Northeast Cambodia Child Survival Program
Chhlong Operation District, Kratie Province, Cambodia
MID-TERM EVALUATION 
PARTNERS FOR DEVELOPMENT
United States: 1320 Fenwick Lane, Suite 406, Silver Spring, MD 20910
Tel: 301-608 -0426, Fax: 301-608-0822, E-Mail: pfdinfo@partnersfordevelopment.org
Cambodia: No. 24, Street 294, BP 551, Phnom Penh, Kingdom of Cambodia
Tel./Fax: 855-23-213-335, E-Mail: PFD.Cambodia@ BigPond.com.kh
by:
Sheryl Keller, MSN, MPH
Som Sophy, MRD-Rural Health
October 2002
Phnom Penh, Cambodia
ACRONYMS
ANC Antenatal Care
ARI Acute Respiratory Infection
CIDA Canadian International Development Agency
CMR Child Mortality Rate
COPE Client-Oriented, Provider-Efficient
CS Child Survival
CSTS Child Survival Technical Services
DHF Dengue Hemorrhagic Fever
DIP Detailed Implementation Plan
EC European Community
EOI Emergency Obstetric Interventions
EPI Expanded Program of Immunization
GI Gastro-intestinal
HC Health Center
HIV/AIDs Human Immune Deficiency Virus/Acquired Immune Deficiency 
Syndrome
HKI Helen Keller International
IEC Information, Education and Communication
IMCI Integrated management of Childhood Illnesses
IMR Infant Mortality Rate
LQAS Lot Quality Assurance Sampling
MOH Ministry of Health
MOU Memorandum of Understanding
NCCDP Northeast Cambodia Community Development Program
NCCSP Northeast Cambodia Child Survival Program
NCRHP Northeast Cambodia Reproductive Health program
NERP Nutritional education Rehabilitation Program
NGO Non-governmental Organization
OD Operational District
ORS Oral Rehydration Solution
ORT Oral Rehydration Therapy
PFD Partners for Development
PHD Provincial Health Department
PSI Population Services International
RACHA Reproductive and Child Health Alliance
RH Reproductive Health
TBA Traditional Birth Attendant
TOT Training of Trainers
TT Tetanus Toxoid
UNFPA United Nations Family Planning Association
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VAC Vitamin A Capsule
VDC Village Development Committees
VHV Village Health Volunteer
VSO Voluntary Service Overseas 
WHO World Health Organization
TABLE OF CONTENTS
Executive Summary……………………………………………………………. i
I. Background
 A. Program Context…………………………………………………………. 1
 B. Program Description
 1. Initial Design…………………………………………………………… 3
 2. Changes and Adaptations to Program Design…………………….. 4
II. Evaluation Methodology 6
III. Findings
 A. Assessment of Program Design………………………………………. 7
 B. Implementation Progress
 1. Status of Planned Activities, Use of DIP………………………….. 9
 2. Field Observations…………………………………………………… 11
 C. Assessment of Program Management 
 1. Program Structure……………………………………………………. 18
 2. Staff Development……………………………………………………. 19
 3. Collaboration with Other Organizations………………………….… 20
 4. Use of Technical Assistance………………………………………… 22
 D. Assessment of Program Impact………………………………………. 22
IV. Discussion and Conclusions
 A. Overview………………………………………………………………….. 26
 B. Village Health Volunteers……………………………………………….. 26
 C. Health System Strengthening………………………………………….. 29
 D. TBA Training……………………………………………………………… 29
 E. Program Management and Staff Development……………………….. 29
 F. Nutrition Interventions……………………………………………………. 30
 G. Monitoring and Evaluation……………………………………………….. 31
 H. Sustainability………………………………………………………………. 32
V. Recommendations………………………………………………………….
A. Overall Recommendations 33
B. VHV Activities 33
C. Health System Strengthening 35
D. Program Management 36
E. Monitoring and Evaluation 36
F. Other: 37
Annexes:
 Scope of Work………………………………………………………………… 38
 Documents Reviewed………………………………………………………… 42
 List of Persons Met…………………………………………………………… 43
 Analysis of Mortality Data……………………………………………………. 45
i
Executive Summary
A partner for Development (PFD), an international NGO specializing in grassroots
community-level interventions in remote and/or underserved areas, has worked in the
isolated, impoverished northeastern provinces of Cambodia since 19921
. PFD was 
awarded a 42-month USAID Child Survival Program Grant from October 2000 to March 
2004. The goal of the Northeast Cambodia Child Survival Program (NCCSP) is to
improve the health of children under five in Chhlong OD of Kratie Province through
control of diarrheal disease, immunization, improved nutrition and promotion of
breastfeeding. 
The program’s primary strategy is to increase caretakers’ case managment abilities and 
promote improved health behaviors through health education conducted by a network of 
Village Health Volunteers (VHVs). Linkage with the health system, and a potentially
sustainable system for supervision of VHV activities, is addressed through the use of
government Health Center (HC) staff to both train and supervise VHVs. The program 
has also trained HC staff and private drug sellers in diarrheal disease management, and 
is pilot testing the “Hearth” model of nutritional rehabilitation and education.
Complementing the NCCSP is an UNFPA/Ministry Of Health (MOH)-funded 
Reproductive Health Program, and a USAID-funded Malaria Program.
In September 2002, the approximate mid-point of the Grant, PFD recruited two
independent consultants to conduct an external evaluation of the Program. The Team
reviewed Program documentation, met with Provincial and Operational District (OD)
health officials, and visited Chhlong OD from 16 – 27 September 2002 to view activities 
firsthand. While in the field, the Team visited every HC in the OD, interviewed the HC
staff responsible for supervision of VHVs, visited a village where the Hearth model
nutrition program was being piloted, and visited 11 other randomly selected villages. In 
each village, 2 VHVs, the village chief or other member of the Village Development
Committee (VDC), and two female villagers with children of the target age were
interviewed. In each of the 11 villages visited, visual checks were made of drug sellers to 
see if they had ORS in stock. 
PFD had conducted a repeat household survey of key indicators in January 2002 and 
the raw data was made available to the Evaluation Team. In addition, statistics on VHV 
activities were available from the Program reporting system, as were statistics on births 
and deaths reported by the VHVs for their catchment areas. Verbal autopsy forms had
been completed for all maternal and under-five deaths reported in 2001. The Evaluation 
Team Leader, with assistance from PFD staff clinicians, analyzed the verbal autopsy
reports and assigned a probable cause of death (see Annex IV). These data, together 
with the more qualitative information gathered from direct observation and extensive
interviews with the randomly selected VHVs and villagers, provided the Team with a
solid base for assessment of the Program.
The Team found that the Northeast Cambodia Child Survival Program has successfully 
implemented almost all planned activities, with a few remaining ones in an advanced
stage of planning. The Program will clearly succeed in implementing all activities prior to 
 
1
Prior to 1996, this was as a part of the US branch of AICF (International Action Against Hunger), from 
which PFD subsequently separated. PFD was incorporated as a separate NGO in 1996 and continued 
management of the former AICF Cambodia program.
ii
the end of the grant period except for three minor ones which have been deleted due to 
poor performance in piloting or low priority In addition, the Program will have
implemented a significant number of additional interventions directly related to child
survival and responsive to documented causes of child mortality and weaknesses of the 
health system. 
The primary strategy of empowering and motivating village women to adapt improved
health behaviors through peer education from Village Health Volunteers (VHVs) has
proven sound and is working well. VHVs are known and active in their communities and 
both qualitative assessments by the Team and quantitative data from a repeat
household survey confirm that they have achieved dramatic success in increasing
knowledge and changing behaviors. The ORT treatment rate has more than doubled
since VHV activities began. Immunization coverage documented by card has increased 
from 14% to 63% -- considerably higher than the national average. Since the nutrition
and breast-feeding interventions were not introduced until the first half of 2002, the mid￾term survey was limited to diarrhea and immunization. However, the Team found clear
indications in the field that VHVs are conducting education on nutrition and breast￾feeding with at least as much intensity as the other intervention areas, and that mothers 
are retaining and acting on these messages.
Village women and community leaders value the Program, as do Provincial and District 
health managers and the staff of health facilities. All HCs reported a noticeable increase 
in attendance for immunization since the Program started, and most also realized an
increase in general utilization of HCs’ antenatal and curative services attributable to VHV 
referrals and publicizing of services.
Key factors in the success of the NCCSP VHVs are:
· Participatory introduction of the Program and VHV selection
· Manageable workloads (1 VHV per 50 households)
· High quality training and appropriate IEC materials
· Close supervision and follow-up
The supervision of VHVs by HC staff is working very well. VHV Supervisors are
providing tangible assistance as well as less tangible but important morale boosts to the 
VHVs, and enjoy the supervision. It has broadened their awareness of the communities 
and given them a point of entry wherein they are assured of a welcome, and an
intermediary who can help sort out issues that arise between facility staff and villagers. It 
has also made their work easier to do and increased their own performance in terms of 
HC utilization and immunization coverage. The time spent on VHV supervision and
associated paperwork is small and does not seem to adversely affect staff’s ability to
carry out their usual HC tasks. Only 2 staff per HC, spending a couple of afternoons per 
month, is required.
While most VHVs are well versed in their current material and active, about 10% are not, 
despite Supervisor efforts, and no productive purpose is served by keeping them in the 
Program. Most VHVs have an adequate grasp of the topics they have been taught but a 
minority needs refresher training.
iii
Analysis of verbal autopsy data and interviews with VHVs, HC staff and villagers
indicates both a need and potential for increasing the range of VHV interventions to
address other significant causes of under5 mortality, e.g., acute respiratory infections 
(ARI), peri-natal causes, dengue/malaria, dysentery, and typhoid.
While the IEC materials provided by PFD are excellent and being well used, the record￾keeping system for the VHVs could be improved upon. There is considerable duplication 
of information between the monthly report and the register, and the information is often 
inconsistent. In addition to recording events and activities in two different places (the
register and the monthly report form) most VHVs first record it on another scrap of paper 
and then transfer the information to the forms at the end of the month.
Although the VHV Program has been very successful, there is a clear consensus among 
VHVs, community leaders, VHV Supervisors and PFD national staff that something
needs to be done to build in a small incentive for VHVs over the long run if the currently 
high performance is to continue.
Preliminary results of the Hearth model look quite encouraging, but it is a very labor￾intensive undertaking. It will therefore be very important to have a solid base of data on 
improvements in nutritional status, which the Program is already poised to collect, and
also data on mortality impact, which can be obtained through the VHV surveillance
system.
Improvements in health status require work at both the demand and supply side.
Cambodia is unique in that, due to decades of civil war and the destruction of social
institutions and human resources during the Khmer Rouge genocide, its public health
system is less than a decade old. The initial Program design assumed that another NGO 
would be building capacity in the HCs, Referral Hospital and OD Management Team,
and in general probably underestimated how weak the system was. The Program has
made appropriate adjustments to provide support to HCs and this can be expected to
improve the situation by the end of the grant period, but the needs of the Referral
Hospital and OD Management Team remain largely unmet. Particularly urgent is the
need for competent, reliably staffed, and equipped 24-hour obstetric facilities and an
inpatient pediatric ward able to provide oxygen, intravenous antibiotic therapy, laboratory 
diagnostics, and management of DHF.
While PFD is in general doing an excellent job of implementing a large program under 
difficult conditions, implementation could be further enhanced through a restructuring of 
Program Officer responsibilities so that one staff has primary responsibility for
overseeing all health-related activities – VHV and health system strengthening, RH
activities, and the malaria program – in a specific geographical area. This would save
travel time and allow for a comprehensive view of village health activities.
The quality, commitment and high morale of PFD’s national staff have been critical to the 
Program’s success. PFD has made a number of investments in developing the capacity 
of its local personnel, who make up the majority of the staff and are the direct
implementers.
The Program has done a good job of obtaining and using baseline data, and conducting 
repeat surveys to measure changes. A survey on nutrition and breastfeeding indicators 
is planned soon. PFD has made skillful use of in-country expertise through
iv
collaborations with other organizations, and has returned the favor by sharing materials 
and lessons learned. PFD has actively pursued partnerships and collaborations with
government, other NGOs, and International Organizations and made skillful use of it in
implementation of the Program. PFD has also actively sought other donor funding to
support complementary or expanded Program activities. In addition, formal external
assistance has been utilized in development of pilot tests and both qualitative and
quantitative research
The NCCSP is better placed for sustainability than most programs since its primary
activity is the imparting of new information, skills, and behaviors to communities. When 
successful – as these appear to have been – such changes are intrinsically self￾sustaining as changed community attitudes and practices get handed down to
subsequent generations. Since the VHV approach has proven so effective, however, it
would be highly desirable for it to continue beyond the current end date of the grant. It is 
possible for this to happen without PFD, since the VHVs are already linked to, and under 
the supervision of, the government health system. However, it will take time before the 
nascent Cambodian health system has the managerial skills and financial resources to 
be able to sustain the VHV program. The best contribution PFD can make to program
sustainability is to continue its efforts to strengthen the health system, and to create
incentive mechanisms for VHVs that are ultimately self-sustaining through normal
market forces (e.g. social marketing). 
The Evaluation Team strongly recommends that the Program continue -- keeping the 
basic structure of VHV selection by communities, one VHV per 50 households and
supervision of VHVs by HC staff -- and expand, resources permitting, to the other OD of 
Kratie Province so that the entire Province is covered. The Team also recommends that 
USAID fund an extension of the Program after the scheduled end date of the grant in
March 2004 in order to allow activities which are having a demonstrable impact on child 
health to continue, and help ensure permanent returns on its investment by supporting 
the Program until the health system is sufficiently developed to take it over.
In addition, a number of specific recommendations are made for expansion and/or 
strengthening of the program, including:
ß A phased expansion of VHV health education/referral to include ARI, pregnancy 
and delivery, malaria/dengue, dysentery/typhoid, skin infections, iodine
deficiency and child safety.
ß VHV social marketing of health commodities in order to provide a small financial 
incentive with long term potential for sustainability, while also increasing access
to, and use of, desirable products.
ß Revision of the VHV record-keeping system (registers and monthly reports) to be 
more accurate and user-friendly, and periodic village censuses to ensure that all
eligible families are covered by the Program.
ß Continued surveillance of maternal and under5 deaths, with revision of the verbal 
autopsy forms to capture more detail and to be completed by the same staff who 
will conduct the analysis and assignment of cause of death; careful monitoring of 
both anthropometrical and mortality data in the Hearth pilot villages.
v
ß Integration of program management so that specific PFD Program Officers
monitor and supervise all activities in a geographical area: RH, VHV education, 
and malaria.
ß A shift in focus by the PFD Water and Sanitation Program from water supply to
environmental sanitation in Chhlong OD, in response to documented causes of
mortality.
ß Community health education using techniques such as drama or puppet shows
on topics that require a broad community response to address, e.g.
environmental sanitation issues. 
ß Replacement of the small number of VHVs who are not active, and targeted
refresher training for those who need it. 
ß TBA training in interventions that do not require availability of emergency
obstetric care, with particular attention to immediate care of the newborn to
establish a patent airway and prevent hypothermia, hypoglycemia.
ß If and when emergency obstetric care is available, specific referral and
partnership mechanisms linking TBAs with the hospital, including arrangements, 
which allow the TBA to maintain a (non-medical) role during the hospital delivery.
ß PFD national staff training in supervisory techniques and management skills, and 
gradual devolution of management responsibilities to them.
ß Expansion of health system strengthening to include the Referral Hospital unless 
another agency is able to do so.
