Goals and objectives: This new mechanism will contribute to HIV prevention in Cambodia by supporting activities and strengthening institutions that provide essential services for HIV, but whose mandate is broader than HIV. Specific objectives are to: 1) improve blood safety through training, organizational, and infrastructure support; 2) promote integration of HIV with maternal and child health services; 3) strengthen the capacity of the Ministry of Health to implement and manage donor resources, especially the Global Fund, with transparency, good stewardship and accountability.

Target population/ coverage: This TBD partner will help build systems and strengthen capacity to deliver safe blood and integrated maternal health services throughout Cambodia, especially in areas of priority for the U.S. government and Global Fund.

Cost efficiency/ transition: Integration of services between vertical programs within the MOH will lead to more efficient and sustainable health systems. Building capacity of managers and program directors will lead to more effective use of resources and better absorptive capacity.

Monitoring and evaluation: CDC technical support will be provided to ensure management and monitoring systems for the cooperative agreement are consistent with U.S. regulations. Progress on program activities and use of resources will be reviewed during quarterly meetings, and through quarterly and annual reports. Program supervisors will conduct joint site visits with CDC staff to review progress and identify problems in implementation.

The new mechanism will be partially funded with resources approved for prevention of mother- to- child infection in prior years and from the PEPFAR Global Fund Collaborative Fund.

The FY 2013 Ministry of Health (MOH) implementing mechanism will improve the capacity of public health workers, program directors, and civil society partners to collect, analyze, and use existing programmatic data. Strategic information funding and technical assistance will address the problem of multiple, non-integrated client datasets that hinder routine performance reviews of the national HIV care program.

Because Cambodia does not yet have a uniform health registration system that allows for the confidential tracking of individuals across service-delivery sites, facilities have developed their own unique, non-integrated systems. As a result, the data that sites pass along to the national level registers feature inconsistencies in the categorization and coding of patients and services delivered and often double count individuals who have visited more than one site or have received more than one service. The implementing mechanism support to the MOHs Department of Planning and Health Information will complement expected central Strategic Information funds from the U.S. Office of the Global AIDS Coordinator and funding to the National Center for HIV/AIDS and Dermatology for tracking individuals across the full continuum of care of health and community services through the use of a unique identifier system for individuals seeking services and to link confidential medical records across HIV testing, care and treatment services. Complementary systems will be developed to introduce unique identifier codes in community-based programs to facilitate tracking of referrals for female entertainment workers, men who have sex with men, and injecting drug users from community to facility-based services.

The implementing mechanism will also support an analysis of routinely collected prevention of mother to child transmission data to determine the cost and effectiveness of a universal testing strategy in the low prevalence context. An additional operations research study will determine the contribution of HIV to maternal anemia in Cambodia, which affects over 40 percent of pregnant women.

The FY 2013 implementing mechanism will strengthen the ability of the Ministry of Health (MOH) to ensure the efficiency and effectiveness of aid/external funds within the health sector in Cambodia.

Cambodias national response to HIV/AIDS relies heavily on external funds, such as the Global Fund, U.S. government, United Nations (UN) agencies. In October 2006, the Ministry of Health decreed the Department of International Cooperation (DIC) be responsible for international cooperation within the health sector to achieve the goals of the Royal Government of Cambodias National Strategic Development Plan and Health Strategic Plan.

DIC will support the development and management of the MOH website and DIC database, which will track health sector external assistance and support the sharing of key policies, programmatic and funding information, promoting transparency of donor resources. DIC will map all external organizations who are currently working in the health sector, including the Global Fund and U.S. government, to identify duplicative or inefficient activities, as well as gaps in service delivery. In addition, the mapping will allow DIC toidentify technical assistance needs and develop strategies to use the information to guide resource allocation and priority setting. These activities will also be used to assist the Cambodian government to predict the cost of the National Strategy and mobilize national and international resources.

With this implementing mechanism DIC will procure technical assistance for project management, including financial, property systems and procurement/supply chain systems. This assistance will support the Global Fund Principal Recipients and the broader MOH management units to help strengthen the MOHs overall project management capacity. The three departments within the MOH, who partnered with CDC previously, reported that establishing systems and structures within their organizations increased project management capacity over time. The DIC will hire staff for a project management team, including a Monitoring and Reporting Officer, an Accountant, and an Administrative Officer to support the leadership and coordination of this implementing mechanism.

