an overview of nutrition sector activities in...

An Overview of Nutrition Sector Activitiesin Cambodia

Helen Keller InternationalCambodia

Helen Keller InternationalA division of

Helen Keller Worldwide

www.hkworld.org

www.hkiasiapacific.org

Special Report

An Overview of Nutrition Sector Activitiesin Cambodia

Helen Keller InternationalCambodia

In collaboration with theHelen Keller International Asia-Pacific Regional Office

Survey teamNathalie SimoneauSim ChhoeunTith DollaryNuon TySao Sovan Vannak

Editorial teamDora Panagides (Writer/Editor)Nathalie Simoneau (Writer/Editor)Saskia de Pee, Ph.D. (Editor)Regina Moench-Pfanner, M.Sc., Ph.D. (Editor)Martin W. Bloem, M.D., Ph.D. (Editor)Federico Graciano (Production Editor)Rino Hidayah (Layout & Design)

© 2002 Helen Keller Worldwide

Reproduction of part or all of this document is encouraged, provided dueacknowledgement is given to the publisher and the publication.

When referencing this publication, please follow the suggested reference below:

Helen Keller International/Cambodia. An Overview of Nutrition SectorActivities in Cambodia. Phnom Penh: Helen Keller Worldwide, 2002.

This publication was made possible through support by the Office of Health,Population and Nutrition, United States Agency for International Development(USAID)/Cambodia, under the terms of Award No. 442-G-00-95-00515-00. Theopinions expressed herein are those of the authors and do not necessarily reflectthe views of USAID.

Executive Summary ...................................... i

List of acronyms used in this report........................... iv

Acknowledgements ..................................... vi

Introduction ........................................... 1

Current Nutrition Situation................................. 2Vitamin A Deficiency ........................................ 2Iron Deficiency Anemia .......................................7Iodine Deficiency Disorders ................................... 10

Malnutrition.............................................. 11

Nutrition and Infectious Diseases ............................ 15Human Immunodeficiency Virus Infection ......................... 15Tuberculosis .............................................. 16

Malaria ................................................. 16

Inventory of Nutrition Interventions in Cambodia .................18Summary of government objectives and strategies in nutrition .......... 18Description of nutrition-related interventions ...................... 19Summary of findings of nutrition interventions in Cambodia ........... 19

Main constraints in conducting the nutrition activities ................24

Gaps and Priorities for Future Programming in Nutrition ........... 25Vitamin A Deficiency (VAD) ................................... 25Iron Deficiency Anemia (IDA) .................................. 25Iodine Deficiency Disorders (IDD) ...............................26Malnutrition ..............................................26

Infectious Diseases .........................................26

Recommendations ...................................... 27General recommendations .................................... 27

Specific program recommendations .............................28

Endnotes............................................. 33

Appendix I. List of organizations interviewed ...................... 35Appendix II. Summary table – Organizational profile and interventions ....36

An Overview of Nutrition Sector Activities in Cambodia 2002

Table of contents

Executive Summary

The health and nutrition situation in Cambodia is among the most critical inthe Asia-Pacific Region. In Cambodia, the infant mortality rate is

estimated at 95 per 1000 live births, the under-five mortality rate at 124 per1000 live births and the maternal mortality ratio at 437 per 100,000 livebirths. Malnutrition and micronutrient deficiencies, such as vitamin Adeficiency (VAD), iron deficiency anemia (IDA), and iodine deficiencydisorders (IDD), are widespread among preschool-aged children and women.Evidence shows that malnutrition, even in its milder forms, increases thelikelihood of mortality from a number of different diseases and can beassociated with up to 56% of all childhood mortality. This makes malnutritionone of the most serious public health problems in developing countries. Inaddition, infection with human immunodeficiency virus (HIV), tuberculosis(TB), and malaria, are serious public health problems in Cambodia. Theseinfections and malnutrition are inextricably related.

Various organizations are currently conducting nutrition activities in Cambodia;however, a clear understanding of the extent and nature of the interventionswas unknown. Given limited resources for nutrition programming, the newRoyal Government of Cambodia (RGC) Nutrition Investment Plan, and theneed for improved coordination in this sector, useful information on ongoingnutrition programs was necessary. Thus, this nutrition sector review wasundertaken to assess what is being done, where, and by whom. Based on thisinformation programming gaps, priorities, and recommendations are presented.

