USAID/CAMBODIA
STRATEGIC OBJECTIVE CLOSE OUT REPORT
SO Name: Improved Reproductive and Child Health
SO Number: 442-002
Approval Date: July 1996
Geographic Area: Cambodia
Total Cost: 
USAID: 1
Mission Funding DA $ 1,954,000
ESF 20,194,367
DP 6,300,000
CSD 1,829,750
GDX 25,000
Global Support DA 900,000
ESF 10,317,000
CSD 2,250,000
DV 985,000
Total USAID Funding $ 44,755,117 + $ 5,132,640 (PVO Co-Financing)
Principle Implementing Partners:
Local Partners:
CARE International
EngenderHealth/Reproductive and Child Health Alliance (RACHA)
Helen Keller International (HKI)
Medicins sans Frontieres (MSF)
Partners for Development (PFD)
Population Services International (PSI)
Reproductive Health Association of Cambodia (RHAC)
World Vision International (WVI)
Global Projects:
BASICS
John Snow, Inc./SEATS II
Background
The health sector in Cambodia faces enormous and persistent challenges. Related to reproductive and 
child health, these include:
Safe motherhood challenges: Cambodia’s maternal mortality rate is the highest in the region. This is 
directly related to low antenatal attendance at health centers; low level of deliveries assisted by trained 
health providers; and, harmful traditional practices during pregnancy, childbirth and postpartum. Most 
maternal deaths are due to complications related to unsafe induced abortion or direct obstetric causes. 
Limited human resource capacity and low level of skills and technical competency of staff across the 
board continue to remain significant challenges in reducing the high levels of maternal mortality in 
Cambodia. 
 
1
 Funds were obligated under this SO beginning in FY 1995. Additional $5,132,640 funds obligated under the
 PVO Co-Financing project during this period contributed to the results reported in this report.
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Family planning/birth spacing challenges: Low contraceptive prevalence; large unmet needs and 
demands for family planning services; and, a high prevalence of unsafe abortions resulting from lack of 
access to voluntary contraceptive services.
Child health challenges: High infant, child and neonatal mortality rates; low use of oral rehydration salts; 
low immunization coverage; low rates of exclusive breastfeeding of infants below five months of age; and, 
indiscriminate use of antibiotics for childhood infections.
Infectious diseases challenges: Tuberculosis, malaria and dengue hemorrhagic fever continue to be
leading causes of morbidity and mortality. HIV/AIDS-TB co-infection is increasing rapidly.
Service delivery challenges: Access to health facilities is a major problem. Thirty years of conflict have 
left Cambodia with a devastated infrastructure and serious lack of human resources. Public health
services are particularly week at the district level and below. Quality of care is also very low. The lack of 
skilled health care providers and tremendous need for capacity building at all levels is a major challenge.
The Ministry of Health is aware of these challenges and is moving to address them, with technical
assistance from a variety of organizations and donors. The USAID program has been primarily focused 
on building human capacity and increasing access to quality maternal, reproductive health and child
survival services, working in partnership with non-governmental organizations.
Summary of overall impact at SO level and IR level
SO: Improved reproductive and child health.
The impact of activities under this SO is reflected in:
s A decrease in infant mortality from an estimated 115 deaths per 1000 live births in 1996 to 95 deaths 
per 1000 in 2000, surpassing the target established in 1996 of 100 per 1000.
s A decrease in child mortality from an estimated 181 deaths per 1000 live births in 1996 to 124.5 deaths 
per 1000 in 2000, again surpassing the target established in 1996 of 155 per 1000.
s An increase in the contraceptive prevalence rate using modern methods from 7% in 1995 to 19% in 
2000, surpassing the 1996 target for 2000 of 17%, and increasing to the 29% to 37% range for USAID 
target areas in 2002.
IR 1: Expanded supply of reproductive and child health services.
An expanded supply of services is reflected in:
® An increase in competent providers of birth spacing services reflected in CYP increase from 100,000 in 
1998 to 432,000 in 2002.
® A substantial decrease in the stock-out rate of essential drugs and contraceptives at health centers 
from 80-90% in early 1998 to 5% in 2002.
® Numerous policies, standards, training modules, guidelines and protocols such as COPE, LSS, Safe 
Motherhood, strategic plans in reproductive health, IMCI, EPI etc. adopted or used by the MoH and 
NGO community in the sector.
IR 2: Increased access to reproductive and child health services.
® Households that has access to safe water in target areas increased from less than 13% in 1996 to over 
50% in 2002.
® 30% of deliveries are attended by trained midwives in RACHA target areas in 2001, a significant 
improvement from almost zero in 1997.