1
I. Background
A. Program Context
Partners for Development (PFD) is an International NGO specializing in grassroots community￾level interventions based on the principles of community organization. Technical areas of
expertise include water and sanitation, maternal/child and reproductive health, and village
agriculture/food security. All interventions are preceded by, and built upon, participatory rural
appraisals and formation of Village Development Committees (VDCs). PFD specifically targets
remote and/or underserved areas, and has worked in the isolated, impoverished northeastern
provinces of Cambodia since 1992.1
Chhlong Operational District (OD)2
 is located in Kratie Province of northeastern Cambodia. It
has a total population of approximately3
 126,000 people dwelling in 103 villages ranging in size 
from less than 100 to over 1,000 households. It is transected by the Mekong River, with the
majority of its inhabitant’s subsistence farmers. Over half of all households are below the
poverty line. 49% of adult women are illiterate, and most of those who can read, do so at only a 
primary level. 15% of the population are ethnic minorities, unusual for Cambodia, which is
largely homogenous. Ethnic minorities in the area include the Cham (indigenous Muslims of
Malay ancestry) and the Stieng (an indigenous hill tribe peoples). Two-thirds of the population is 
concentrated in villages along the banks of the Mekong, with the remainder in scattered,
isolated inland villages. Roads are extremely bad, often impassable in the rainy season, and
flooding is common. Greater than usual flooding has occurred for the past three years. Riverine 
villages can be accessed by boat during the rainy season, but inland villages are often
accessible only by lengthy walks through deep mud or by oxcart.
Within the general breakdown of riverine versus inland, there are further regional differences in 
Chhlong OD. Among riverine communities, those on the eastern banks of the Mekong are the
most socioeconomically advanced, with a number of thriving markets. Villages on the western 
banks are less developed, with fewer markets and less commerce. A significant minority of
riverine villages are ethnic Cham, and are unusually organized and cohesive by Cambodian
standards. Inland, with the exception of one sizable town (the capital of Snuol administrative
district), villages are scattered and remote, but differ considerably in livelihood and lifestyle.
Some are largely self-contained rice farming communities wherein people remain in the village 
much of the time, camping out in their rice fields only during the peak agricultural seasons of
planting and harvest, and thereby having considerable opportunities to meet. Other villages are 
engaged in year-round cash crop cultivation or work on rubber plantations, with the result that 
residents are rarely at home and may stay overnight for extended periods in their fields,
resulting in infrequent contact and interaction among villagers. Some inland villages contain
significant numbers of ethnic Stieng, who have markedly lower levels of literacy and education, 
and do not always speak Khmer, isolating them from the larger society and limiting their access 
to markets and other services.
 
1
 Prior to 1996, this was as a part of the US branch of AICF (International Action Against Hunger), from which PFD 
subsequently separated. PFD was incorporated as a separate NGO in 1996 and continued management of the 
former AICF Cambodia program.
2
 An Operational District is an administrative division designated by the Ministry of Health, covering a population of 
approximately 100,000 persons. It is the primary locus of health care services and headed by a District Management 
Team.
3
 All population figures are based on the 1998 census adjusted for a growth rate of 2.49% per year since 1998.
2
The PFD Northeast Cambodia Community Development Program (NCCDP), funded by
USAID/Cambodia since 1993, has conducted participatory rural appraisals, facilitated the
development of Village Development Committees (VDCs), and assisted communities in
installation of tube wells and latrines throughout the Provinces of Kratie and Steung Treng. As a 
result, the majority of villages in Chhlong OD have functioning VDCs and a source of potable
water. Latrines are less common, especially in the inland communities.
In addition to the infectious diseases common throughout Cambodia (respiratory infections,
diarrhea, typhoid, immunizable diseases etc), much of Chhlong OD is highly endemic for
malaria. Dengue, previously confined to urban areas., has recently spread into the rural areas of 
Cambodia and is a new problem in Chhlong OD. Schistosomiasis is also present and there
have been cholera outbreaks in the past. Iodine deficiency is very common. Infant and child
mortality are higher than the already-high national average, with an Infant Mortality Rate (IMR) 
of 97/1,000 and Child Mortality Rate (CMR) of 68/1,000 compared to 80/1,000 and 53/1,000
respectively for the country overall (1998 Census)4 Almost all deliveries occur at home, and are 
usually performed by Traditional Birth Attendants (TBAs).
Malnutrition is widespread and undoubtedly contributes to mortality from other causes. A 1998 
survey found that 25% of children 6-59 months were wasted (<-2.00whz) and 40% were 
stunted (<-2.00haz). Vitamin A deficiency is widespread, with night-blindness reported in 3.3%
of children aged 24-59 months, and 4.0% of pregnant women. Due to the combination of
inadequate iron intake (especially in the early weaning ages), parasites, and frequent malarial 
infections, anemia is extremely prevalent among young children in the NCCSP area: 81% have 
hemoglobin’s below the WHO cut-off of 11.0 g/dl. It is also extremely widespread among
pregnant women (86%)5
.
In keeping with the Ministry of Health (MOH) guidelines, the first level of health care in Chhlong 
OD are the Health Centers (HC) which provide preventive health services (immunization,
antenatal care, family planning) and simple outpatient curative care. Immunization is conducted 
on an outreach basis for villages beyond walking distance while other services are facility￾based. HCs are open only in the mornings, Monday through Friday. There are 10 designated
HCs in Chhlong. One of these, Snuol, covers a population size more than double the MOH
standard (20,790 as opposed to a standard of 10,000 per HC). In addition, the catchment area 
of Snuol is exceptionally large in geographical terms, with some villages as much as 30km away 
from the HC. PFD has assisted the OD in constructing two “Health Posts” (smaller versions of 
HCs with fewer staff and less comprehensive services) in Snuol to increase accessibility. Even 
with these, much of the population are unable to access services due to the length of time and 
cost of travel. Further aggravating this problem is the fact that the communities furthest away
tend to be those engaged in cash crop cultivation or employment in the rubber plantations, and 
thus unusually constrained in the time available to travel for health services. 
Of the 10 HCs, 9 meet MOH standards in terms of minimal number of staff and have been
issued a full drug kit. One, the remote inland HC of Damrei Pong, has an inadequate number 
and quality (level of qualification) of staff, preventing it from receiving the full drug kit and
 
4
 Mortality rates for the program area are the average for the province as a whole; OD-specific rates are 
unavailable. The 1998 census, due to the model used for indirect estimation, underestimated infant and 
overestimated child mortality rates as subsequently demonstrated in two national demographic and health surveys. 
However, since the latter sources do not provide data specific for Kratie province, census rates are used here to 
enable comparison between the program area and the country as a whole.
5
 UNICEF-WFP Baseline Survey of Community Action for Social Development Program survey 1998. Data reflect 
Kratie and Steung Treng Provinces combined.
3
severely impeding its ability to provide services on a consistent basis. Of the 9 HCs which meet 
MOH minimal staffing standards, six are functioning at or above the national norm, i.e. are
reliably open, providing services on a regular basis, and are being utilized by villagers for 
curative care, antenatal services and family planning. Three others have significant problems 
resulting in underutilization. Together with Damrei Pong this makes 4 out 10, or 40%, of HCs
either not functional or poorly performing. The Referral Hospital is likewise weak with very low 
levels of utilization and virtually no deliveries talking place, despite the fact that it is the sole
point of referral for obstetric emergencies in the OD.
In 1998, PFD won a two-year entry-level Child Survival Program Grant from the USAID Private 
and Voluntary Cooperation (PVC) Bureau in Washington DC. for development of a child
survival program in Chhlong OD. This grant ran from October 1, 1998 to September 30, 2000, 
during which time baseline quantitative and qualitative research was conducted, a Detailed
Implementation Plan (DIP) designed, and partnership arrangements were finalized with the
government and other NGOs. Based on the DIP, PFD was then competitively awarded a 42-
month USAID Child Survival Program Grant from October 2000 to March 2004. 
B. Program Description
1. Initial Design
The goal of the Northeast Cambodia Child Survival Program (NCCSP) is to improve the health 
of children under five in Chhlong OD through control of diarrheal disease, immunization,
improved nutrition and promotion of breastfeeding. Specific objectives include:
1. Increase the proportion of diarrheal episodes which are appropriately managed at
household level (ORT, recognition and referreal for danger signs, continued feeding
during, and increased feeding after, diarrheal episodes);
2. Increase the preoportion of caretakers practicing hygiene behaviors that prevent
diarrhea (hand-washing, dafe drinking water);
3. Increase the proportion of children who are fully immunized;
4. Increase the proportion of women of reproductive age immunized at least twice for
tetanus;
5. Reduce the proportion of children under 3 years of age with severe or moderate
malnutrition;
6. Reduce the prevalence of micronutrient deficiencies (especially Vitamin A and iron) in
children 6-59 months old;
7. Increase the proportion of mothers exclusively breastfeeding infants up to 5 months of 
age;
8. Increase the proportion of mothers who initiate breastfeeding within one hour of delivery;
9. Increase the proportion of mothers providing appropriate weaning foods at age 6
months;
10. Increase the proportion of diarrhea cases in children under 5 which are correctly
managed by health center staff or trained drug sellers;
11. Increase the capacity of health center staff to provide EPI services
4
12. Increase the capacity of TBAs to promote appropriate breastfeeding; and, 
13. Increase the capacity of HC staff to promote breastfeeding, provde Vitamin A
supplementation, identify malnutrition (growth monitoring) and provide appropriate
nutrition counselling.
The Program’s primary strategy is to increase caretakers’ case managment abilities and
promote improved health behaviors through community health education conducted by a
network of Village Health Volunteers (VHVs). VHVs are selected by communities in a
partcipatory manner and responsible for approximately 50 households apiece. In addition to its 
primary task of educating mothers on improved care taking and preventive behaviors, the
Program also planned to promote linkages between the community and the government health 
system and to increase the capacities of both public and private providers. Linkage with the
health system, and a potentially sustainable system for supervision of VHV activities, was
addressed through the use of HC staff to both train and supervise VHVs. The program planned 
to train HC staff and private drug sellers in diarrheal disease management, and to provide
training and support (transport, cold chain equipment) for HC immunization activities.
In addition to promoting improved breastfeeding and weaning practices through VHV health
education, the program planned to pilot test three different approaches to improved nutrition: (1) 
education alone (6 HC catchment areas); (2) education plus growth monitoring (2 HC catchment 
areas); and (3) education plus implementation of the “Hearth” model of nutrition intervention,
whereby a positive deviance study is conducted at village level followed by a Nutrition Education 
and Rehabilitation Project (NERP) in which the community is assisted in preparation and
feeding of nutritious supplemental meals to malnourished children using locally available,
affordable food sources. NERPs are accompanied by growth monitoring and intensive
education of mothers, and were planned for 2 HC catchment areas.
The Northeast Cambodia Child Survival Program (NCCSP) is primarily funded by USAID, with
matching funds from a variety of donors, including the Canadian International Development
Agency (CIDA), the Japanese Embassy, and the European Community (EC). The NCCSP is 
staffed by 1 Program Co-Ordinator (international), 1 VSO nurse (international, volunteer), 1
Team Leader (national), 9 Program Officers (national) and 2 administrative staff. 7 of the
Program Officers are currently assigned to VHV community health education while the other
two and the VSO nurse are assigned to strengthening of the health system. In addition, a
national physician Child Survival Officer devotes 50% of his time to the Program, focusing on
Health System Strengthening. The remaining 50% of his time is spent on the PFD Malaria
Program, which is funded by USAID. 
Complementing the NCCSP is a UNFPA/MOH-funded Reproductive Health Program in which
village-based agents sell contraceptive pills and condoms and provide IEC on birth-spacing and 
HIV prevention in 80 of the 103 villages of the OD (those within walking distance of a Health
Center are excluded). In some cases these agents are also VHVs; in others, both PFD social 
marketing agents and VHVs are in the same villages. Three national staff are assigned fulltime 
to the RH program.
2. Changes and Adaptations to Program Design
The overall goal, strategies, and primary activities of the program have remained unchanged, 
with only a few revisions, additions and deletions to planned activities as outlined in the DIP.
5
Revisions:
In order to render the nutrition pilot more manageable in size and complexity, and to avoid the 
ethical dilemma inherent in identifying severe malnutrition without providing an adequate
intervention, the “education plus growth monitoring” group was dropped, leaving a group
receiving only nutrition education, and a group receiving the “Hearth” model – education, growth 
monitoring and NERPs. The Hearth group will be smaller than originally envisioned (2 HC
catchment areas, which would equal approximately 20 villages) as it is extremely labor
intensive. The actual number of villages which can be covered by Hearth before the end of the 
grant period remains to be seen, but looks to be in the range of 10 villages total, still sufficient 
for purposes of comparison. 
The establishment of physical “hand-washing corners” in households, originally planned as part 
of the VHV hygiene intervention, was revised after it encountered considerable community
resistance and practical problems (lack of space in homes, many of which are one room
shacks). Hand-washing remains an intervention but measured in terms of presence of soap and 
water within the home and reported/observed behavior.
The cooking demonstrations originally planned by VHVs to promote appropriate weaning foods 
has been modified to have VHVs demonstrate the foods and explain their preparation, owing to 
the logistical difficulties of actual food preparation, and because the means of preparation
(adding ingredients to rice porridge) is already well known to Cambodian mothers.
Formal mother’s support groups for nutrition and breastfeeding have not been formed, since the 
concept of “support group” is alien to the culture and the VHV catchment areas (typically
containing about 10 women with a child under age 2) already serve the same purpose in a more 
informal manner, gathering women together for group education and discussion.
Additions:
The level of involvement with HCs has been expanded beyond the originally envisioned training 
on diarrhea, nutrition and immunization. At the time of program design it was expected that
another NGO would be working with the health system to strengthen overall management and 
service delivery in the HCs and Referral Hospital. When this did not materialize, and
weaknesses in the health system proved a significant barrier to improving community health
status, the program added a Health System Strengthening component, focusing on Health
Centers. This initiative includes training and follow-up in Integrated Management of Childhood
Disease (IMCI), training of HC staff in use of the “Client-Oriented Provider-Friendly” (COPE) tool 
to identify and solve service delivery problems, and technical assistance in management and
service delivery for the four weakest HCs.
Severe flooding in 2001 and 2002 created an emergency need for safe drinking water as usual 
sources were temporarily contaminated or submerged. The VHV network was used to distribute 
water purification tablets and ORS packets to households in flood-affected villages.
Deletions:
The following minor activities were dropped from the original design:
6
· a possible soap-making initiative was ruled out due to labor intensiveness and the
availability of soap in the province. The program still plans to promote soap distribution, 
possibly by social marketing, with commodities obtained commercially or from an NGO.
· a possible soy product-making initiative was discontinued after pilot testing was
unsuccessful.
· referral of malnourished children to HCs was dropped because HCs currently do not
provide any type of nutritional rehabilitation. Neither does any other part of the
Cambodian health system. Malnourished children who are ill are, of course, still referred 
for curative care. 
II. Evaluation Methodology
In September 2002, the approximate mid-point of the Grant, PFD recruited two independent 
consultants to conduct an external evaluation of the Program. The Evaluation Team consisted 
of Sheryl Keller, MSN, MPH (Team Leader), and Ms. Sam Sophy, a specialist in rural
development and primary health care. Ms. Keller is a public health professional with extensive 
international experience, including over 13 years experience in Cambodia. Ms. Sophy is a
Cambodian national on staff with the Ministry of Rural Development’s Department of Rural
Health. The Scope of Work for the evaluation appears in Annex I.
The Team reviewed the DIP, baseline survey, annual report and other relevant Program
documentation (see Annex II) and visited Chhlong OD from 16 – 27 September 2002 to view 
activities firsthand. While in the field, the Team visited every HC in the OD, interviewed the HC 
staff responsible for supervision of VHVs, visited a village where the Hearth model nutrition
education/rehabilitation program was being piloted, and visited 11 other villages selected as
follows: 1 village per HC catchment area for the 9 HCs which cover 7-11 villages each, and two 
villages from the one HC (Snuol) which covers a larger catchment area of 20 villages. Within the 
HC catchment areas, a village (or, in the case of Snuol, 2 villages) was selected randomly with 
probability proportional to size. In each village, 2 VHVs, the village chief or other member of the 
Village Development Committee (VDC), and two female villagers with children of the target age 
were interviewed. In villages with more than 2 VHVs total, VHVs were selected by random draw 
on the day of the visit, so that neither PFD, the HC nor the VHVs knew in advance whom would 
be interviewed. VDC members and village mothers were selected through convenience
sampling but excluding any living in the immediate vicinity of the VHVs interviewed. 