Information gathered from 58 governmental and non-governmentalorganizations (NGOs), and United Nations agencies, shows that the maininterventions being conducted in nutrition are nutrition education, foodsupplementation, vitamin/mineral distribution, growth monitoring,breastfeeding promotion, nutritional assessment, and homestead foodproduction. The major organizations involved with nutrition programs includethe MOH, UNICEF, WHO, WFP, HKI, and WV-C, and other importantcontributors include ADRA, CARE, FAO, GTZ, HU, LWS, PFD, RACHA,SC-A, and SC-F. The scope and scale of nutrition programs was found to belimited and, in general, there is a lack of coordination among programs andbetween organizations.

This review found that many organizations face the same types of constraintsin their efforts to conduct nutrition activities. These include limited human,material and financial resources. Another major constraint is the lack oftraining opportunities in nutrition for NGO and government health/nutritionstaff. This low level in staff knowledge was reported as an obstacle thatresults in reduced capacity to conduct extensive training and expand nutritioninterventions at the community level. Because of these constraints, there aremany gaps in the area of nutrition programming in Cambodia. This is true forprograms related to vitamin A deficiency, iron deficiency anemia, iodinedeficiency disorders and malnutrition – vitamin A capsule coverage for

An Overview of Nutrition Sector Activities in Cambodia 2002 i

Executive Summary

preschool-aged children and postpartum women is low, there are fewinterventions targeting groups at high-risk for iron deficiency anemia, fewhouseholds consume iodized salt and there is poor knowledge among healthworkers, staff of various agencies, and community members about infant andchild feeding.

Because of the impact that nutrition has on maternal and child morbidity andmortality, governmental and non-governmental organizations and UNagencies urgently need to increase support for nutrition programs in order toimprove the lives of Cambodian women and children. The following actionsare recommended:

• Upgrade capacity of the Ministry of Health (MOH)/Nutrition and NGOstaff to implement nutrition programs.

• Provide financial and technical support to the MOH/Nutrition Unit, andNational Council for Nutrition, for nutrition programs.

• Strengthen the health care delivery system by improving health center staffknowledge and capacity to implement nutrition interventions, bysupporting outreach services, by ensuring adequate supplies anddistribution of commodities, and by establishing adequate healthinformation systems.

• Establish a nutrition and health surveillance system to monitor keyindicators of program implementation and impact on health and nutrition.

• Raise community awareness about nutrition using a “social marketing-type” campaign and training village health volunteers for communitymobilization.

• Support the National Vitamin A Capsule Distribution Program in order toimprove VAC coverage nationwide by improving the health system andsocial mobilization.

• Support pilot projects addressing the problem of IDA in preschool-agedchildren and based on findings, establish a policy for iron supplementation– prevention and treatment.

• Support homestead food production activities aimed at increasingproduction and consumption of plant and animal products, ultimatelyimproving food security and household income.

• Intensify efforts related to salt iodization by garnering political support forlegislation, and investigate the feasibility of fortifying other foods withvitamin A and iron.

ii An Overview of Nutrition Sector Activities in Cambodia 2002

• Coordinate efforts focusing on improving infant and child feeding practices,especially promotion of exclusive breastfeeding and timely introduction ofquality complementary foods.

• Support operations research related to infectious diseases and nutrition,especially HIV/AIDS, TB and malaria.

Programs to improve the nutritional situation of women and children muststart early on in the lifecycle and will need to focus on improving the healthcare system and mobilizing community members for nutrition activities.Efforts will require strong local and political commitment, clear policies andguidelines, and coordination between governmental agencies, UN agenciesand local and international NGOs. In addition, donors must be made awarethat the consequences of malnutrition on individuals and societies aredevastating, long lasting and often irreversible and in order to prevent furtherdamage to the next generation of Cambodians, action must be takenimmediately.