® Availability of RCH services in target areas increased from nearly zero in 1997 to 37% in 2002.
® The contribution of health centers to the contraceptive prevalence rate using modern methods rose 
more than five-fold between 1998-2001.
® Vitamin A coverage has increased from less than 15% in 1997 to over 85% in USAID supported target 
areas by 2002.
® Increased immunization coverage rates in CARE’s project areas from 18% in 1995 to 84% in 2002.
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IR 3: Strengthened demand for reproductive and child health services.
A strengthened demand for quality services is reflected in:
® Couple-years of protection (CYP) directly attributable to USAID-supported interventions increased from 
just over 100,000 in 1997 to 432,000 in 2002.
® A substantial increase in the volume of services provided by RHAC clinics – from less than 100,000
clients in 1998 to over 350,000 in 2002. 
® Over 45 health feedback committees and 30 village development committees established and working 
with health centers and target communities to improve access to health center services.
® Increased sales of ‘Number One’ brand condoms from zero in 1994 to 18.5 million in 2002.
® Increased sales of ‘OK’ brand oral contraceptives from zero cycles in 1997 to over 700,000 in 2001.
Significant changes in the Results Framework during the life of the SO 
This SO was approved in 1996. Many of the projects were built on activities initiated under earlier projects 
(i.e., PVO Co-Financing). The IRs were changed in 1999 to better respond to changes in program 
activities due to prohibitions on working with the Ministry of Health after the mid-1997 political events and 
reduced funding levels. The SO and IRs were modified from maternal and child health (MCH) to 
reproductive and child health (RCH) in 2000.
Summary of activities used to achieve the SO and their major outputs
Strengthening of Integrated Community-level MCH/FP Services
® Community level services in Cambodia are delivered in an integrated fashion, with Health Centers 
(HCs) and HC outreach sessions as the primary source of MCH, family planning, and curative care. 
Three USAID-funded projects (RACHA, CARE and PFD) strengthen community-level services in 
accordance with the MoH Health Coverage Plan and Guidelines for Operational Districts (ODs) through 
technical assistance, training, mentoring, facilitative supervision and logistical support to HCs, Referral 
Hospitals (RHs), HC Outreach, and HC feedback committees. All implementing partners achieved a 
much higher rate of service delivery and service utilization than is noted in ODs without the USAID￾funded technical assistance support.
Family Planning
® Number One condoms socially marketed by PSI are the best-recognized brand of condoms in the 
country. Total sales in 2002 were 18.5 million. This program contributes to increased access to 
contraceptive services, and also plays an important role in curtailing the transmission of STDs and HIV.
® Social marketing of oral contraceptives has had a significant positive result on access and use of 
Combined Oral Contraceptives (COCs), especially in urban and peri-urban areas, and has the potential 
to do the same for injectable contraceptives.
® Support to the Reproductive Health Association of Cambodia (RHAC) has contributed to the 
development of model urban private sector RH clinics, providing a full range of FP methods, diagnosis 
and treatment of RTIs and STDs, ante and postnatal care and counseling on HIV prevention. In 
addition to direct provision of a significant amount of FP and STD services, RHAC has the capacity to 
provide high quality training in clinical techniques, IEC and counseling to NGOs and government.
® Implementing organizations have supported the delivery of family planning services in health centers 
(HC) and during HC outreach through training, coaching and mentoring of HC staff, and logistical 
assistance with outreach sessions.
Maternal Health
® Technical assistance through the USAID-funded RACHA project has contributed to the development of 
national policies and guidelines for safe motherhood. A competency-based training course for 
midwives, Life-Savings Skills (LSS), has been developed and serves as a model for the country. In 
USAID-funded project areas, LSS-trained midwives have significantly improved the quality and quantity 
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of their services, measured by three-fold increase in the number of clients seen by LSS graduates. 
Keys to this success have been careful training selection criteria, practical training provided in a setting 
with a high volume of deliveries, and intensive post-training follow-up.
Child Survival
® Formative research on vitamin A deficiency and strategies for distribution of vitamin A capsules (VAC) 
have directly contributed to the establishment of a National Vitamin A Policy and incorporation of VAC 
into expanded programs of immunization nation-wide.
Infectious Diseases
® Community-based distribution of impregnated bed nets and IEC by Partners for Development (PFD) in 
a province with high malaria transmission has achieved 100% coverage of the population and a 
documented threefold decrease in the incidence of malaria. This effort is a model with potential for 
wider replication.