Of the 22 randomly VHVs selected for interview, 20 were successfully located and interviewed; 
two others (each from a different village) where away at the time of interview. Of a total of 20 
HC staff who supervise VHVs, 19 were interviewed and one was away for training. Village
chiefs were successfully located for interview in 9 villages; in the remaining two, a VDC member 
and the wife of the village chief were interviewed as the village chief was unavailable. In each of 
the 11 villages visited, visual checks were made of drug sellers to see if they had ORS in stock. 
Those who did were asked about the levels of sales and receipt of any training.
PFD professional staff were interviewed, and meetings were held with the Operational District 
Health Team in Chhlong and with the Provincial Health Department in Kratie to elicit
government feedback on the Program. A full list of persons met appears in Annex III.
PFD had conducted a repeat household survey of key indicators in January 2002 and the raw 
data was made available to the Team. In addition, statistics on VHV activities were available
7
from the program reporting system, as were statistics on births and deaths reported by the
VHVs for their catchment areas. Verbal autopsy forms had been completed for all maternal and 
under-five deaths reported in 2001. The Evaluation Team Leader, with assistance from PFD
staff clinicians, analyzed the verbal autopsy reports and assigned a probable cause of death
(see Annex IV). These data, together with the more qualitative information gathered from direct 
observation and extensive interviews with the randomly selected VHVs and villagers, provided
the team with a solid base for assessment of the Program
III. Findings
The Evaluation Team’s findings will be presented in four parts:
1) Assessment of Program design; 
2) Implementation Progress, successes and constraints
3) Program Management: structure, staff development, collaboration with other
organizations and use of technical assistance; and 
4) Assessment of Program impact.
A. Assessment of Program Design
The Program has proven possible to implement largely as planned, with only minor changes. 
VHVs have been selected in every village, and have catchment areas of about 50 households 
each. Most VHVs are active and respected by their communities, and supervision of VHVs by
HC staff is taking place as planned. The fundamental design of the Program is sound, has
proven feasible to implement, and – as will be described subsequently – is having the desired 
impact. The Evaluation Team identified three issues with respect to Program design, as follows:
1. Time required to establish the Program
2. Expectations of the health system 
3. Focus of VHV Interventions
Timeline
The original timeline for activities was over-ambitious given the need to select VHVs in 103
different villages in a participatory manner (thereby ensuring their credibility with mothers in the 
village), train PFD staff and HC staff in adult training methodology as well as course content, 
conduct courses for the VHVs in the four intervention areas, and train HC staff in supervision of 
the VHVs. All of this was originally projected to be completed by the end of 2001, whereas in
reality it took until June of 2002. 
The main flaw in the original timetable was an under-estimation of the time required to assist
villagers in selection of a VHV in 103 different villages scattered across a large geographical
area, with very poor roads and frequent floods making access extremely time-consuming, and 
the time it would then take to train 400 VHVs in batches of 20 each. In addition, the amount of 
information that could be included in a single course proved to be less than anticipated. It was 
initially planned to combine both immunization and diarrheal control in a single module, but this 
proved impractical, especially since the first module also needed to include an explanation of
the VHV role and record-keeping system.
8
The development of training and IEC materials suitable for rural Cambodia proved more time￾consuming than anticipated, as a total of five manuals and related IEC materials had to be
identified or newly developed: VHV training manual for Immunization, VHV training manual for 
diarrhea, VHV training manual for nutrition / breastfeeding, VHV Supervision training manual,
and TOT Training Manual for VHV Supervisors.
An additional problem was that the possibility of some VHVs dropping out after the Program
actually began, with the consequent need to recruit and train replacements, was not anticipated. 
30 of the originally recruited VHVs dropped out shortly after receiving the first training,
apparently because of unrealistic expectations regarding incentives and workload.
Although over-ambitious expectations of the time required to fully establish the Program has
resulted in many activities being about 6 months behind schedule, this is not likely to detract
from achievement of Program objectives. As will be discussed shortly, survey data and 
observations in the field demonstrate that significant progress is being made towards 
achievement of all key objectives and mid-term targets have been reached or surpassed in most 
cases.
Health System
The originally planned level of involvement with the health system reflected both an
overestimation of the capacities of the system and the expectation – reasonable at the time of 
Program design – that another NGO would be working with HCs, the Referral Hospital and the 
District Health Management Team. Unfortunately, that NGO was forced to withdraw from
Chhlong due to an interruption in funding, and the capacities of the health system have proven 
to be much weaker than anticipated, creating a significant constraint. While the Program’s
design in terms of working with communities and effecting positive changes in health status
through demand-side interventions was sound, it may have underestimated the importance of
addressing both demand and supply sides of the equation, especially in a country where the
health system is still in very early stages of initial development.
The Program has made necessary and appropriate adaptations to address weaknesses at
Health Center level, including assignment of staff to work intensively with the weaker health
centers, support for basic training of HC staff (the MOH “Foundation of Health Center Training 
course)”, support for the establishment of Village HC Feedback Committees, and, more
recently, the planned introduction of Integrated Management of Childhood Illnesses (IMCI) in all 
HCs through support for IMCI training and intensive on-the-job follow-up. The latter is being
undertaken in close coordination with the MOH IMCI working group and is part of a national pilot 
with the potential for informing nationwide policy. Still largely absent, and much needed, is
support for the District Referral Hospital and strengthening of the capacities of Operational
District Health Managers. There is some possibility of another NGO undertaking these starting 
early 2003, but funding is not yet certain.
Interventions
The intervention focus areas could be improved upon given causes of mortality, as shown in
table 1 below. However, this detailed information, derived from the VHV registers and verbal
autopsies, was not available at the time the interventions were selected. PFD was aware that 
Acute Respiratory Infection (ARI) was a major cause of death in children, but decided not to
include it due to lack of a health system sufficiently strong to effectively handle referrals at the 
time the Program was initiated (see above).
9
Table 1: Under5 Deaths Chhlong OD May- December 2001
Probable Cause of Death Number Percentage
ARI 43 25%
Peri-natal 20 12%
Meningitis/encephalitis 19 11%
Malaria 17 10%
Neonatal Tetanus 15 9%
Typhoid/other infectious 10 6%
GI Other 8 5%
Accidents 7 4%
Diarrhea 6 4%
Dysentery 5 3%
DHF 4 2%
Malnutrition/Starvation* 3 2%
Sepsis 3 2%
Unknown 11 6%
TOTAL 171 100%
* Refers to malnutrition as the sole cause of death. Malnutrition as a contributing factor to death from infectious 
disease is not reflected and, based on known nutritional status in this population, can be assumed to be considerable.
A detailed report, included methodology and criteria for assigning cause of death, appears in 
Annex IV.
As can be seen from the above table, diarrhea is not a major cause of death among children 
under five in the Program area, whereas ARI, other infectious childhood diseases (including
malaria), and peri-natal causes are quite significant. The relatively low contribution of diarrhea
may reflect both the clean water interventions PFD had already conducted in the area (tube
wells, household water filtration systems, and related health education) and the fact that
Cambodian mothers traditionally continue or increase breastfeeding, and provide traditional
teas, to children during diarrhea.
While diarrhea has not proven to be a leading cause of mortality in the area, the
diarrhea/hygiene interventions are still helpful. Improved hygiene will help reduce the incidence 
of dysentery and typhoid, and better feeding practices with diarrhea will reduce malnutrition 
which in turn is an important contributing factor to child deaths from infectious disease. There is 
sufficient time left in the Program to add on interventions that address what are now known to 
be more important causes of mortality, and the VHV infrastructure to absorb and implement
such new interventions is solidly in place.
B. Implementation Progress
1. Status of Planned Activities, Use of DIP
The DIP is being actively used by Program staff to plan activities and assess progress. As noted 
in Section IIIA above, modifications to the DIP have been minimal and appropriate. The 
following table summarizes the status of all activities outlined in the DIP except for three minor 
activities noted in section IIIA above has having been deleted.
10
Table 2: Status of Planned Activities
Activity Status
400 VHVs from 103 villages selected with village participation. 
Replacements trained for 30 VHVs who dropped out after the 
Program began
Completed
20 staff from 10 HCs selected and trained as VHV Supervisors Completed
Appropriate IEC materials identified or developed. (Visually￾literate immunization and diarrhea flip-charts were developed by 
PFD; a suitable nutrition/breastfeeding flipchart was obtained 
from Helen Keller International (HKI).)
Completed
Training of Trainers (TOT) in adult learning techniques, 
immunization, diarrhea, nutrition and breast-feeding provided to 
PFD staff and HC VHV Supervisors
Completed
VHVs trained in immunization, diarrhea, nutrition and 
breastfeeding
Completed
VHV registers and monthly report forms developed and 
training provided
Completed
VHV-led health education to village mothers on immunization, 
diarrheal control, nutrition and breastfeeding
Ongoing in all villages 
VHVs mobilize mothers and children for immunization sessions Ongoing in all villages
VHVs assist in community mobilization for VAC distribution 
campaigns
Being done every six months in 
partnership with HKI 
Supervision by VHVs by HC staff Ongoing in all villages
Drug sellers identified and ORS supply channels established Completed
Drug sellers were trained to promote sale of ORS Completed (156 sellers)
Hearth model piloted Underway in two villages, 
expansion to others planned 
HC capacities assessed Completed – HC Resource 
Survey and assessment of 
consultation practices
HC staff trained in diarrhea management Completed in all HCs via the 
“Foundation for HC Training” 
course which includes diarrhea 
management
HC training on cold chain maintenance and record-keeping Completed
Establishment of Child Survival Coordinating Committee Completed and functional
HCs provided with transport to conduct EPI outreach and VHV 
supervision
Completed all HCs - motorcycle 
and reimbursement of fuel
Follow-up survey to assess impact of VHV health education Done for immunization and 
diarrhea; planned end of this 
year for nutrition and 
breastfeeding
TBA training on breastfeeding promotion Planned for 2003
ORS corners established in HCs Planned starting 4th quarter 2002
HC staff trained and encouraged to provide ANC iron 
supplementation
Planned for 2003
Iron distribution by VHVs pilot tested Planned for 2003
11
As can be seen from the above, the overwhelming majority of planned activities have taken
place and the Program is well poised to complete all before the grant end date. In addition to the 
planned activities, several others not originally in the DIP have been conducted or are planned, 
most of them related to strengthening of the health system. These include:
· EPI outreach coverage assessment and identification of underserved areas (done)
· Interventions to address causes of low EPI outreach in identified villages (done – per diem 
and transport support for villages far from the HC)
· Introduction of the COPE self-improvement tool in HCs (done)
· Formation of Village HC Feedback Committees (the official linkage between HCs and
communities) (done by PFD in 3 HCs by PFD, the remaining 7 by another agency.)
· Intensive technical assistance, facilitative supervision, and on-the-job training, in the 4
lowest-performing HCs (commenced and ongoing)
· Introduction of IMCI in all 10 HCs as part of a national pilot (in preparation phase. PFD is
actively participating in the national IMCI workforce and training of OD and HC staff will
commence this year)
· .Analysis of birth and mortality data from VHV registers (done for 2001).
· Verbal autopsies for under5 and maternal deaths with analysis of probable cause (done for 
2001, see Annex IV for full report).
· Training of HC midwives in family planning, safe delivery, handling of obstetrical
emergencies, post-partum care (planned for 2003).
· Training of TBAs in safe delivery, recognition and referral of complications, and care of the 
newborn.
· Social Marketing of safe birth kits (pilot).
· In-service training on computer use for OD staff (done).
2. Field Observations 
VHV Activities
PFD has recruited and trained a total of 402 VHVs, including 30 replacements for VHVs who
completed the first training session but proved either unwilling or unable to actually function. At 
less than 10%, for a volunteer Program, that drop-out rate is not excessive. In all 11 randomly
selected villages visited by the Team, community leaders6
 were aware of the VHV Program and 
could identify the specific VHVs for their village by name. 10 out of 11 could describe the
activities of the VHVs in detail; the eleventh knew only that it was some type of health
education. Of the 22 mothers approached in the 11 villages (convenience sampling, but out of 
immediate range of a VHV’s house), all were aware of the VHV Program and could give the
name of the VHV responsible for their household. All reported having been approached by the 
VHV and 20 of the 22 had received health education from her, while 2 stated they had been
asked to attend but not gone due to being “too busy”. Above all, VHVs were associated in
 
6
 These consisted of the village chief in 9 villages, a VDC member in one village, and the wife of the village chief in 
one village.
12
mother’s minds with the immunization program, as the person who let them know when
immunization would take place and reminded them to bring their children. Mothers also recalled 
that the VHVs had flipcharts about child health. All but two could remember the subject matter, 
and most could describe the content in detail from memory.
Although all of the 20 VHVs interviewed by the team were found to be active, the HC staff who 
supervise VHVs indicated that overall about 10% of the total are not functional (ranging from 0 –
20% per HC catchment area) due to low motivation or lack of time. This is not an unusually high 
percentage for a volunteer program in its second year, but worth addressing through
replacement of the minority who are not able to function in their designated capacity.
All community leaders interviewed expressed the opinion that the Program was valuable and
important. Suggestions for the future included expansion and/or intensification of VHV activities 
(introduction of other intervention areas, particularly ARI, malaria/dengue) and provision of
some type of incentive to VHVs to ensure continued motivation. Mothers described the VHVs 
as either “useful” or “very important”, with the main reason being that it helped ensure
immunization for the children and increased villagers’ knowledge about health. Most mothers
expressed a desire to have VHVs teach other topics, particularly ARI, dengue, malaria, and
general management of a child with fever.
Of the 20 VHVs interviewed without advance notice, (2 each from 9 villages and one in each of 
two others), 100% had IEC materials with them and all but one had her register of families on 
hand to show. In addition to possessing flip charts and brochures, a number of VHVs had health 
education posters prominently displayed on the walls of their homes. Based on their own
descriptions and information gathered from community leaders and mothers in the village, all 20 
were active as VHVs although the level of activity varied considerably. All VHVs were carrying 
out mobilization for immunization, and this activity was seen as the easiest to conduct since it 
was quite clear who to target and when a particular household no longer needed to be targeted. 
Health education presented more of a challenge since it was not linked to receipt of a service
and there is no clear-cut beginning and end to the education of a mother. 
It appeared that all VHVs had initially conducted education on each of the topics (immunization, 
diarrhea/hygiene, and nutrition/breastfeeding) to their entire catchment area, or as much of it as 
they could reach, immediately after receiving the training. Since then, each has settled into her 
own routine which varies considerably by individual VHVs. At the lowest end of the spectrum, a 
few were conducting group education only on the days when the HC Supervisors come (once a 
month) and reaching only those who readily come forward to attend. At the high end of the
spectrum were VHVs who systematically visited every household with a pregnant women or
child under five monthly, and made use of special opportunities such as the birth of a new baby 
or an episode of diarrhea to review specific topics with the mother. 
VHVs varied in the approaches used and had largely developed them on their own, some being 
more creative in doing so than others. There is scope for learning from each other, but no single 
strategy applies to all since there are important differences in localities that affect how and when 
VHVs can reach mothers. In villages on the river, individual home visits are possible except
during peak rice farming times (planting and harvesting), while some of the inland villages are 
engaged year round in cash crop cultivation and rarely at home, making it necessary to set up 
special appointments for group education sessions.
VHVs in the more socioeconomically developed villages along the river expressed difficulty in
repeatedly conducting education on the same messages and a need for a wider repertoire in
13
order to keep the mothers interested in attending. However, in remote inland villages where
levels of education are minimal and the population have little contact with the outside world,
VHVs reported that it took multiple sessions on the same topic for information to sink in. These 
perceptions of the VHVs were consistent with Team findings in discussions with mothers. In the 
riverine villages, particularly those on the more developed eastern side of the Mekong, mothers 
could readily rattle off the health education messages they had learned in great detail and took 
obvious pride in doing so. In inland villages, mothers had more difficulty and often could
describe only the general topic without specifics; some needed probing to identify topics even
though they had attended health education sessions with the VHV.
VHVs also varied considerably in their grasp of the material and skill in teaching it. All could use 
the flip charts, which are well designed, visually-literate and appropriate to the rural conditions
and culture. All VHVs in the riverine communities and some of those inland displayed a clear
grasp of the material and expressed a feeling of confidence. However, about half of the VHVs 
in the inland areas said they had either forgotten or were unclear on some of the information. 