Executive Summary

An Overview of Nutrition Sector Activities in Cambodia 2002 iii

ECHO European CommunityHumanitarian Affairs Office

EU European Union

FAO Food and AgricultureOrganization

FHI Food for the Hungry International

GMP Growth Monitoring PromotionGTZ-IFSP German Technical Cooperation-

Integrated Food Security Program

Hb HemoglobinHC Health CenterHI Handicap InternationalHNI HealthNet InternationalHIV/AIDS Human Immunodeficiency Virus/

Acquired ImmunodeficiencySyndrome

HKI Helen Keller InternationalHU Health Unlimited

ICC International CooperationCambodia

IDA Iron Deficiency AnemiaIDD Iodine Deficiency DisordersIEC Information/Education/

CommunicationIMCI Integrated Management of

Childhood IllnessesITN Insecticide-Treated NetsIVY International Volunteers of

Yamagata

KHANA Khmer HIV/AIDS NGO AllianceKHReDO Khmer Human Resources for

Development OrganizationsKRDA Khmer Rural Development

AssociationKWCD Khmer Women’s Cooperation for

DevelopmentKWWA Kratie Women’s Welfare

Association

AAH Action Against HungerADRA Adventist Development and Relief

AgencyANC Antenatal CareAOC Asian Outreach CambodiaAOG Assemblies of GodAusAID Australian Agency for

International Development

BF BreastfeedingBMI Body Mass Index

CADET Cambodian Association for theDevelopment of Economy Together

CARE Cooperation, Assistance, ReliefEverywhere

CCK Chamroeun Cheat Khmer ChivithThmey

CERCP Cambodian Development andRelief Centre for the Poor

CHED Cambodian Health EducationDevelopment

CIDA Canadian InternationalDevelopment Agency

CIDSE Coopération Internationale pour leDéveloppement et la SolidaritéProgramme in Cambodia

CNMS Cambodia National MicronutrientSurvey

CORD Christian Outreach Relief andDevelopment

CRD Community for Rural DevelopmentCSB Corn-Soya BlendCSCS Cooperation for a Sustainable

Cambodian SocietyCWDA Cambodian Women’s Development

AssociationCWS Church World Service

DFID Department for InternationalDevelopment

DHS Cambodia Demographic andHealth Survey

List of acronyms used in this report

iv An Overview of Nutrition Sector Activities in Cambodia 2002

LWS Lutheran World Service

MCH Maternal and Child HealthMDM Médecins du MondeMHD Malteeser GermanyMOH Ministry of HealthMSF Médecins sans FrontièreMODE Minority Organization for the

Development of EconomyMUAC Mid-Upper-Arm CircumferenceMTCT Mother-To-Child-Transmission

NCHP National Centre for HealthPromotion

NCN National Council for NutritionNGO Non-Governmental OrganizationNIDS National Immunization DaysNIP National Immunization ProgramNMCHC National Mother and Child Health

Centre

OD Operational DistrictORS Oral Rehydration Solution

PEM Protein Energy MalnutritionPFD Partners for DevelopmentPHD Provincial Health DepartmentPNC Postnatal Care

RACHA Reproductive and Child HealthAlliance

RE Retinol EquivalentsRGC Royal Government of Cambodia

SC-A Save the Children – AustraliaSC-F Save the Children – FranceSC-UK Save the Children – UKSIDA Swedish International

Development AgencySNAP Supplemental Nutrition Action

Program

TB TuberculosisTBA Traditional Birth AttendantTOT Training of Trainers

U5 Under 5UN United NationsUNICEF United Nations Children’s FundUSAID United-States Agency for

International Development

VA Vitamin AVAC Vitamin A CapsuleVAD Vitamin A DeficiencyVADD Vitamin A Deficiency DisordersVDC Village Development CommitteeVHV Village Health VolunteerVSG Village Support Group

WFP The United Nations World FoodProgramme

WR-C World Relief – CambodiaWV-C World Vision – CambodiaWHO World Health OrganizationWOSO Women’s Service Organization

An Overview of Nutrition Sector Activities in Cambodia 2002 v

List of acronyms used in this report

Acknowledgements

The development and production of this report was generated by the needfor up-to-date and comprehensive information on what is currently being

done to improve nutrition, and its impact on the health of Cambodians, andwhat gaps need to be addressed. This need – and the means by which it couldbe met – was identified by the United States Agency for InternationalDevelopment (USAID), both in Cambodia and in Washington. We would liketo acknowledge USAID for their support to nutrition programming inCambodia. In particular, we would like to acknowledge Mr. Ngudup Paljor ofthe Office of Public Health, USAID/Cambodia, who has been especiallysupportive of this project and who was instrumental in making it happen.

We would like to thank the many agencies and organizations that providedinformation for this report (see Appendix I for a list). They were eager toshare information about their program activities and were willing to spend thetime to do so. Without their help, this report could not have been produced.Our sincere thanks go out to all those involved, for their cooperation, interestand motivation. While the information in this report aims to provide anaccurate reflection of the state of the art in Cambodia, it is possible that thework of some organizations may have been missed and that new nutritionactivities may have started since the review was conducted. Therefore, weapologize for any omissions in this report.

