV care, treatment, support and community based activities 2008 2012 28.70

ROUND 3 MALARIA

ROUND 7 MALARIA 2009 2013 30.80

United States (PEPFAR and USAID) Preventing H5N1 virus transmission within animals and humans 2008 2013 1.50

HIV/AIDS prevention, care and treatment

88.00

Total

929.70 Source: Ministries of Health of Cambodia, Lao PDR and Viet Nam and ADB and other donors’ websites

APPENDIX 19:

PERFORMANCE BASED MANAGEMENT

ADB TA – REG: Second GMS Regional Communicable Disease Control Project.

Appendix 19: Performance Based Management– Final Consultant Report April 2010 Page i

ABBREVIATIONS AND ACRONYMS ............................................................................................. ii I. PERFORMANCE BASED MANAGEMENT - MONITORING AND EVALUATION

FRAMEWORK ......................................................................................................................... 1 A. Results Based Management ................................................................................................ 1

A.1 ADB and Managing for Development Results (MfDR) .................................................. 1 A.2 What is Managing for Development Results .................................................................. 1 A3. Results-Based Monitoring and Evaluation ..................................................................... 2

B. Outline of the Monitoring and Evaluation Framework ........................................................... 2 C. Principles for Monitoring and Evaluation Strategy ................................................................ 3

C.1 Guiding Principles.......................................................................................................... 3 C.2 Conceptual Definitions and Relationships ...................................................................... 4

D. Elements of the Project Monitoring and Evaluation Framework ........................................... 5 D.1 Major Health Problems ................................................................................................. 6 D.2 Program Access, Coverage, and Quality of Health Care. .............................................. 6 D.3 Staff Technical and Management Skills ......................................................................... 7 D.4 District and Provincial Institutional Capacity (in Health Program Management) ............. 7 D.5 Community Participation ................................................................................................ 7 D.6 Gender Equity ............................................................................................................... 8

E. Key Indicators ...................................................................................................................... 8 E.1 Quantitative ................................................................................................................... 8 E.2 Routine Disease Indicators ............................................................................................ 9 E.3 Disease Outbreaks ........................................................................................................ 9 E.4 Demographic Indicators ................................................................................................. 9 E.5 Program Coverage Indicators ...................................................................................... 10 E.6 Behavioural Change Indicators .................................................................................... 11 E.7 Quality of Care (Dispensaries and District Hospitals) ................................................... 11 E.8 Hospital Treatment Indicators ...................................................................................... 12

ANNEX 1: LIST OF PROPOSED INDICATORS ........................................................................ 13 ANNEX 2: Baseline Provincial and District Key Data and ANALYSIS

(Example of Health Facility Data that can be used for Baseline) ............................... 24 Figure 1. Results Based Management Concept 1 Figure 2. Definitions of Key Terms 4 Figure 3. Relationship between Planning, Monitoring and Evaluation 5 Figure 4. Impact of increased Skills and Improved Management on Health Status 6


Appendix 19: Performance Based Management– Final Consultant Report April 2010 Page ii

ABBREVIATIONS AND ACRONYMS ADB Asian Development Bank AIDS Acquired Immune Deficiency Syndrome AP Annual Plan ARI Acute Respiratory Illness ARI Acute Respiratory Infections BCC Behavior Change Communication BCG Bacillus Calmette-Guerin (TB vaccine) BS Birth Spacing CA Capacity Assessment CBR Crude Birth Rate CDD Control of Diarrheal Diseases CPR Contraceptive Prevalence Rate DH District Hospital DHD District Health Department DOP Department of Organization and Personnel DPT3 Diphtheria, Pertussis, and Tetanus (third vaccination) DRF Drug Revolving Fund EPI Expanded Program on Immunization EU European Union GOL Government of Lao People’s Democratic Republic HC Health Center HIV Human Immunodeficiency Virus HMIS Health Management Information System HRD Human Resource Development IBN Impregnated Bed Nets IMR Infant Mortality Rate M&E Monitoring and Evaluation MCH Maternal and Child Health MfDR Managing for Development Results MDG Millennium Development Goals MMR Maternal Mortality Rate MOPH Ministry of Public Health NGO Non Government Organisation OECD Organisation for Economic Co-operation and Development PH Provincial Hospital PHD Provincial Health Department PHC Primary Health Care PME Project Monitoring and Evaluation PMT Project Management Team RBM Results Based Management TB Tuberculosis TBA Traditional Birth Attendant TFR Total Fertility Rate TOR Terms of Reference TT2 Tetanus Toxoid (second vaccination) U5MR Under-Five Mortality Rate UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Emergency Fund VHV Village Health Volunteer WCBA Women of Child Bearing Age WES Water (Supply) and Environmental Sanitation WHO World Health Organization


Appendix 19: Performance Based Management – Final Consultant Report April 2010 Page 1

I. PERFORMANCE BASED MANAGEMENT - MONITORING AND EVALUATION FRAMEWORK

A. Results Based Management

A.1 ADB and Managing for Development Results (MfDR) 1. MfDR is the RBM approach the ADB have adopted and it is endorsed by the Development Assistance Committee of the Organisation for Economic Co-operation and Development (OECD-DAC), which is a key forum for major bilateral donors to work together to increase development effectiveness. ADB has developed the Managing for Development Results (MfDR) Action Plan (2009-2011) which provides a roadmap for advancing the implementation of MfDR in ADB and its developing member countries (DMCs) and builds on the progress and lessons learned from the previous action plan of 2006-2008, MfDR 2009-2011 aims to further expand efforts to mainstream the MfDR approach within ADB's operations and among DMCs.

A.2 What is Managing for Development Results 2. MfDR is a management approach that focuses on using results information; specifically outputs, outcomes and impact, for projects to achieve clearly defined project or development goals, and involves the following key phases: (Figure 1.) Figure 1. Results Based Management Concept

1. Focus the dialogue on results at all phases Principle 1. At all phases – from strategic planning through implementation to completion and beyond – focus the dialogue on results for partners, implementing agencies/depatments, and other stakeholders. 2. Align programming, monitoring, and evaluation with results Principle 2. Align actual programming, monitoring, and evaluation activities with the agreed expected results. 3. Keep measurement and reporting simple Principle 3. Keep the results reporting system as simple, cost-effective, and user-friendly as possible. 4. Manage for, not by, results Principle 4. Manage for, not by, results, by arranging resources to achieve outcomes. 5. Learning and decision making



Principle 5. Use results information for management learning and decision making, as well as for reporting and accountability, and thereby contributing to a community of practice as part of knowledge management

A3. Results-Based Monitoring and Evaluation 3. Monitoring and Evaluation (M&E) involves the systematic collection of performance information about project activities and progress towards results, which are used for management decision making. Previously M&E has mainly been used for measuring inputs and outputs which are clearly definable, with an emphasis also on process indicators as a reflection of capacity building. Increasingly M&E has been used to assess results and achievements (change) and therefore is a major component of MfDR. 4. Monitoring and Evaluation is also at the centre of sound governance arrangements. They are necessary for the achievement of evidence-based policy making, budget decisions, management, and accountability. The bottom-line of success is the extent to which the M&E information is being used to improve governance performance. 5. The Monitoring and Evaluation Framework outlined in this document sets out a range of proposed indicators as a means to promote learning and measure results based performance of CDC2 project activities.

B. Outline of the Monitoring and Evaluation Framework 6. The purpose of the M&E Framework is to provide a conceptual framework and methodology for Monitoring and Evaluation through the life of CDC2, and to describe specific tools that will be used to facilitate information collection and reporting. The M&E Framework is therefore primarily intended to be useful for the provincial and district staff who are responsible for the implementation of the health services program. It should be used as a document which guides the effective management, Monitoring and Evaluation process that will be conducted by the GOL staff at the district and provincial levels to serve their needs, and for reporting on progress of the project over time, and it should not be seen as being just for the MOH PMU or Asian Development Bank (ADB). As the M&E Framework is specifically for the Project it is hereinafter referred to as the Project Monitoring and Evaluation (PME) Framework. 7. The PME Framework as outlined below includes details tools and processes that can be used by the Project to monitor the implementation and quality of health services, as well as listing of the proposed indicators for CDC2. More specifically, the PME Framework:

Incorporates project planning, Monitoring and Evaluation policy and guiding principles; Outlines project Monitoring and Evaluation objectives and strategies, including the

processes for the involvement of GOL provincial and district planners, and the participatory methods to be used for village planning and review activities;

Defines quantitative and qualitative performance indicators and data sources; Outlines the frequency and schedule for monitoring activities, and data collection,

analysis and reporting; Describes who will be responsible for the collection, analysis, reporting and use of

information; Outlines the resources required to undertake monitoring activities; and Takes into account the development of national HIS policy and systems.

8. The purpose of the Project is to improve the capacity of the provincial and district governments of the project provinces and districts to provide appropriate and effective community services, which will have a positive impact on health. The PME Framework strongly emphasizes the Monitoring and Evaluation of those capacity building processes that are undertaken in the course of strengthening the capacity of District and Provincial teams to achieve key health outcomes, and reflecting the overall Goal of the Project. The PME Indicators described in this section are in 2 parts. The first is the Key Performance Indicators that have to be agreed between



MOH’s and ADB and will be the basis of their regular monitoring. The second set of M&E indicators are those additional indicators that can be used by the provinces and districts to monitor a broader range of health service planning, management and delivery. Because of the varying degree of capacity of GOL health staff at the different levels it could be foreseen that these indicators be introduced as the staff build capacity and skills over the life of the Project, and beyond. Details of the indicator definitions and application are included in Annex 1 of this document.

C. Principles for Monitoring and Evaluation Strategy 9. Under the respective policies of decentralisation in CLV, the district is primarily responsible for annual planning and budgeting while the Province is responsible for longer-term strategic planning. Thus, the Project will should focus on strengthening the capacity of District PHC teams in evidence-based planning, while at the same time supporting, where possible, the provincial strategic planning process. This PME Framework proposes several key elements:

A focus on monitoring processes assessed as key achievements in progress towards a district and provincial health program management system that employs data for decision-making;

An emphasis on the quality and timeliness of the collection, analysis, documentation, and application of information essential for:

District-level health program planning and management; Provincial-level collation, analysis, and use of district information for long-term planning,

evaluation, and policy development; A system of tracking progress in achieving core skills in the management and technical

quality of primary health care programs; and A focus on monitoring trends in the frequency of major identified health problems in the

provinces as well as coverage and utilisation of services aimed at addressing those problems.

C.1 Guiding Principles 10. In developing the PME Framework, the following guiding principles should underpin the CDC2 approach to Monitoring and Evaluation: Simplicity and Ease of Management 11. It is proposed that where possible the existing reporting formats be used, and if additional information is required then these forms should be designed so that they are appropriate for multiple audiences, and additional information collection and reporting is minimised. Existing data sources that are entered into the MOH’s Management Health Information System (MHIS) should be the basis of the collection and reporting of information. Local Participation and Feedback to Stakeholders 12. The long-term sustainability of the health program depends on local planning and participation by government health program staff, health workers, and communities. Community representatives and government counterpart staff need to be involved in both health program monitoring activities and in the more formal periodic evaluations. Establishing Monitoring and Evaluation as an activity internal and integral to health program implementation will establish sustainability of local-level analysis and use of the information generated for developing implementation work plans. Strengthening the capacity of local government staff and communities to monitor and evaluate their own activities is an essential part of the PME process. The framework is intended to provide a basis for monitoring activities, a format for recording progress in key project areas, an outline for periodic reporting of Project achievements, and a guide to issues for project evaluation. In addition, periodic reviews of the indicators specified in the framework should guide annual work plan development and adjustment of activities under each component and output to achieve the Project objectives. Linkage to and Use of Existing Data Collection Methods 13. The existing MHIS within the respective countries can provide useful data for health program monitoring. As part of the capacity building component, CDC2 will improve health management and the demonstration of the usefulness of the data for the PME which should



increase the commitment of staff to improving data collection, recording and reporting. The review of the current system and found that the HIS is extremely cumbersome and complicated, and provides little useful information to health program managers and planners at any level. The PME aims to provide a framework within which key data categories are selected from within the existing system and are compiled, analysed, documented (eg, through trend graphs), and discussed on a regular basis (at least three-monthly) at the district and provincial levels. The emphasis will be on monitoring this process and its link to decision-making (in the three-monthly district and provincial planning meetings) rather than on achieving time-defined quantified targets, which would most usually be project-driven.

Emphasis on Validity, Timeliness, and Feasibility of Indicators 14. Indicators should be timely, that is, time and effort should only be spent on measuring them at intervals when some measurable change may be expected to have occurred. CDC2 is a five-year Project which aims to strengthen CDC systems and health care service delivery, more generally, and communities’ access to and choosing available services. Thus, the PME places an emphasis on monitoring process indicators, including key points to evaluate the strategies and approaches being adopted and their efficacy. Access to services, availability and quality of services, and coverage of services comprise the main targets of monitoring. These should be developed by the districts and provincial staff to allow them to assess their own performance.

