5-311-502

ROBERT C. WOLCOTT

The Cambodian National HIV/AIDS Program:

Successful Scale-Up through Innovation

Late one evening in January 2005, Dr. Mean Chhi Vun, head of Cambodia’s National Center
for HIV/AIDS, Dermatology and STD (NCHADS), sat in his Phnom Penh office and pondered
how to further expand care and treatment programs in his nation.

NCHADS had accomplished much since its establishment in 1998, but Cambodia’s citizens
still relied on its programs to keep HIV/AIDS under control and to stop it from escalating. Dr.
Vun needed to make a decision about proceeding with critical initiatives to control the spread of
the disease and save the lives of thousands of Cambodians who were dying from it each year.

Dr. Vun was concerned about three particular areas. First, he needed to improve logistics and
supply management in order to get the best prices and ensure patients had access to life-saving
medicines. Second, he needed to decide how to quickly and cost-effectively improve the national
HIV/AIDS laboratory support infrastructure. Finally, he needed to figure out how to provide
sustainable care and treatment to the thousands of Cambodian children living with HIV/AIDS.

Cambodia
The Kingdom of Cambodia, which bordered Thailand, Laos, and Vietnam in Southeast Asia,
was similar in size to the U.S. state of Missouri and had a population of more than thirteen
million in 2008 (Exhibit 1).1 Its capital, Phnom Penh, had a population of 1.3 million, with an
urbanization rate of 8.4 percent, one of the highest in the world. Despite the recent high growth of
its urban population, Cambodia was still predominantly rural—83 percent of Cambodians still
lived outside cities.2

Cambodia was the product of a troubled history. In 1975 the Khmer Rouge came to power
and conducted a brutal campaign to transform Cambodia into a “model” agrarian society. This
campaign included emptying cities and exterminating intellectuals and other professionals.
Nearly two million Cambodians were estimated to have died under Khmer Rouge rule by 1979,
when the Vietnamese military successfully defeated the Khmer Rouge and established the Heng
Samrin government and the People’s Republic of Kampuchea (PRK).

1
National Institute of Statistics, Ministry of Planning, “General Population Census of Cambodia 2008,” August 2009,
http://www.stat.go.jp/english/info/meetings/cambodia/final_br.htm.
2
World Bank, http://siteresources.worldbank.org/inteapregtopurbdev/Resources/Cambodia-Urbanisation.pdf.

©2011 by the Kellogg School of Management at Northwestern University. This case was prepared by Alex Hurd ’11 and Stephanie
Wolcott under the supervision of Professor Robert C. Wolcott. Cases are developed solely as the basis for class discussion. Cases are
not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. To order copies
or request permission to reproduce materials, call 847.491.5400 or e-mail cases@kellogg.northwestern.edu. No part of this publication
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CAMBODIAN NATIONAL HIV/AIDS PROGRAM 5-311-502

The next two decades were marked by international isolation, including a United Nations
embargo and civil war between the PRK and remnants of the Khmer Rouge. The country began
to open once Vietnamese troops started withdrawing in 1989. The trend continued after the fall of
the Soviet Union, which had been the main source of funding for the Heng Samrin government.

In 1991 the Paris Peace Agreement was signed, ending the civil war and paving the way for
the inflow of foreign aid3 and an ambitious reconstruction campaign under the supervision of the
UN Transitional Authority in Cambodia. Despite this campaign, 2007 figures showed Cambodia
to be one of the poorest countries in the world, ranking number four on the list of least developed
countries in Asia.4

Cambodia’s Healthcare System

The Khmer Rouge destroyed the entire healthcare system—equipment, supplies, and
personnel. By 1979 it was estimated that only a few dozen medical doctors had survived, as the
regime had targeted educated professionals for elimination. After the defeat of the Khmer Rouge,
the new and fragile government faced a disastrous situation. Most major infrastructure, including
hospitals, had been destroyed. Lack of adequate water, sanitation, education, transportation, and
communication caused huge problems in the reestablishment of health services. Besides
geographic and physical barriers, trained health personnel from Phnom Penh were reluctant to be
isolated in distant locations.5

With the help of the World Health Organization (WHO) and the World Bank, Cambodia’s
public health system was restructured in the 1990s into three levels of facilities: provincial
hospitals, operational district referral hospitals, and community health centers. Provincial
hospitals offered the highest level of public care. Provinces were divided into several operational
districts, a division specific to the healthcare system. Each operational district typically had one
small district-level referral hospital and an average of eleven health centers. Each health center, in
turn, served several villages—around 13,500 people on average.6

HIV/AIDS
HIV (human immunodeficiency virus) is a virus that gradually attacks cells in the immune
system. AIDS (acquired immunodeficiency syndrome) refers to the most advanced stages of HIV
infection, which can be accompanied by any of twenty opportunistic infections or HIV-related
cancers. The U.S. Centers for Disease Control and Prevention (CDC) defined AIDS on the basis
of a CD4 positive T cell count of less than 200 per mm³ of blood.