We would also like to acknowledge the key role of the Helen KellerInternational (HKI)/Asia-Pacific Regional Office, which was instrumental inthe preparation of this document. Among the HKI/Asia-Pacific team whocontributed their time and expertise to provide guidance and other assistanceto this review were Dr. Saskia de Pee (Regional Scientific Advisor),Dr. Anuraj Shankar (Micronutrient Supplementation ProgramDirector/Indonesia and Regional Advisor on Interactions betweenMicronutrients, Immunity and Infectious Diseases), Dr. Regina Moench-Pfanner (Regional Coordinator) and Dr. Martin W. Bloem (Regional Director).We are also grateful to the HKI/Asia-Pacific Publications Unit for theirassistance with the layout of this document.

vi An Overview of Nutrition Sector Activities in Cambodia 2002

An Overview of Nutrition Sector Activities in Cambodia 2002 1

• Type of communication tools and strategies• Main constraints faced in the implementation

of the program/s or activities• Future plans

The information from the questionnaires wascompiled, and a profile of the differentorganizations was organized into a table tofacilitate analysis. This table is presented inAppendix II and it describes each organization’sactivities in nutrition. From this analysis, asummary of findings describing current nutritioninterventions in Cambodia, and geographiccoverage, was made possible.

In Section II of this report, a comprehensivesituation analysis of the major nutritional issuesin Cambodia is presented, namely vitamin Adeficiency, iron deficiency anemia, iodinedeficiency disorders, and malnutrition. Thissection describes the prevalence of the nutritionalproblem, possible causes, and strategies toaddress the deficiency. The next section of thereport (Section III) describes the interactionbetween malnutrition and infection, andespecially focuses on the problems of humanimmunodeficiency virus/acquiredimmunodeficiency syndrome (HIV/AIDS),tuberculosis (TB) and malaria.

Section IV gives a summary of findings from ananalysis of the information gathered in interviewsconducted with the 58 participating organizations.It is organized by nutrition intervention anddescribes the extent to which that intervention isbeing addressed in Cambodia. Based on theanalysis of agency work, compared to objectivesof the Royal Government of Cambodia, a gapsand priorities table was developed (Section V).The report concludes with general and program-specific recommendations.

I. Introduction

This nutrition sector review is the first of itskind in Cambodia. The main objectives in

conducting this review were to better understandcurrent nutrition programming in Cambodia – toassess what is being done, where, and by whomand based on that, identify the programmaticgaps, and prioritize areas of need for futureactions in the field of nutrition. This was done bydocumenting, describing and analyzing thedifferent nutrition interventions underway inCambodia by the Royal Government of Cambodia(RGC), United Nation’s Agencies, and local andinternational non-governmental organizations(NGOs). This review could also serve as a tool tofoster greater sharing of information andexperiences among agencies working in nutrition,and can also be used to guide decision-makers ontechnical and financial support needed fornutrition programming in the coming years.

This nutrition sector review focused onorganizations that were identified as workingdirectly or indirectly in the field of nutrition.Organizations that support activities in one ormany sectors of nutrition, such as nutritioneducation, food supplementation, vitamin/mineraldistribution, growth monitoring, breastfeedingpromotion, nutritional assessment and homesteadfood production, were selected to be part of thisreview. A total of 71 organizations werecontacted. Of these 71 organizations, 8 were notconducting any nutrition programs/activities, and5 did not return our calls and/or messages.Therefore, 58 organizations were interviewed,which included government departments, UNorganizations, and local and international NGOs.A questionnaire was administered to arepresentative of each organization involved inthe nutrition program/s. The interviews werestructured to record information in the followingareas:

• Main objectives of the organization’s nutritionprogram/s or activities

• Target areas (province, district, commune)• Target groups• Implementation strategy• Type and frequency of training activities and a

description of the trainees

2 An Overview of Nutrition Sector Activities in Cambodia 2002

Vitamin A is crucial for effective immune-system functioning, protecting the integrity of

epithelial cells lining the skin, the surface of theeyes, the inside of the mouth and the alimentaryand respiratory tracts. When the body’s defensebreaks down as a consequence of vitamin Adeficiency (VAD), the person is more likely todevelop infections, and the severity of aninfection is likely to be greater. Vitamin Adeficiency disorders (VADD) can affect the entirepopulation but those most at risk are preschool-aged children, and pregnant and lactating women.Results from the first National MicronutrientSurvey of Cambodia show that each of these riskgroups has high prevalence rates of vitamin Adeficiency.