C.2 Conceptual Definitions and Relationships 15. For the PME Framework the definitions of key terms used are presented in Figure 2. The description of the relationships between activity and input monitoring is a rather straight forward process of documenting that activities and inputs are executed according to the quantity budgeted or planned and according to the timing proposed in annual work plans. Monitoring of outputs and outcomes is more concerned with an assessment of the quality of the processes undertaken and completed. For the purposes of this Framework, the concepts are clustered in Figure 3. 16. Evaluation of outputs and outcomes is a more intensive assessment of achievements using methods that are not as easily done frequently. Monitoring and Evaluation indicators may not be the same for a given output, as monitoring must rely on methods and data that are more readily accessible on a frequent basis, whereas evaluation can use methods which require more resources and are more in-depth, such as special studies or more intensive data reviews. Figure 2. Definitions of Key Terms

Monitoring On-going process of information and data collection, analysis and reporting, concerned with activities conducted by the Project and inputs. Outputs are also the subject of monitoring, and where feasible, outcomes.

Evaluation Periodic review of the outcomes of Project interventions, concerned with the immediate short term and, where possible, the longer term impact of the Project on the target groups. The target groups include the health program planners (PPIU/PHS/DHS/technical team), the MOH and health personnel, as well as women, men, children and communities.

Indicator The information we need to help us determine progress towards meeting project objectives. Indicators provide, where possible, a clearly defined unit of measurement and a target detailing the quantity, quality and timing of expected results.

Impact The anticipated result of Project interventions.

Outcome Short and medium term results of Project activities.



Output The specific results and tangible products (goods and services) produced by undertaking a series of tasks or activities.

Activity An intervention that the Project is directly responsible for conducting, implementing or achieving.

Input The resources required to undertake the activities and produce the outputs, eg personnel, equipment, and materials.

Means of Verification

Means of verification should clearly specify the expected source of the information we need to collect. We need to consider how the information will be collected (method), who will be responsible, and the frequency with which the information should be provided.

Figure 3. Relationship between Planning, Monitoring and Evaluation

D. Elements of the Project Monitoring and Evaluation Framework 17. The four key elements of the PME framework are as follows:

Trends in major health problems. Trends in program access, coverage, and quality. Trends in health staff technical and management skills. Trends in district and provincial health program management capacity.

Identify Problems

Develop Objectives

& strategies

Activities Inputs

Outputs Outcomes

Impact

Planning

Monitoring

Evaluation



Figure 4. Impact of increased Skills and Improved Management on Health Status

D.1 Major Health Problems 18. A review of existing health information suggests that most morbidity and mortality is associated with the following seven health problems:

Malaria/Dengue; Enteric diseases (eg, diarrhoea, dysentery, hepatitis, intestinal parasites); Acute respiratory infections (ARI) and TB; Measles; Reproductive health problems, in both women and men, including high fertility;

complications of pregnancy, childbirth, and postpartum; sexually transmitted infections, including HIV; and other reproductive tract infections;

Neonatal problems, including low birth weight, neonatal tetanus, and infantile beriberi; and

Nutritional deficiencies 19. The development of the PME will involve selection of a limited number of feasible and measurable indicators from within these problem areas

D.2 Program Access, Coverage, and Quality of Health Care. 20. Important outcome indicators include:

access by communities to clinical services (including assisted deliveries) at dispensaries, district & provincial hospitals, and mobile teams;

access by communities to health promotion and primary care services by village health volunteers;

access by communities to affordable and appropriate essential drugs at each level; utilisation of clinical services (including assisted deliveries) by communities; coverage of key prevention programs, including impregnated bed nets, EPI vaccination,

contraception, antenatal care, tetanus toxoid vaccination, growth monitoring, vitamin A supplementation, iodised salt, health and nutrition promotion, de-worming programs and health education;

Improvement in population’s health status

Improved access to

health services

Improved coverage of

health services

Improved information

management

Improved quality of health

services

Improved district & provincial planning, monitoring, and evaluation capacity

Improved technical skills and management



quality of clinical services at dispensaries and district hospitals; quality of preventive services; coverage of households with access to clean water and latrines; and

D.3 Staff Technical and Management Skills 21. Outcomes o f t raining pr ograms will b e m onitored by as sessing t he s kills o f di spensary, district, and provincial staff in core areas, including:

Collection of routine health information; Analysis of routine health information; Collection and a nalysis o f q ualitative i nformation us ing p articipatory r apid a ppraisal

methods; Use of data in program planning and evaluation; Training capacity and use of appropriate training methods; Program reporting; Budgeting, finance and resource management; Human resource management, including gender analysis; Relevant technical skills, including: Relevant technical skills, including:

Communicable disease control, including immunization; Child and maternal nutrition; Reproductive health, i ncluding pr egnancy a nd delivery c are, birth s pacing, and

management of STIs and RTIs; Epidemic investigation and response; Essential drugs management; Safe injections; and Water and sanitation construction and maintenance.

D.4 District and Provincial Institutional Capacity (in Health Program Management) 22. The M&E Framework will include monitoring of the capacity of district and provincial health teams to undertake a regular process of evidence-based planning, summarised as follows:

1. Analysis of information and assessment of public health needs; 2. Definition of major local health and health service problems; 3. Establishment of priorities; 4. Definition of objectives:

Based on outputs (activities achieved) Based on medium term outcomes, such as improved program coverage, positive

changes in community health-seeking and nutrition practices Based on impact (positive changes in disease and mortality rates)

5. Review of resource needs and constraints; 6. Consideration of gender and ethnicity issues and roles of communities; 7. Development of activity schedule and budget; 8. Development of risk management plan; 9. Identification of information needs for Monitoring and Evaluation; and 10. Participation in quarterly planning meetings and the presentation of data analysis at

those meetings.

D.5 Community Participation 23. The M &E F ramework w ill ad dress participation o f v illagers i n P roject planning and implementation through:



1. Monitoring the establishment and effectiveness of Village Development Committees, and water user groups. Indicators of effectiveness will be timely development of plans and record keeping; and

2. Monitoring community support to VHV and TBA.

D.6 Gender Equity 24. The M&E Framework will address equity by monitoring indicators relating to gender, poverty, and ethnicity.

Gender 1. Disaggregated data on attendance at training courses compared to gender ratio in

the respective health service; 2. Gender of TBA, VHV and dispensary workers with the intention of increasing

women’s access to female health workers, and hence the health service; and 3. Data on women’s health issues.

Poverty 1. District and village level data on poverty which is largely based on governments

Poverty Guidelines; and 2. Participation by the poor in rice banks and credit or loan schemes where the poor

are defined by the VDC. Ethnicity

1. Dominant ethnicity of all villages within the Project districts; 2. Ethnicity of dispensary staff, VHV and TBA; 3. Health facility data disaggregated to determine if there are barriers to ethnic groups

from accessing the health services. Where there appears to be a problem the situation will be monitored; and

4. Studies to assess ethnic differences in health and nutrition knowledge and practices conducted, analysed, and documented.

E. Key Indicators

E.1 Quantitative 25. The following indicators are proposed not as project indicators but rather indicators that would be monitored routinely by district and provincial health staff. Not all will be influenced by the Project in terms of the direction of trends over time; however, the Project can support health staff in improving the quality and coverage of collection, analysis, and use of this information. No quantified objectives should be attached to these indicators (that is, the emphasis is on their correct collection, analysis, and use for planning rather than on a change of “X% in Y years”). These indicators can be calculated from data that are already included in the routine health information system, although the data are currently collated and reported by different vertical departments (eg, malaria control, epidemic control, routine disease reporting, MCH) and not aggregated or reviewed by the PHD and DHO department staff looking at health problems and health services issues in a holistic and integrated manner. The aim of the M&E principles as outlined in section C.1 is to promote three-monthly meetings at the Provincial level, at which each district would present a review of their programs using an analysis and graphing of data. Initially this will mean that one person in each district be trained in epidemiology, as well as 3-4 provincial staff. Staff from the vertical programs should be an integral part of these meetings.

26. In addition it is proposed that the Project also consider the feasibility of simple population surveys, conducted every 1-2 years on the following indicators, which have been assessed as problematic to estimate using the routine MHIS (see below):

Prevalence of acute and chronic malnutrition in children under-five years of age Coverage of the targeted EPI vaccines in the target age group



Coverage of tetanus toxoid vaccination in women of child-bearing age Contraception use prevalence among couples of reproductive age

27. When calculating morbidity and mortality rates, the denominator used will be the total population of the district and province, even though the Project is not covering all districts and all zones within project districts. This is the denominator that health staff should be using to calculate rates. Nevertheless, reports will be marked by the name of the district and dispensary; therefore, a sub-analysis of areas covered by the PPIU/PHD staff is possible.

28. Note: Caution must be used in interpreting trends in disease incidence and mortality rates. As coverage of health services (and the MHIS) expands, there may be an apparent increase in rates which is merely a function of the improved coverage of the MHIS rather than a real increase in morbidity and mortality.

E.2 Routine Disease Indicators 29. As a basis of starting the following key disease indicators could be collected, collated, analysed, and graphed on a three-monthly basis:

1. Malaria and Dengue incidence (under-five and all ages); 2. Diarrhoea incidence (under-five); 3. ARI (pneumonia) incidence (under-five); and 4. Measles incidence (under-five).

30. Source of data: Initially from Health Centres, District Hospitals, and Provincial Hospital. The project will promote gradual expansion of reporting on some of these diseases by VHVs. Note that malnutrition prevalence is considered an important health indicator for monitoring by district and provincial health staff. The Project is encouraged to consider conducting two annual population surveys of malnutrition prevalence (acute and chronic).

E.3 Disease Outbreaks 31. Outbreaks of the following diseases will be monitored and the response assessed and documented (the indicator will be the quality of outbreak investigation and control measures):

1. Newly emerging disease (Through the surveillance system). 2. Measles; 3. Malaria; 4. Cholera; 5. Dysentery; 6. Meningitis; and 7. Dengue Haemorrhagic Fever.

32. The key steps in the investigation of an epidemic should be included in the basic field epidemiology training (BFET).

E.4 Demographic Indicators 33. The following data will be collected through the routine reporting system and collated, analysed (rates calculated), graphed, and interpreted on a three-monthly and annual basis. Although the national birth and death reporting system already includes these indicators, the Project is working actively to improve the quality, timeliness, and coverage of village- and dispensary-level reporting:

1. Births; 2. Neonatal deaths (0-28 days); 3. Infant deaths (0-11 months);



4. Under-five deaths; 5. Maternal deaths; and 6. Deaths (all ages).

34. From this data, the rates can be calculated according to the indicator definitions in Annex 1. Calculation methods would have been included in the initial basic epidemiology training.

Crude Birth Rate Neonatal Mortality Rate Infant Mortality Rate Under-Five Mortality Rate Maternal Mortality Rate Crude Mortality Rate

35. Source of data: District Administration, Health Centres, District and Provincial Hospitals, and VHV’s. 36. Note: This data is likely to be under-reported initially, as the village-level reporting of births and deaths is currently quite incomplete.

37. Data relating to poverty and ethnicity were reviewed during the Baseline Survey but were not for evaluation because the Project does not address the identified root causes of poverty. Indicators could be:

Percentage of poor villages from District data using the District definition of poverty that relates largely to self sufficiency in rice. It is worth noting that there is not a standard across all Districts;

Percentage of food insecure families from village data; and Dominant ethnicity for each village.

E.5 Program Coverage Indicators 38. This information would be as part of the monthly collection of Data through the HIS, and would be collated and analysed each 3 months and annually:

1. Proportion of expected VHV monthly information reports actually received and satisfactorily completed;

2. Proportion of expected outreach visits actually conducted by dispensary staff;

3. Dispensary staff visits to villages as a proportion of the population of the dispensary catchment villages;

4. Proportion of expected dispensary monitoring visits by district staff actually conducted;

5. The number of impregnated bed nets distributed (indicator being ratio of bed nets to households);

6. Proportion of malaria smears positive for malaria;

7. Number of Oralyte (ORS) packets prescribed1 by Dispensaries and District/Provincial Hospital Outpatients (indicator being ratio of ORS packets to number of cases of diarrhoea in children under-five reported);

8. Number of deliveries in Dispensary or Hospital (indicator being proportion of all births that take place in a health facility);

1 Note that the number of ORS packets prescribed is not currently reported routinely; however, health staff are able to compile the data during routine supervisory visits to health centres.