3
Markus Bühler, David Wilkinson, Jenne Roberts, and Tap Catalla Jr., “Turning the Tide: Cambodia’s Response to HIV & AIDS,
1991–2005,” Joint United Nations Programme on HIV/AIDS (UNAIDS), August 2006, p. 27, http://data.unaids.org/pub/Report/2006/
20060801_cambodia_turning_tide_en.pdf.
4
UN Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries, and the Small Island
Developing States (UN-OHRLLS), “Least Developed Countries,” http://www.unohrlls.org/en/ldc/25 (accessed October 10, 2011).
5
The government has made much progress, but in 2005 many provincial hospitals lacked antibiotics, other medicines, and cold
storage facilities, so vaccine distribution—already difficult due to transportation problems—was very challenging.
6
Cambodia Ministry of Health, “Administrative and Health Facility Mapping: Health Coverage Plan 2004–2005,” Phnom Penh,
Department of Planning and Health Information.

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Since the first cases of AIDS were reported in 1981, more than 25 million people worldwide
had died from the disease. As of 2009, there were more than 33 million people living with
HIV/AIDS, with more than an additional two million new cases each year.

There is no cure for AIDS. Once HIV progressed to AIDS, patients without proper treatment
typically survived six to nineteen months.7 With antiretroviral (ARV) treatment, a patient’s
survival rate rose 80 percent and the death sentence was converted into a manageable chronic
disease. ARVs were most effective when multiple types were combined, preventing the virus
from building resistance. This type of therapy was called highly active antiretroviral therapy
(HAART). If ARVs were not taken regularly, the virus mutated, making it even harder to treat.
Missing just one dose of scheduled ARV intake drastically reduced the effectiveness of the
treatment and the patient’s survival rate, so strict adherence was essential for patients on HAART.

HIV/AIDS in Cambodia

The first HIV-infected person in Cambodia was officially diagnosed through serologic
screening of blood donations in 1991. The HIV/AIDS epidemic spread rapidly, causing
Cambodia to have the highest national prevalence of HIV in the adult population (ages 15–49) of
Asia by 1998 (Exhibit 2).8 It was estimated that in 1997/98 approximately 3 percent (more than
150,000 people) of Cambodia’s adult population was living with HIV/AIDS.9 Nearly one hundred
Cambodians were infected every day. In 2003 Cambodia had one of the highest prevalence rates
outside of sub-Saharan Africa (Exhibit 3).10

Unlike many other countries, which were slow to acknowledge the disease, Cambodia moved
quickly and made a strong commitment to the prevention, care, and treatment of HIV/AIDS.
Because of the Khmer Rouge and decades of civil war, however, Cambodia had neither a well-
functioning public health system nor a stable political environment, which substantially
complicated its response.11

In 1993 the government created the National AIDS Program to implement a strategic plan.
Renamed in 1998 as NCHADS, it represented a comprehensive national response to the
HIV/AIDS epidemic. Dr. Vun was appointed the first head of NCHADS in 1998.

Dr. Mean Chhi Vun

Dr. Vun was born in the 1950s in Battambang, a provincial capital 300 kilometers northwest
of Phnom Penh. He began his medical studies at Phnom Penh University in 1972. The day the
Khmer Rouge marched into Phnom Penh in 1975, Dr. Vun quickly disposed of his glasses; the
regime identified glasses as symbols of intellectualism and often conducted on-the-spot
executions of anyone wearing them.

7
UNAIDS/World Health Organization, “AIDS Epidemic Update,” December 2001, http://www.who.int/hiv/facts/en/
isbn9291731323.pdf.
8
Vonthanak Saphonn et al., “Current HIV/AIDS/STI Epidemic: Intervention Programs in Cambodia, 1993–2003,” AIDS Education
and Prevention 16, Supplement A (2004): 64–77.
9
Ibid.
10
UNAIDS, “Report on the Global AIDS Epidemic: 4th Global Report,” June 1, 2004, http://www.un.org.np/node/10254.
11
Bühler, “Turning the Tide,” p. 6.