Mothers’ ability to describe what they had learned from VHVs tended to be consistent with the 
VHVs level of knowledge and confidence (see above). While there is likely some direct cause
and effect between VHV skills and success in educating mothers, both are also the result of a 
common set of causes affecting these communities: extreme isolation and poverty, very low
levels of socioeconomic development, lack of mass media, extremely low levels not only of
education and literacy but also of basic ability to articulate ideas, and widespread anemia, 
iodine and other micronutrient deficiencies, which have a direct impact on the ability to
conceptualize, convey information and remember it.
While the IEC materials provided by PFD are excellent and being well-used, the record-keeping 
system for the VHVs could be improved upon. It consists of a register to identify target
households and track pregnancies, births, deaths, and immunization status, plus a monthly
report form on VHV activities (number of education sessions, referrals to the HC etc). There is 
considerable duplication of information between the monthly report and the register, and the
information is often inconsistent. Some of the VHVs do not understand how to record (or
perhaps how to calculate) immunization coverage. Most are recording pregnancies and births, 
but recording of deaths seems to have tapered off with time to the point that few were found on 
the register for this year (unlike 2001 where reported deaths were close to the number
expected). VHVs were aware of the deaths in their catchment area of 50 households, and could 
readily provide that information but had in most instances not written it down. A likely reason for 
the better recording of pregnancies and births than of deaths is that the former information is
used by the VHV herself while the latter is not, and the importance of recording death
information has not been stressed by Supervisors. In addition to recording events and activities 
in two different places (the register and the monthly report form) most VHVs first record it on
another scrap of paper and then transfer the information to the forms at the end of the month. 
The activity reports are collected monthly by the Supervisors and seem to be more complete
than the registers, which are meant to serve as a tool for organizing VHV activities and provide 
annual data which can guide Program intervention. These purposes are not well understood by 
many VHVs.
VHV Supervision
100% of the VHVs interviewed reported receiving supervision from HC staff, knew their
supervisor by name, and described the supervision as being helpful and supportive, and
occurring regularly once a month. Supervisors, for their part, were able to list by name the VHVs 
in any given village without advance notice, were clearly familiar with each individual VHV, and 
14
knew which ones were most active and knowledgeable. The vast majority of VHV Supervisors 
seemed sincerely interested in and supportive of the VHV’s work. The good rapport between
VHVs and their Supervisors from the HC is reflected in the extent to which each group
advocated for the other in talks with the Team. HC staff made a point of raising the incentive
issue and pleading on behalf of the VHVs, while VHVs made a point of stressing the good work 
being done by their Supervisors, and some were observed to speak in defense of the HCs with 
regard to problems or criticisms raised by villagers. Most VHVs saw publicizing HC services
and encouraging HC attendance as part of their job and expressed a good understanding of HC 
issues. For example, they could explain that the reason HCs often did not supply the
medications desired by villagers was because they were following national protocols, and that
overuse or misuse of antibiotics is harmful.
All Supervisors recalled receiving training from PFD, both a 5 day training course specifically in 
VHV supervision and TOT for immunization, diarrheal disease and nutrition/breast-feeding. The 
training was described as adequate and all 19 Supervisors interviewed felt confident in their role 
and ability to oversee VHV activities. They also seemed to be actively enjoying it, and to have a 
closer knowledge of village health needs and perceptions than is usually found among HC staff 
in Cambodia. Indeed, the HC staff may be gaining as much as the VHVs are from the
relationship as it gives them an entry point into the villages and an advocate to help them
negotiate the class and cultural barriers that otherwise often impede provider-client relations in 
Cambodia.
All HCs reported a noticeable increase in attendance for immunization since the Program
started, and several expressed that in addition to getting better coverage, the work of
immunization outreach was now much easier to do, since HC staff no longer had to try to
persuade busy villagers to stop and bring the children but rather found the people already
assembled and waiting for them. This not only saved time, but removed a potential source of
friction between HC staff and villagers, and avoided the previously common problem of HC staff 
traveling long distances to villages only to come away having immunized few or no children. 8 
out of the 10 HCs also reported an increase in general attendance at the HC (both curative 
and antenatal) attributable to VHV referrals and publicizing of services, and one mentioned that 
people are now more accepting of ORS whereas previously they had not wanted it and insisted 
on antibiotics. The better HCs are realizing the benefits of VHV referrals considerably more than 
the weaker ones, where erratic working hours or perceived poor quality of care discourage
attendance. 
The Supervisors have a checklist provided by PFD to aid them in assessing VHV effectiveness 
and to provide feedback on training sessions. Most described it as easy to use and “helpful”, but 
none could show the Team a completed checklist so it is unclear if they actually fill it out during 
supervision or have simply taken it as a general guideline. In any case, the supervision being
done seems effective.
Health System Strengthening
As previously noted, original plans to train HC staff on immunization, nutrition and diarrhea have 
been expanded to more systematically address weaknesses in the health system since other
NGO assistance failed to materialize. The 4 weakest HCs (Snoul, Ksim, Tamao and Damrei
Pong) are receiving intensive on-the-job training and facilitative supervision, the latter in
collaboration with OD managers. PFD staff spend approximately 6 days per month working side 
by side with the consultation staff of these HCs to improve their diagnostic and case
management abilities. A simplified IMCI algorithm has been introduced and training in full IMCI 
15
is planned for October for all HCs, with on-the-job follow through by PFD staff afterwards. IEC 
materials for HC use on ORS have been developed and the establishment of “ORS corners” is 
planned. PFD staff are also working with these HCs on general management issues, including 
the use of cost recovery funds and staff regulations/attendance.
Not yet begun, but planned, is formal clinical training for HC midwives and on-the-job follow up 
in the areas of safe delivery, management of obstetrical complications, ante/post-natal care and 
family planning. Training of TBAs in safe delivery, recognition and referral of complications,
breastfeeding promotion and immediate care of the newborn is also planned. These
interventions have the potential for considerable impact given the high contribution of peri-natal 
causes to infant mortality in Chhlong and significant number of maternal deaths (see Annex IV). 
All 10 HCs in the OD have been assisted in the formation of HC Village Feedback Committees, 
provided with the “Foundation of Health Center Training” (an MOH course which includes
diarrhea and immunization), trained in use of the COPE self-assessment tool, and provided with 
transportation for EPI outreach (one motorcycle per HC plus reimbursement of fuel). Since HCs 
were found not to be providing regular immunization outreach services to remote villages, PFD 
is providing per diem for EPI in cases where the distance and travel requirements legitimately
exceeds the single flat rate available from the MOH. PFD is in the process of procuring
kerosene refrigerators for all HCs, which currently have to travel to the OD to collect vaccine.
Training in “MPA Module 10” (an MOH course for HC staff on nutrition counseling and growth 
monitoring) will be supported as soon as revisions to that module are completed. 
No assistance is provided at present to the Referral Hospital and the current level of PFD
staffing would not permit it, but the need is great as it is the only source of referral for HCs. It is 
hoped that another NGO will obtain funding and start assistance to both the Referral Hospital
and the OD Health Management Team, which is also quite weak. PFD is providing some
assistance to the OD, primarily capacity building in EPI management and supervision, and use 
of the COPE quality-assurance tool, but the level of input is far less than would be necessary to 
bring OD capacities up to the level necessary for effective management of the OD health
system.
Hearth Model
The Hearth model has been introduced in 2 villages, both of which are in their second round of 
NERPs. One of these two was visited by the Team on the third day of the second NERP round. 
In that village, 1/3 of the children had been identified initially as moderately or severely
malnourished (weight for age) and enrolled in the first NERP which by all accounts went very
well. Mothers, VHVs, PFD staff and even commune officials were enthusiastic about the
initiative ,and mothers appear to have internalized the lessons learned, including messages
contrary to pre-existing traditional beliefs. Staff reported that “when we first started preparing the 
porridge and added trakouen (an indigenous leafy green vegetable) and fish, the mothers’ eyes 
got wide and frightened because they had always heard it is dangerous for small children. But 
after they saw the children eat it with no problem they relaxed, and by the second day they
helped to make it. Now they feed it to their children regularly”. Several mothers and VHVs
emphasized that the villagers were convinced of the validity of the educational messages
because they could see a difference in the children with their own eyes. Mothers were very
eager to weigh their children (one had even gone into the marketplace to use a vegetable scale 
in between the NERP rounds) and discussed the amount of weight gained. Although a few
mothers were resistant to bringing the children to NERP during round one, they joined after
seeing the others attend and by the second round there was no significant resistance
16
encountered; indeed, the staff had problems with mothers begging for admission for children
above the cut-off weight for age. The growth monitoring conducted prior to the start of the
second round found no new cases of malnutrition in the village, and 6 out if 11 children
previously identified were now above the cut-off point for moderate/severe malnutrition.
It remains to be seen how long NERPs need to be conducted in a village before levels of
malnutrition drop to an acceptable point and whether that is sustained after NERPs cease. The 
model plans to institutionalize growth monitoring within the villages so that mothers are able to 
assess their children’s nutritional status on their own, armed with the nutritional knowledge
provided during the NERPs. The answer to both questions is likely to vary greatly by village.
The village cited above was quite small in size with fully a third of the children under 3 reached 
by the first NERP, allowing for a very rapid saturation with educational messages. Larger
villages would likely take a much longer time, as may inland villages where levels of education 
and speed of comprehension of new information are markedly lower.
The great strength of the Hearth model is that it is built around healthful existing indigenous
practices, identified through a positive deviance inquiry, utilizes food resources available in the 
village, and provides intensive education tailored specifically to local practices and locally
available foods. However, these same factors make it extremely labor intensive, since every
single village has to be separately assessed in terms of beliefs, behaviors and food resources.
Training of drug sellers
The NCCSP trained 156 drug sellers in the OD on use of ORS and assisted in establishing a 
supply source of them. In the 11 villages visited by the team, ORS was found to be available in 
all drug stores and drug stalls. However, it was unavailable in cases where there was either no 
drug store or only a vendor of multiple products with a few medicines among them. In general, 
these were the inland villages. Drug stores reported that the ORS packets sold well, and the
packets seen looked new, suggesting rapid turnaround of stock.
The possibility of having VHVs sell ORS has been explored by PFD but met with difficulty due to 
lack of government policy on the selling of government supplied ORS outside of health facilities. 
There is, however, an explicit government policy that permits this with contraceptives on a cost￾sharing basis, so a precedent exists. Alternatively, non-government sources of ORS could be
sold.
Iron Distribution Pilot
The NCCSP DIP calls for a pilot test of three approaches to iron supplementation for women of 
reproductive age and children, in collaboration with the MOH, WHO and HKI. This activity has
not yet begun due to the need to first develop national guidelines for iron supplementation and 
to locate an appropriate formulation. It is scheduled to start in 2003. It is unclear whether the 
iron formulation, being identified by HKI, will also include folic acid, an important consideration 
given the contribution of malaria to anemia in this population.
Constraints and Unmet Needs
Most VHVs raised the issue of incentive either directly or indirectly, making it clear that they
understood they were volunteers and did not expect a salary, but did need, in the words of one 
VHV, “need some little incentive to feel able to carry on”. This issue was also uniformly raised 
by HC Supervisors and PFD national staff, and there is a general consensus that the currently 
17
satisfactory level of performance will not be sustainable over the long haul unless some tangible 
incentive is introduced. The amount of incentive needed does not appear to be high – for
example, many VHVs expressed envy of the Reproductive Health social marketing agents,
whose average profit is only about US $1-2 dollars per month. The possibility of having VHVs 
also serve as social marketing agents for various health commodities was raised with each
Supervisor, PFD staff, some VHVs, the OD and the PHD and received a favorable response
except for one Supervisor who was doubtful that it would be viable in her specific catchment
area due to the large number of markets and goods already readily available (riverine area). 
Aside from incentives, all VHVs and Supervisors expressed a desire for further VHV training. 
While many mentioned “refresher training”, only a minority of VHVs – most of them in remote 
inland villages -- actually seem to need a detailed review of the existing material, while the
others were seeking a chance to come together with other VHVs and PFD, share experiences 
and generally get a morale boost. All VHVs and their Supervisors were interested in expanding 
the range of VHV interventions, with the most frequently mentioned requests being ARI,
dengue, malaria, safe motherhood, typhoid, general fever management, and scabies/other skin 
infections. It is noteworthy that these closely conform to the causes of death identified in the
verbal autopsy data (see Annex IV) and that village chiefs, mothers in the village, and HC staff 
cited the exact same topics as being health priorities.
VHVs in areas where the HCs are weak expressed problems in referring people and indicated 
that they are “blamed” by villagers if they refer them to the HC and it turns out to be unstaffed or 
otherwise unacceptable. PFD has recently begun working with these Health Centers through
on-the-job training, collaborative supervision with the OD Managers, and coaching. Formal
training in IMCI and intensive follow-up is planned. Based on the experience in those HCs
already functioning at an acceptable level, the combination of HC strengthening and VHV
referrals can be expected to produce improved utilization in these HCs once the former is
achieved. 
While the VHVs have greatly facilitated immunization outreach, there are still supply-side 
problems in some villages due to failure of the HC staff to conduct outreach as scheduled. This 
problem was cited in the more remote inland villages, some of which are as much as 30km
away from the HC and complained of no outreach at all for months at a time, or failure of the HC 
staff to show up as promised, thereby damaging the VHV’s credibility and making it harder to
mobilize people in the future. One reason for poor outreach coverage in remote areas is that
the MOH provides a single flat rate per diem for outreach (funded by UNICEF) irregardless of 
distance or actual travel costs. As a result, there is a clear economic incentive to conduct
outreach in villages that are inexpensive to reach and a disincentive – indeed, a financial loss in 
some cases – for conducting it where travel is difficult and costly. Recognizing this problem,
PFD has recently begun supporting per diem for immunization team travel to remote areas
where the government per diem is inadequate. In addition, PFD is in the process of acquiring
cold chain equipment (funded by a grant from the Japan Fund) for each HC, which will eliminate 
the time-consuming process of getting vaccines from the OD on the day of immunization.
As previously noted, there are problems with the VHV record-keeping system and a need to
improve and streamline it so that there is no duplication and information is entered only once, at 
the time it is obtained, rather than on one paper and subsequently transferred to another with 
the room for error this creates. In addition, VHVs need more training and Supervisor 
reinforcement in the use of the register as a tool for targeting households and planning
activities, and a special effort is needed to capture information on 2002 deaths before it is
forgotten.
18
HCs provide only outpatient care and cannot handle obstetric emergencies; in fact, they have 
little capacity to perform even normal deliveries due to lack of 24 hour midwifery staff and
inpatient beds. There is a very pressing need to strengthen both the technical capacity of
Referral Hospital staff and overall hospital management, with particular attention to obstetrics
and inpatient pediatric care. Pneumonia, dengue hemorrhagic fever (DHF), malaria,
meningitis/encephalitis, and typhoid together account for over half of all under5 mortality in the 
Program area, and are not easily managed on an outpatient basis. Community level
interventions can reduce the prevalence of some, but not all, of these problems and there is
simply no getting around the need to have a first line of referral with inpatient capacity. Villagers 
and village leaders interviewed by the Team where quite vocal in complaining about the
hospital, particularly with reference to the recent outbreak of DHF.
As noted in table 2 (page 10), training of TBAs has not yet begun. The planned content has 
expanded beyond the initial focus on breast-feeding to also include safe motherhood and
immediate care of the newborn. Maternal and child mortality data (see Annex IV) for the
Program area testify to the urgent need for this. Peri-natal factors are the 2
nd leading cause of 
death in Chhlong OD, and many of the verbal autopsy forms indicated that the baby was
cyanotic from birth. Cambodian TBAs do not customarily clear the airway of newborn infants,
and even trained midwives are often observed to neglect this simple but life-saving measure.