9. Number of women who attend an antenatal clinic three times during their pregnancy (indicator is the proportion of pregnant women [which can easily be calculated from the birth rate and the population size] who attend ante-natal clinics);

10. Trends in MCH clinic utilisation (apart from ante-natal visits) as a proportion of (i) women of child-bearing age (xx% of the population, of which xx% would be expected to give birth in any one year) and (ii) children under five years of age (xx% of the population);

11. Number of women employing some form of contraception (indicator being proportion of women of reproductive age using some form of contraception)2;

12. Number of children who are vaccinated against the standard six diseases (indicator being the proportion of children in the target age group 12-23 months who are completely vaccinated) and women of reproductive age who receive tetanus toxoid (indicator being proportion of women of reproductive age who receive 5 doses of TT)3;

13. Number of children under-five who are weighed and measured at least once every three months (indicator being the proportion of all children under-five who have routine growth monitoring)4;

14. Proportions of children who fall into the three categories of nutritional status (well nourished, mildly malnourished, and severely malnourished); and

15. Number of children who receive a supplement of Vitamin A (indicator is the proportion of children under five who receive two doses of Vitamin A per year).

E.6 Behavioural Change Indicators 39. These “indicators” should not be quantified; however, the project will promote annual (or more frequent) assessments of trends through the use of PRA techniques. The emphasis in this section is on the collection and use of the data rather than quantifiable changes in the behaviours. The PME indicator would be that this information is collected, analysed, and used in planning on a regular basis (say, annually). The actual information categories might need to be determined, but a few examples are given below. The use of PRA studies would assess how common are the following knowledge and behaviours:

1. Exclusive breast-feeding until 6 months of age; 2. Introduction of appropriate supplementary food at six months; 3. Food taboos in pregnancy and in the post-partum period; 4. Knowledge and attitudes towards antenatal care, attended deliveries, and

contraception; 5. Food taboos during child illness; 6. Caring practices during childhood illness; 7. Practices related to children with diarrhoea (for example, giving more fluids and

continuing breast-feeding); and 8. Knowledge and awareness of HIV/AIDS transmission and its prevention.

E.7 Quality of Care (Dispensaries and District Hospitals) 40. Regular assessments of the quality of health worker practices in dispensaries and district hospital outpatient departments should be conducted by provincial clinical team members, and district health staff. These assessments could be based on structured observation checklists and interviews. This process needs to be agreed to by the districts and provinces and is a provisional 2 This may be a difficult figure to estimate from the routine MHIS because many women buy contraceptives outside the formal health system. This information may need to be collected by periodic population surveys (eg, every 1-2 years) 3 The current system of monitoring coverage on the basis of dividing the number of vaccine doses administered by the “target” number of children has many problems. Thus, this indicator may also need to be collected through periodic population surveys. 4 This will require some modifications to the existing system whereby dispensaries maintain lists of children under-five years of age in their cluster villages and record their weights, ages, and heights.



section of the M&E Framework. The indicator would be that the assessments are done and that trends demonstrate improvement in health worker practices consistent with the objectives of training workshops. Examples of quality indicators might include adequacy in the following procedures and tasks:

Assessment and management of a child with diarrhoea and dehydration; Diagnosis and treatment of malaria; Assessment and management of a child with fever and cough; Advice given to mothers on the vaccination schedule for children; Advice given to mothers on breast-feeding and weaning foods; and Interpretation of weight, height, and age measurements and advice given to mothers. Useful indicators would be. Percentage of dispensaries with at least one woman staff member; and Percentage of villages served by either a VHV or TBA and by women volunteers.

E.8 Hospital Treatment Indicators 41. The following data could be collected through the routine hospital reporting system and collated, analysed, graphed, and interpreted on a three-monthly and annual basis at the district and provincial levels:

1. Case-fatality ratio for diarrhoea in children under-five; 2. Case-fatality ratio for pneumonia in children under-five; and 3. Case-fatality ratio for malaria (all ages).

42. Source of data: Initially, probably only district and provincial hospitals. 43. Useful Resources for M&E in CDC2: Each country should list its key reference documents and criteria that guide their own M&E activities. Supporting Annexures Annex 1. List of Proposed Indicators Annex 2. Baseline Provincial and District Key Data and Analysis (Example of Health Facility Data that can be used for Baseline)



ANNEX 1: LIST OF PROPOSED INDICATORS KEY PERFORMANCE INDICATORS: (A) HEALTH OUTCOME/IMPACT INDICATORS Health Outcome/Impact Indicators linked to the Project Design and Monitoring Framework (DMF) And the outcome indicators are used to measure the long term impact of the Program activities and would normally be measured at mid-term and at the t ime of t he final evaluation; and would include; Infant mortality rate. Under-five mortality rate. Maternal mortality ratio. Infant Mortality Rate (IMR) Definition: The number of deaths of infants below one year of age (between 0 to 364 days after birth) per 1,000 live births during a given year.

Numerator: Number of deaths of infants below one year of age (between 0 to 364 days after birth) during one year x 1,000. Denominator: Number of live births during the same period of time.

Use: Measurement of specific causes of mortality, if possible may serve several purposes. It can be used:

to establish the relative public health importance of the different possible determinants or causes of death;

to evaluate trends over t ime, especially as a m ethod of evaluating the probable impact of intervention programmes;

to select place and program interventions; to evaluate health service utilization for pregnant women and children; to assess health services capability in health facilities; and for planning priority health interventions.

Data S ources: National c ensus; v ital r egistration; sample r egistration s ystem; i nfant d eath surveillance system; demographic surveys. Under-Five Mortality Rate (U5MR) Definition: The number of deaths of children below five years of age per 1000 live births during a given period of time. More specifically, the probability of dying between birth and exactly five years of age is expressed per 1000 live births during a given period of time.

Numerator: Number of deaths of children below 5 years of age during 1 year x 1,000. Denominator: Number of live births during the same period of time.

Use: Measurement of specific causes of death, if possible may serve several purposes. It can be used:

to establish the relative public health importance of the different possible determinants or causes of death;

to evaluate trends over t ime, especially as a m ethod of evaluating the probable impact of intervention programmes;

to select place and programme interventions; to evaluate health service utilization by pregnant women and children; to assess health services supply capability in health facilities; and to evaluate health promotion programmes for mothers.



Data S ources: National c ensus; v ital r egistration; s ample r egistration s ystems; s urveillance system; demographic surveys. Maternal Mortality Rate (MMR) Definition: The total number of maternal deaths per 100,000 live births during one year.

Numerator: Number of maternal deaths during 1 year x 100,000. Denominator: Number of live births during the same period of time.

Use: Maternal mortality is not only affected by health services, but also by social factors such as education and economics, and environmental factors such as housing, sanitation and safe water supply.

Data Sources: Registration of births; survey-based information; hospital registrations. The availability of data for these indicators will depend on the undertaking of specialized surveys. (B) INDICATORS THAT MEASURE HEALTH SERVICES COVERAGE AND QUALITY Monitoring and Evaluation (M&E) Key Indicators The selection of Key Indicators will be through a process of consultation between the PMU team, the Baseline Survey Team, ADB representatives, and other partners. These are indicators that will be an essential part of measuring the progress over time of the CDC2 Project and will be reported on r egularly t o t he PMU a nd ADB. T he PP IU/PHD will be r esponsible for t he c ollection of this information from; The district level health services, f rom other donors and NGO’s working in the Province, as an essential part of m easuring the pr ogress o f i mproving CDC a nd Basic He alth Services ov er t ime, a nd s hould b e r eported on Q uarterly and/or Annually ( depending o n t he indicator). The following 30 indicators could be the base or core indicators measured over the life of the CDC2 Project. 1. Number of Consultations at Health Centres Definition: The number of consultations in health centres during a given period of time. Numerator: Number of consultations in a health centre during a given period of time Denominator: Total population in the health centre catchment during the same period of time.

Use: Measurement of the health services utilization in health centres, and can be used: to measure health resources utilization in health centres; to evaluate basic health services supplied by health centres; and for health planning to improve health services at health centres.

Data Sources: District health office reports and health centre records. 2. Percentage of Pregnant Women attending Antenatal Care Consultations. Definition: The number of pregnant women who attend antenatal care consultations during their period of pregnancy.

Numerator: Number of pregnant women who have attended antenatal consultations x 100. Denominator: Number of live births during the same period of time.

Use: Measurement of the quality of health care for pregnant women at local level and can be used:

to measure the quality of antenatal care supplied by health facilities; for monitoring, supervising and evaluating maternal health care; and to evaluate local and national maternal and child health programmes.



Data S ources: Monthly M CH pr ovincial and district h ealth statistics r eport; N ational health surveys. 3. Percentage of pregnant women immunized with 2 doses of tetanus toxoid. Definition: A pregnant woman is considered adequately immunized against tetanus when she has r eceived at l east t wo do ses o f t etanus t oxoid dur ing pr egnancy. T he number o f pr egnant women w ill be b ased o n t he num ber o f l ive bi rths or es timated new born i nfants as t he denominator.

Numerator: Number o f pregnant w omen given at l east 2 doses of T T i n a s pecific area and during 1 year x 100. Denominator: Estimated number of newborn infants in t he same ar ea and during t he same period of time.

Use: Measurement of immunization with TT2 for pregnant women can be used: to evaluate TT2 immunization programmes for women at provincial and district levels; and to compare the relationship between TT2 coverage rates for women and neonatal tetanus

incidence in infants.

Data Sources: Provincial and district immunization records. 4. Number of deliveries at a health facility attended by trained health staff Definition: The n umber o f attended deliveries by t rained h ealth personnel a t a health facility during one year. Numerator: Number of attended deliveries at a health facility. Denominator: Number of live births during the same period of time.

5. Number of deliveries at home attended by trained health staff Definition: The number of a ttended deliveries by t rained health personnel at home during one year. This also includes trained TBA’s Numerator: Number of attended deliveries at a home. Denominator: Number of live births during the same period of time.

Use: Measurement of quality of health services supplied by trained staff at the village level or at a health facilities and can be used to:

evaluate health services management at provincial, district or health facilities; Evaluate the effectiveness of trained staff including TBA’s, and evaluate, monitor and supervise maternal health care.

Data Sources: Monthly M CH r ecords at province and di strict; an nual h ealth s tatistics records. 6. Number of women practicing modern contraceptive methods

Definition: The number o f women of child bearing age (WCBA -15-49years) practicing modern contraceptive methods during a given period of time. Numerator: Number of women using contraceptive methods during a given period of time x 100. Denominator: Number of WCBA during the same period of time.

Use: Measurement of the number of women using modern contraceptive methods and can be used:

to evaluate contraceptive methods used; to evaluate family planning programmes at national and local level; and for national family planning programmes.

Data Sources: Monthly MCH records at province and district; annual health statistics records.



7. Number of children under 1 year of age immunized with DPT3

Definition: This includes the children immunized against diphtheria, pertussis, t etanus (DPT3), before their first birthday. Numerator: Number of children given DPT3 before their first birthday during 1 year x 100. Denominator: Number of children less than 1 years of age during the same period of time.

Use: Measurement of national immunization levels and can be used to: evaluate health immunization programmes; and compare the relationship between these diseases and their immunization coverage.

Data Sources: Monthly MCH records at province and district; and surveys. 8. Number of children 12 to 23 months immunized against Measles. Definition: This in dicator i s us ed principally t o as sess t he i mmunization of c hildren a gainst measles, with the assumption that they would have received DPT3 and OPV3. before their second birthday. Numerator: Number of children 12 to 23m given measles immunization 1 year x 100. Denominator: Number of children 12 to 23 months of age in the same area and during the same period of time.

Use: Measurement of national immunization levels and can be used to: evaluate health immunization programmes; and compare the relationship between these diseases and their immunization coverage.

Data Sources: Monthly MCH records at province and district; and surveys. 9. Percentage of Population with Impregnated Bed nets (IBN) Definition: The number of bed nets (that have been impregnated in the last 12 months) available in an “at risk population” in a given period of time. MOH c riteria for c overage i s b ased on 2.5 persons per double bed net. Impregnation means a bed net treated with a chemical in accordance with the MOH’s Centre for Malariology and Parisitology and Entomology IBN criteria.

Numerator: Number of impregnated bed nets available in an “at risk population” in a given period of time x 100. Denominator: Total “population at risk” during the same period of time.

Use: Measurement of the malaria prevention program and can be used to: evaluate the impact of control measures aiming at reducing malaria morbidity & mortality; measure the workload on the health staff undertaking the IBN program; and community attitudes to sleeping under an IBN

Data S ources: Provincial a nd D istrict m alaria de partments for d etails o f I BN pr ogram, a nd populations at risk data. National health surveys 10. Proportion of villages with availability of a Village Drug Kit with essential drugs

Definition: The availability and use o f a basic drug k it a t t he v illage level i s governed by MOH regulations and the training of the VHV and/or Community Health Worker (CHW)5.