Logistics Management
® Technical assistance and training in logistics management of drugs and contraceptives have been 
conducted nation-wide through the RACHA project, augmented by district-level follow up in operating 
districts (OD) where they work. Dramatic improvements in stock levels have occurred in areas where 
both the training and subsequent follow-up (including computerization down to OD level) were 
provided.
Research and Policy
® The Demographic and Health Survey (DHS) conducted in 2000 provided government, donors and 
implementing agencies with reliable health indicators for the first time; RACHA studies on causes of 
maternal and child mortality provide the first, and only, population-based information on causes of 
maternal and infant/child deaths; and, studies by HKI have drawn attention to micro-nutrient 
deficiencies and directly contributed to policy and program interventions.
Prospects for long-term sustainability of impact and principal threats to sustainability
The prospects for long-term sustainability of impact are good in view of the substantial progress made 
under the SO. Yet Cambodia is still in the process of developing its nascent health service system. 
Tangible results are evident three to four years after completion of the initial plans, but development of 
the planned system is still far from complete. There is good reason to expect that the Ministry of Health 
(MoH) will continue to make significant progress towards the goal of accessible health services nation￾wide. However, progress will be made in stages, and will take time. The need to deliver RCH 
interventions is urgent and cannot wait for full development of the health care system. At the same time, 
interventions cannot be delivered without such a system and will always be constrained by the level and 
pace of system development. RCH efforts in Cambodia must therefore proceed on two tracks, 
simultaneously: strengthening the nascent service delivery system, and promoting the delivery of specific 
interventions.
Many of the gains achieved under the SO can be sustained through the efficacy of Cambodian and 
international partners, and the strong commitment of the Cambodian government. The principal threats 
to sustainability are the weak institutional capacity of public health services, the overall poverty within 
Cambodia with increasing landlessness and inability of the poor to access adequate nutrition, and the 
possibility of renewed violence.
Lessons learned
s Competency-based training of midwives has significantly improved the quality of their services and 
utilization. Keys to this success have been careful training selection criteria, practical training provided 
in a setting with a high volume of deliveries, and intensive post-training follow-up.
s Very dramatic reductions in malarial morbidity and mortality can be achieved through a combination of 
IEC and distribution of insecticide impregnated bed nets when carried out by NGOs in a structured, 
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intensive manner at community level, accompanied by careful monitoring and evaluation of both 
behavioral change (maintenance and use of bed nets) and impact (decrease in incidence of malaria).
s There are numerous potentials for linkages between RCH and HIV/AIDS/STD interventions which 
would render both more effective, e.g., HIV/AIDS/STD and RCH IEC efforts; antenatal, obstetric and 
post-natal care and prevention of mother to child transmission of HIV; family planning and STD/HIV 
prevention; antenatal care and STD prevention and treatment; and, voluntary counseling and testing 
and family planning.
s Social marketing is an appropriate and cost-effective strategy for increasing access and demand for 
family planning methods. However, current marketing strategies do not effectively reach the rural 
areas where the majority of the population resides. There is also untapped potential for using social 
marketing to improve access to and demand for RCH services, e.g. ORS, iron/folate supplements, etc. 
s In the Cambodian context, where human resource capacity is extremely weak, and change is needed 
not only in information and skills but in basic attitudes and expectations, effective TA and training 
requires extensive, prolonged, hands-on follow-up, coaching and mentoring at the actual service 
delivery point. To achieve this, it is critical that implementing agencies systemically approach, and 
allocate resources for, capacity-building of their own national staff so that they are well positioned to 
serve as mentors.
Performance indicators 
Indicator 1: Couple-years of protection (CYP).
CYP is a summary measure of protection against pregnancy provided by birth spacing services based on 
volume of commodities sold or distributed. Each commodity has a specific conversion factor to estimate 
the duration of contraceptive protection, thus allowing aggregation into a single figure. Conversion factors 
incorporate assumptions about the failure rates and other factors that impact the duration of protection.
Given the nascent nature of the overall service delivery system, CYP is the most practical and reliable 
measurement of modern contraceptive methods being distributed. It gives us a good picture of the need 
and demand for family planning services as well as the output of our implementing partners.
Indicator 2: Percentage of target population with access to safe water.
Target areas are the communities in which the implementing partner works, namely areas of two 
northeastern Cambodian provinces. To be counted in the numerator, a household must be within 200 
meters of a project-installed well or if outside 200 meters, use a project-designed family water filter for the 
household’s drinking water. The denominator for this indicator grows as security constraints make more 
of the target population accessible for implementing partner activities.