To date, Program health education has been confined to VHV sessions with mothers, although 
the DIP includes plans for broader community health education using such approaches as
drama and puppet shows. VHV education appears to work quite well in reaching mothers, but 
there are several areas in which a broader audience needs to be reached in order to effect the 
necessary behavioral change. Most of these fall into the general category of environmental
sanitation, e.g:
· the relationship between stagnant water, uncovered water jars, and DHF (requiring
community action to promote drainage around houses and in the markets);
· the role of flies in disease transmission (typhoid, dysentery, diarrhea) and measures to both 
decrease fly proliferation and protect food from contamination; and,
· the value of sanitary latrines and inexpensive means of constructing them.
Iodine deficiency is highly endemic in the area. Although the VHVs have been taught to promote 
iodized salt, it is not universally available and costs more than regular salt, with the result that
this message is probably having little effect. Supply-side interventions to assure the availability 
of affordable iodized salt are needed.
C. Assessment of Program Management
1. Program Structure 
The Program began with a flat organizational structure: one expatriate Program Co-ordinator 
assisted by initially six Cambodian Child Survival Program Officers, subsequently increased to
eight, plus a VSO nurse volunteer who is assisted by two Cambodian staff and works on
strengthening of the health system. Recently, one of the Program Officers has been promoted 
to Team Leader, creating a more tiered structure and manageable span of control for the
19
Program Co-Ordinator. The recently appointed Team Leader has exceptional technical,
programmatic and leadership skills and a high level of commitment. His retention and continued 
professional development will be extremely important, as the presence of a core of highly
skilled national staff is critical not only to the success of the NCCSP but to PFD as an
organization. 
The UNFPA/MOH-funded RH Program operates parallel to the Child Survival Program, with a 
designated Team Leader and two staff. This arrangement, while making it easy to separate out 
staff costs by donor, does not facilitate an integrated approach to maternal and child health nor 
make most efficient use of staff time, since two separate cadres of staff undertake time￾consuming travel to the same villages and oversee interventions that both target women of
reproductive age.
The Program Co-Ordinator is based fulltime in Chhlong, supervised and supported by a Phnom￾Penh based expatriate Health Program Manager who spends 50% of her time back-stopping 
the Child Survival Program. Above the Health Program Manager is the Country Representative, 
who also helps support the Program, particularly on administrative issues and in dealings with 
external agencies. 
This staffing configuration provides adequate technical and administrative oversight for the
Program. The Phnom Penh-based Health Program Manager may need a fulltime assistant as 
PFD has recently received a new health grant from USAID/Cambodia and is expanding into
other parts of the country. Likewise, the Chhlong-based Child Survival Team Leader may need 
an assistant in the future as he is directly managing a large number of staff (7).
2. Staff Development
PFD has made a number of investments in developing the capacity of its local personnel , who 
make up the majority of the staff and are the direct implementers. PFD National Staff received 
training on IEC, focus groups, Vitamin A, computer skills, quantitative survey methodology, adult 
learning techniques, the COPE HC improvement tool, and monitoring and evaluation. PFD staff 
also received the same training as HC VHV supervisors on immunization, diarrhea, nutrition and 
breast-feeding.
In addition to formal training, on-the-job mentoring is provided by the Program Co-Ordinator and 
VSO nurse. The majority of local staff described the management style as facilitative and
supportive, and morale is quite high. One factor which has greatly helped in that regard is an
unusual level of camaraderie and affection among the staff, who share communal housing, and 
actively socialize together. (“Child Survival staff love each other” was the way one local
employee put it.) This esprit de corps has facilitated the rapid transfer of skills and attitudes to 
newer staff. All staff interviewed, including several with the Program six months or less and
coming from a non-community based background, clearly articulated an understanding of the
principles of community organization and community participation. When asked how working for 
PFD compared to working with other NGOs (for those staff with prior NGO health experience), 
responses included:
· “it works from the community level up, not top down”
· “the purpose and activities are very clear, very focused”
· “before this, I never knew what was going in the communities”.
20
Staff expressed the feeling that working collaboratively with communities takes more time but is 
more satisfying than conventional approaches: “they (PFD) get the idea from the community
rather than imposing it”. Staff with the Program during the entry level phase had the opportunity 
to learn and conduct participatory rural appraisals, but newcomers have not received training 
on community organization. Rather, they appear to have picked up the idea and philosophy
from the others, a method which works well now due to the currently high level of staff cohesion 
and socialization, but which might not if the interpersonal dynamics of the team change.
Most staff felt that they were actively involved indecision-making (“in PFD, staff can think for
themselves and plan and solve problems”). A small minority of staff, who appeared shyer in
temperament, indicated that they felt their ideas were not actively solicited by management.
Workloads are described as manageable, another factor contributing to good morale (“some
days we are extremely busy but other days are slower, so it is all right”). Although staff have
received training in a number of areas, formally and informally, all expressed the need for
further training specifically in the areas of management skills and supervision, appropriate since 
much of their time is spent overseeing the supervisory work of others.
3. Collaboration with Other Organizations
True to its name, PFD has actively pursued partnerships and collaborations with government, 
other NGOs, and International Organizations and made skillful use of same in implementation of 
the Program. PFD has also actively sought other donor funding to leverage USAID resources
with funding for complementary or expanded Program activities.
Government
PFD has official Memorandums of Understanding (MOU) with both Chhlong Operational District 
(OD) and Kratie Provincial Health Department (PHD) and is in daily contact with the OD and
more than weekly contact with the PHD. A Child Survival Coordinating Committee consisting of 
PFD staff, key OD staff and representatives from the PHD has been established to help oversee 
the Program and also discuss and resolve health system issues impacting on child health. Both 
the OD and the PHD expressed satisfaction with the Program and the working relationship in
discussions with the Team, and the PHD has requested expansion of the activities to the other 
OD of the Province.
PFD is an active participant in the MOH IMCI Working Group, and has also worked closely with 
the MOH National Malaria Center and National Center for Maternal and Child Health on
technical issues. PFD played a major role in development of the new national malaria strategy.
International Organizations
PFD works closely with the World Health Organization (WHO) in regard to the IMCI pilot and
shares information and seeks technical input from the WHO Malaria Advisor. PFD works closely 
with UNFPA on reproductive health issues, and received EC funding through them for the RH
Program in Chhlong. PFD has extensively discussed with UNICEF issues related to the national 
immunization Program and iodized salt distribution.
21
NGOs
PFD has a formal Memorandum of Understanding (MOU) with Helen Keller International (HKI) 
and the two agencies have partnered in a number of activities. PFD and HKI collaboratively 
assisted the OD with twice-yearly VAC distribution campaigns. HKI has assisted PFD in
establishing Village Model Gardens in many communities to complement PFD’s nutrition
education efforts. PFD uses an HKI-developed flipchart for VHV nutrition and breastfeeding 
education. HKI trainers assisted PFD in training of PFD and OD staff on Vitamin A..
PFD has obtained advice and assistance from the Reproductive and Child Health Association 
(RACHA) in liaison with, and training of, private drug sellers. The questionnaire used by PFD 
for the Health Center Resource Survey was developed through modification of a survey
instrument provided by RACHA. 
PFD and OD staff received TOT on the use of the COPE quality assurance tool for HCs from 
RACHA and CARE, and both organizations have provided guidance on its introduction.
Staff from the local NGO Khmer Students Association were utilized to provide computer training 
for PFD staff. 
PSI has partnered with Population Services International (PSI) in submission of a proposal for 
malaria social marketing to the Global Fund, with the approval of the MOH and the Global Fund 
Country Coordinating Mechanism.
PFD is an active member of Medicam, the official forum for NGOs active in the health sector in 
Cambodia.
Donors
PFD has a long-standing relationship with the USAID/Cambodia Mission and has received
grants from them for health activities since 1996. PFD has taken an active role in assisting
USAID’s collaborative development of a new HIV/MCH strategy and monitoring and evaluation 
system.
PFD has successfully secured matching funding for the Child Survival Program from the
Japanese Embassy (cold chain and other HC equipment), the EC and CIDA. PFD has also
obtained volunteer staff from the British Voluntary Service Overseas organization for two
consecutive terms, providing a nurse to assist with strengthening of the health system.
PFD has obtained funding for a community based vector control Program from the Australian 
Agency for International Development ( AUSAID), and funding from the EC for malaria activities 
(including the cost of construction of two health posts in the malaria endemic area of Snuol, and 
support for Foundation Training for Health Centers). EC funding has also been obtained
indirectly through UNFPA for reproductive health activities (HIV/AIDs education and social
marketing of contraceptives).
Recently, PFD has received funding from the World Bank for a study of health practices and
access to services by ethnic minorities in Kratie Province, information which will both be used by 
22
the World Bank in development of its strategy for ethnic minorities, and be useful to PFD in
refining approaches strategies within the Child Survival Program area.
4. Use of Technical Assistance
As noted above, PFD has made skillful use of in-country expertise through collaborations with 
other organizations (and has returned the favor by sharing materials and lessons learned). In
addition, formal external assistance has been utilized for the following:
· development of the Hearth Model and training of staff in its implementation
· staff training in the LQAS methodology
· monitoring and evaluation and development of a sustainability plan
· a study of health beliefs, practices and barriers to health care among ethnic minorities in 
Kratie
· the mid-term evaluation
PFD has also availed itself of the TA available from USAID/Washington’s Child Survival
Technical Services (CSTS) with regard to survey methodology and IMCI.
Future TA will be needed for refinement of the verbal autopsy form and training of PFD staff in 
conducting verbal autopsies and analyzing the information, and for help in piloting the
introduction of social marketing by VHVs. The latter might be obtainable through partnership
with PSI; if not, an external consultant may be necessary as the logistical aspects of a new
social marketing initiative are considerable. 
D. Assessment of Program Impact
The foregoing observations are qualitative, based on information gathered from VHVs,
Supervisors, villagers, community leaders, and PFD staff, and direct observations in the field.
Augmenting this is quantitative data from a repeat survey done by PFD in January of 2002 to
assess changes in baseline indicators as documented in the baseline survey done during the
two year entry level grant. Since the nutrition and breast-feeding interventions were not
introduced until the first half of 2002, the mid-term survey is limited to diarrhea and
immunization. However, the Team found clear indications in the field that VHVs are conducting 
education on nutrition and breast-feeding with at least as much intensity as the other
intervention areas, and that mothers are retaining and acting on these messages. The progress 
demonstrated in immunization and diarrhea in the January 2002 survey (at which point VHVs 
had been active in immunization for 8, and diarrhea for 4 months) is therefore likely to be
indicative of that which will be achieved in nutrition and breast-feeding. 
Table 3 below compares data on key indicators from the baseline survey to that of the January 
2002 survey. The baseline survey was a 30 cluster sample. The January 2002 survey was a 
Lot Quality Assurance Sample (LQAS) in which an equal number of randomly selected
households was interviewed for each HC catchment (VHV Supervision) area, This yields
average estimates per HC catchment area, which is not the same as the average for the
population, since HC catchment areas vary greatly in population size. The baseline survey
provides estimates for the population as a whole. In order to render these two data sets
comparable, the raw data from the LQAS was weighted proportionate to the population of each 
23
“lot” (HC catchment area). Although such weighting increases the sampling error, all indicators 
underwent change of sufficient magnitude to be statistically significant.
It should be noted that the diarrhea indicators at baseline were collected on children ages 0-24 
months while the repeat survey took only children aged 12-24 months. The Team was unable to 
obtain the raw data from the 1999 baseline to disaggregate the 12-24 month-olds. It is
impossible to say whether doing so would increase or decrease the change which has occurred 
in maternal knowledge and behavior. However, the magnitude of change is so great that there 
would still clearly be a sizable improvement.
Table 3: Comparison of Baseline and Mid-term Household Survey data
DIARRHEAL DISEASE INDICATORS 1999 Jan. 2002 CHANGE
1. Breastfed child more than usual during diarrhea 21% 51% 145%
2. Provided more fluids than usual during child's diarrhea 34% 78% 129%
3. Provided more or same amount of food during child's diarrhea 47% 76% 62%
4. ORT Use during diarrhea (ORS, sugar/salt solution, home fluids) 15% 41% 171%
5. Mother can describe correct management of diarrhea (fluids, feeding, 
referral) 42% 80% 90%
6. Mother has heard of ORS 3% 94% 3369%
8. Mother knows danger signs in diarrhea (when to take child to 
HC/hospital) 45% 81% 81%
9. Mother knows to feed child more when recovering from diarrhea 17% 72% 326%
IMMUNIZATION INDICATORS 1999 Jan. 2002 CHANGE
1. Child Has Immunization Card 32% 87% 170%
2. Child Fully Immunized (Among Children With a Card) 44% 73% 65%
3. Child Fully Immunized (Out of All Children Total, Immunized by Card) 14% 63% 347%
4. Mother knows age at which child should receive measles vaccine 10% 39% 301%
5. Mother knows purpose of TT vaccine 25% 52% 109%
6. Mother has maternal health card 21% 76% 255%
As can be seen from the above, an enormous increase in key indicators related to both
immunization and diarrheal disease has occurred since the institution of VHV activities. The
magnitude of change is all the more impressive taking into account that the diarrhea intervention 
had been in place only 4 months and the immunization intervention, only 8. It is also extremely 
impressive compared to nationwide data. At baseline, the Program area had significantly lower 
immunization coverage than the national level of 32% (for immunization with card); it is now
twice as high. Likewise, knowledge of ORS at baseline was only a fraction of the national rural 
average (3% versus 48% for nationwide rural), but is now nearly double it. 
Figures 1 and 2 display the change which has occurred in the Program area between 1999 and 
January 2002 pictorially.
24
Figure 1:
Diarrheal Disease Indicators
21%
51%
34%
78%
47%
76%
15%
41% 42%
80%
3%
94%
45%
81%
17%
72%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1999 Jan. 2002
Survey Dates
Percentage
BF Fluids Feeding ORT Use
Knowledge Knows ORS Danger Signs Feed After
25
Figure 2:
IMMUNIZATION INDICATORS
32%
87%
44%
73%
14%
63%
10%
39%
25%
52%
21%
76%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1999 Jan. 2002
Survey Dates
Percentage
Has Card % with card immunized % Fully Immunized Child
Knows measles Knows TT Has Mat Hlth Card
26
The preceding table and graphs are confined to those indicators for which baseline data was
available for comparison. A number of other indicators were also measured in the January 2002 
survey, for which baseline data is unavailable but Program targets were set. The key ones are 
shown in table 4 below. Since no baseline was available, the data is presented as measured by 
LQAS, that is to say, as the average value per HC catchment area. The experience with
weighting of the indicators for which baseline data was available indicates that the percentage 
for the population as a whole is usually slightly higher than the average per lot, since the HC
catchment areas with the lowest populations also tend to be the lower-performing.
Table 4: Other 2002 Indicators
 (No Baseline Available)
Indicator 2002 Average Value per 
“Lot”
Program Target
Sanitary disposal of child’s 
feces (self-reported)
70% 70%
Hand-washing before eating 
or cooking, after defecation 
(self-reported)
95% 100%
Soap Use in hand-washing 90% 90%
Place in household set aside 
for hand-washing
55% 60%
Presence in the home of 
water, soap/ash, and clean 
cloth
65% 50%
Receipt of VAC in past 6 
months (child 6-59 mos)
90% 90%
Adequate TT protection during
pregnancy7
65% 70%
IV. Discussion and Conclusions
A. Overview
The Northeast Cambodia Child Survival Program has successfully implemented almost all
planned activities, with a few remaining ones in an advanced stage of planning. The Program
will clearly succeed in implementing all activities prior to the end of the grant period except for 
three minor ones which have been deleted due to poor performance in piloting or low priority . In 
addition, the Program will have implemented a significant number of additional interventions
directly related to child survival and responsive to the documented causes of child mortality and 
weaknesses of the health system. 
B. Village Health Volunteers
The primary strategy of empowering and motivating village women to adapt improved health
behaviors through peer education from Village Health Volunteers (VHVs) has proved sound and 
is working well. VHVs are known and active in their communities and both qualitative
 
7
 Defined as receipt of 2 or more TT during pregnancy if not previously immunized, or at least one TT 
during pregnancy if previously immunized.