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Initially Dr. Vun survived by pretending to be a bricklayer. Later he was sent with the
majority of the population to work in the rice fields in rural Cambodia. It was not until early
1980, following the liberation of Phnom Penh by Vietnamese forces, that Dr. Vun was able to
return to the capital to continue his studies.

In 1984 Dr. Vun earned his degree as a medical doctor. The following year the Ministry of
Health sent him to Ratanakiri, Cambodia’s most remote province, located along the country’s
border with Laos and Vietnam. Travel between Phnom Penh and Ratanakiri required four to five
days; given that large stretches of Cambodia’s northeastern territory remained under Khmer
Rouge control, travelers had to cross the border into Vietnam. No direct communication with the
Ministry of Health was possible—the only way to communicate with Phnom Penh was two-way
radio through the Ministry of Defense.

Dr. Vun was named hospital director in one of the province’s main cities. When he arrived he
found the Khmer Rouge had destroyed the hospital building, making him a hospital director
without a hospital. Dr. Vun improvised, as he would frequently throughout his career, and began
conducting everything from surgery to labor and delivery to pediatric care in temporary locations.
He also introduced the concept of employing community health workers. Eventually he received
resources to build a new hospital, and in 1987 became the provincial health director for
Ratanakiri. His team began building hospitals and health posts throughout the province.

In 1990, after six years in Ratanakiri, the Ministry of Health brought Dr. Vun back to Phnom
Penh to head the National Immunization Program. With the financial backing of Rotary
International, the UN International Children’s Fund (UNICEF), and the Global Alliance for
Vaccines and Immunization, Dr. Vun organized a national polio vaccination campaign. Drawing
on his experiences with mobilizing health workers, setting up surveillance systems, and attracting
reluctant patients in Ratanakiri, Dr. Vun led the polio eradication program with great success. The
last case of polio in Cambodia was identified in 1997.

In 1995 the University of New South Wales extended a scholarship to Dr. Vun for a one-year
master’s degree program in public health. It was during his stay in Australia that Dr. Vun learned
English and gained some familiarity with management theory.

When he was asked by the Ministry of Health to lead NCHADS in 1998, Dr. Vun was
reluctant to take the position because he was still busy with the polio eradication campaign.
However, he understood that AIDS had the potential to undo the delicate healthcare advances that
the newly established Cambodian government had achieved since the fall of the Khmer Rouge, so
he decided to accept the ministry’s appointment.

As NCHADS director, Dr. Vun built on the efforts of the charismatic Dr. Tia Phalla, who, as
head of the previous National AIDS Program, had succeeded in raising the profile of the HIV
threat in Cambodia and mobilizing political leadership to support the program. By 2005,
however, Cambodia needed to build institutions that could deliver a sustainable, effective national
program.

NCHADS’s Approach
As soon as Dr. Vun took command of NCHADS, he gathered as much information as
possible before formulating a strategy. He first explored the epidemic, in particular how it was

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spreading and how it might be managed. In line with advice from international experts, NCHADS
first focused on decelerating the spread of the disease. Once NCHADS had made progress on that
front, it planned to work on identifying and assisting infected individuals.

In 1998 wide-scale treatment of infected individuals was not a realistic option because of lack
of resources.12 The NCHADS strategic approach between 1998 and 2005 consisted of three
phases:

 1998–2000: Sharpen focus on prevention activities for high prevalence populations

through the 100 percent Condom Use Program (CUP).
 2000–2003: Establish and expand the Voluntary Confidential Counseling and Testing
(VCCT) network to identify HIV-infected individuals.
 2003–2005: Launch the Continuum of Care (CoC) model and initial expansion of
nationalized care and treatment of people living with HIV/AIDS.

Phase 1: Initial Plan (1998–2000)

Research in the late 1990s indicated that the epidemic in Cambodia was concentrated around
the sex industry, with brothel-based female sex workers displaying a 20.8 percent prevalence rate
in 2003.13 This led to prevention programs such as CUP, which had been successfully rolled out
in Thailand a few years before. NCHADS launched the program to provide support and services
to sex workers and their clients. The sex industry provided a key focus for intervention, as
significant levels of HIV transmission in Cambodia were reported between sex workers and their
clients; once infected, men could spread the disease outside the sex industry to their spouses or
girlfriends. HIV-infected women in turn could, if they became pregnant, pass the disease to their
children during pregnancy, at birth, and while breastfeeding.

