October 31, 2006 at 7:59 am (Lee's Posts)

My job has been quite interesting, challenging and filled with opportunities for learning. There is quite a steep learning curve due to all the policies and acronyms and government bodies that we work with. Unfortunately, I have yet to go for a site visit to the rural provinces to see HIV+ adults and children who are benefiting from the work we’re doing in trying to get them ARV medicines cheaply. But feeling fulfilled by my work is too much to expect in 3 weeks anyway.


Oh, yeah, the basics. I am working for the Clinton Foundation HIV/AIDS Initiative, whose Cambodia office consists of my boss Alex and me. We work inside of the National Center for HIV/AIDS, Dermatology, and STIs (NCHADS) in Phnom Penh. NCHADS is a body of the Ministry of Health (MoH)—really, a whole lot of acronyms. My title is “Cambodia Country Analyst” and I just got business cards made—my first ever! I work in a small room near my boss’ front room; that’s where there was a free desk. Sharing the office with me is Sonyouth, a fun 26-year-old Cambodian who works on Data Management (he majored in Computer Science) and is studying for his MBA. Also in the office about half the time is Nicole Seguy, a middle-aged French woman from the WHO who (haha) is assisting NCHADS with scaling-up treatment and establishing a more efficient data management system.


My first project was to create a poster to visually demonstrate the linkages that need to be made in the Cambodian health system between the Prevention of Mother-to-Child Transmission (PMTCT), pediatric AIDS care, and early diagnostic services like the co-treatment of opportunistic infections (OIs). My first draft of it was apparently too complicated, though graphically easy to follow. The director of NCHADS, Dr. Mean-Chhi Vun, told me to keep it simple (stupid!) and include cartoons, because Cambodians love cartoons.


Essentially, there was an initial crevasse in our communication—I had thought the poster was to train doctors and nurses, but Dr. Vun had wanted it to be accessible mostly to community health workers and the general public (it will be translated into Khmer and available in both languages). He told me that Drs and nurses can read about the exact procedures in a government policy, but that community health workers who only had a minute to glance and learn about the system of referrals needed something bold and simple, something that grabbed them. The project was a great learning experience, both in terms of integrating policy into visual substance, and in terms of better understanding my audience and the needs and structure of the Cambodian health system.

Here’s the complicated poster:


Complicated Poster



And the simple one:





My most challenging project so far has been to write, almost single-handedly, Standard Operating Procedures (SOP) for a government-based coordinating mechanism to implement social care for orphans and vulnerable children (OVC—again with the acronyms). Essentially, I had 2.5 days to draft national policy about something I knew nothing about at the beginning of that first day. We had an initial meeting with members of NGOs working on social care with OVC, namely, Save the Children Australia, UNICEF, New Hope for Cambodian Children (a local NGO run by an American) and members of NCHADS’ AIDS Care unit who specialize in Pediatric AIDS Care. After the meeting, and an initial meeting with the director of NCHADS, Dr. Vun, I set off to read about 300 pages of policy and reports given to me by the meeting attendees. I had one day to read all this, take notes, and then I began writing the next day.


I received a lot of positive feedback from all stakeholders in the draft process—we had two more consultations with the NGOs listed above and I met with Dr. Vun, who told me what needed to be added and changed according to his vision of NCHADS role in providing the mechanism for social care (rather than implementing it themselves).


So the content of the SOP—NCHADS does not have the funds to provide nutritional support, transport subsidies for medical purposes, and educational subsidies (mainly for supplies, because education is supposed to be free impoverished children) for all HIV+ children, much less all OVC in the country. However, Dr. Vun understood that there was a lack of coordination among NGOs operating in the same provinces and districts, and that as a result many funds were wasted and many OVC were not identified (because of the great fear of many NGO funders who require that grants to demonstrate how a project is original and does not overlap with anything currently being implemented).


At the same time, NCHADS will ensure psychosocial support for OVC in the form of peer support groups that meet on the same day as the peer support groups they already set up for HIV+ adults. They will provide funding for these groups.