27
assessments by the Team and quantitative data from a repeat household survey confirm that
they are successful in both increasing knowledge and changing behaviors. Village women and 
community leaders value the Program, as do the staff of health facilities, who have gained
easier and more productive access to the community and better service utilization as a result of 
VHV activities.
Key factors in the success of the NCCSP VHVs are:
· Participatory introduction of the Program and VHV selection: although very time￾consuming and labor intensive, PFD’s strategy of working together with each individual 
village to introduce the concept, build support for it, and select VHVs acceptable to the 
community has paid off significantly. The communities understand the Program and feel 
a sense of ownership over it. The right people (i.e. persons respected and credible in the 
community) are serving in the VHV capacity and community expectations of VHVs are
realistic.
· Manageable workloads: many health volunteer Programs fail due to unrealistic
expectations of the amount of time and effort volunteers can supply. The NCCSP has
one VHV per 50 households; since VHVs work only with mothers of children under five 
or pregnant women, this means an actual workload of about 30-35 families, all living in 
the VHV’s immediate vicinity. This makes it possible for VHVs to fill their role without
undue expenditure of time or adverse effect on their household and agricultural tasks.
· High quality training and appropriate IEC materials: the training provided to trainers and 
VHVs utilized appropriate, participatory adult learning methodologies. Pre and post tests 
were done and additional training provided to low scorers. The IEC materials provided to 
the VHVs are user-friendly pictorial flipcharts showing typical rural Cambodian life and
familiar objects, with no written text on the side facing the mother so that no literacy is 
required.
· Close supervision: VHVs are supervised monthly by staff from the HCs who were
specifically trained in adult training techniques, the technical content areas, and
supervision of VHVs. PFD staff in turn supervise the supervisors, and make occasional 
spot checks or problem-solving visits to VHVs.
Although the VHV Program has been very successful, this should not be grounds for
complacency. Experience worldwide is that it is easier to get a volunteer health program going 
well than it is to sustain it. There is a clear consensus among VHVs, community leaders, VHV 
Supervisors and PFD national staff that something needs to be done to build in a small incentive 
for VHVs if the currently high performance is to continue over the long run. While periodic
meetings, new trainings and the like work in the short-term, they do not provide volunteers with 
a clear sense of what they can expect to receive for their efforts and are also totally dependent 
on continued NGO investment. A better alternative worth exploring would be having VHVs
serve as Social Marketing agents of health commodities. In addition to providing a small
commission, this would strengthen their education messages by ensuring the availability of
items necessary to the behaviors being taught (e.g: soap, iodized salt, ORS). While the setting 
up of a social marketing initiative will be labor intensive for PFD, requiring considerable trial￾and-error to identify commodities with sufficient sale potential, locate suppliers and establish
distribution channels, this could ultimately become a self-sustaining activity.
28
Somewhat related to the incentive issue is the proliferation of different cadres of volunteers in 
the Program villages, often one per vertical intervention. PFD’s Reproductive Health Program,
which includes social marketing of contraceptives and HIV education, runs in parallel to the VHV 
Program, usually with different village-based staff. The Malaria Program created a separate
cadre of village “malaria volunteers” for a one-time bed net distribution (a decision made by the 
MOH, despite PFD recommendations to use the existing VHV network); this has been
particularly contentious since the “malaria volunteers” each received a bicycle, a fact VHVs
often raised in discussions with the Team. While political realities and the need to work
collaboratively with government may not always make it possible, every effort should be made 
to utilize the well-established VHV network to distribute information and commodities rather
than create separate one-time cadres of volunteers for special purposes.
It would also be highly desirable to integrate the NCCSP with PFD’s UNFPA/MOH-funded 
Reproductive Health (RH) Program since it is targeting the same villages and often the same
women. Furthermore, RH volunteers have to opportunity to earn a small income from
contraceptive sales commissions, which VHVs currently lack. It would not be possible for every 
VHV to sell contraceptives since their catchment areas are too small, but at least a few could. 
This is discussed further under Recommendations.
The supervision of VHVs by HC staff is working very well, a somewhat surprising finding given 
that VHVs are community-based and community-selected while HC staff are part of a
government system which often encounters class barriers in its interactions with the general
population. VHV Supervisors are providing tangible assistance as well as less tangible but
important morale boosts to the VHVs, and enjoy the supervision. It has broadened their
awareness of the communities and given them a point of entry wherein they are assured of a
welcome, and an intermediary who can help sort out issues that arise between facility staff and 
villagers. It has also made their work easier to do and increased their own performance in terms 
of HC utilization and immunization coverage. The time required for VHV supervision and
associated paperwork is small and does not seem to adversely affect staff’s ability to carry out
their usual HC tasks. Only 2 staff per HC, spending a couple of afternoons per month, are
required.
There is a need to expand the range of health education topics covered by VHVs to include
others of great health significance. The approach used for the initial modules – gradual
introduction of new material with time in between trainings to practice what was taught – worked 
well and should be retained. In addition, since new material is always more attractive than old, 
each new training should include a review of previous topics and discussion of strategies for
presenting the information on all topics to the communities. 
While most VHVs are well versed in their current material and active, there is a need to address 
the problem of those who are not. It appears from discussions with Supervisors that about 10% 
overall are not active despite Supervisor efforts, and no productive purpose is served by
keeping them in the Program. Removal and replacement of non-functioning VHVs should be
done prior to the introduction of new trainings and incentive measures. VHVs who are
functioning but lacking full understanding of the existing health messages need to be identified 
and provided with more in depth refresher training. 
29
C. Health System Strengthening
Improvements in health status require work at both the demand and supply side. The initial
Program design assumed that another NGO would be building capacity in the HCs, Referral
Hospital and OD Management Team, and in general probably underestimated how weak the
system was. The Program has made appropriate adjustments to provide support to HCs and
this can be expected to improve the situation by the end of the grant period, but the needs of the 
RH and OD Management Team remain largely unmet. As previously mentioned, this situation 
must change if major causes of child mortality are to be addressed. Particularly urgent is the
need for competent, reliably staffed and equipped 24-hour obstetric facilities and an inpatient 
pediatric ward able to provide oxygen, intravenous antibiotic therapy, laboratory diagnostics,
and management of DHF.
D. TBA Training
As has been previously noted, plans for TBA training have expanded to include more than
breastfeeding. This is thoroughly justified given the child and maternal mortality findings for the 
Program area (see Annex IV). However, training on danger signs and referral will have little
relevance until such a time as the health system offers a viable referral point (see above). One 
solution would be a two-phased training, the first commencing in the immediate future and
focused on interventions that are not dependent on the availability of emergency obstetric
interventions (EOI) : breastfeeding promotion, referral for ANC/TT, aseptic technique and use of 
safe birth kits, abstention from harmful practices, and care of the newborn. The latter should
receive heavy emphasis, and TBAs should be supplied with bulb syringes and made to role play 
the clearing of an infant’s airway and wrapping of the newborn. 
A second phase, to be done after basic EOI is available, would involve danger signs in
pregnancy and delivery and referral. To be successful this needs to be accompanied by the
creation of linkages between hospital staff and TBAs, preferably in the form of partnership
arrangements whereby TBAs who refer women are allowed to remain during the labor and
delivery and continue to provide psychological and spiritual support. Aside from financial
considerations (which are very real, since TBAs both cost less and accept credit or payment in 
kind), the psychological and spiritual support provided by TBAs is a key factor in their popularity. 
Cambodian women believe TBAs to possess special powers to reduce labor pain and protect 
the mother, and TBAs are much more versed in nurturing and comfort measures than trained
midwifes. Such partnership arrangements have been piloted elsewhere in Cambodia with
considerable success, most notably in the Sotnikhom “New Deal” project where health facilities 
also share the delivery fee with TBAs. 
E. Program Management and Staff Development
While PFD is in general doing an excellent job of implementing a large Program under difficult 
conditions, implementation could be further enhanced through a restructuring of staff
responsibilities so that each Program Officer has primary responsibility for overseeing all
activities – VHV and health system strengthening, RH activities, and the malaria Program – in a 
specific geographical area. This would save considerable travel time, and will allow for a
comprehensive view of village health activities. Expansion of VHV interventions and introduction 
of social marketing will be labor intensive, making such economies important. Additional
measures which could be taken would be replacing the current level of PFD supervision with
spot audits of HC VHV Supervisor performance in those HC catchment areas with strong VHVs 
and strong Supervisors, freeing up more staff time for the new initiatives.
30
The quality, commitment and high morale of PFD’s national staff have been critical to the
Program’s success. While PFD’s organizational culture and supportive management style make 
a positive contribution to staff morale, it alone cannot create the unusual level of esprit de corps
now present and there is no guarantee it will not change with time due to factors beyond the
organization’s control. It would therefore be wise to provide staff with more formal training in
community organization and Program goals and objectives rather than relying on peer
acculturation. Also, formal training in management skills and supervision would strengthen
staff‘s professional development and ability to gradually assume more of the responsibilities
currently handled by the expatriate Program Co-Ordinator and VSO nurse, freeing up their time 
to address expansion of the Program in scope and, possibly, geographical location since the
success clearly warrants expansion to the rest of the Province, and Provincial authorities are
receptive to it.
While most staff report being able to give input readily, and management is perceived as
facilitative and receptive, individuals vary in their willingness to volunteer opinions and a more
regular system of staff meetings with a concentrate effort to ensure that everyone has a say
would be useful.
As previously noted, PFD has recently promoted one of the national Program Officers to the
position of Team Leader. Over time, there is scope for additional delegation of management
responsibilities to this individual, with the expatriate manager taking on more of an advisory and 
less of a direct administrative role. This transition will need to be made gradually to avoid
overwhelming staff and ensure the needed on-the-job training to develop the requisite skills and 
experience. 
F. Nutrition Interventions
Preliminary results of the Hearth model look very encouraging, but it is a very labor-intensive 
undertaking. It will therefore be very important to have a solid base of data with which to
evaluate its impact, since government and donors are wary of interventions with time￾consuming and complex “software” requirements. This means not only data on improvements in 
nutritional status, which the Program is already poised to collect, but data on mortality impact. 
The VHV network provides a means of recording vital events for the entire population, and this 
should be done with particular care in Hearth villages. Most urgently, mortality data for the year 
preceding the start of the intervention is needed to serve as baseline. This is already available 
from VHV registers and monthly reports but needs to be pulled out for the specific villages and 
re-verified to ensure no deaths were missed, preferably by a house-to-house rapid survey.
Likewise, mortality data since the intervention began should be updated and verified annually. 
Since this will be a surveillance of the entire village, rather than a sample, no sampling error is 
involved and direct estimates can be obtained. The under5 mortality rate for Cambodia is
sufficiently high that two or three villages alone will generate enough deaths to be able to
measure change from year to year. The extent of malnutrition in the areas where Hearth is
being done is so high that a measurable mortality reduction will occur within a few years after 
improvement on nutritional status, if that improvement is significant and sustained. Clear proof 
of mortality reduction is probably what it would require for the broader health community –
government, donors and other NGOs – to scale up the intervention given its complexity and
labor intensity.
31
G. Monitoring and Evaluation
See above with respect to the Hearth pilot. 
The record-keeping system of the VHVs needs to be streamlined and new training provided in 
the use of simplified forms. The recording of deaths needs to be revived through regular
reminders by Supervisors during their monthly visits, and a concentrated effort should be made 
to capture all 2002 deaths (many of which have not yet been recorded) and conduct verbal
autopsies as was done for 2001. The verbal autopsy procedure, however, needs revision as
that previously used collected too little information and was collected by persons other than
those who later conducted the analysis and assignment of probable cause of death. 
At the onset of the Program, VHVs were given a general description of their catchment area and 
told to list all eligible women (mothers of children under 5). There was no formal household
census done to ensure that all houses in the village were covered. A comparison of the total
number of children under five reported by VHVs with the number expected assuming that the
fertility and mortality levels documented in the 1998 census have remained static suggests that 
this initial listing was close to complete, missing no more than 10% of eligible women. Even so, 
with time more omissions are likely to seep in as new families or family members arrive in the 
area. A periodic village census, preferably combined with some other activity that requires
censusing (e.g. mosquito bed net distribution or voter registration) needs to be undertaken
every few years to update VHV registers and ensure complete coverage. 
The Program has done a good job of obtaining and using baseline data, and conducting repeat 
surveys to measure changes. A survey on nutrition and breastfeeding indicators is planned
soon. To enable comparison with the baseline data without weighting, it would be better to
modify the sampling design so that it is a random sample stratified by HC catchment area with 
number of households in each proportional to the catchment area’s population but with the
smallest catchment area including sufficient households to be statistically representative at HC
catchment level. This will produce a self-weighting estimate of indicators for the population as a 
whole plus “lot” specific estimates allowing comparison between supervision areas and
identification of low performers.
In piloting iron distribution by VHVs, the original design in the DIP of three different approaches 
(each of which would require monitoring of changes in hemoglobin level) will be unnecessarily 
labor intensive and a simplified design should be considered. The original plan is to have one 
group receiving free daily supplementation, one receiving free weekly supplementation, and one 
purchasing supplements themselves with VHV promotion. A single dosage plan would be
adequate, and daily dosage is both easier to remember and known to be more effective. 
Testing of free distribution should be undertaken only if there is a reasonable likelihood that
government and donors would be able to support the costs of free mass distribution on a wide 
scale (very improbable). Unless there is reason to think that free mass supplementation is a
possibility, piloting of some type of social marketing approach (possibly with subsidization)
should be considered instead. There is no point in piloting something that has no realistic
potential for scale-up, and the implementation and monitoring/evaluation aspects of one
approach are considerable enough without the exponential increase created by multiple
variants. 
32
H. Sustainability
The NCCSP is better placed for sustainability than most Programs since its primary activity is 
the imparting of new information, skills and behaviors to communities. When successful – as 
these appear to have been – such changes are intrinsically self-sustaining as changed
community attitudes and practices get handed down to subsequent generations. The DIP
contains a list of sustainability objectives which are not contingent on continued support for the 
VHVs, and to date the indicators listed have been met. 
Since the VHV approach has proven so successful, however, it would be highly desirable for it 
to continue beyond the current end date of the grant. It is in theory possible for this to happen 
without PFD, since the VHVs are already linked to, and under the supervision of, the
government health system. However, the government health system would require both greater 
managerial capacities and greater financial resources than it currently possesses to be able to 
sustain the VHV Program.
Cambodia is unique in that its public health system is less than a decade old. Prior to the
warfare which engulfed the country from 1970 – 1993, there had never been a functioning public 
health system in the rural areas, and what human resources and facilities did exist were
completely obliterated during the Khmer Rouge genocide. The Ministry of Health had virtually no 
trained managers, and controlled no budget, prior to 1993. The country completely missed out 
on the developments in primary health care which swept through the rest of the world in the
1970’s-1990’s. It is therefore hardly surprising that Chhlong OD is far from capable of carrying 
out its current functions adequately, let alone undertaking new ones, and that both the level of 
government budget allocations to the health sector and the effectiveness of budget
disbursement to the periphery are inadequate for basic service delivery. 
This should not be cause for pessimism, however, as the Cambodian health system is
extremely new and steadily improving. Enormous progress has been made in less than a
decade in creating a functional Ministry and the basic framework of a national health system
from a near-zero base. Reform efforts are underway with regard to both capacity building and 
increased resources/ financial accountability. Looking back at the progress that the government 
health system has made in less than a decade, there is every reason to expect that it will
eventually reach a point wherein these problems have been satisfactorily addressed and the
system is capable of assuming management of initiatives such as the VHV Program. This will, 
however, take time – realistically, not less than 5, and possibly as much as 10, years. Continued 
USAID support beyond the current end date of the grant will not only allow activities which are 
having a demonstrable impact on child health to continue, but help ensure permanent returns on 
the investment by supporting the Program until the health system is sufficiently developed to
take it over. 
The best contribution PFD can make to Program sustainability is to continue its efforts to
strengthen the health system, and to create incentive mechanisms for VHVs that are ultimately 
self-sustaining through normal market forces (i.e. social marketing). 
The sustainability of health system strengthening interventions is in a similar situation.