Dr. Vun focused on building an organization that was transparent and efficient, promoted
hard work, and isolated political appointees who were interested in illicit personal gain. With the
support of his trusted long-term advisor, Peter Godwin, Dr. Vun’s team developed a functional
task analysis for every department within NCHADS, including outlining responsibilities for every
position within the organization. He had each department issue standard operating procedures for
every major activity under its purview. This became useful for training new staff and providing
transparency for day-to-day operations. Standardization was also important for managerial and
quality control and allowed for decentralization of activities to provincial and district levels.

In addition, Dr. Vun adopted an organizational strategy that emphasized planning and
reporting at all levels. Based on targets set in the strategic plan, NCHADS and provincial health
authorities developed annual operational plans and budgets, using a standardized format linked to
an electronic financial management system that integrated all activities and sources of funding
into a single comprehensive work plan. This work plan was then reviewed twice a year at all
levels for progress.

12
This would change dramatically only five years later, when advancements in science and production of cheap ARV medicines
would allow millions of infected individuals around the world to benefit from life-saving treatments.
13
Chhuon Samrith and Saphonn Vonthanak, “Report on Sentinel Surveillance in Cambodia 1998,” NCHADS, Ministry of Health,
Cambodia, http://www.nchads.org/Publication/HSS/HSS1998.pdf.

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Phase 2: Voluntary Confidential Counseling and Testing (2000–2003)

After the successful rollout of CUP, NCHADS shifted programmatic attention to laying the
foundation for comprehensive HIV/AIDS patient care. The team established a system allowing
individuals to voluntarily seek counseling and testing in a confidential setting. NCHADS’s vision
was to eventually have a VCCT center within a 15-kilometer radius of every citizen. In order to
allow for immediate referral into the health system, it located VCCTs within hospitals and health
center grounds.

Once these centers proved effective, NCHADS quickly began opening new VCCTs with the
support of donors and partners, expanding the network from seven locations in 1998 to seventy-
four by the end of 2003. Though the coverage of centers for testing expanded rapidly, NCHADS
was not yet ready to offer widespread comprehensive treatment for HIV/AIDS through the public
healthcare system; at this stage in the national response, it focused primarily on secondary
infections and other sexually transmitted diseases (STDs).14

Phase 3: Launching the Continuum of Care (2003–2005)

With prices falling dramatically for ARVs around the world and the mobilization of new
resources such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, comprehensive care
and treatment for people living with HIV/AIDS gradually became possible. Eager to expand
treatment to all Cambodian citizens living with HIV/AIDS, NCHADS set out to sustainably
deliver treatment services nationwide.

With the help of national and international partners, NCHADS developed its comprehensive
CoC treatment model and launched it at a pilot site in 2003 (Exhibit 4). The CoC established a
set of guidelines and procedures for staff at health facilities to refer HIV-positive patients to
treatment clinics, to link patients to NGOs (non-governmental organizations) providing financial
and psychosocial support, and to connect them with support network organizations for people
living with HIV/AIDS. The CoC included clear treatment, professional conduct, and behavioral
guidelines to all medical and non-medical staff in order to reduce stigmatization of people living
with HIV/AIDS; it also included a rigorous training program for all CoC positions. Oversight of
CoC teams was delegated to provincial boards consisting of senior representatives of provincial
government, the health sector, NGOs, and people living with HIV/AIDS. The involvement of
senior provincial and district leaders proved to be an additional effective tool to combat stigma
and discrimination. Following the successful launch in 2003, NCHADS replicated the CoC at
eighteen new sites in 2004 and planned to double its footprint by the end of 2005 (Exhibit 5).

Dr. Vun’s vision for NCHADS and the expansion of Cambodia’s national HIV/AIDS
program was based on five pillars: ownership, good partnerships, integration, decentralization,
and community participation (Exhibit 6).

14
Fortunately, several NGOs had been able to initiate limited treatment of HIV/AIDS during this phase. Médecins du Monde had
pioneered care and treatment, setting up an outpatient department for HIV co-infections in collaboration with a Phnom Penh hospital
in 1995 and introducing ARVs in 2000. Médecins Sans Frontières set up another HIV/AIDS clinic in Phnom Penh in 2000/01. By not
only keeping patients alive but also returning them to a relatively healthy, productive life, these initiatives demonstrated the
effectiveness of treatment intervention. John Tucker, a missionary at Maryknoll Orphanage, could not bear the sight of children dying
from AIDS. In the absence of wide-scale treatment offerings by the government in 2001, he began smuggling pediatric doses of ARVs
from Thailand to become one of the first sites in Cambodia to treat children living with HIV/AIDS. These initial treatment models,
though effective, proved costly due to the use of foreign doctors and branded medicines.