Numerator: Number of villages with a village drug kit x 100 Denominator: Total number of villages in the same area.

5 The terminology for CHW will vary between the CLV.



Use: Measurement of health care coverage in terms of minimum essential drugs and can be used:

to evaluate essential drug distribution. determine expansion of coverage of essential drugs program; and local health planning for training of VHV & VHP, and re-supply of drugs.

Data Sources: Provincial and district data on population catchment areas; health surveys.

PROVINCIAL AND DISTRICT HOSPITALS 11. Number of Outpatient Consultations at Provincial and District Hospitals Definition: The number o f outpatient consultations in district hospitals during a given period of time. Numerator: Number of outpatient consultations in the provincial and district hospitals during a given period of time Denominator: Total number of population in the district during the same period of time.

Use: Measurement of the number of patients utilizing district hospitals can be used: to measure health resources utilization in district hospitals; to evaluate basic health services supplied by district hospitals; and for health planning to improve health services in district hospitals.

Data Sources: District health statistics reports; hospital outpatient records. 12. Number of Inpatient Consultations at Provincial and District Hospitals Definition: The number o f inpatient in provincial and district hospitals during a given per iod o f time. Numerator: Number of inpatient consultations in a district hospitals during a given period of time Denominator: Total number of population in the district during the same period of time.

Use: Measurement of the number of patients utilizing district hospitals can be used: to measure health resources utilization in district hospitals; to evaluate basic health services supplied by district hospitals; and for health planning to improve health services in district hospitals.

Data Sources: District health statistics reports; hospital outpatient records. 13. Hospital Bed Occupancy Rates at Provincial and District Hospitals Definition: The occupied bed-days to the available bed-days as determined by bed capacity in district hospitals during a given period of time. Numerator: Actual number of occupied bed-days in the hospitals during a given period of time x 100. Denominator: Total available bed-days during the same period of time.

Use: Measurement of hospital bed occupancy rates in district hospitals can be used: to evaluate hospital management; to evaluate utilization of hospital beds in public hospitals; and for national or local health planning.

Data Sources: Monthly district hospital records; annual health statistics records.



(C) INDICATOR THAT MEASURE COVERAGE AND QUALITY OF HEALTH SERVICES. 14. Percentage o f P opulation w ith adequate H ealth Care F acilities ( including es sential drugs) within a reasonable distance from their village of residence

Definition: The number of persons with adequate health care facilities (including essential drugs) within a 5 k m or 60 m inutes w alk ( in the dry s eason)6 from t heir v illage of r esidence per 10 0 population during a given period of time.

Numerator: Number of persons with adequate health care facilities within a reasonable distance from their residence during a given period of time x 100. Denominator: Total population in the same area and during the same period of time.

Use: Measurement of health care facilities distribution and can be used: to evaluate health resources distribution. determine outreach services for those populations outside the 3hour catchment area; and for national or local health planning.

Data Sources: Provincial and district data on population catchment areas; VHV monthly reports.

15. Number of O utreach Services un dertaken from Health Centres a nd D istrict Health

Office Definition: Determine the number o f Outreach services conducted from health centres and the district health office as a proportion of the planned outreach services in a given period of time

Numerator: Number of villages visited for outreach services in one year x 100 Denominator: Number of villages visits planned to be undertaken during one year.

Use: To assess the provision of health outreach services provided to outer lying villages within a district, and used to;

Assess the effectiveness of the health outreach services. Monitor implementation of health promotion strategy. Assess community attitudes. Monitor increases in usage of health facilities due to HP/IEC activities; and Measure the workload on the health staff undertaking outreach services.

Data Sources: District h ealth s ervices quarterly and a nnual plans, M&E reports to community, health facilities; VHV reports, and health facilities utilization reports. 16. Number of “Health Days” conducted at Health Centres. Definition: Determine the number of Health Days conducted at Health Centres as a proportion of the planned outreach services in a given period of time Numerator: Number of Health Days conducted in one year x 100 Denominator: Number of health Days planned to be undertaken during one year.

Use: To assess the provision of Health Days as a service provided to support local communities within a catchment area of a Health Centre, and used to;

Assess the effectiveness of the Health Days services. Monitor implementation of health promotion strategy. Assess community attitudes. Monitor increases in usage of health facilities due to HP/IEC activities; and Measure the workload on the health staff undertaking outreach services.

Data Sources: District heal th services quarterly and a nnual plans, M&E reports to community, health facilities; VHV reports, and health facilities utilization reports. 6 The minimum criteria for “access to health services” will be different between CLV.



17. Percentage of Villages with Access to a Village Water Supply and Family Latrines

Definition: The num ber o f v illages w ith a functional v illage w ater s ystem a nd family l atrines during a given period of time. Numerator: The number of villages with a village water system and family latrines during a given period of time x 100. Denominator: Total number of villages and population in the same area and during the same period of time.

Use: Measurement of National Water and Sanitation Program (WES) and can be used: to evaluate national WES programmes for providing the population with WES facilities; allocation of resources for WES program (e.g. materials and per diems).

and for health promotion planning for the improvement of health and hygiene in communities.

Data Sources: Provincial and District Nam Saat departments for WES details and v illage data; Provincial and District HIS reports; National household surveys. HEALTH PLANNING AND MANAGEMENT 18. Number of Quarterly and Annual Planning Meetings Undertaken. Definition: To determine if the number of quarterly meetings undertaken relating to the annual planning cycle and Monitoring and Evaluation activities are regularly conducted.

Numerator: Number of quarterly planning meetings held in one year x 100 Denominator: Total number of quarterly planning meetings that were planned to be h eld in 1 year.

Use: For assessing the Annual Planning Cycle and Monitoring & Evaluation activities. For monitoring and evaluating health services and annual planning; to present the analysis of district information received over the last 3 months; and as remedial action and/or revision of the next 3 months programmes.

Data Sources: District or Provincial data; minutes of Quarterly Planning meetings. 19. Number of Quarterly Intersectoral Meetings held at Provincial and District levels. Definition: To det ermine if t he num ber o f quarterly meetings un dertaken relating t o the Intersectoral issues and Monitoring and Evaluation activities are regularly conducted.

Numerator: Number of quarterly planning meetings held in one year x 100 Denominator: Total number of quarterly planning meetings that were planned to b e held in 1 year.

Use: For assessing the Intersectoral Cooperation and Monitoring & Evaluation activities. For monitoring and evaluating health services and annual planning; to present the analysis of district information received over the last 3 months; and as remedial action and/or revision of the next 3 months programmes.

Data Sources: District or Provincial data; minutes of Quarterly Intersectoral meetings. 20. Number of Routine Health Information System (HMIS) Reports submitted to a higher

level including SCA. Definition: Number of monthly a nd qu arterly HMIS re ports f rom prov inces a nd districts

submitted during a given period. (Using the WHO model indicators). % of hospitals & dispensaries that collect reliable data on the health service & health

outcome indicators;



% of health services with a written work plan; % of health staff with an appropriate job description; % of supervisors who monitor services regularly; % of supervision visits that include problems identified & actions taken; % of health workers who have received training or refresher training.

Numerator: Number of HMIS reports received during a given period x 100.

Denominator: Total number of HMIS reports expected to be received during the same period of time.

Use: To m easure the e fficiency o f the HIS f or the routine collection an d di stribution o f information in the health system. information in the health system.

To measure health service activities during the reporting period; to measure utilization rates; to monitor clinical and outreach activities; for health planning; and to improve health services utilizations.

Data Sources: Provincial and District HMIS reports, M&E Reports HRD SKILLS AND CAPACITY BUILDING 21. Number of training courses conducted (HRD) Definition: Determine i f provincial an d district s taff have r eceived h ealth pl anning an d management (HP&M) skills training to enable them to better plan, implement and evaluate health services.

Numerator: Number of training courses conducted during a given period of time x 100. Denominator: Number of planned training courses to be conducted during the same period of time.

Use: To assess the number and quality of training courses undertaken as per the Training Plan and can be used to.

Number of PHD and DHO trained and providing improved services. Monitor implementation of new skills and improved capacity in the work environment. Monitor the implementation of the training strategy and plan. Assess the utilization of the HMIS data for planning and monitoring. Assess if human resources are allocated according to need.

Data S ources: Provincial an d D istrict T raining P lans; M &E s upervisors r eport, q uarterly Work Plans, Quarterly and Annual Planning. 22. Number and type of technical skills training courses conducted. (No. participants to

be disaggregated by sex and ethnic group) Definition: Determine if provincial and district staff have received health technical skills training to enable them to better undertake health services.

Numerator: Number of technical training courses conducted during a given period of time x 100. Denominator: Number of planned training courses to be conducted during the same period of time.

Use: To assess the number and quality of technical health skills training courses undertaken as per the Training Plan and can be used to. per the Training Plan and

Number of Provincial and District staff trained and providing improved services. Monitor implementation of new skills and improved capacity in the work environment. Monitor the implementation of the training strategy and plan.



Assess the utilization of the HMIS data for planning and monitoring. Assess if human resources are allocated according to need.

Data S ources: Provincial an d D istrict T raining P lans; M &E s upervisors r eport, q uarterly Work Plans, Quarterly and Annual Planning. 23. Number of TBA’s and VHV’s participating in annual training and re-training courses.

(No. participants to be disaggregated by sex and ethnic group) Definition: Determine if TBAs and VHVs have received appropriate health technical skills training to enable them to better undertake community based activities.

Numerator: Number of TBAs and VHVs who receive technical training during a given period of time x 100. Denominator: Number of TBAs and VHVs planned to be trained during the same period of time.

Use: To a ssess the number a nd q uality of t echnical h ealth s kills t raining for T BAs a nd V HVs undertaken as per the Training Plan and can be used to. undertaken as per the Training Plan and can be used to.

Number of TBAs and VHVs trained and providing improved services as community level. Monitor implementation of new skills and improved capacity in their work environment. Monitor the implementation of community based programs. Assess if the number of TBAs and VHVs are sufficient according to need of the community.

Data S ources: Provincial an d D istrict T raining P lans; M &E s upervisors r eport, q uarterly Work Plans, Quarterly and Annual Planning. HEALTH FINANCING INDICATORS REVENUES 24. Total Provincial and District Hospital Revenues

Definition: Defines the total revenue received at the Provincial and District hospitals from the sale of drugs and services as a percentage of the total of all revenues received at a district hospital in a given period of time. Numerator: Total provincial and district hospital revenues from sale of drugs and services x 100. Denominator: Total provincial and district hospital revenues from all other sources.

Use: Measurement of revenue from sale of drugs and services against total revenue received by district hospital, and can be used to: district hospital, and can be used to:

evaluate revenue from sale of drugs and services at a district hospital; and compare all di strict h ospital r evenue against t he r evenue from t he s ale o f dr ugs a nd

services. Data Sources: Approved district budget plan; annual district and provincial financial records.

25. Total Health Centre Revenues

Definition: Defines the total revenue received at a he alth centre f rom the sale o f dr ugs an d services as a percentage of the total of all revenues received at a health centre in a given period of time. Numerator: Total health centre revenues from sale of drugs and services x 100. Denominator: Total health centre revenues from all other sources.

Use: Measurement of recurrent health budget by district administration, and can be used to: evaluate district budget allocation for health services; and compare district budgets and health services demand.

Data Sources: Approved district budget plan; annual district and provincial financial records.



BUDGETS 26. Annual Funding received from Central level for Provincial and District Health Sector activities. Definition: The annual allocation of funds received from Central level for provincial and district health s ector activities as a p ercentage o f t he t otal provincial and district budgets al located for health sector during one year. Numerator: Total central level allocation for health sector budget during 1 year x 100. Denominator: Total provincial and district budgets during the same period of time.

Use: Measurement of Central level budget contribution to provincial and district government, and can be used to:

evaluate provincial and district budget allocation and expenditures for health services; and compare provincial and district budget and health services demand.

Data Sources: Approved budget contribution f rom central level budget plan; annual provincial and district financial records. 27. Proportion of Provincial Recurrent Budget allocated to Health Definition: The proportion of provincial recurrent budget allocated to health as a percentage of the total provincial budget during one year. Numerator: Total provincial recurrent health budget during 1 year x 100. Denominator: Total provincial recurrent budget during the same period of time.

Use: Measurement of recurrent health budget by provincial government, and can be used to: evaluate provincial budget allocation for health services; and compare provincial budget and health services demand.

Data Sources: Approved provincial budget plan; annual provincial financial records. 28. Proportion of District Recurrent Budget allocated to Health Definition: The proportion of district recurrent budget allocated to health as a percentage of the total district budget during one year. Numerator: Total district recurrent health budget during 1 year x 100. Denominator: Total district recurrent budget during the same period of time.

Use: Measurement of recurrent health budget by district administration, and can be used to: evaluate district budget allocation for health services; and compare district budgets and health services demand.