Improvements in staff technical skills, attitudes and procedures are inherently sustainable once 
internalized, but only if the system as a whole provides adequate resources in the form of a
living wage and adequate operating budget, and effectively monitors and supervises the sector. 
None of these conditions yet exist, but there is progress towards them.
33
V. Recommendations
A. Overall Recommendations
1. The Program should continue and expand, resources permitting, to the other OD of 
Kratie Province so that the entire Province is covered. 
2. The basic structure of VHV selection by communities, one VHV per 50 households and 
supervision of VHVs by HC staff should continue. 
3. USAID should fund an extension of the Program after the scheduled end date of the
grant in March 2004 in order to allow activities which are having a demonstrable impact 
on child health to continue, and help ensure permanent returns on its investment by
supporting the Program until the health system is sufficiently developed to take it over.
B. VHV Activities
1. Non-performing VHVs (approximately 10% of the total) should be identified and
replaced, and training provided to the replacements.
2. Special remedial refresher training should be provided to the minority of VHVs who do
not have a firm grasp of their material. This will need to be preceded by a screening
process, since only some VHVs need this training, and among those who do, it will not 
always be in the same intervention areas. One approach would be to test VHVs at a time 
when they have come together for another purpose (e.g. for training in a new
intervention) in order to identify the number of trainees and subjects needed.
3. Periodic village censuses (every 1-2 years) should be conducted and VHV registers 
updated accordingly to ensure that all eligible families are covered by the Program.
4. The VHV register should be revised to contain only mother/caretakers name, child’s
name, pregnancies, births, deaths, immunization status and contacts in that year. The
latter should consist of a simple tick mark made every time the VHV imparts health
education to the mother, regardless of whether in a group or individually.
5. The VHV monthly report form should be revised to simply list activity by type (individual 
education, group education, referral) with tick marks, and VHVs trained to make a tick 
mark in the appropriate box and on the register “contact” column immediately after each 
activity.
6. VHVs should be trained in additional interventions. These should be phased in one at a 
time, with 1-2 months in between new trainings to allow practical experience before
going on to new material. Suggested new interventions, in order of priority, are:
34
Intervention Comments
ARI Need to also train drug sellers.
Emphasize: distinguishing between simple colds and LRTI; danger 
signs and referral; importance of a complete course of antibiotics
Pregnancy and Delivery Might possibly be combined with TBA training, using HC midwives as 
trainers.
Emphasize: nutrition during pregnancy and lactation, importance of 
ANC and TT, danger signs during pregnancy, use of safe birth kits, 
danger signs during delivery and post-partum, immediate initiation of 
breastfeeding, and newborn care
Dengue and Malaria Emphasize cause and prevention: bed nets, “baby nets” for infants and 
children in the day time; mosquito coils, covering/treatment of water 
jars, drainage to remove stagnant water, importance of following full 
course of MOH-approved malaria treatment, signs if malaria and DHF 
and need for prompt medical care.
Dysentery and Typhoid Emphasize cause (poor hygiene, flies, improper food handling and 
preparation) and prevention: environmental sanitation, hand-washing, 
use of plastic or net covers to protect food from flies, exclusive 
breastfeeding for infants under 5 months
Skin Infections Emphasize cause and treatment of scabies; danger of wound infection 
and appropriate home management of simple cuts; signs of wound 
infection requiring medical care; home management of simple sashes 
(keep dry/gentian violet/HC if not improved)
Iodine Deficiency 
Disease
Teach only in accompaniment with a subsidized social marketing 
campaign.
Although IDD has been mentioned in VHV training on nutrition, the 
complexity of the problem and need to convince people of the value of 
iodized salt warrant a separate training and flip chart.
Child Safety Emphasize prevention of drowning, falls, vehicular accidents, and 
poisonings. Target older siblings (especially girls) as well as mothers
7. VHVs who are interested should be assisted to become social marketing agents of
health commodities in order to provide a small financial incentive with long term potential 
for sustainability while also increasing access to, and use of, desirable products. Since 
this will be labor intensive to establish and there is no way of knowing in advance which 
commodities will sell, this should be piloted first, a few commodities at a time, in a
random sampling of villages (both riverine and inland). Commodities should be clearly
linked to health education messages and VHVs reminded that the health education is to 
be provided to everyone in the catchment area, regardless of whether they wish to
purchase commodities. Possible commodities are:
35
Commodity Associated Health Education Comments
Iodized salt IDD, nutrition Price will need to be subsidized
ORS Diarrhea Discussions with MOH needed to 
develop policy for sale of MOH 
packets; otherwise, locate non￾MOH supply source
soap Diarrhea, dysentery/typhoid
nailbrushes Diarrhea, dysentery/typhoid
food covers Diarrhea, dysentery/typhoid Ready-made plastic, or VHVs 
could be taught to make out of 
used bed nets and bamboo
impregnated mosquito 
nets
Malaria Bed and hammock nets
“baby” nets for 
infants/small children
Malaria/dengue VHVs could be taught to make 
these from used mosquito netting 
and bamboo. Design so that can 
nets can be used on both flat 
surfaces and hammocks.
mosquito coils, repellent Malaria and dengue
PSI malaria kits Malaria Villages without drug sellers
water jar covers Dengue New water permeable ones are 
available from the national 
Program
larvicide Dengue
safe birth kits, iron Pregnancy and delivery
Iron/folate Pregnancy and delivery
scabies soap/scabicide Scabies/skin infections
povidone iodine , gauze 
or swabs
Wound care
gentian violet and swabs Skin infections
C. Health System Strengthening
1. If other NGO assistance for the Referral Hospital does not materialize, PFD should seek 
the necessary funds and staff to provide this. At least one expatriate manager and two 
experienced local clinicians (one of them a secondary midwife) would be needed.
2. Planned training of midwives in HCs should go forward, but serious consideration should 
also be given to inclusion of hospital midwives.
3. PFD should explore alternatives to HC staff travel to villages for immunization by piloting 
means of subsidized transport to bring villagers to the HC on specific das of the month 
per village, using locally appropriate means of transport: ox-cart, motorcycle cart, boat 
etc. Provision of means of transportation to a villager selected by the community in
exchange for providing this transportation on specified days (in lieu of payment) might be 
considered.
36
4. The present VSO nurse position is essential and should be retained. Consideration
should be given to changing it to a salaried position in the interests of continuity since
the incumbent will complete a three year volunteer stint in April.
5. PFD should continue to advocate with the PHD for allocation of additional staff to
Damrei Pong HC and consider assisting in provision of relocation costs or housing if a
potential transfer can be identified.
6. PFD should work actively with the PHD and central MOH to ensure that the conditions in 
Snuol HC catchment area are addressed in the forthcoming revision of the Health
Coverage Plan.
7. PFD should pursue the possibility of a World Bank-funded equity fund for the hospital
(planned in the next WB Project with locations not yet determined).
D. TBA Training
1. TBA training should be undertaken as soon as possible in interventions that do not
require availability of emergency obstetric care, with particular attention to immediate
care of the newborn to establish a patent airway and prevent hypothermia,
hypoglycemia.
2. If and when emergency obstetric care is available, specific referral and partnership 
mechanisms linking TBAs with the hospital should be developed, including 
arrangements which allow the TBA to maintain a (non-medical) role during the hospital 
delivery
E. Program Management
1. Integration of the RH and VHV volunteer functions should be promoted through utilizing 
VHVs whenever new or replacement RH workers are needed and vice versa.
2. Program management should be integrated so that each PFD Program Officer monitors 
and supervises all activities in a geographical area: RH, VHV education, malaria.
3. PFD national staff should receive training in supervisory techniques and management
skills, preferably provided at the work site, and there should be a gradual devolution of
management responsibilities to national staff over the remainder of the grant period, so 
that by the end of the current grant the expatriate functions in a primarily advisory
capacity
F. Monitoring and Evaluation
1. Supervisors should be instructed to review all deaths in the past year with their VHVs 
and ensure they are recorded on the register, and continue to ask about deaths on a 
regular basis.
37
2. Verbal autopsy for maternal and child deaths should be conducted annually after
compilation of mortality statistics from VHVs. However, the current should be
substantially revised to ascertain the exact age at death and include detailed questions 
appropriate to each age group (neonatal, post-neonatal and child). Immunization status 
should be included along with duration and severity of symptoms and temporal
relationship of each symptom mentioned to death. Diarrhea should be described in
terms of quantity, duration and type (watery, mucoid etc). Presence of chills with fever, 
cough, and any type of skin lesion should be specifically probed. Verbal autopsy forms
should be completed by the same staff who will conduct the analysis and assignment of 
cause of death. These need to be experienced clinicians and expatriate TA will be
required, either from the VSO nurse or a consultant.
3. In Hearth villages, growth monitoring should be continued after the end of NERPS
throughout the grant period and careful records kept of anthropometrical data. In
addition, mortality data should be maintained specific to those villages, based on VHV
registers with a rapid house-to-house survey for verification. Baseline data should be
constructed in the same fashion using VHV registers from May 2001 – April 2002,
verified by household survey. 
4. Future household surveys should be done as a random sample stratified by HC
catchment area with number of households in each proportional to the population but 
including sufficient households to be statistically representative at HC catchment level.
This will produce a self-weighting estimate of indicators for the population as a whole
plus “lot” specific estimates allowing comparison between supervision areas and
identification of low performers.
G. Other:
1. Community health education should be conducted using techniques such as drama or
puppet shows on topics that require a broad community response to address, e.g.
environmental sanitation issues. Entertainment should be followed by group discussion 
and analysis of the village situation, perhaps using videos or photographs of households 
and market areas, followed by an action plan to rectify identified problems.
2. The PFD Water and Sanitation Program should shift emphasis in Chhlong from water to 
sanitation, in order to reduce the incidence of dysentery and typhoid, which between
them account for almost 10% of under5 deaths. 
3. The planned iron distribution pilot should (a) use an iron/folate preparation rather than
iron alone, given the contribution of malaria to anemia in this population; (b) be limited 
to approaches with a realistic potential for scale up if successful; and (c) keep the
design as simple as possible, preferably just one intervention which could be revised if
needed based on experience rather than multiple approaches.
38
Annex I: Scope of Work
PARTNERS FOR DEVELOPMENT
United States: 1320 Fenwick Lane, Suite 406, Silver Spring, MD 20910
Tel: 301-608 -0426, Fax: 301-608-0822, E-Mail: pfdinfo@partnersfordevelopment.org
Cambodia: No. 24, Street 294, BP 551, Phnom Penh, Kingdom of Cambodia
Tel./Fax: 855-23-213-335, E-Mail: PFD.Cambodia@ BigPond.com.kh
Location: Chhlong OD, Kratie Province.
Duration: September 2002. (LOE: 15 working days)
Supervisor: Country Representative/Program Manager for Health.
I SUMMARY 
Northeast Cambodia Child Survival Program (NCCSP)
Goal: To improve the health of children less than five years old in Chhlong OD, by focusing on 
control of diarrheal disease, immunization, nutrition and micronutrients, and promotion of 
breastfeeding.
In 1998, PFD expanded its focus on health interventions in Kratie, with implementation of a
USAID-funded Child Survival Program in the Chhlong Operational District, with a total
population of 129,000 covering a target population of 14,500 children under five and 27,000
women. This coverage accounts for 48% coverage of the target population of Kratie Province. 
The aim of the Child Survival Program is to improve the health of children under five years
through a three-pronged approach – by educating mothers on improved care-taking and
preventive behaviors; by training health center staff on the treatment and management of
childhood illnesses; and by building capacity of the operational district managers, to plan and
implement health center and outreach activities. The Child Survival Program's key interventions 
focus on immunization, control of diarrheal disease, nutrition, and breastfeeding. The Program 
is funded to March 2004 by USAID Global Health Bureau in Washington DC.
The CS Program is coordinated by a full-time expatriate coordinator based in Chhlong OD, with 
a current staff complement of 1 VSO Public Health Advisor, 10 Program officers and 2
administrative staff. 
Historically, (PFD) implemented its two-year entry-level Child Survival Program, the Northeast 
Cambodia Child Survival Program (NCCSP), from October 1, 1998 to September 30, 2000. The 
accomplishments and constraints of the first year of the Program are described in the annual 
report, submitted in October 1999 to USAID.
During the second year of the entry grant, PFD focused its efforts on finalizing Program 
planning, consolidating partnerships, and conducting the community organizing work needed to 
implement the 42-month Child Survival Program, that succeeds the entry grant. 
39
In October 2001, PFD commenced Phase 1, for full implementation of the Child Survival
Program. The Detailed Implementation Plan outlines the overall framework for the full CS
Program while also detailing the annual workplan and timeframes proposed. The Annual Report 
for Phase 1 (Oct 2000- September 2001) describes the achievements and lessons learned to
date. 
Northeast Cambodia Reproductive Health Program
Goal : to improve the health status of men and women in Chhlong OD by increasing access to 
and availability of high quality reproductive health education and services at community level, 
and by reinforcing linkages between the community and the district health system. 
To complement PFD's Child Survival Program and to address the reproductive health needs
expressed by community members during PRA activities, PFD initiated the Northeast Cambodia 
Reproductive Health Program (NCRHP) in Chhlong Operational District in April 1999. NCRHP 
started as a two-year CBD pilot Program funded by UNFPA to serve as an operations research 
tool for Ministry of Health. The CBD project is implemented in collaboration with health centers 
in the catchment areas, whereby HC staff serve as trainers and supervisors for the Program. 
The aim is to develop the capacity of health center midwives and operational district staff to
implement and manage the Program in the longer term. 
The Program has now gone to scale with expansion to 100 target villages in Chhlong OD with 
the inclusion of a Male CBD Program to complement the original Female CBD Program. The
Female CBD Program is conducted by trained agents from each community, who were selected 
by the respective communities, using MOH selection criteria. 
The Program provides training on HIV/AIDS and STDs for all CBD agents, using training
materials specially developed and adapted to the cultural context, by the PFD staff. The training 
manual will be shared with other NGOs and training agencies to strengthen the national training 
resources for reproductive health and HIV/AIDS with a unique focus on the rural population of
Cambodia. Following intensive training, the CBD agents conduct regular group education
sessions in their village on birth spacing, HIV/AIDS transmission and prevention and where to
seek medical treatment for STDs. The male CBD workers educate men about birth spacing,
counsel men about male involvement in birth spacing, and promote STD/HIV prevention. The
Program is managed by a Khmer Doctor who works with two other staff to implement the
Program. The Program is funded by UNFPA and executed by MOH through to December 2003.
In addition to field implementation. PFD participate actively in contributing to shaping
government policy for IMCI and Reproductive health through the MOH IMCI working groups. 
This forum provides the opportunity for PFD to feedback from lessons learned in the field and 
contribute models of best practice for both public and private healthcare practitioners. 
PFD also participate as a representative voice for implementing NGOs in the Rollback Malaria 
Technical Advisory group. This provides the opportunity to advocate for the remote rural
populations that PFD serve and represent their interests and needs for malaria control while
equally contributing to improvement in the technical design of malaria Programs. 
40
II SCOPE OF WORK
A. Purpose::
1. Determine the achievement, or progress towards achievement, of the Child Survival 
Program’s quantitative and qualitative objectives and planned outputs.
2. Identify factors contributing to and constraining the achievement of same.
3. Make appropriate recommendations to address any identified weakness and/or 
constraints.
B. Specific Tasks:
In achieving the stated Purpose, the Evaluation Team will specifically respond to each of the 
following questions, including explanation of factors contributing to or constraining performance 
and recommendations for improvement where appropriate:
1. Are the village health workers (VHVs) effective as a channel for community health 
education? 
2. Are the training, support, incentives and supervision provided to the VHVs by PFD 
effective and appropriate in enabling them to carry out their functions in the 
community?
3. Are the Project’s activities, strategies and approaches effective in enabling target 
communities to effect improvement in their own health, through improved household 
practices and improved health care seeking behaviors?
4. How and to what extent have Project activities and approaches contributed to the 
following:
· community participation and community empowerment? 
· linkages between the community and the health system? 
· activities of other VHVs, TBAs and FBCs at village level? 
· strengthening of the Operational District health system?
· OD health staff perceptions of their roles and responsibilities in terms of their 
work with the communities?