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OWNERSHIP

Significant time and resources were spent on explaining the vision of the program to all
partners and implementers in the field, allowing them avenues to comment and contribute their
perspectives. At all levels of the program, from the Ministry of Health headquarters in Phnom
Penh to the most remote health post, Cambodians felt a strong sense of “owning” the program,
making them both proud and genuinely accountable. Strong political backing at the highest levels
of government also strengthened the sense of ownership. National leaders often referenced
HIV/AIDS in their communications, and senior members of the Ministry of Health conducted
frequent visits to provincial- and district-level sites. Finally, standardized, easy-to-understand
policies and guidelines developed on evidence-based findings, international best practices, and
the input of all stakeholders made maintaining the program’s quality of services relatively easy.

GOOD PARTNERSHIPS

NCHADS was very pragmatic in its approach to inviting international and local partners to
contribute to the success of the national program. Anyone interested was able to join the mission
as long as they agreed to follow its leadership and standard implementation model. Because of his
sure vision and management skills, Dr. Vun was able to identify where such technical assistance
would be most useful, and how to use it not only to solve an immediate technical issue but also to
build the capacity of his own, Cambodian staff.

Years later Dr. Vun explained his approach to external support offers: “We never say ‘no’;
we never say ‘yes.’” External partners were eager to work with NCHADS, which had established
a strong culture of participative decision making and teamwork: all major decisions were reached
by consensus within technical working groups and strategy committees. Partners recognized and
appreciated NCHADS’s transparency and accountability in all its programmatic and financial
aspects.

INTEGRATION

While many interventions initially started in isolated settings, NCHADS made strong efforts
to continuously bring all activities and services into the existing healthcare infrastructure and
systems. NCHADS used existing facilities and healthcare personnel and applied new resources
toward infrastructure upgrades and training of current personnel instead of establishing separate
systems. By doing this, NCHADS fostered a culture of cooperation between different power
groups at national, provincial, and hospital levels. For example, instead of offering stand-alone
pediatric HIV/AIDS care and treatment services, NCHADS chose to integrate pediatric HIV into
general pediatric services. Resources from the HIV/AIDS program were used to revitalize general
pediatric services in hospitals with success and sustainability.

DECENTRALIZATION

Operationally, NCHADS trained provincial teams how to develop annual work plans and
submit them to NCHADS for funding and routine follow-up. Financially, NCHADS had a strict
policy of annual budget planning cycles. Funds were directly linked to operational work plans,
and managers were held accountable for meeting their goals and responsibilities.

COMMUNITY PARTICIPATION

From the onset of the program, PLHA (people living with HIV/AIDS) were invited to
actively support the NCHADS mission and support their peers. Many found employment in peer

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support groups and local NGOs. MMM, a local support group (the acronym MMM stood for
“Friends Helping Friends” in Khmer language), was established at all CoC sites and held monthly
meetings with PLHA, healthcare staff, NGOs, and government, religious, and community leaders.
The MMMs offered an open forum for PLHAs to express concerns and highlight problems within
the system. PLHAs received financial support to attend these meetings, and all attendees received
a free lunch.

Driving Further Expansion

By 2004 NCHADS had more than 100 staff and well over 120 partner organizations, ranging
from large bilateral/multilateral donors such as USAID and the Asian Development Bank, to
academic institutions such as UCLA and Brown University, to local NGOs such as the Khmer
HIV/AIDS NGO Alliance and the Cambodian People Living with HIV/AIDS Network. In the
summer of 2004 NCHADS was awarded substantial new funding from the Global Fund, allowing
for major scale-up initiatives for mid-2005 in three key areas: improving access to supplies and
logistics management of ARVs and other health supplies, enhancing the national laboratory
infrastructure, and introducing pediatric HIV/AIDS care (Exhibit 7).

Improving Access to Laboratory Testing

One of the first steps in the national treatment protocol outlined for recently identified
HIV/AIDS patients was an initial medical exam followed by a CD4 test to determine eligibility
for treatment. Once a patient’s CD4 count dropped to less than 200, guidelines called for
automatic initiation of ARV treatment. Without access to CD4 testing, doctors relied entirely on
judgment, and many hesitated to prescribe ARVs due to unfamiliarity with this novel treatment.
The lack of a widespread and functioning CD4 laboratory system therefore had proved to be a
critical barrier to initiating treatment.

