Handicap International – Cambodia Programme © Éric Martin / Le Figaro / Handicap International Study on Sustainability in the Physical Rehabilitation Sector: Cambodia Perspective Nepal, January 2013 Dr. Vivath Chou

Outline of the presentation Context Participation in the study Inputs from the study Limitations How Handicap International made use of the study’s findings Key questions

Country context Population: 15,3 million (IMF 2012) Surface Area: 181,035 Km 2 Population density: 81.8 p./Km 2 Sub-devisions: 24 provinces Average income: US$1.5/day HDI: 0.523

Rehabilitation sector context Physical rehabilitation centres (PRCs) supported from the 1990s by a variety of INGOs More than 50% of disabled population are children. Evolution of the PRC patients profile overtime. Research implemented in 2006 with EU support estimates 150,000 persons are at need of assistive device, 90% located in rural areas End 2011, more than 64,000 landmine casualties. Around 50% of PRC clients in the country gets amputation Absence of sector policy resulting in no standardisation of management and monitoring tools

Context : Handicap International (HI) history & coverage HI involved in the rehabilitation sector since 1992 supporting 5/16 PRCs established Rehabilitation network created following major humanitarian crisis= Khmer Rouge period, country highly affected by landmines and cluster munitions Process of handover to the Government – formalised with a MoU signed for the period of At the time of the study, HI France and HI Belgium were managing 3 out of 11 PRCs

Participation in the study –Initial research field missions organised in 2009 Comparison studies on 3 HI PRCs completed 1 day workshop conducted to understand what sustainable PRCs meant to different actors, to further explore the handover process and to identify the main actors of the rehabilitation sector –In 2010 a workshop was organised with all the actors to define sustainability and identify common core sustainability indicators.

Inputs from the study Opportunity for all stakeholders to understand the sustainability concept Opportunity to define the different dimensions of sustainability Opportunity to reflect PRC (centre based) into the national context (sector based)

Limitations MoSVY was not involved into the process The indicators were not designed to serve as a monitoring matrix and support a system of control from national level that should come along the principle of delegation Too many indicators, some beyond the scope of the rehabilitation sector with little input for improving the piloting of the sector Some indicators are hardly manageable into the political context / unrealistic

Limitations Some indicators were embedded into standardised procedures that at the time of the study did not exist / feasibility The notion of quality of services is too broad and is questionable. Supposes that agreed references are set / affordability, acceptability The impact of rehabilitation upon the clients not considered

Limitations Technical / operational / administrative / financial requirements for implementation not addressed Indicators addressing health outcomes (number of clients) and outputs of health service delivery (productivity) were included into routine M&E; other indicators developed under quality assurance system remained outside this frame Indicators were not operationalized Responsibilities for data collection & analysis were not identified

How Handicap International made use of the study’s findings To input into the quality assurance system deployed at Kampong Cham PRC overtime To advocate for needs vs coverage study To develop the framework of a study assessing the impact of the handover in one PRC managed by HI Main indicators used reflect management of the PRC vs sector

Rehabilitation services analysis

How can we better consider users and community based organisations into sustainability framework ? –for measuring performance ? –For contributing to the sustainability of the system ? How can minimum standards for viable and affordable service delivery be established? What is the necessary pre-requisite for setting monitoring systems ? How can links between rehabilitation and health systems be developed to ensure continuum of care and better conditions for sustainability ? Key questions