6. How effective has PFD been in providing the following to national staff and associates:
· Training appropriate to Project job requirements?
· On- the- job coaching and mentoring? 
· Understanding of the goals and objectives of the Child Survival and related 
Reproductive health Program, including both the desired Program impact, and 
the broader goals of sustainability and community empowerment?.
41
· Appropriate and manageable workloads?
· A positive attitude towards their work for PFD, the target communities, and the 
public health system?
7. Have constructive working relationships been established and fostered among and 
between PFD managers, PFD staff, associate staff, government counterparts and 
community leaders?
8. Do the initial needs assessments and baseline data provide an adequate base for 
development and implementation of Project activities, and have they been effectively 
employed for this purpose?
9. Is the Project’s Community Surveillance system:
· User-friendly and well understood by both staff and village health workers?.
· Designed so as to yield reliable information for Project monitoring? 
· Effectively collected, recorded, reported and used by PFD and Health System 
staff?
·
10. Assess the level of integration and synergy between the Child Survival Program and the 
Reproductive Health Program, and make any necessary recommendations to increase 
it.
11. Has the Project effectively coordinated with the public sector (PHD, PDRD, 
POE), INGOs, LNGOs and other organizations working in the field of Child 
Survival and IMCI? 
12. What is the likelihood of and feasibility of Program benefits being sustained 
beyond the period of PFDs assistance, and how might this be enhanced?
42
Annex II: Documents Reviewed
Ministry of Health, Guidelines for Operational Districts, MOH, Phnom Penh 1997.
Ministry of Health, Health Coverage Plan, MOH, Phnom Penh 1996.
Ministry of Health and Ministry of Planning, Cambodia Demographic and Health Survey 2000, 
MOH/MOP, Phnom Penh 2001.
Ministry of Planning, Cambodia Socio-Economic Survey 1999, MOP, Phnom Penh 2000.
Ministry of Planning, Cambodia Poverty Assessment, MOP, Phnom Penh 1999.
Ministry of Planning, General Population Census of Cambodia 1998, MOP, Phnom Penh 1999.
Partners for Development/Cambodia, Annual Report of Child Survival Program, Kratie Province, 
Cambodia, PFD, Phnom Penh 2002.
Partners for Development/Cambodia, Health Center Resource Survey, Chhlong Operational 
District, Kratie Province, PFD, Phnom Penh 2001.
Partners for Development/Cambodia, Hearth Model Lessons Learned, PFD, Phnom Penh 2002
Partners for Development/Cambodia, Hearth Model Trainer’s Guide, PFD, Phnom Penh 2002.
Partners for Development/Cambodia, Northeast Cambodia Child Survival Project, Additional 
Annex to Detailed Implementation Plan, PFD, Phnom Penh 2000.
Partners for Development/Cambodia, Northeast Cambodia Child Survival Project Baseline 
Survey on Knowledge, Practice and Coverage (KPC), PFD, Phnom Penh 1999.
Partners for Development/Cambodia, Northeast Cambodia Child Survival Project Detailed 
Implementation Plan, PFD, Phnom Penh 2000.
Partners for Development/Cambodia, Revised Proposal to UNFPA and the Cambodian Ministry 
of Health for the Northeast Cambodia Reproductive Health Program, PFD, Phnom Penh 2001.
Partners for Development/Cambodia, VHV Trainer’s Guide: Immunization, PFD, Phnom Penh 
2001.
Partners for Development/Cambodia, VHV Trainer’s Guide: Diarrhea, PFD, Phnom Penh 2001.
Partners for Development/Cambodia, VHV Trainer’s Guide: Nutrition and Breastfeeding, PFD, 
Phnom Penh 2002.
White, Patrice, Crossing the River: Traditional Beliefs and Practices of Khmer Women During 
Pregnancy, Birth and Post-Partum, PFD, Phnom Penh 1995.
World Bank, A Poverty Profile of Cambodia, World Bank Discussion Paper No. 373, Washington 
DC 1997.
43
Annex III: LIST OF PERSONS MET
Ministry of Health
Kratie Provincial Health Department
Dr. Cheam Saem Director of PHD
Dr. Chuong Sengly Deputy Director of PHD
Ngy Bulen PHD EPI chief
Long Mardy PHD Continuing Education Training Chief
Pech Seima PHD MCH chief
Mao Sophalla Deputy Chief or PHD Bureau Technique 
Hem Sothy PHD HIS Chief
Ministry of Health
Chhlong Operational District
District Management Team
Chhneang Sovutha Director of Chhlong OD
Ros Rithy OD Health System
Cheng Sam Ath OD EPI chief
Health Centers
Meav Ramo Chambok HC Chief (VHV Supervisor)
Tuon Rinda ChamBak HC staff (VHV Supervisor)
Por Songly ChroyThmor HC Chief (VHV Supervisor)
Chhun Samoeun Chroy Thmor HC staff (VHV Supervisor)
Koh Sok Heang Chroy Thmor HC staff
Chak Chin Damrei Pong HC Chief (VHV Supervisor)
Thiv Tharith Kanchor HC Chief (VHV Supervisor)
El Rany Kanchor HC Staff (VHV Supervisor)
Moth Sam An Ksach Andett HC Chief
Thuch Hong Kry Ksach Ande HC staff (VHV Supervisor)
Heng Sokha Ksach Ande HC staff (VHV Supervisor)
Nuon Nearng Ksim HC Chief (VHV Supervisor)
Khen Chy Ksim HC Chief (VHV Supervisor)
Hong Narin Pong Ror HC Chief (VHV Supervisor)
You Narith Pong Ror HC staff (VHV Supervisor)
Morm Vichett Prek Prosob HC Chief 
Leng Chanthy Prek Prosob HC staff (VHV Supervisor)
Seng Chantrea Prek Prosob HC staff (VHV Supervisor)
Orng Vannara Snoul HC Chief
Theam Phanith Snoul HC staff (VHV Supervisor)
Chhiv Tithya Snoul HC staff (VVH Supervisor)
44
Annex III: LIST OF PERSONS MET - continued
Ministry of Health
Chhlong Operational District
Health Centers – continued -
Prak Chan Nareun Snoul HC staff (VHV Supervisor)
Men Sovann Tamao HC Chief (VHV Supervisor)
Partners For Development
Ann Canavan Health Program Manager, PFD Phnom Penh
Michelle Lang Child Survival Program Coordinator, PFD Chhlong
Dul Setha Child Survival Team Leader, PFD Chhlong
Maria Doyle VSO Public Health Advisor, PFD Chhlong
Chim Hen Child Survival Program Officer
Hoeum Heoun Child Survival Program Officer
Ngoun Ly Health System Strengthening Program Officer, PFD D Chhlong
Yim Nady Child Survival Program Officer
Ya Saroeun Child Survival Program Officer, PFD Chhlong
Uch Sarom Health System Strengthening Program Officer, PFD Chhlong
Keang Sochany Child Survival Program Officer
Dr. Kiv Sokha Child Survival Physician
Kim Seng Yada Child Survival Program Officer
45
Annex IV: Analysis of Mortality Data
Methodology
Village Health Volunteers maintained a register of all mothers and children in their catchment
area (approximately 50 households), including pregnancies, births and deaths. The Program
began in April-May 2001, so that by the end of 2001 data had been collected for about an 8
month period. VHVs, assisted by supervisors from the Health Center, completed a form for each 
death based on interviews with the mother or other caretaker for a total of 164 deaths in children 
under the age of five. The forms elicited the details in case of an accidental death and the
presence or absence of the following symptoms in the case of deaths due to disease: fever,
convulsions, diarrhea, dysentery, difficulty breathing, and malnutrition. Other observations and
notes were written in on many forms. In addition to the 171 deaths of infants and children under 
the age of five, 8 deaths to women during pregnancy, delivery or in the post-partum period were 
reported, with description of the time of death relative to the pregnancy and symptoms.
 The total number of under five deaths recorded (171) is about 20% lower than the number that 
would be expected if the birth rates and mortality rates found in the 1998 census have continued 
unchanged. Some underreporting is therefore likely, although the difference may also reflect
changes in fertility and mortality since the 1998 census. The number of maternal deaths
reported is consistent with the generally accepted national estimate of 400 deaths per 100,000 
live births, suggesting little underreporting of maternal death.
The forms were reviewed by a nurse with a Masters degree in Public Health and in Nursing and 
extensive clinical experience in the region, and probable cause of death assigned based on the 
age of the child at death, the symptoms reported, the time of year, and prevalence of specific
diseases in the village as reported by villagers, PFD staff, and Health Center staff. In cases
where the assignment of probable cause of death was difficult, the reviewer consulted with
three PFD staff, an expatriate registered nurse and two Cambodian secondary nurses familiar 
with local disease patterns and local terminology/beliefs.
Findings
The following tables show the probable cause of death for under fives and pregnant/postpartum 
women. It should be kept in mind that these are probable causes of death only, based on a 
review of verbal autopsy information, and that some errors are inevitable. Detailed notes on the 
criteria used for assigning deaths to each cause follow each table.
46
Table 1: Deaths to Infants and Children Under the Age of Five
 Chhlong OD May- December 2001
Probable Cause of Death Number Percentage
ARI 43 25%
Peri-natal 20 12%
Meningitis/encephalitis 19 11%
Malaria 17 10%
Neonatal Tetanus 15 9%
Typhoid/other infectious 10 6%
GI Other 8 5%
Accidents 7 4%
Diarrhea 6 4%
Dysentery 5 3%
DHF 4 2%
Malnutrition/Starvation* 3 2%
Sepsis 3 2%
Unknown 11 6%
TOTAL 171 100%
* Refers to malnutrition as the sole cause of death. Malnutrition as a contributing factor to death from
infectious disease is not reflected and, based on known nutritional status in this population, can be
assumed to be considerable.
Notes:
ARI: Deaths were classified as due to ARI if difficulty breathing, with or without high fever, was 
described in the absence of other likely causes. Although cough was not included in the list of 
symptoms on the verbal autopsy form, a number of the cases wrote it in under “other”. There is 
no way of determining how many of the ARI deaths were due to post-measles pneumonia or
other immunizable diseases. It is possible that in some cases the difficulty breathing was an
agonal event rather than a primary symptom and the death actually due to non-respiratory 
causes. However, the number of cases is so large that the reviewer feels confident in stating 
that ARI is clearly the most common cause of death. This impression is consistent with reports 
from villagers and health facilities.
Peri-natal causes: the 20 deaths ascribed to peri-natal causes include 17 in which the infant
died within a few hours of birth, one which died within 24 hours, and 2 who died after 3-4 days 
with the notation that the baby had been weak with no sucking reflex from birth. A number of the 
deaths immediately after birth included notations that the baby was cyanotic at birth. No
information was available regarding length of gestation or birth weight. 18 of the births occurred 
at home and two in a private clinic or home of a private midwife. 
Meningitis/Encephalitis: deaths were assigned to this cause if the child had convulsions, with 
or without high fever, was beyond the age for neonatal tetanus, and either did not live in a
village with high prevalence of malaria or died during the season when malaria is rare. While
meningitis/encephalitis are noted as significant causes of death in national facility-based death 
statistics and in the only other report based on rural surveillance (RACHA 2000), the number is 
surprisingly large. Even allowing for some misclassifications (e.g. cerebral malaria occurring off￾season, or febrile seizures accompanying another infectious disease process), it would seem
47
that there is an unusually high prevalence of such deaths in this population and further
investigations are warranted, particularly in terms of identifying possible transmission of
Japanese B encephalitis. One of the reports mentioned the death of another family member with 
the same symptoms. Pig farming is widespread in the area.
Malaria: Deaths were classified as probable malaria if high fever was reported without
respiratory symptoms and the death occurred during the rainy season in a village known to
have high endemicity. A few of the cases specifically noted “malaria” in the margin and one had 
been to a health facility and had a positive malaria test. Most died at home without a blood
smear or dipstick done. Some misclassification is likely and the actual number of deaths due to 
malaria may be either somewhat higher (due to deaths from malaria occurring “off season” or in 
villages with low prevalence, which will have been classified as “other infectious”) or lower (due 
to some of the deaths ascribed to malaria actually being from other infectious causes).
However, the reviewer feels confident in citing malaria as one of the six major causes of
infant/child death for this population, whatever the exact percentage.
Neonatal tetanus: of the 15 cases classified as probable neonatal tetanus, 13 of the forms
specifically stated the death was due to neonatal tetanus (in a child of the right age) and two
others described death from convulsions in an infant less than one month of age. It is possible 
that a few were actually meningitis or encephalitis deaths, especially since the forms did not
specify exact age in days in most cases.
Typhoid and Other Infectious Diseases: the ten deaths ascribed to this group featured high
fever as the sole symptom, occurring either in a non-malarious area or in the cool or dry season 
when malaria is infrequent. Typhoid is known to be hyper-endemic in Cambodia, and more than 
half of these cases reported continuous high fever of several days duration. In the absence of
laboratory tests it is not possible to be sure, but it is probable that some were indeed due to
typhoid or paratyphoid, with the remainder other infectious diseases. It is also possible that
some malaria, occurring either “off season” or in areas of usually low prevalence, is
misclassified in this group (see under Malaria above).
Gastro-intestinal – other: deaths in this category consist of infants and children without
diarrhea but with clear GI symptomatology, e.g. hard and rigid abdomen, abdominal distention, 
abdominal pain, severe vomiting .Causes may include intestinal obstruction or peritonitis.
Accidents: the seven deaths in this category include four drownings, one fall from a bicycle,
and two poisonings
Diarrhea: Deaths were ascribed to diarrhea if the child was reported to have had diarrhea, with 
or without fever, prior to death and lacked signs of respiratory infection or convulsions. The
number is relatively low, which is consistent with villager and Health Center reports that diarrhea 
is not a major cause of mortality. PFD has installed deep tube wells in most of these villages 
under it’s Northeast Cambodia Community Development Program.
Dysentery: Deaths were ascribed to dysentery if the child was reported to have had bloody
stools, with or without fever, prior to death. The term for dysentery in Khmer is quite specific and 
distinct from the term for watery diarrhea, making confusion between the two unlikely.
Dengue Hemorrhagic Fever: DHF has moved into the rural areas of Cambodia over the past 
two years and is widely reported to be a significant health problem in the villages. The four
48
deaths classified as DHF featured high fever and hemorraghic manifestations, e.g. petechiae or 
ecchymosis. One child was reported to have vomited blood.
Malnutrition/Starvation: the deaths in this group include a child with cleft lip/palate, a baby
who was bottle fed, and a 7 day old infant with severe thrush from birth which prevented intake. 
All three of these cases clearly died from primary malnutrition/starvation and/or dehydration.
However, malnutrition as a contributing factor is not reflected in this data and, based on what is 
known about nutritional status in the population, probably played a role in many of the deaths 
from infectious disease.
Sepsis: Deaths classified as sepsis featured fever, blistering or rash on the skin, or “black color 
on the body” occurring at ages or in seasons when DHF was unlikely. Some misclassification
between DHF, sepsis, and “other infectious” is likely.
Unknown: 11 deaths could not be classified based on the information available. In 10 cases, 
the only symptom noted by the family was crying. In one case, the only symptom noted was
blisters on the lips on the day of death. All cases were less than one year of age.
Table 2: Maternal Deaths, Chhlong OD May-December 2001
Probable Cause of Death Number
Direct Obstetric Cause: prolonged/obstructed labor; 
possible uterine rupture
4
Eclampsia 1
Post-partum Infection 1
Severe Anemia/cardiac 1
Non-maternal causes 1
Notes:
The four women classified as dying from direct obstetrical causes all died during labor, one of
them while undergoing an emergency Cesarean section at the hospital.
The woman classified as eclampsia died during labor with edema and convulsions.
The woman classified as post-partum infection died 8 days after delivery with a high fever.
One woman died 37 days post-partum having had significant generalized edema for the entire 
postpartum period. In the reviewer’s Cambodian experience, such women are usually severely 
anemic and the death has therefore been classified as due to anemia/heart failure, although this 
is purely speculative and other pathology (e.g. kidney disease) cannot be ruled out.