NCHADS had long desired to build a national CD4 testing system, with regional hospitals
owning diagnostic equipment and covering the testing needs of surrounding CoC sites.
Unfortunately, NCHADS had only been able to secure funding for the purchase of two CD4
machines as part of its Global Fund grant. Many of the NGOs had secured separate funding to
buy their own CD4 machines. As Dr. Ly Penh Sun, deputy director at NCHADS, noted:

Building national CD4 testing capacity was one of our main priorities for 2005. At the
time, the Pasteur Institute was the only laboratory in Cambodia that could produce
reliable CD4 tests. The price per test they charge us is about 10 to 15 dollars, which is
quite high. In order to scale up the public health program aggressively, we needed to
build our own capacity.

In discussions with representatives of a leading CD4 equipment provider in late 2004, Dr.
Vun was informed of the possibility of leasing equipment instead of purchasing it. NCHADS
would receive four CD4 machines free of charge as part of the leasing arrangement for a three-
year period, and had to agree to purchase an annual minimum threshold of CD4 reagents
(necessary for running a CD4 test). In order to meet the minimum threshold, NCHADS had to
design a regional referral network so that all CoC sites could have access to testing. In addition,
NCHADS had to ensure that all CD4 tests would be run on the leased equipment in order to
secure the minimum annual testing threshold. This meant that the NGOs that had secured funding

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from the Global Fund to buy their own equipment would need to be convinced to not buy any
additional equipment and instead use the public health laboratory NCHADS was looking to
strengthen. In exchange, NCHADS would offer the NGOs access to testing at a nominal fee of
$0.25. The two possible options were:

 Option 1: Purchase two machines for the national program and place one in Phnom Penh
and the other at a site to be determined. In addition, NGOs would procure machines for
their own sites, most of which were in Phnom Penh.
 Option 2: Lease CD4 machines15 and install the equipment in geographically dispersed
locations to ensure regional coverage for all CoC sites. This option carried a contractual
obligation by the Cambodian government to purchase a fixed amount of reagents per
year, albeit at a special price. If minimum thresholds were exceeded, per-reagent pricing
would fall to lower levels.

Managing Logistics

Logistics planning and supply management for ARVs and HIV/AIDS supplies represented
the most problematic area for care and treatment programs around the world. ARVs represented
the largest single cost driver. The difficulty arose from the limited shelf life of ARVs (generally
two years from manufacturing date) and the fact that missing a single dose of ARVs could lead to
resistance to treatment and the spread of mutated forms of AIDS, for which the national treatment
protocols would no longer prove effective. Further complicating matters, some of the ARVs and
laboratory reagents required refrigeration at all times.

The Ministry of Health’s warehousing, distribution, and logistics system was run by Central
Medical Stores (CMS), an arm of the ministry that had displayed many weaknesses in structure
and human capacity and was plagued by a lack of transparency. There were frequent irregularities
in the arrival dates and times of CMS distribution trucks and in the quantities of medicines
distributed. It was also not uncommon for CMS to deliver expired medicines to hospitals. In light
of this, NGOs typically set up their own procurement and distribution system for the sites they
supported and took care of the entire supply chain cycle, from purchase of the goods to final
delivery to the patient. This proved reliable but inefficient overall, as each NGO had to replicate
this function.

NCHADS’s ability to carry out nationwide logistics was limited and already overwhelmed.
As Dr. Prok Kaheanh, head of the logistics unit, explained:

We are stretched to our limits. Our small warehouse is completely full and we have only
two people in our team, including myself, plus a warehouse manager. We have our hands
completely full just with distributing HIV/AIDS diagnostic tests to all the VCCT sites. We
currently only manage a relatively small quantity of ARVs. We don’t have the capacity to
forecast and track demand—that is the NCHADS AIDS Care Unit’s job. I don’t know
how we are going to be able to take on more tasks without additional help.

15
U.S. medical technology company Becton Dickinson established this option under its Reagent Rental Program.

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Dr. Vun had recently met with representatives of the WHO and NGO community, who offered to
pay for additional staff and train the entire logistics team on how to forecast demand and set up
national distribution systems using basic technology, including spreadsheets and standard forms.

Moreover, the fragmented nature of ordering led to higher prices for ARVs in Cambodia than
in the rest of the region. Dr. Vun knew that in order to achieve the best possible pricing for ARVs
for patients in Cambodia, he needed to find a way to consolidate orders at the national level to
secure large enough volume to qualify for discounts. He also needed a system to reliably forecast
future ARV needs to avoid stock-outs and/or expiration of medicines.