NCHADS wishes to create the coordinating mechanism for all operations pertaining to social and medical care for OVC, basically providing fora to discuss successful and unsuccessful procedures in order to implement the most effective models in each district. Essentially, the coordinating mechanism model seeks to create flexibility at the local level rather than dictating national policies that must be followed.


The SOP first lists the services that must be included in a Standard Minimum Basket of Social Care for OVC—psychosocial, nutritional, educational, and transport support (recognizing that other essential services like sustainable local socioeconomic projects, adequate shelter, etc are vital but could not be included in the SOP). The SOP creates the mechanisms for meeting at the district level (there are at least 3 districts in each of Cambodia’s 24 provinces) and delineating who should attend the meetings. Allowing for flexibility, these members include Directors of local hospitals, the Head HIV/AIDS officer of the district, the provincial officers from the ministry of education and the ministry of social affairs, reps of NGOs operating in the district, People Living with HIV/AIDS (PLHA), coordinators of peer support groups, and others.


The SOP describes a community-based model for identifying OVC and providing them with social care services. A model centered on pagodas has been very effective across Cambodia. Essentially, the NGOs we consulted with, as well as NCHADS, believe that, rather than create new institutions, the institution most ingrained and established in local Cambodian life—the pagoda—can and, where possible, should be utilized to help the surrounding community. Of course, this model misses certain sectors of the population, and the SOP describes a similar but secular model for performing these tasks.


The Pagoda-Based System:

· Monks, once trained as advocates, spend time visiting communities, identifying OVC—most of whom are in non-residential care settings such as family care, child-headed households, kinship care, community foster care, etc—and talking about HIV/AIDS treatment and prevention.

· Each monk working on the OVC support group shall oversee one neighboring village, depending on its size—monks can successfully conduct OVC identification and social care visits for 15-30 OVC.

· NGOs and donors shall facilitate training, and throughout the identification process, monks shall work with NGOs and donors to map each village under their jurisdiction.

· After establishing presence in the community, village chiefs often assist the reporting of additional OVC to monks.

· Each pagoda calls for practical and supportive responses to care for the children affected, as well as for the communities from which they come. The pagoda assesses separately the needs of individual children and their families.

· The pagoda works with NGOs and donors to provide material and emotional support to these children.


All in all, it’s an innovative and interesting approach to community-based support. There are still many problems, like the gap of trust that exists between HIV+ women and male monks. In this situation, the women often choose not to disclose their HIV+ status to monks, which may reduce the support they and their children receive. Resourceful strategies for building trust at the local level are still needed, and the hope is that the coordinating meetings between relevant stakeholders might generate some of these strategies.


Finally, the SOP delineates the exact procedure and chain-of-communication for connecting the identification of OVC with voluntary HIV testing for many different sectors engaged in work with OVC and HIV/AIDS (NGOs, orphanages, pagodas/faith-based organizations, schools, PMTCT centers, Home-Based Care (HBC) teams, adult peer support groups for PLHAs, and the child protection network). The need for this is obvious—while overall prevalence of HIV in the Cambodian population is estimated at 2%, the estimated level for orphans is 10%+. Basically, these children need to get tested to know their status, to receive immediate HIV education, to learn important preventative measures which have shown to have efficacy in Cambodia (95% of brothel-based sex workers now use condoms, and the overall rate of condom use has increased greatly), and, most importantly, to begin the process of accessing treatment.


The job is quite interesting, and I feel an immediacy to my work, that it might be useful to the people I am writing for/about. I think this is what has driven me to explore public health and global health in general. This immediacy is something that I definitely did not feel while writing my thesis last year in my carrel at Brown, even as I was writing about people I lived with and cared about.


The one thing that most bothered me, however, is that they assigned ME, of all people, to write the SOP. Clearly they value the quality of my writing, but to assign the person who has spent 1 week in the country and has never worked in a healthcare or policy setting to write the SOP—this just seemed ludicrous and irresponsible. I’m sure that if I had gotten off track, they would have told me, and the revisions suggested by Dr. Vun served that purpose.