Prevalence

Preschool-aged Children. Results from theCambodia National Micronutrient Survey showthat vitamin A deficiency is still a problem ofpublic health significance. In seven (7) of the 10provinces included in the micronutrient survey,the prevalence of night blindness, the first clinicalsign of vitamin A deficiency, among children aged

18-59 months was above the WHO cut-off thatindicates a public health problem. The prevalenceof night blindness, and with a WHO cut-off of1%, is only the tip of the iceberg – suggesting thata large proportion of children in Cambodia sufferfrom VADD,3 including a higher risk of morbidityand mortality. Figure 1 shows night blindnessprevalence by province. Night blindnessprevalence varies by province. In the provinces ofPreah Vihear, Rattanakiri, Otar Meanchey, Koh

II. Current Nutrition Situation

The health and nutrition situation in Cambodia is among the most critical in the region. The infantmortality rate is estimated at 95 per 1000 live births, the under-five mortality rate at 124 per 1000 live

births and the maternal mortality ratio at 437 deaths per 100,000 live births.1 The main causes of childillness are acute respiratory infections and diarrheal diseases, which are estimated to account for abouthalf the under-five deaths. Other major causes are dengue fever epidemics and malaria, the effects ofwhich are compounded by widespread malnutrition and micronutrient deficiencies. Evidence shows thatmalnutrition, even in its milder forms, can increase the likelihood of mortality from a number of differentdiseases and may be associated with up to 56% of all childhood mortality. This makes malnutrition oneof the most serious public health problems in developing countries.2 Furthermore, micronutrientdeficiencies have been shown to increase the risk of morbidity, impair cognitive development and growthand lower work productivity.

In 2000, HKI, in partnership with the Royal Government of Cambodia, and with funding from USAID,conducted the first Cambodia National Micronutrient Survey (CNMS) to assess the magnitude and keydeterminants of micronutrient deficiencies in the country. This section describes findings from thatsurvey as well as possible causes and strategies for addressing nutritional deficiencies in Cambodia. Themain problems are vitamin A deficiency (VAD), iron deficiency anemia (IDA), iodine deficiencydisorders (IDD) and malnutrition.

Vitamin A deficiency

0

0.5

1

1.5

2

2.5

3

3.5

4

Svay Rien

g

Preah V

ihear

Rattanak

iri

Otar Mean

chey

K Cham Kandal

Koh Kong

Kampot

Battamban

gK Thom

Prop

ortio

n (%

)

Figure 1. Prevalence of night blindness among childrenaged 18-59 months, by province. (n=12,820)Bars indicate 95% CI (Confidence Interval) corrected fordesign effect.


Kong and Kampong Thom it is above the cut-offindicating a public health problem, while for SvayRieng and Kampot the 95% confidence intervalincludes the cut-off of 1%, which means that inthose two provinces the prevalence could also beabove 1%.

Women. The CNMS also found that vitamin Adeficiency is a large problem among lactatingmothers and during pregnancy. Figure 2 showsthe prevalence of night blindness among lactatingwomen and during the mother’s most recentpregnancy, by province. Night blindnessprevalence among lactating women ranged from1.1-6.8% in the 10 provinces included in thenational survey. The reported prevalence of nightblindness during the last pregnancy in theprevious 3 years ranged from 2.0-9.3%. However,a much larger proportion of women in Cambodiaare likely to suffer from VADD; again, this is onlythe “tip of the iceberg”.

Causes of vitamin A deficiency

Vitamin A deficiency, as a public health problem,results from a chronic, insufficient dietary intakeof vitamin A. It often occurs in association withprotein-energy malnutrition, other micronutrientdeficiencies and, as part of a “vicious cycle” with

infection, in which one exacerbates and increasesvulnerability to the other.