Data Sources: Approved district budget plan; annual district and provincial financial records. EXPENDITURE

29. Proportion of actual provincial non-salary recurrent health expenditures Definition: Defines the actual provincial recurrent expenditure on health not including salaries. Numerator: Actual provincial non-salary recurrent health expenditures x 100. Denominator: Budgeted provincial non-salary recurrent health expenditures.

Use: Measurement o f recurrent health expenditure by pr ovincial administration (not i ncluding salaries), and can be used to: salaries), and can be used to:

evaluate provincial expenditure for health services; and compare provincial budget allocations and expenditures against health services demand.

Data Sources: Approved district budget plan; annual district and provincial financial expenditure records.



30. Proportion of actual district non-salary recurrent health expenditures Definition: Defines the actual district recurrent expenditure on health not including salaries. Numerator: Actual district non-salary recurrent health expenditures x 100. Denominator: Budgeted district non-salary recurrent health expenditures.

Use: Measurement of district expenditure on recurrent health services (not including salary) by a district administration, and can be used to:

evaluate district expenditure on health services; and compare district allocations and expenditure against health services demand.

Data Sources: Approved district budget plan; annual district and provincial f inancial expenditure records.



ANNEX 2: BASELINE PROVINCIAL AND DISTRICT KEY DATA AND ANALYSIS (EXAMPLE OF HEALTH FACILITY DATA THAT CAN BE USED FOR BASELINE)

District:-

INDICATORS NumberRate or

% TotalNumber

Rate or

% TotalNumber

Rate or

% TotalNumber

Rate or

% TotalNumber

Rate or

% TotalNumber

Rate or

% TotalNumber

Rate or

% Total

Service Delivery

Number of consultations at Num. Number of outpatient consultations Monthly 100 0.5% 110 0.7% 120 0.5% 130 1.1% 140 0.4% 150 1.5% 750 0.7%Health Centres Denom. Total population in HC catchment area. 20,000 15,000 22,000 12,000 35,000 10,000 114,000

Percentage of Pregnant women having Num. Number of Pregnant women with 3 ANC Monthly 250 16.5% 360 38.9% 470 33.1% 530 48.9% 590 25.7% 650 91.0% 2,850 35.8%at least 3 Antenatal consultations Denom. Total number of expected births. 1,518 925 1,421 1,085 2,293 714 7,957

Percentage of pregnant women immunised Num. Number of pregnant women with 2 TT. Monthly 300 19.8% 400 43.2% 500 35.2% 600 55.3% 550 24.0% 450 63.0% 2,800 35.2%with at least 2 doses of Tetanus Toxiod Denom. Total number of pregnant women 1,518 925 1,421 1,085 2,293 714 7,957

Number of deliveries at health facility Num. Number of attended deliveries at health facility Monthly 800 52.7% 270 29.2% 330 23.2% 390 36.0% 450 19.6% 510 71.4% 2,750 34.6%attended by trained health staff. Denom. Total number of expected births 1,518 925 1,421 1,085 2,293 714 7,957

Number of deliveries at home Num. Number of attended deliveries at home Monthly 240 15.8% 375 40.5% 240 16.9% 260 24.0% 480 20.9% 186 26.0% 1,781 22.4%attended by trained health staff. Denom. Total number of expected births 1,518 925 1,421 1,085 2,293 714 7,957

Number of women (15-49) practicing Num. No. of women practicing modern contraceptive Monthly 100 1.5% 200 4.9% 300 4.8% 400 8.4% 500 5.0% 600 19.1% 2,100 6.0%modern contraceptive methods Denom. Total number of woment 15-49 6,664 4,059 6,238 4,760 10,064 3,136 34,922

No. of children <1 immunised with DPT3 Num. No. of children <1 immunised with DPT3 Monthly 150 9.9% 160 17.3% 170 12.0% 180 16.6% 190 8.3% 200 28.0% 1,050 13.2%Denom. Total number of children <1 years old 1,519 925 1,422 1,085 2,294 715 7,958

Children 12 -23 months immunised Num. No. of children <24 mths immunised with MSV Monthly 400 27.0% 410 45.4% 420 30.3% 430 40.6% 440 19.7% 450 64.5% 2,550 32.8%with measles (MSV) Denom. Total number of children <24 months. 1,482 903 1,387 1,058 2,238 697 7,764

Proportion of population with Impregnated Num. Total population at risk Quarterly 1,850 37.0% 100 1.5% 200 2.9% 300 4.0% 400 5.0% 500 5.9% 3,350 7.9%Bed Nets Denom. Total number of bednets impregnated in 1 year. 5,000 6,500 7,000 7,500 8,000 8,500 42,500

Proportion of Villages with availability Num. No. villages with availabilty of 4 essential drugs Quarterly 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%of 4 essential drugs Denom. Total number of villages 59 34 51 44 94 41 323

District Hospital

Number of Outpatient Consultations Num. Number of outpatient consultations Monthly 120 0.5% 130 0.3% 140 0.5% 150 0.2% 160 0.8% 700 0.4%at District hospital Denom. Total population 25,071 38,525 29,400 62,156 19,365 174,517

Hospital Bed Occupancy Rate Num. Numbrer of inpatient days Monthly 1,000 27.4% 1,500 41.1% 1,200 32.9% 1,400 5.5% 1,100 30.1% 6,200 15.4%at District hospital Denom. Number of beds x 365 days 3,650 3,650 3,650 25,550 3,650 40,150

Deaths due to malaria (public sector) Num. Number of confirmed deaths due to malaria Annual #REF! 15 16 17 18 19 120

Number of Pulmonary TB smear Num. No. of TB (+) patients completing treatment Annual #REF! #REF! 31 16.2% 32 16.7% 33 17.1% 34 17.5% 35 17.9% 195 16.9%positive cases. Denom. Total no. of TB smear (+) patients diagnosed. #REF! 191 192 193 194 195 1,155

Health Financing

Revenue

Hospital Reveues (,000 Kip) Num. Total hospital revenues from sale of drugs Monthly 40,320 57,244 141,515 66,909 9,600 18,857 334,445 and user fees FY 2002 - 2003

"EXAMPLE" Figure XX.1.1 - Comparison of Key Indicators - XXXXXXX Province

Total Prov.

freq

uen

cy o

f

Rep

ort

ing

DEFINITIONS

APPENDIX 20.1:

REGIONAL COORDINATION UNIT

TERMS OF REFERENCE

ADB TA – 7279- REG: Second GMS Regional Communicable Disease Control Project

Appendix 20.1 - Regional Coordination Unit TOR - Final Consultants Report April 2010 Page 2

APPENDIX 20.1 - REGIONAL COORDINATION UNIT - TERMS OF REFERENCE

Preamble:

The R egional C oordination U nit ( RCU) w as es tablished under t he auspices o f t he ADB funded GMS CDC P roject1 to assist i n t he i mplementation a nd c oordination of the C DC Project i n Cambodia, Lao PDR and Vietnam (CLV) and to establish collaborative approaches with partners and donors engaged in Communicable Disease Control (CDC) initiatives in the Greater Mekong Subregion (GMS)

The second GMS Regional CDC Project2 aims to build on the experience of CDC1 and strengthen the coordination o f regional activities to include China (Yunnan P rovince in particular), Thailand, and M yanmar as m ore ac tive p artners in t he e xpanded CDC2 , as w ell as bei ng pr oactive i n promoting a s tronger forum of partners engaged in CDC in the GMS. The Terms of Reference of the RCU are detailed below. Regional Coordination Unit

The overall responsibility of the RCU will include:

Technical and financial management of the RCU activities.

Provision of management and technical advice and support to the PMUs in CDC2.

Co-organizes with National PMUs Regional events.

Undertaking a leading role in the integration of China, Thailand and Myanmar into CDC2.

Monitoring of implementation of project activities in the participating countries.

An a nalysis o f P roject per formance on a quarterly basis for t he A DB P rincipal Health Specialist and the PMU’s.

Liaison with major donors, institutions, and implementing agencies active in regional CDC activities.

Maintenance o f t he C DC d atabase and promotion o f k nowledge m anagement an d communities of practice.

Provision of technical and contract advice to consultants engaged on ADB contracts.

Regional Forums

Coordination of regional activities which could include, but is not be limited to:

Assisting countries in identifying experts as speakers for regional forums/symposiums.

Providing oganisational, logistical, editorial and financial support to undertake the regional activities.

Coordinating with key partners and regional organisations/institutions to ensure maximum participation and benefits for the participants and the success of the forums.

Coordinate countries participation to other non - GMS CDC regional events.

1 Referred to as CDC1 2 Referred to as CDC2



The end objective is that the National countries will be able to ultimately be able to organise and conduct these regional forums with limited or no support from the RCU.

Collaborating Partnerships in CDC

WHO t hrough S EARO and WPRO, an d M ekong B asin D isease Surveillance ( MBDS) ar e k ey partners in CDC2. RCU responsibilities will include regular liaison with partners, as well as;

Dialogue and collaboration with r egional bodies/initiatives ( APEC, ASEAN, ASEAN + 3 , GMS, A CMECS, e tc) t o ensure t hat t he P MU an d p articipating c ountries i n C DC2 ar e informed on current a nd c hanging policies a nd s trategies r elating t o r egional m atters particularly relating to CDC.

Participate in the MOH’s annual donors meetings and other international forums to promote CDC2 r egional a ctivities, a nd so licit increased te chnical a nd f inancial support.

Encourage s pecific do nors, INGOs or r esearch institutions t o undertake s elected research relating to CDC and relevant issues i n the Project districts in the border regions.

Knowledge Management and Communities of Practices

The RCU will continue to strengthen existing networks, knowledge management and community of practice. Other activities will include but not be limited to maintaining and further developing;

The CDC database and associated activities.

The Directory of GMS CDC Professionals

Calender of Events

RCU as a repository of all project documents/resources of CDC1 and CDC2.

Collect within a nd beyond t he G MS al l i nformation and dat a r elated t o pr ojects i n Communicable Diseases from partners, agencies, and institutes.

In or der t o further dev elop K M and C oP t he RCU of C DC1 developed a c oncept paper w hich proposed l ocating o f t he C learinghouse w ithin a r egional i nstitutional s uch as MBDS f or t he following reasons:

the RCU is only a project entity with no intended sustainability.

All i nvestments m ade by t he R CU i n s upport t o r egional c oordination c an only be t ime-bound and with limited impact.

To optimize what has been identified as the basics for a sound regional coordination, it is paramount that this i s a pplied at/by an e ntity t hat has t he pr oper l egitimacy and sustainability.

Under CDC2 it is not possible to fund this proposal in its entirety because of budget restrictions. Details of the proposed “Clearinghouse” is detailed in Appendix 20.2.



Management of RCU The management role of the RCU will include:

Specific task as defined in the section above.

Technical and financial management of the RCU activities.

Management of day to day operations and RCU staff.

Regular liaison with national PMUs and ADBs Principal Health Specialist.

Provision of s ecretariat s upport t o t he R egional Steering Committee a nd o ganisation of regional meetings as required.

Coordination of the recruitment of consultants engaged on ADB contracts and professional and technical support to the consultants during their contracted period.

Coordination of the overall Baseline Survey and quarterly and annual review.

Logistical and technical support to the Short term consultants engaged to participate in the baseline survey across 3 countries.

Other tasks as determined by ADB or the Regional Steering Committee. RCU Staffing

The R CU l isted bel ow w ill pr ovide ov erall s upport for C DC2 project. D etailed TOR f or these positions are included in Appendix 8 - Implementation Arrangements.

International Chief Technical Adviser (CTA) and manager of the RCU.

Program Officer (National)

Secretary/Finance

Interpreter/Support staff

All the above positions are for 5 years.