On the upside, completing the project gave me the opportunity to read about many policies of NCHADS and to learn about a variety issues and multi-sectoral responses to social care, pediatric HIV/AIDS care, the overall status HIV/AIDS care in Cambodia, and the status of OVC here.



  1. msoule said,

    WOW. tons of info and details and what a lot to chew on and ruminate about! Sweet. A few thoughts and questions that arose while reading your post:
    How does competition between NGOs for funding create gaps in identifying OVC? Because the NGOs are unccordinated? Can you outline a little bit of how this happens?
    What goes on at the meetings that you described (where PLWHA, hospital heads, NGO reps, etc are meeting)?
    Sounds like there needs to be some norm-shifts in the community of monks that allows HIV+ women to reveal their status. What’s the atmosphere like there for women at risk? (This dovetails nicely with the discussion going on about gender ratios in India!)
    That condom use rate among brothel-based sex workers is amazing! Is it true?
    And finally, you just have to have faith that you are the right person for the job. They wouldn’t have asked you if you weren’t competent (we hope) and it doesn’t do you any good to second-guess your skills. Also, this is what you studied for so many years at school and you wrote your thesis about stuff like this! So as someone who knows you, I’d say you’re quite qualified. All the better that you’re not a career policy guy, I think. That way you see beyond the boundaries they might stop at, right?
    Hot work, man. Way, way hot.

  2. misarita said,

    I’m superbly impressed with what you’re up to. As someone who doesn’t know you, can I ask why your thesis was on?

    I’m also impressed by the condom rates among sex workers. I heard of an example here in India where they have close to 100% coverage in one area where sex workers are in high demand. They managed to get the women to bond together and promise that everybody would insist on using condoms, so that nobody would be losing business because of trying to protect herself. Any idea how they got such high coverage? Given that much of the transmission in developing countries goes from sex workers to men to their wifes to their children, that seems like a good model to begin with to cut down transmission.

  3. msoule said,

    This may (Lee, correct me if I’m wrong) be a difference in the status of women’s power in each society. It would take a long study to determine what the real differences are. But let’s have a little roughshod go at it. Lee, what would you say the place of women in Khmer society is?

  4. Lee said,

    Hi Sarah, Michael, and anyone else reading,
    Sorry it’s taken me a week to respond. Responses are divided up by question.

    **How does competition between NGOs for funding create gaps in identifying OVC? Because the NGOs are unccordinated? Can you outline a little bit of how this happens?

    Sorry for not clarifying in my previous post. First of all, competition is not just between NGOs but within the whole system of funding for Global Health—Foundations, IOs, and NGOs who are both recipients and purveyors of funding. Essentially, because everyone is competing for scarce resources, all funding and grant proposals must outline exactly how a particular project is unique, necessary, and provides a service where there was previously a void. At least these is the complaints of those I’ve talked to in the Gov and NGO sector in Cambodia. The fear of overlapping projects and funding is so high that it creates cracks, with the obvious and unfortunate consequence of people falling through the cracks.

    In my context, funders are more scared of “double-dipping” by impoverished PLHAs than of establishing an adequate and comprehensive Continuum of Care. There has been a lack of coordination between different projects—between Home-Based Care (HBC) teams and monks providing social care to OVC in the area, for instance. In this case, HBC teams often fail to notify a pagoda or the local NGO providing the pagoda’s social care funding when a parent dies. Support is cut off for the children in the family precisely because the parent dies and the child becomes an orphan! It may take over a month before that child is identified as OVC and gets hooked into social care services.

    One of the purposes of the SOP I was working on was to provide that needed coordinating mechanism and promote linkages between various sectors—between HBC teams and OVC social care teams, between OVC identification and getting those kids tested so they know their HIV status and can be treated if necessary, and between OVC social care and the existing psychosocial support services for children living with HIV/AIDS.