Vitamin A deficiency can begin at an early agewhen an infant is exposed to poor breastfeedingpractices. In Malawi, premature introduction ofcomplementary foods and early cessation ofbreastfeeding were associated with increased riskof preschool xerophthalmia (severe VAD).4 InCambodia, few children 0-6 months areexclusively breastfed and, many mothers discardthe colostrum (first breastmilk that is rich inimmunoglobulins and nutrients). Introduction ofcomplementary foods occurs too early, and thesefoods are often of poor quality, as good sources ofmicronutrients are often more expensive foodsthat are outside the economic reach of poor ruralhouseholds. For young infants, especially duringthe weaning period, and for pregnant and lactatingwomen, there are also food taboos that need to beaddressed as these play a role in the type of foodsthese vulnerable groups can and cannot consume.For example, in Cambodia, nutritious foods suchas green leafy vegetables, fruits and most types ofmeats are prohibited in the diet of infants duringthe weaning period, as they are believed to causediarrhea (fruits and vegetables) and worminfestation (meats).5

The 2000 Cambodia National MicronutrientSurvey showed that vitamin A intake was verylow. When vitamin A intake was estimated usingthe conversion factors for vitamin A obtainedfrom fruits and vegetables that are based on recentresearch in Indonesia and Vietnam,6 less than 10%of women and children met their recommendeddaily intake (500 and 350 RE, respectively). But itwas also found that vitamin A intake was higheramong women and children of households thatgrew fruits and vegetables and/or kept poultry.Over 70% of the households had some poultry,but more than three-quarters of them used theeggs mainly for producing new poultry, whileonly 19% mainly used them for their ownconsumption.

In addition to dietary intake, disease also plays arole in the “vicious cycle” contributing to VADD.Severe diarrhea, dysentery, measles, and other

Section II: Current Nutrition Situation

0

2

4

6

8

10

12

14

16

Svay Rien

g

Preah V

ihear

Rattanak

iri

Otar Mean

chey

K Cham Kandal

Koh Kong

Kampot

Battamban

gK Thom

Prop

ortio

n (%

)

LactatingLast Pregnancy

Figure 2. Prevalence of night blindness among lactatingwomen (child < 24 mos; n=9,050) and during the mother’smost recent pregnancy (< 3 yrs ago; n=14,933), by province.Bars indicate 95% CI (Confidence Interval) corrected fordesign effect.



severe, febrile illnesses are frequently reported toprecede xerophthalmia.7 The CNMS found thatone third of children surveyed suffered fromdiarrhea on one or more days during the previoustwo weeks. And, reports from the Ministry ofHealth (MOH) and WHO show that measlesoutbreaks are still common in certain parts of thecountry.

Strategies to address vitamin A deficiency

The main strategies for addressing the problem ofvitamin A deficiency include supplementation tohigh risk groups (preschool-aged children andpostpartum women), dietary diversification andfortification. These efforts should be donealongside efforts to reduce infectious diseases.

Supplementation

Periodic, high-dose vitamin A supplementationremains the most widely practiced direct means toprevent vitamin A deficiency by governmentsthroughout the world. Supplementation has beenproven to be effective in preventing VADD. Thisis evident from results from the CNMS. Bothamong the provinces where the prevalence ofnight blindness was equal to or greater than thecut-off of 1% as well as among the provinceswhere the prevalence of night blindness wasbelow this cut-off, children that had received aVAC had a 2.2 - 2.3 times lower risk to be nightblind than those who had not received a VAC.8

This shows that VAC are protective againstvitamin A deficiency, also in the provinces wherethe prevalence of night blindness was below thecut-off of 1%.

In Cambodia, a national vitamin A working group,consisting of members from the MOH, UNICEF,WHO and HKI, was formed in 1993, whichdrafted a National Vitamin A Policy that wasadopted by the RGC in 1994. A national vitamin Asupplementation program was launched toprovide VACs to all children 6-71 months of ageevery 3 - 6 months. In 1996, following a pilot in1995 by the MOH, WHO, UNICEF and NGOs,including HKI, VAC distribution became fullyintegrated into the National Immunization Days

(NIDS). In 1998, VAC distribution was fullyintegrated into the National ImmunizationProgram (NIP) in 15 major provinces withdistribution three times per year and coordinatedwith sub-national immunization days. In 1999, arevised national vitamin A policy was drafted withtarget groups for universal supplementation beingchildren 6-59 months of age (100,000 IU vitaminA capsule for children aged 6-11 mo and 200,000IU for children aged 12-59 mo) and women up toeight weeks postpartum (200,000 IU). Forchildren, the strategy includes improving VACcoverage through routine immunization outreachtwice a year.