Optional Extra - Clearing House Team3 (Subject to funding)

International Knowledge Management Adviser (3 years)

IT/GIS Specialist (National) (3 years)

3 See Appendix 20.2 for the detailed concept and TORs of the Clearing House team

APPENDIX 20.2: REGIONAL CLEARING HOUSE

TERMS OF REFERENCE

Greater Mekong Subregion Communicable Diseases Control Project Regional Coordination Unit

Room 2104, 21st floor, Thanh Cong Tower, 57 Lang Ha Street, Ba Dinh district, Hanoi, Viet NamTel. (84)(04) 35 14 79 33 Fax. (84)(04) 3514 80 12 email: [email protected]

APPENDIX 20.2

Terms of Reference

AA RREEGGIIOONNAALL

““CCLLEEAARRIINNGGHHOOUUSSEE””

FFOORR CCOOMMMMUUNNIICCAABBLLEE DDIISSEEAASSEESS PPRROOGGRRAAMMMMEESS IINN TTHHEE GGRREEAATTEERR MMEEKKOONNGG SSUUBBRREEGGIIOONN

PROVIDING THE INDISPENSABLE BASIS FOR REGIONAL COORDINATION

OF COMMUNICABLE DISEASES INITIATIVES IN THE GREATER MEKONG SUBREGION

Stéphane P. Rousseau Regional Coordinator

RCU, Hanoi, December 2009


Page 2 of 21 Room 2104, 21st floor, Thanh Cong Tower, 57 Lang Ha Street, Ba Dinh district, Hanoi, Viet Nam

Tel. (84)(04) 35 14 79 33 Fax. (84)(04) 3514 80 12 email: [email protected]

Table of Content

RATIONALE: ............................................................................................................. 3 DDEETTAAIILLEEDD DDEESSCCRRIIPPTTIIOONN OOFF TTHHEE CCLLEEAARRIINNGGHHOOUUSSEE’’SS FFUUNNCCTTIIOONNSS .............. 7 FUNCTION 1. COLLECTION OF PROGRAMMATIC DATA ................................. 8 FUNCTION 2. INFORMATION FILTERING & DISPATCHING .............................. 9 FUNCTION 3. MAINTENANCE OF THE DIRECTORY OF PROFESSIONALS INVOLVED IN COMMUNICABLE DISEASES IN THE GMS. .................................. 10 FUNCTION 4. REGIONAL CALENDAR OF CDC-RELATED EVENTS .............. 11 FUNCTION 5. ACT AS A REGIONAL REPOSITORY FOR CDC-RELATED MATERIALS 12 FUNCTION 6. REGIONAL GEOGRAPHIC INFORMATION SYSTEM (GIS) SERVICES. 13 FUNCTION 7. REGIONAL KNOWLEDGE MANAGEMENT IN CDC. .................. 14 FUNCTION 8. PROMOTION, ENHANCEMENT AND MAINTENANCE OF THE NETWORK OF CDC PROFESSIONALS IN THE GMS. ......................................... 15 FUNCTION 9. MAINTENANCE OF A JOINT GMS CDC/MBDS WEBSITE. ........ 15 EEXXPPEECCTTEEDD OOUUTTPPUUTT OOFF TTHHEE CCLLEEAARRIINNGGHHOOUUSSEE ................................................ 16 PROPOSED TERMS OF REFERENCE OF THE CLEARINGHOUSE TEAM (2 pax)......................................................................................................................... 18

International Consultant:................................................................................... 18National Consultant: .......................................................................................... 19

Equipment and Supplies needed for the Clearinghouse .................................... 20




RATIONALE: “Enhancing coordination in the f ight against communicable diseases in the Mekong Subregion” has been the recommendation at the en d of almost a ll CDC -related regional events. Yet, no concrete answer has been brought forward, to date, on how to proceed. The following is the suggested establishment of a particular body that will not have for mandate to “coordinate” (for reasons invoked below) but will p rovide all the indispensable conditions f or an e fficient and ef fective coordination; c onditions which, at the current stage, do not exist. In t he current s ituation, t he f ollowing s hould be taken into consideration:

Regional bo dies/initiatives ( APEC, A SEAN, M BDS, GM S, A CMECS, e tc) 1 encounter difficulties t o coordinate their respective actions (i.e. duplication and clashes of schedules of regional events are not rare).

With the ex ception o f MBDS an d t he [ADB-supported] GMS P rogramme, which have both exactly the same geographical coverage, al l other regional bodies have different geographical coverage. They are therefore overlapping in some areas but not in all.

The “regional” significance therefore varies c onsiderably, for i nstance between regional bodies such as APEC covering 21 “economies” -- ranging from Peru to Russia but excluding GMS countries2 such as Cambodia, Lao PDR and Myanmar – and a grouping of 5 countries, such as ACMECS, that excludes China -- yet, one major partner in CDC the GMS.

What is the optimal “regional” coverage for regional coordination in CDC?

There is actually no real epidemiological justification for the mapping of these regional bodies’ delimitations. They are mainly political by design.

On a mere programmatic poi nt of view, a l imited coverage is m ore manageable, he nce more lik ely t o reach impact. The r iver Mekong by i tself cannot j ustify t he d elimitation o f r egional CDC initiatives on pu re epidemiological bases; Nevertheless some cultural affinities (notably between [Theravada B uddhist] Myanmar, T hailand, C ambodia, a nd L ao P DR and between C hina and Vietnam), as well as s ome territorial and i nfrastructural considerations – i.e. “Indochinese Peninsula” block, the c urrent i ncreased accessibility ( “economic c orridors”) – favor the G MS as a proper, sizeable, and manageable ar ea f or diseases c oordination. This is however purely conventional a nd, i n t erms o f di seases c ontrol, will onl y m ake s ense if it evolves within an overall Global coordination effort.

Even c onsidering t he G MS as a n ap propriate ar ea for c oordination, t he question of who is/should be mandated to coordinate CDC efforts in the GMS area remains a s ensitive one. It carries indeed political sensitivities (among countries an d am ong multilateral organizations). While WHO, a s t he UN World he alth ag ency would s eem t he m ost a ppropriate m ultilateral body t o coordinate, his role has been somewhat hampered in the GMS by having i ts

1 Asia Pacific Economic Cooperation (APEC), Association of Southeast Asian Nations (ASEAN), Mekong Basin Diseases Surveillance (MBDS), Greater Mekong Sub-Region (GMS), The Ayeyawady-Chao Phraya-Mekong Economic Cooperation Strategy (ACMECS), 2 GMS Countries include Cambodia, China, Lao PDR, Myanmar, Thailand and Vietnam. Greater Mekong Subregion and Mekong Basin are the same entity (i.e. GMS and MBDS cover the same geographical areas)




own geographical coverage zones split across the GMS area (SEARO3 and WPRO). Other institutional a nd inter-institutional c onsiderations, i ncluding within the UN, may also complicate the position of WHO in this coordination role.

At the current stage, it is therefore not thinkable to imagine a supra-national body that would have the mandate and the authority to coordinate all efforts in CDC in the GMS. If coordination cannot be assured directly, it is still thinkable to consider a de facto coordination taking place as a “by-product” of agreed upon services to all CDC initiatives undertaken in the region. The provision of these services is what this proposed Clearinghouse is suggested for.

Indeed, the reason why coordination is being constantly recommended is the frequent occurrences of d uplications, c lashes of r egional ev ent s chedules, unfilled g aps, lack o f synergies, etc. At th e c urrent s tage, even w ell-intentioned or ganizations w illing indeed to s ynergize, simply cannot do s o, because there is nowhere to find a comprehensive overview of what all others are doing.

The p roposed Clearinghouse i s therefore n ot a s upra-national " Super-Coordinator", but simply a special and small regional unit that will address all these current programmatic weaknesses in coordination, notably by gathering, filtering and r e-distributing all in formation and data on regional CDC-related initiatives, and on providing centralized and common services to all countries and pr oject concerned. For instance the centralizing of all regional events’ schedules ( within a f lexible geographical delimitation) will f acilitate t he coordination of these events, notably by knowing when the very same officials will be invited.

It i s par amount t o i nsist h ere that t he C learinghouse w ill by no m eans duplicate w ith a ny o ther ex isting or ganization i n t he c ollection of epidemiological data. Its role will be more specifically collecting programmatic data from all relevant partners (projects/donors/countries). In short, the overall purpose of the Clearinghouse is not to answer the question “what is the epidemiological s ituation o f communicable diseases in the region?” (prevalence, incidence, mortality, morbidity, etc) but rather “who is doing what on (one or s everal) communicable di seases i n t he r egion:, an d “how t o enhance the coordination?”

The following proposed “Clearinghouse” is based on lessons learned by the Regional Coordination Unit (RCU) of the ADB GMS CDC p roject4 throughout its p ast t hree ye ars; i t attempts to a ddress most c hallenges to regional coordination in the CDC in the GMS, as identified by experiences.

The proposed locating of the Clearinghouse within the MBDS premises is for the f ollowing reasons: the RCU is only a pr oject e ntity with no intended sustainability. A ll investments made by the R CU in support to regional coordination c an o nly b e time-bound and w ith l imited i mpact. To op timize what has been identified as the basics for a sound regional coordination, it is paramount that this is applied at/by an entity that has the proper legitimacy and sustainability.

3 In the GMS, the WHO South-East Asia Regional Office (SEARO) is mandated for Thailand and Myanmar, and the WHO Western Pacific Regional Office (WPRO) mandated for Cambodia, China, Lao PDR and Vietnam. 4 as well as the author’s 7 years of experience in regional coordination capacity (within WHO and ADB).




The Mekong B asin D iseases S urveillance ( MDDS) o ffice appears then the most a ppropriate b ody t o h ost s uch a c learinghouse, since i t supports coordination and c ollaboration i n C ommunicable D iseases surveillance an d response in the GMS. While, MBDS does not have as strong an institutional status, as AS EAN may hav e for i nstance, it d oes however cover a m ore manageable ar ea ( defined e arlier) an d it benefits from a s trong G MS countries’ ownership after s ome 10 years o f ex istence. M BDS wa s also visionary i n t hat i t w as c reated b efore even t he serious SARS epidemic in 2003; th e adjunction of t he C learinghouse to i ts current o ffice and role i s in line with i ts pioneering spirit, and will significantly boost i ts legitimate role in the region.

Those Clearinghouse services would include the following:

1. Pro-actively collect a ll relevant information on Communicable Diseases (CD)

initiatives in the region (the programmatic data NOT the epidemiological data which is already covered by WHO (WPRO/SEARO) and – to some extents – by the ASEAN+3 EID programme)

2. Filter ( eliminate d uplicates, i rrelevant, j unk, etc) al l i nfo/press c lips on Communicable Diseases in the region and/or scientific new findings.

3. …and redistribute to very targeted readership (so as to avoid the too frequent information overload) ("too much info is worse than not enough...")

4. …which s upposes t he m aintenance of a D irectory of a ll C DC-related professionals in the GMS (which RCU has initiated…)

5. Gather all various partners’ Communicable Diseases-related planned events in the subregion and pr oduce a O NE calendar of Communicable D iseases events (see RCU calendar in www.gms-cdc.org).

6. Develop a g eneral d atabase containing all programmatic information on al l regional i nitiatives/activities/projects ( a t ask often much m ore c omplex t han one may think!), possibly following the A PSED f ramework s o as t o b etter identify the core capacities gaps and supports available ( ref. RCU-contracted database).

7. Maintain an online repository of all documentations related to Communicable Diseases in t he r egion. ( Internet-accessible c omprehensive ar chiving, ref. GMS CDC website at http://www.gms-cdc.org/resource/documents.html)

8. Maintain a regionalized GIS mapping service for all Communicable Diseases projects/initiatives. (i.e. instead of having each project struggling with its own GIS mapping, have the whole regional mapping done for all)

9. Promote K nowledge Management, in par ticular Communicable D iseases professionals' Communities of Practices (best practices, lessons learned, etc)

10. Promote, enhance a nd m aintain t he Network o f CDC P rofessionals in t he GMS.

Such a proposed unit will actually not be very costly, especially given the saving it will provide by preventing duplications and the “re-inventing of the wheel”, e tc. For th e geographical r easons i nvoked e arlier, as w ell as building on t he M BDS well-recognized r egional i nitiative, t he C learinghouse could be es tablished within t he MBDS o ffice5. However people in charge of the Clearinghouse activities should be

5 Much more discussions with and within MBDS need to take place until the idea of the Clearinghouse is accepted – if it is ever accepted. As this is likely to take some very




specifically assigned to it and NOT involved in managing other programmes. This is indeed a r ecurrent problem observed everywhere: officials/officers a re always too absorbed by their operations to take t ime sharing information and experiences, and get seriously involved in regional cooperation or Knowledge Management activities in general. In a ll, t he w hole c oncept of the “Clearinghouse” turns more around the notion o f “services” that that o f a s imple “repository”. The Clearinghouse is more a service-providing entity than a mere “Information Center”. It will be responding directly and pro-actively to the dire needs of the countries and partners; In other words, it will act more like an attractive and efficient shop -- constantly seeking client’s satisfaction -- than a dusty museum awaiting rare visitors. Two full-time professionals – (i) the [GMS CDC] Regional KM Advisor, International professional [GIS, Database, K M, public he alth] and (ii) t he IT/GIS S pecialist, National professional [IT, GIS, database] – equipped with one computer each, should suffice to run the “clearinghouse”, at least in its initial stage. The two TA consultants will report t o the MBDS coordinator, but lia ise c losely wit h the ADB GMS CDC2 Chief TA in Hanoi (sending their reports to RCU). Funding for these two posts as well as for the equipments, supplies and running costs ( tel. fax. Internet, electricity) of the Clearinghouse (see ToR of the two TA further down) will be covered under the GMS CDC2 Pooled Fund budget. Products of the Clearinghouse will be the dual property of the MBDS and ADB with equal rights to publish. Sustainability: past the GMS CDC2 funding support (3 years) to the Clearinghouse -- and pending a thorough evaluation of its output -- MBDS may consider the long-term and sustainable funding of its services through an annual membership fee collected from all benefiting projects in the region, alike is already successfully done nationally in some c ountries (ref. membership or ganizations such a s CCC or Medicam i n Cambodia). Such membership or ganization s tatus of the C learinghouse will a lso guarantee ownership and accountability.