    **What goes on at the meetings that you described (where PLWHA, hospital heads, NGO reps, etc are meeting)?

    Well, I don’t know what happens at similar multisectoral meetings regarding pediatric AIDS care. But the proposed agendas for these meetings includes:

    • How many OVC exist in the Operational District (OD—covering around 10 or so villages each)
    • How many new OVC have been identified during the month
    • How these OVC are being identified
    • How organizations are coordinating OVC social care support groups
    • How these OVC support groups are implementing social care
    • What components of social care are being provided successfully, and
    • How social care can be improved

    **Sounds like there needs to be some norm-shifts in the community of monks that allows HIV+ women to reveal their status. What’s the atmosphere like there for women at risk? (This dovetails nicely with the discussion going on about gender ratios in India!)
    **Lee, what would you say the place of women in Khmer society is?
    **That condom use rate among brothel-based sex workers is amazing! Is it true?

    The atmosphere for women at risk—it’s difficult for me to assess. I don’t really work on the prevention side of things and I’ve only been here for a couple of weeks and don’t speak Khmer, but I can provide some initial impressions.

    In Cambodia, there is a huge (but gradually receding) stigma against PLHAs. The stigma is more severe for women. Women’s place in Cambodian society is to be, essentially, very proper and quiet. They are not supposed to wear revealing clothing, they are never to drink alcohol, and their ability to maneuver across society is pretty reduced compared to men. In NCHADS, there are few women working in positions requiring a degree or title, though there are a few female doctors. I have an Australian female friend who works in the national drug prevention center, and she is one of two women working in that whole office (a total of one Cambodian). At the same time, there is a sector of women who work as waitresses, sales clerks, in big offices for real estate and business, etc.

    There’s an enormous sex-worker sector here—beer girls, karaoke girls, casino girls, barmaids, masseuses, brothels. It’s such a substantial sector that, though the work is looked down upon, there seems to be a general understanding that the motivation for sex work is directly one of economic necessity. There is greater protection and support for brothel-based sex workers, possibly because of the ease of identification and targeting them for government-led programs. For these women, NCHADS has provided HIV education, reproductive health education, condom use education, counseling services and, like in India, a certain decided-upon solidarity. NGOs and IOs support and augment the government’s activities. 100% CUP programs have been pretty successful with this sector of the population, with estimates of 90-95% use.

    Unfortunately, the majority of sex workers are non-brothel-based (I don’t know exact percentages), and the condom-use rate is only at about 55% for these women. Thus, the greatest risk, and the least support, is for these women. Transmission of HIV is typically through sex workers to men to their wives to their children. Often, there’s little support for at-risk women, whether or not sex workers. Because the “proper” role of Cambodian women is one of, to greater and lesser extents, docility and submission, any woman who contracts HIV is “improper.” Meanwhile men, especially police officers in Cambodia, visit many sex workers (Gov programs have tried to target police officers with HIV education, with some success—the number of police officers who have visited a sex worker in the last year is estimated to have dropped to 50%, which is still very high).

    Due the subordinate status of women and the lack of other economic and social opportunities available to them in Cambodia, support for women at risk is minimal.

    As I learn and experience more here, I’ll keep everybody updated on this issue.

    **Can I ask why your thesis was on?

    I concentrated in Development Studies, and my thesis analyzed social structural transformations caused by rural-urban migration in a small coastal village in Ecuador. It principally used notions of social capital to understand changes in the intra-group bonds and external linkages of the community. It only cursorily looked at health issues—briefly mentioning illnesses carried back by return migrants and how these shaped rural notions about the urban experience and the decision to migrate.

    Global health is an interest that struck me halfway through Burden of Disease in Developing Countries, 1st Semester Senior Year. Between that class, my Development Studies interests, my experiences with Family Health Desk at RI Hospital, and analyzing myself, I decided to explore the world of global health to see if it will be something that will sustain my interest and hard work and devotion in the long-term. I’m certainly challenged and engaged by my work and life every day in Cambodia!

  5. rajesh said,

    Nice information .thank you so much.HIV Aids Treatment

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