This indicator was useful for what it was and a good proxy for child survival indicator but falls outside the 
traditional RCH indicator. Because of the history and the evolution of USAID PHN sector support, the 
implementing partner PFD was asked to provide support for basic community development activities. As 
the country was slowly recovering from the devastation of the “Killing Field” era, the most pressing 
problem in rural areas, especially in the northeast provinces of Rattanakiri and Strung Teng was the total 
absence of access to safe water. In the course of seven years of PFD work in the above provinces, 
access to safe water increased from close to zero in 1995 to 50% in 2001.
Other indicators directly related to RCH services included availability of essential RCH services at 
established service delivery points such as the health centers, EPI and Vitamin A coverage which 
provides reliable and verifiable information on access to and utilization of services. 
Indicator 3: Number of Number One brand condoms sold.
Calculated from actual Population Services International social marketing sales figures. This indicator 
provides a good indication of demand for condoms but does not necessarily correlate to the actual use of 
condoms for disease prevention or birth spacing purposes. Moreover, Number One brand, as successful 
as it has been, is promoted and perceived as such in association with HIV/STI prevention and not as an 
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essential RCH service product. While demand creation for condom use in the escalating war against 
HIV/STI prevention is critical, this indicator specific to Number One is not an appropriate indicator for 
strengthened demand for RCH services. However, there are other more appropriate indicators used 
under IR3 such as CYP, utilization rates, number of functioning health center feedback committees which 
provides more reliable and accurate indication of the demand for RCH services. 
Evaluations and special studies
USAID Reports and Assessments
USAID/Cambodia Results Review and Resource Request (R4): March 1997, February 1998, April 1999, 
April 2000, April 2001
USAID/Cambodia Annual Report: March 2002
USAID/Cambodia, Population, Health and Nutrition Assessment, June 2001.
USAID/Cambodia, Interim PHN Strategy 2002-2005, February 2002.
Partner Evaluations
CARE Mid-Term Evaluation, 1999 
PSI Assessment Report, DFiD 2001
RHAC Strategic Review, 2002
RACHA Assessment, 2000, 2002
HKI Nutrition Sector Assessment, 2001
PFD Child Survival Review, 2000
Annual/Semi-Annual Partners Reports, 1999, 2000, 2001, 2002
[CARE, PFD, PSI, HKI, RHAC, RACHA]
Instrument close out reports
Prepared per ADS 202.3.8 for contracts, grants, and cooperative agreements
Key contacts
USAID/Cambodia
Office of Public Health [OPH]
USAID/Cambodia
Phone: (855-23) 216-436
Fax: (855-23) 217-638
Mark A. White
Supervisory PHN Officer
Email: MAWhite@usaid.gov
Ngudup Paljor
Maternal & Child Health Advisor
Email: NPaljor@usaid.gov
USAID/Cambodia Attachment 1
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Local Partners
CARE International
Sharon Wilkinson, Country Representative
# 52, Street 352, Phnom Penh, Cambodia
Email: care@bigpond.com.kh; jesserattan@bigpond.com.kh
Phone: (855-23) 215-267; Fax: (855-23) 426-233
EngenderHealth/Reproductive and Child Health Alliance (RACHA)
Dr. Richard Sturgis, Program Manager
# 30, Street 360, Phnom Penh, Cambodia
Email: RSturgis@racha.org.kh
Phone: (855-23) 213-724; Fax: (855-23) 213-715
Helen Keller International
Dora Panagides, Country Representative
# 60, Street 310, Phnom Penh, Cambodia
Email: hki_cd@bigpond.com.kh
Phone: (855-23) 210-851; Fax: (855-23) 426-852
Partners for Development (PFD)
Michael Chommie, Country Representative
# 24, Street 294, Phnom Penh, Cambodia
Email: pfd@bigpond.com.kh
Phone: (855-23) 213-335; Fax: (855-23) 213-335
Population Services International (PSI)
Barry Whittle, Country Representative
# 29, Street 334, Phnom Penh, Cambodia
Email: bwhittle@bigpond.com.kh
Phone: (855-23) 218-660
Reproductive Health Association of Cambodia (RHAC)
Dr. Ouk Vong Vathiny, Executive Director
# 6, Street 150, Phnom Penh, Cambodia
Email: vathiny@rhac.org.kh
Phone: (855-23) 885-135; Fax: (855-23) 885-093
Global Projects:
BASICS
Management Sciences for Health, Inc.
1515 Wilson Boulevard, Arlington, VA 22209
(703) 524-6575
(703) 524-7898 [fax]
SEATS II
John Snow, Inc.
1616 N. Fort Myer Drive, Arlington, VA 22209
(703) 528-7474
(703) 528-7480 [fax]