Options for achieving these ambitious objectives were the following:

 Option 1: Continue current system, with every organization procuring and distributing
stocks independently.
 Option 2: Turn over the entire ordering and distribution system for ARVs and HIV/AIDS
supplies to CMS. Many forces within the ministry were pushing for this option.
 Option 3: Set up a national logistics management unit within NCHADS to coordinate
forecasting, ordering, and delivery of all ARVs and HIV/AIDS medicines and supplies to
CoC sites. This option faced significant resistance from some NGOs, who were hesitant
to give up control of this essential element of the care and treatment system to a
government entity that they did not trust. It also faced resistance from powerful forces
within the ministry who wanted to make sure CMS was given control. Moving forward
with this option would give NCHADS full control over ARVs, with the downside that
any stock-outs would fall directly on Dr. Vun’s shoulders and undermine everything
NCHADS had built up.

Providing Pediatric Care and Treatment

Care and treatment for HIV-positive children had recently become a topic of heated
international debate. Care and treatment programs for adults were starting to take off in countries
around the world, but there was a real concern about the apparent neglect of children born with
HIV/AIDS. Policy experts could not reach a consensus on the optimal delivery model for treating
children—meanwhile, hundreds of thousands of children worldwide were dying due to lack of
access to medication.

In Cambodia several NGOs, including Angkor Hospital for Children, Kuntha Bopha,
Maryknoll, and Médecins Sans Frontières, were already offering pediatric HIV/AIDS care and
treatment programs, but the government was not yet in a position to provide these services. Dr.
Vun was deeply concerned about the lack of services for children living with HIV/AIDS, but he
faced a critical political challenge on how to launch these services. The ministry had decided that
the National Pediatric Hospital should take leadership on pediatric HIV/AIDS care and treatment,
but the hospital’s leaders seemed preoccupied with other matters and were not proceeding quickly
on a scale-up.

Meanwhile, Dr. Vun was coming under mounting pressure from patients, support groups of
people living with HIV, NGOs, and the UN to take action. He was considering treating children
immediately at adult HIV/AIDS care and treatment sites with existing treatment protocols for

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adult patients. He realized, though, that doctors at many of these sites were already overburdened
with increasing numbers of adult patients. Appropriate protocols and measures for treating
children were still unclear at the time. The only site within the national system to actually treat
children was the National Pediatric Hospital, already stretched to its resource limit. Politically he
faced an additional challenge: if he moved forward on his own he risked creating powerful
enemies within the ministry, which would prove counterproductive in the long run. Dr. Vun was
anxious to get more assistance to children, but he wanted to make sure it was done properly and
sustainably.

The options he considered were:

 Option 1: Start treating children immediately at adult HIV/AIDS care and treatment sites
with existing treatment protocols for adult patients.
 Option 2: Allow the National Pediatric Hospital to establish a clear set of treatment
guidelines and use each CoC site’s pediatric service department, including doctors, staff,
and facilities, to provide pediatric HIV care and treatment.

Where To From Here?

Dr. Vun wondered how he should proceed. NCHADS had accomplished much in its brief
history, but the citizens of Cambodia and the region relied on the continued, expanded success of
its efforts. How should Dr. Vun manage logistics, improve access to laboratory testing, and
provide pediatric care and treatment?

He summarized the options in a brief table (Exhibit 8). The problems were complex and the
political pressures were intense—Dr. Vun needed to think creatively about the best solution for
each initiative.

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CAMBODIAN NATIONAL HIV/AIDS PROGRAM 5-311-502

Exhibit 1: Map of Kingdom of Cambodia

GEOGRAPHY
– Location : Southeast Asia
2
– Surface area : 181,035 km
– Border : Vietnam, Laos, Thailand
– Administration : 24 provinces/cities
– Capital : Phnom Penh
– Language : Khmer
– Religion : Buddhism (90%)
– Climate : Tropical climate (rainy/dry season)

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5-311-502 CAMBODIAN NATIONAL HIV/AIDS PROGRAM

Exhibit 2: HIV Prevalence Rate in Cambodia

HIV PREVALANCE RATE AMONG ADULT POPULATION IN CAMBODIA (AGES 15–49)

Source: Markus Bühler, David Wilkinson, Jenne Roberts, and Tap Catalla Jr., “Turning the Tide: Cambodia’s Response to HIV & AIDS,
1991–2005,” Joint United Nations Programme on HIV/AIDS (UNAIDS), August 2006, p. 27, http://data.unaids.org/pub/Report/2006/
20060801_cambodia_turning_tide_en.pdf.