The DIC project management team and CDC will adapt the Standard Operating Procedures, currently used by other CDC supported MOH centers, and they will be implemented for use with all partners supported under this mechanism. The project management team will assist other CDC supported MOH centers to organize efficient and accountable project management systems, recruit and hire staff, and consolidate information for semi-annual reports. DIC will convene quarterly meetings with the National Blood Transfusion Center, National Maternal and Child Health Center, and Department of Planning and Health Information and CDC to monitor progress, identify and resolve implementation challenges, track expenditures, and ensure overall consistency.

A PEPFAR supported task order control to carry out an assessment of the Cambodian blood supply system and develop a five year strategy and action plan will be finalized in August 2012.

This new TBD mechanism provides funding to the Ministry of Health (MOH) and National Blood Transfusion Center to implement activities identified in the five year strategy and action plan not supported by other donors. A complementary TBD mechanism funds a partner to provide technical support to the MOH to ensure effective implementation of the action plan, including development of training materials and protocols, monitoring activities, and mentoring leaders.

Lack of capacity is a major constraint for ensuring safe blood in Cambodia. The lack of capacity has resulted in a poorly organized blood system without standardized protocols or trained personnel. Transfusion practices in hospitals do not follow international standards. Because of poor absorptive capacity, the MOH returned funds to the Global Fund in 2011.

To address these gaps, activities in this program include: 1) supporting 500 health workers from the public sector blood banks and hospitals providing transfusions to patients to attend training workshops on appropriate transfusion techniques, identification of transfusion transmitted infections, immune-hematology, quality assurance, and laboratory auditing; 2) organizing training workshops for managers who oversee the national blood supply system and regional blood banks; 3) printing and disseminating the blood safety action plan and revised guidelines and protocols; 4) procuring materials to implement quality control systems for the safe production of blood components; and 5) implementing a computerized information system to enhance voluntary donor recruitment and forecasting of blood supply and equipment needs.

Specific targets and expected outcomes for the national blood system will be outlined in the action plan. Reporting and monitoring tools will be developed in collaboration with the technical assistance TBD partner. Reports will be reviewed by the blood safety technical working group. Site visits to assess progress will be carried by MOH leadership and technical advisors in collaboration with CDC.

The FY 2013 Ministry of Health (MOH) implementing mechanism will provide support to improve the performance of prevention of mother to child transmission (PMTCT) activities supported by Global Fund grants, including improving monitoring and evaluation, reporting and management systems and streamlining financial processes.

Cambodias Global Fund resources provide funding for reducing infant HIV infection, but significant challenges have hampered the ability to implement programs and meet performance expectations. The FY 2013 implementing mechanism will provide financial and technical support for a senior maternal and child healthprogram pfficer to improve the performance of the combined National Maternal and Child Health Center (NMCHC) and National Center for HIV/AIDS, Dermatology and STDs PMTCT programs.

This implementing mechanism will support the MOHs plan to improve provision of family planning services for people living with HIV and at risk for contracting HIV with a focus on provision of dual protection, so that those who desire to limit, prevent, or delay pregnancy are able to access appropriate care at government health facilities. Training of providers within the antiretroviral treatment (ART) clinics with the training materials developed by NMCHC and CDC will address educate ART providers about how to prescribe contraceptive methods. Appropriate training and supportive supervision will ensure that clinicians working in the ART and sexually transmitted infections clinics offer patients who desire to prevent or delay pregnancy informed choice of family planning methods, as well as ensuring maternal and child primary health care providers have the knowledge and skills to counsel on dual protection and meet the unique needs of women with HIV or at risk of contracting HIV who are seeking birth spacing options.

To address maternal mortality, NMCHC wishes to establish a national maternal death audit secretariat. The secretariat which would oversee the review of the current maternal death audit curriculum, ensure its consistent implementation, and support provincial and district maternal death audit committees to review all deaths for significant and modifiable predictors of maternal death such as advanced HIV disease by triangulating sources of information for maternal death case reporting (e.g. death certificates and PMTCT cohort registers).

Finally, the MOH is interested in strengthening health systems for pre-cancer screening among women at high risk of cervical cancer. Creating a common vision between technical experts and health policy makers is needed. This mechanism will convene stakeholders to develop a roadmap to foster high quality cervical pre-cancer screening.