____________

significant time, it is first recommended to establish the Clearinghouse within the GMS CDC RCU until such a time when it can be smoothly handed over to MBDS, in all due mutual agreements.




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Table of content

FUNCTION 1. Collection of Programmatic Data

FUNCTION 2. Information Filtering & Dispatching

FUNCTION 3. Maintenance of T he D irectory of P rofessionals involved in Co mmunicable Diseases in the GMS.

FUNCTION 4. Regional Calendar of CDC-related Events

FUNCTION 5. Act as a Regional Repository for CDC-related Materials and Documentations

FUNCTION 6. A Free Regional Geographic Information System (GIS) Service.

FUNCTION 7. Regional Knowledge Management In CDC FUNCTION 8. Promotion, enhanc ement and maintenance o f the Network of CDC

Professionals in the GMS.

FUNCTION 9. Maintenance of a joint GMS-CDC/MBDS Website




FUNCTION 1. COLLECTION OF PROGRAMMATIC DATA

The Cle aringhouse s taff will p ro-actively -- and on a routine bas is -- collect a ll relevant programmatic information and dat a on Communicable D iseases (CD) initiatives in the region6

The data collected include:

1. Name of Organization (with logo, all contact details, history, mandate, legal status, etc.)

2. Name of Project (with all contact details).

3. Involvement (Donor/Implementer?) [to prevent double-counting]

4. Diseases covered by the project.

5. Target population of the project.

6. Geographical coverage of the project (Region, Country, Province, District).

7. Type of activities covered (Capacity Building, procurement, TA provision, etc)

8. Budget ( as detailed a s p ossibly available, C apital c ost, R ecurrent C ost, b y province/districts, etc).

9. Project timeline.

Note: a database recording all these information has already been initiated by the RCU an d w ill n ow r equire a good s teady m aintenance. T he c ollection of programmatic data -- while recognized by all as “critical” to prevent duplication and better synergized actions – is a very complex and tedious exercise. Moreover, it is only helpful if it is up-to-date, therefore constantly updated on a rolling basis. This is what the Clearinghouse will p rovide. The Clearinghouse must provide an incentive f or or ganizations/projects to willingly c ontribute t he sharing o f their projects’ data. T his m ay include the f ree del ivery of a yearly directory of al l organizations/projects i nvolved i n C ommunicable D iseases i n the r egion, w ith mapping, analysis, and case studies, etc (see further down for further incentives to contributors).

In addition to collecting the raw data, the Clearinghouse, will analyze these data, produce maps and matrices as well as develop cases studies for KM purposes, etc (see further down), and send back to originators their data, once processed.

In or der t o ensure a n e asier a nalysis of t he ac tivity c overage, o ne m ay recommend the database and matrices to follow the APSED framework (so as to ease the identification of synergies or gaps, i.e. various donors’ support to core capacities in a country, etc.)

6 The programmatic data NOT the epidemiological data which is already covered by WHO (WPRO/SEARO) and – to some extents – by the ASEAN+3 EID programme.




FUNCTION 2. INFORMATION FILTERING & DISPATCHING

Professionals hav e little t ime t o spare f or readings an d nowadays the ov er-information – notably through WWW access – makes se arches for i nformation and data tedious and time-consuming.

The Cle aringhouse staff will r eview on a d aily b asis a ll i n-coming new s, announcements, ar ticles, related t o C ommunicable D iseases i n the r egion and send out to all relevant professionals what is deemed helpful to their work. This filtering function includes:

1. Pro-actively s earch n ews, articles of i nterest on s pecific di seases. This includes s earching t he WWW, s ubscribing t o most r elevant C DC-related electronic n ewsletters, and m ake r epeated c alls t o p artners for s haring information.

2. Review each article and eliminate duplicates, irrelevant, junk, etc.

3. Select only unique ar ticles w ith pr ofessional interest and dispatch to r eady-made list of CDC professionals as per an pre-agreed subscription by topics. Keep all due credit to the source.

4. Articles may include:

a. All info/press clips on one or several c ommunicable diseases in t he region

b. All r elevant scientific new f indings on a p articular di sease ( may not need to be regional here).

c. All announcements for GMS national and regional events on o ne o r several Communicable Diseases.

d. Announcements o f u pcoming Communicable D iseases experts missions,

e. Reports of missions.

f. Any information of relevance to the CDC professional community.

5. Dispatching these specially filtered news throughout the professional network, using s pam-free L istServ system. While t he f iltering will require the v ery critical j udgment o f a Communicable D iseases expert at t he C learinghouse (International Professional), the dispatching will be as automated as possible.

6. Subscribers should be able in the system to decide whether they want a real time dispatching of news, or daily, weekly or monthly basis.

7. A monthly G MS CDC Newsletter, compiling al l news filtered throughout the month, will be produced and sent out to all subscribers.

Note: The Clearinghouse officers should seek as many agreements from publishers for the free d ispatching of their published articles. To that effect, the Clearinghouse should take advantage of all agreements WHO has negotiated with such publishers for developing countries.




FUNCTION 3. MAINTENANCE OF THE DIRECTORY OF PROFESSIONALS INVOLVED IN COMMUNICABLE DISEASES IN THE GMS.

The G MS CDC RCU in itiated a Directory of P rofessionals i nvolved i n Communicable Diseases in the GMS (ref. http://www.gms-cdc.org/resource/cdc-directory-of-professionals-.html). The latter will play a growing role in establishing professional C DC n etworks, Community o f Practices, list o f regional ev ents invitees, etc. if i t c an be m aintained on a r olling b asis. T he C learinghouse w ill assure that function.

The Directory contains:

1. Name of professionals

2. Title, Function

3. Institution he/she belong to.

4. All contact details.

5. Educational backgrounds

6. Main expertise.

7. Other expertise they wish to be recorded in.

8. Country in which they work.

The Directory produced directly from the database will be divided into four chapters: professionals “sorted by countries”, “sorted by names”, “sorted by diseases/expertise”, “special expertise”.

The Clearinghouse function here will include:

1. Pro-actively in forming professionals o f the ex istence o f t he D irectory a nd invite them to the free registration.

2. Regularly sending the registration form to new professionals contacted.

3. Deleting names o f pr ofessionals leaving involvement i n t he G MS, updating functions of moving professionals, and adding new professionals who fill out the registration form.

4. In addition to updating the database, a new electronic edition of the Directory is produced every quarter.

Note: the C learinghouse w ill need to take special precaution to prevent spammers from “high jacking” names and contact details from the Directory. One possibility would be to produce i t in a PDF “picture format”, o r – but less recommended as it would m ean a l oss o f t he purpose -- to grant access t o t he D irectory through a password only.

http://www.gms-cdc.org/resource/cdc-directory-of-professionals-.html

http://www.gms-cdc.org/resource/cdc-directory-of-professionals-.html




FUNCTION 4. REGIONAL CALENDAR OF CDC-RELATED EVENTS

The Cle aringhouse o fficers will p ro-actively g ather all various partners’ Communicable Diseases-related planned events in the subregion and produce a ONE calendar o f Communicable D iseases events ( see R CU c alendar i n www.gms-cdc.org).

The purpose of such a centralized (regionalized) Calendar of Events is to prevent the too frequent clashes of schedules of too many similar events taking place at the same time, inviting the same professionals, at different locations, leading to duplications, w aste of funding, a nd high o pportunity c osts. The c entralized Calendar o f E vents should assist the synergizing o f ev ents, the b etter coordination of donors (notably encouraging the co-sponsoring of events), etc.

The Calendar of events will include:

1. All national and regional level events related to one or several communicable diseases. T his i ncludes workshop, s ymposium, f orums, w orking group meeting, etc.

2. Visits of renowned experts in the GMS countries.

3. International Days for specific diseases (i.e. HIV/AIDS day, etc)

4. Project evaluation missions (seeking more joint evaluations among projects)

5. All a ctivities r elevant to Ca pacity Building in Co mmunicable Dis eases (Training c ourses, s eminars, s upervision m issions, m entoring o pportunities, etc)

6. Other events as deemed helpful by/to CDC professionals.

Note: to assist the initialization of the Calendar of Event, Governments may make it mandatory t o al l Communicable Dis eases projects r egistering i n t he c ountry, t o forward all upcoming events’ programme to the GMS CDC Clearinghouse.

http://www.gms-cdc.org/




FUNCTION 5. ACT AS A REGIONAL REPOSITORY FOR CDC-RELATED MATERIALS

The C learinghouse w ill also act as a r egional online r epository for all documentations related to Communicable Diseases in the region.

Documentations made available will include:

1. Partners’ communicable diseases projects progress reports7.

2. Communicable D iseases d ocuments o f r eferences ( WHO Guidelines, Manuals, etc)

3. Databases available produced by various partners

4. Compilation o f l egal i nstruments r elated t o r egional cooperation a nd t o communicable diseases ( ref. R CU-commissioned s tudies t o I FRC on l egal preparedness)

5. IEC/BCC materials produced in the region on communicable diseases.

6. All Press reviews on specific diseases (ref. filtering function above)

7. All partners’ publications related to Communicable Diseases in the GMS (incl. research findings, etc).

Note: for the same existing function, ref. GMS CDC we bsite a t http://www.gms-cdc.org/resource/documents.html

7 ADB communication policy promotes transparency in general; however some countries and partners may request their project reports to be only available under “restricted access”. In such cases, the Clearinghouse should seek authorization from these partners to access all documents at least to exert the KM review, i.e. extract Lessons Learnt, Good Practices, and sources for Case studies, even if this means without quoting the sources afterward. This is however not the preferred option -- as source indication always substantiates better a product – and all efforts should be made to have public access to the reports.

http://www.gms-cdc.org/resource/documents.html

http://www.gms-cdc.org/resource/documents.html




FUNCTION 6. REGIONAL GEOGRAPHIC INFORMATION SYSTEM (GIS) SERVICES.

While it is recognized by all as “most needed”, it is at present extremely difficult to draw an exact mapping of all communicable diseases activities in the GMS. This proposed regional GIS service by the Clearinghouse will address that issue.

Because projects are often “struggling” themselves with the GIS mapping of their own activities.

Because data recorded by different projects are of different natures.

Because projects often use different GIS software (HealthMap, MapInfo, ArcView, etc), the production of regional maps is often tedious and inaccurate.

To address al l these i ssues at o nce, t he C learinghouse w ill of fer free G IS services to all projects involved in (one or several) communicable diseases in the region8. The free service constitutes the incentive for projects to send their data in a pre-agreed standard format so as to enable that mapping at regional level.

The regional GIS mapping service should allow the following:

1. Mapping – hopefully down to the district level – of all activities

a. per disease,

b. per target population,

c. per type of activities (capacity building, procurement, TA, KM, etc),

2. …and the following analytic correlations

a. Disease prevalence and donor’s involvements

b. Populations at risk and donors’ involvements

c. CDC s imilar activities on c ontiguous b orders ( Cross-border opportunities?)

d. Diseases and finding repartitions.

e. All analysis of partners’ synergies, and coverage gaps.

8 It is strongly recommend here to organize a preliminary workshop on the functions of the Clearinghouse, so as to have countries and partners agree on the exact GIS services they want, the standards, the priority maps, the level of analysis, etc. The suggested free service is here to provide an incentive and address the otherwise very difficult regular collection of data from all partners. However, in the future, MBDS may consider turning into a “Membership Organization” -- still under the Governance of the Governments -- but opening to associate membership of all willing partners; this will allow the levying of a membership fee to fund the services in a sustainable way (ref. MEDICAM and CCC in Cambodia).




FUNCTION 7. REGIONAL KNOWLEDGE MANAGEMENT IN CDC.

The Cle aringhouse will play a pr oactive role in enhancing Knowledge Management (KM) in CDC in the region, through all means available. Knowledge Management – seen here as an efficient way to improve on-the-job performance of CDC professionals – is an integral part of Capacity Building activities. This will be done b y promoting exchanges of Good P ractices, nurturing Communities o f Practice (CoP) of CDC professionals, etc. Knowledge Management professionals will therefore work closely with Programmes managers to ensure Clearinghouse’s KM products contribute to the enhancement of programme results and impact in the quickest and measurable way.