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CAMBODIAN NATIONAL HIV/AIDS PROGRAM 5-311-502

Exhibit 3: HIV Prevalence Rates across Selected Countries in 2003

HIV PREVALENCE RATES ACROSS ADULT POPULATION (AGES 15–49) IN SUB-

SAHARAN AFRICA, ASIA, EUROPE, AND THE AMERICAS

Source: UNAIDS, “Report on the Global AIDS Epidemic: 4th Global Report,” June 1, 2004, http://www.un.org.np/node/10254.

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5-311-502 CAMBODIAN NATIONAL HIV/AIDS PROGRAM

Exhibit 4: Continuum of Care Model, 2005

ANC: Antenatal Care CBO: Community-Based Organization

HBC: Home-Based Care IPD: In-Patient Department

OPD: Out-Patient Department PMTCT: Prevention of Mother-to-Child Transmission

TB: Tuberculosis

Source: World Health Organization, The Continuum of Care for People Living with HIV/AIDS in Cambodia, Case Study, Perspectives in
Public Health, April 2003.

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CAMBODIAN NATIONAL HIV/AIDS PROGRAM 5-311-502

Exhibit 5: Map of Continuum of Care Sites, 2005

Source: Courtesy of NCHADS, 2005, Phnom Penh.

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5-311-502 CAMBODIAN NATIONAL HIV/AIDS PROGRAM

Exhibit 6: NCHADS Pillars of Success

Community
Ownership Good Partnerships Integration Decentralization Participation
 Clear vision  “We never say  Incorporate all  Train provincial  PLHA invited to
explained to all ‘no,’ we never say activities and teams to develop actively support
stakeholders and ‘yes.’” services into the annual work plans the NCHADS
all allowed to existing and have those mission and
contribute their  Teamwork and infrastructure and teams prepare support peers
perspectives culture of systems plans
participative independently  MMM established
 Political decision making  Apply new thereafter at all CoC sites—
commitment by resources toward forum for PLHA to
highest levels of  Transparency and infrastructure  Strict policy of express concerns
government accountability for upgrades and annual budget and highlight
all programmatic training planning cycles issues/problems
 Standardized, and financial at local CoC sites
easy-to-understand aspects  Foster culture of  Funds linked to
policies and cooperation operational work
guidelines  Anyone invited if between power plans and
they follow groups at managers held
NCHADS national, accountable for
leadership provincial, and meeting goals
hospital levels

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CAMBODIAN NATIONAL HIV/AIDS PROGRAM 5-311-502

Exhibit 7: NCHADS Budget, Fiscal Year 2005

NCHADS Work Plan 2005 Funding Sources Amount ($) % of Funding
NGOs in provinces (47) 5,287,640 38
Global Fund/NCHADS 2,608,923 19
UK Department for International Development 1,978,419 14
U.S. Centers for Disease Control 988,678 7
University of New South Wales 744,377 5
EUROPAID 687,175 5
World Bank 500,000 4
Cambodian National Budget 398,792 3
Clinton Foundation 221,600 2
AusAID 187,559 1
Asian Development Bank 97,204 1
World Health Organization 75,480 1
Family Health International 75,000 1
ITM 33,840 0
AHF 41,175 0
UNICEF 24,300 0
Global Fund/Pharmaciens Sans Frontier 17,600 0
Cambodia Treatment Access Program 16,440 0

Total 13,984,202 100

Source: Courtesy of NCHADS, 2006, Phnom Penh.

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CAMBODIAN NATIONAL HIV/AIDS PROGRAM 5-311-502

Exhibit 8: NCHADS Decisions and Options, January 2005

DECISION 1 DECISION 2 DECISION 3
Expanding National HIV/AIDS Laboratory Logistics and Supply Management for ARVs and Other
Support Infrastructure HIV/AIDS Supplies Pediatric HIV/AIDS Care and Treatment
Option 1 Option 2 Option 1 Option 2 Option 3 Option 1 Option 2
Government and NGO Establish national NGOs and Turn over ARV Establish ARV Treat children at CoC Focus on national
stakeholders CD4 lab system via government sites and HIV supplies and HIV supply sites immediately by pediatric AIDS
independently lease purchasing, ordering and management, adult physicians treatment guidelines,
purchase CD4 storing, and distribution to forecasting, and let National Pediatric
machines distributing ARVs CMS purchasing Hospital take lead
independently capacity within
NCHADS

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