The Clearinghouse will enhance KM by:

1. Encouraging the establishing of various CDC professionals' Communities of Practices (notably with the use of The Directory [see above])

2. By p ro-actively c ollecting, analyzing a nd di sseminating Best Practices, Lessons Learnt, etc, among the various projects in the region. The collection may i nclude a systematic r eview of all pr ogress r eports of CDC -related projects from the various partners, etc.

3. By developing Case S tudies – based on the Lessons Learnt collected and analyzed ( above), w hich can be presented afterward i n regional t raining courses, seminars or workshops.

4. By providing KM advices to organizers of regional events so as to ensure a better event’s output (optimizing setup, programme, template, timing, etc for better and more fruitful exchanges).

5. Moderating the GMS C DC electronic f orum in E nglish a nd pr oviding support to t he V ietnamese, L ao a nd Khmer m oderators i n their r espective language f orums. These f orums were es tablished within the G MS CDC website during the GMS CDC CDC1 ; see – as a sample – the Lao forum at http://www.gms-cdc.org/forum/viewforum.php/lang,lo/f,5/ ).

6. Organize public debriefings of professionals before their departure (end of projects, repatriation, etc), so as to learn from their experiences.

7. Add to the repository, compilation of analyses of Lessons Learnt, and all Best Practice materials, easily accessible within the GMS CDC website.

http://www.gms-cdc.org/forum/viewforum.php/lang,lo/f,5/




FUNCTION 8. PROMOTION, ENHANCEMENT AND MAINTENANCE OF THE NETWORK OF CDC PROFESSIONALS IN THE GMS.

The good functioning of the Clearinghouse will undoubtedly rely on the good relation established and maintained between its officers and the Network of CDC Professionals, within the ministries or organizations alike. The Clearinghouse officers will also assist the enhancement of the Network itself by assisting the liaising and the linking of members among themselves. This will be done notably through the various activities detailed in the previous Functions such as :

a. Promoting and nurturing Communities of Practices. b. Moderating electronic forums. c. Pro-actively develop and maintain the Directory of Professionals. d. Enhancing the KM aspects of regional events. e. Other relevant networking activities.

_________

FUNCTION 9. MAINTENANCE OF A JOINT GMS CDC/MBDS WEBSITE.

All functions detailed above will use the joint MBDS/GMS CDC website as a support (alike is already partially done in the existing GMS CDC website: www.gms-cdc.org). This includes:

a. The regular posting of filtered information and news on communicable diseases in the GMS.

b. The easy online access to the various database, matrices and documentations (database of all partners, GIS maps, guidelines, manuals, IEC/BCC materials, Case studies, Good Practices collections, progress reports, research findings, etc).

c. The Calendar of CDC-related events. d. Answering any inquiries from partners on CDC activities in the GMS. e. Allowing electronic topical discussions on technical matters (electronic

forums in English, Lao, Khmer and Vietnamese [to be extended to Chinese, Burmese, and Thai])

_________

http://www.gms-cdc.org/




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Output 1. An up-to-date d atabase of who-does-what-where-when-how-with-how-much in

Communicable Di seases i n t he G MS available t o all. T his i nformation is t he basics of any coordination efforts. This database will assist partners and c ountry Governments ali ke in their pl anning o f r espective involvements, and as sist i n synergizing and filling pr ovincial, nat ional, r egional a nd cross-border c overage gaps. Experience has showed that the bui lding of such database i s of no us e i f this i s not maintained on a r olling basis. This is what the Clearinghouse will do. Given the services the Clearing house will provide to Governments, the latter may insert the regular sending of updated programmatic data to the Clearinghouse in the country regulations for all par tners ( International O rganizations and NG Os alike) working in t he c ountry. However, t his s hould n ot constitute an addit ional workload to these organizations as data collected should be s ame as otherwise prepared and shared in other mandatory progress reports. (suggested indicator: the online database exists and is up-to-date, and contain all main partners/project involved)

Output 2. All par tner or ganizations w orking on Co mmunicable Diseases i n t he GMS, ar e well inf ormed of an y n ew d evelopment i n their field of work, and ar e regularly kept abreast through a v ibrant Net work. Information ov erflow is well addressed t hrough a sound filtering, henc e saving precious time to k ey managers and ot her pr ofessionals ali ke. (suggested i ndicators: nu mber o f Newsletters produced, growing numbers of subscribers, qualitative feedback from readers, pr ogressive s haring o f i nformation from partners, qual itative s urvey of the readership [satisfaction/appraisal])

Output 3. All professionals i nvolved in Communicable Diseases i n the region can access easily materials they need for their practice or research. They can liaise easily with other professionals to discuss technical matters and solve practical on-the-job challenges they face. (suggested i ndicators: number of materials uploaded by m onths, nu mber o f materials r eceived from par tners, num ber o f materials consulted/downloaded by the website users, number of requests by Professionals to the Cl earinghouse f or doc umentations, num ber of linkages am ong professionals facilitated by the Clearinghouse (emails), feedbacks f rom users on how h elpful t he C learinghouse s ervices ha ve been in t heir work, frequentation and use of the electronic forum)

Output 4. Production of high quality Knowledge M anagement materials: Case Studies, collections of Good Practices and lessons learnt (produced by the Clearinghouse officers ba sed on partners’ progress r eports and study f indings). (Suggested indicators: nu mber of c ase s tudies pr oduced, Lessons Lear nt r eports, G ood Practice technical cards, etc)

Output 5. All professionals involved in Communicable Diseases in t he region are aware of all i ncoming relevant events in t he GMS countries, and can pla n their schedule accordingly, resulting in no or less clashes of schedule, and lower opportunity c osts. (suggested i ndicator: number of e vents r ecorded i n t he Calendar, nu mber o f e vents announc ed by par tners for sharing, s urvey o n t he usefulness and u se of t he Ca lendar o f CDC E vents by par tners, num ber o f clashes of schedule oc currences, number o f synergized events [ co-sponsoring, joint organization, etc])

Output 6. An up-to-date Directory of Professionals involved in Communicable Diseases in t he G MS, f acilitating t he building of C ommunities o f P ractices, q uick problem s olving, pr eparation o f par ticipants li sts f or r egional e vents, et c. (Suggested I ndicators: nu mber o f pr ofessionals r egistered i n t he Di rectory, number o f new r egistrations in the m onth, survey o n us e of t he D irectory by partners in their various activities)

Output 7. Easy access by all to maps of all activities related to communicable diseases in the region countries, allowing better analysis of the investments, identifying the




needs for more coordination, the gaps t o addr ess, et c. (suggested i ndicators: number of maps produced in the month, up-to-date status of the maps)

Output 8. Free G IS servi ces to a ll par tners deliv ering t heir dat a t o t he C learinghouse: a “win-win” setup i n w hich par tners save the c ost o f GIS management i n their projects, while the Clearinghouse recei ves regularly t he n ormally hard-to-obtain data from the projects. This wi ll also allow a standardized GIS mapping, rendering analysis mu ch easier and wo rthwhile. (Suggested I ndicators: number of maps requested by par tnership, num ber of maps produced, anal ysis reports made based on the GIS mapping, number of data received/collected from partners, survey of the usefulness of the GIS service)

Output 9. A well documented and resourceful w ebsite, gaining growing f requentation by GMS pr ofessionals. (Suggested I ndicators: us ual w ebsite s tatistics of frequentation and use, survey of users)

Output 10. A growing and v ibrant Network o f professionals, eager t o e xchange G ood Practices and “tips of the trade”, producing significant output (although admittedly hardly m easurable), i ncluding an i ncrease of the on -the-job per formance. (Suggested Indicators: number of discussions in the electronic forums, number of spontaneous r equest f or r egistration i n t he Dir ectory, number o f linkages made during the month [email orientation services], survey on how the networking has helped in job performance)

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PROPOSED TERMS OF REFERENCE

OF THE CLEARINGHOUSE TEAM (2 pax)

International Consultant: Regional Knowledge Management Advisor Main duty:

Ensure the Clearinghouse is well fulfilling its purpose. Supervise the good running of each of the Clearinghouse functions. Provide a leadership role in regional Knowledge Management in CDC, notably

working closely with Programmes managers to ensure Clearinghouse’s KM products contribute to the enhancement of programme results and impact in a quick and measurable way.

Supervise the output of the National Consultant Detailed tasks:

Make regular calls to the partners for sharing their programmatic data, news, announcements

Pro-actively collect all news related to Communicable Diseases, and especially in the GMS, filter them and dispatch them to the relevant professionals by the specific group lists. Prevent any information overflow in general (eliminate the “nice to know”; keep only the “must know”)

Liaise closely with the respective GMS countries’ Ministries of Health and Institutions for a back-and-forth exchange of data.

Arrange with newspapers and various publications publishers the right for free dispatching of their CDC-related news by the Clearinghouse.

Develop and maintain email group list (ListServ preferably) so as to target at best the sending of information/news. (Use the directory for that purpose)

Proactively collect all CDC-related announcements for upcoming CDC-related events in the region and have them posted in the Calendar of CDC Events on the website.

Proactively collect all CDC-related materials (various project progress reports, other partners’ newsletters, guidelines, manuals, research findings, articles, etc) and have them uploaded onto the website as well as in the GMS-CDC/MBDS newsletter.

Ensure programmatic data sent out by partners are entered into the GIS system and maps produced. Check the quality of the maps and their usefulness for analysis (notably for programme management and coordination purposes).

Review all partners’ reports and extract from them the lessons learnt and Good Practices. Produce Technical Cards accordingly. Have their draft posted for discussion on the forum before finalization, then have them posted on the website as KM resources made available to all.

Assist in the developing and nurturing of various Communities of Practice, notably by providing advices to regional events organizers on how to optimize the KM aspects and output of these events (room setup, agenda, timing, networking, exchanges, name tagging, felt output in anonymous evaluation reports, etc).

Extensively liaise with all Stakeholders, in support of the MBDS coordinator. Moderate the English electronic forum, and provide technical support to the GMS

countries’ moderators. Review all incoming regional events’ programmes and provide advice to organizers

on how to optimize their KM aspects for a better output. May be asked to facilitate Working Groups of experts to discuss the fine-tuning of the

needed maps and database; on Knowledge Management Products needed by professionals, etc.

Preferred profile:

At least 5-10 years of experience in similar functions. Proficient in Knowledge Management concepts and practices. Prior sound experience in service-providing membership organizations a great asset.




Proven very good communication skills Good knowledge of the GMS Development & Cooperation context, aware of the GMS

political sensitivities (should have good experience in at least 3 of the 6 GMS countries).

Very well acquainted with communicable diseases programmes and projects in the GMS countries

Have a sound experience in communicable diseases programme management, both at central and field level.

Good command of Microsoft Word, Excel, Access and Outlook, and acquainted with webmaster administration as well as GIS software.

Good abilities in international correspondence writing. Fluent in spoken and written English (Good command of one or several languages of

the GMS countries is an asset.) Experience in moderating professional electronic forums. Ability to work in inter-cultural environment

Qualifications:

Master of Public Health, International Relations, Political Science, Public Administration, development & Cooperation, Knowledge Management, or any relevant field.

[PhD Candidate on Regional Cooperation in CDC topic would be a “win-win”] National Consultant: IT/GIS Specialist Main duty: The national consultant will process all the data received and collected by the Clearinghouse. That includes all work on GIS, database and on the website. Detailed tasks: in close collaboration with the International consultant, will…

Create all the maps based on the data provided. Create and maintain the readership group lists -- through ListServ systems -- for all

dispatching of information/news, Create and maintain all the Clearinghouse database (Directory of Professionals,

Database of Partners/Project involved in CDC in the GMS, etc) Maintain the website by populating it on a daily basis (announcements, news, articles,

events calendar, electronic form maintenance, etc.). Acting as the webmaster. Produce the website-linked GMS-CDC/MBDS Newsletter on a regular basis.

Preferred profile: The national consultant is an IT professional, proficient in GIS (preferably in Arcview), in database, as well as in website administration.

At least 5 years experience in a similar job. Proficient in GIS, and able to transfer from one GIS software to another. Proven good experience in Webmaster functions, notably within the Joomla or any

other Open Source systems. Good knowledge of database building (notably in MS Access) Proficient in spoken and written English Good ability for team-working while able to work also without direct supervision

Qualifications:

Bachelor IT with specialty in GIS Diploma/Certificates in database and website building.




Equipment and Supplies needed for the Clearinghouse The Clearinghouse will need:

IT equipment: o Two PC (2) computers with all licensed software needed for the work (MS

Office Pro, Arcview notably), o Two printers, including one for large (A3) color quality printouts (maps) o One high resolution scanner. o UPS for the two PCs and printers.

High Speed Internet Connection Furniture: one working post (desk and chair) for each consultant, two (2) filing

cabinets, and two (2) bookshelves cupboards. Two (2) large whiteboards and two (2) billboards Air conditioner (one per room) All necessary stationary supplies.

-- Stéphane P. Rousseau / Hanoi / December 2009