The Cambodian National Micronutrient Surveyand Assessment of the Vitamin A Program foundthat coverage varies widely between differentcommunes within a province, because healthcenters face different challenges with respect todelivery of the capsules. Some health centers havea large turnover of staff, in which case new staffis often unaware of the VAC distribution policyand distribution schedule. Associated with this isoften a poor understanding of staff roles andresponsibilities, which could also be due toinsufficient coordination at the national level. Itfrequently happens that VACs are not taken forimmunization outreach activities because theimmunization staff think that VAC distribution isnot one of their responsibilities or because thehealth center staff think that VACs are not meantfor distribution outside the health center. Also, themore remote areas are the most difficult to reachand are often neglected due to poor infrastructureand the high costs associated with transportation,which becomes increasingly difficult during therainy season. Figure 3 describes the factorscontributing to low VAC coverage in Cambodia.

Another important underlying factor related topoor VAC coverage is budget constraints faced bythe national VAC distribution program. Thisaffects all stages of VAC distribution, includingoverall planning, training, supervision, outreachactivities and social marketing of VAC. Inaddition, health worker salaries are low, whichmay result in low motivation and absenteeism. Inorder to address these problems, and hence

Section II, Cu"ent NuMion Situotion

Figure 3. Factors contributing to low VAC coverage in Cambodia

Noti"o".."

Prnv',,'oIOo,,'HCL..".

Cornrn""yL.."

iocrease VAC coverage, it is important to improvethe delivery ofVAC, the demand for VAC and thehealth care system in general.

Postpartum women are also an important target

group for VAC supplementation. The barriers for

reaching women are similar to those for reaching

children. An additional challenge is that often

times women do not deliver at a health facility and

neither are most births attended by trained health

personnel. Because of this, the opportunities for

postpartum women to receive a VAC are limited.

Another main barrier is that VAC has to be givenwithin 8 weeks after birth and is therefore not

suitable for a twice yearly campaign, it has to be

available on a continuous basis.

In order to address this problem, it is important not

only to address the problems described above but

also to improve access to VAC for postpartum

women by making VAC available each time

outreach staff travel to communities. As part of

the training, health center staff will know that

during a child's first immunizations, but only when.

they take place within the first 8 weeks of birth, .

the mother should also receive one dose' of

200,000 IU of vitamin A to be taken at least 24

hours apart.

The immunization outreach program can be agood strategy for reducing the risk ofVADDamong Cambodian children, because it is one ofthe very few programs that is designed to reachall communities throughout the country on a

regular basis. However, the coverage of theimmunization outreach program was relatively lowin alii 0 provinces included in the CNMS, andalthough receipt ofVAC was higher whenimmunization coverage was higher, VAC coveragewas consistently lower than immunizationcoverage.

In order to improve VAC distribution coverage to

postpartum women, better coordination betweenthe health center outreach teams, the traditional

birth attendants (TBAs) and village health

An O"",iew of Nutrition Sedor AdMti" in Cambodio '°0'



volunteers (VHVs) (who are closest to thecommunity) must happen. An efficient system ofidentification of postpartum women within villages,and distribution of VAC to those women withineight weeks after delivery, is important for themothers’ health as well as for the health of hernewborn.

Dietary Diversification

Improving dietary intake of high-risk groupsrequires an adequate, affordable, and diversesupply of food sources of vitamin A throughoutthe year, and their sufficient consumption,especially by those highest at risk. A first-linedietary intervention to protect infants and youngchildren from VADD is prolonged breastfeedingwith proper complementary feeding. Vitamin A-rich foods such as soft red, orange, yellow fruitsand vegetables, dark green leaves, eggs, and fishwith liver, should be provided during the weaningperiod.10

In Cambodia, many foods rich in vitamin A andother micronutrients are too expensive for themajority of the population. However, making thesefoods available at the homestead can result inimproved intake. Various small-scale homesteadfood production programs are underwaythroughout the country. While most do notspecifically address VADD, the HKI programdoes. HKI has successfully implemented a small-scale homestead food production program inseveral districts of seven provinces and one urbanslum area of Phnom Penh since 1998. Theprogram, modeled after the HKI homestead foodproduction program in Bangladesh, consists ofproviding essential technical and managerialsupport to NGOs, which adopt/expand thehomestead food production as part of their packetof activities. In this way, HKI has been able toimprove homestead food production practicessuch as year-round production of a wider varietyof nutrient-rich fruits and vegetables, increaseconsumption of vitamin A-rich foods, increaseincome and improve empowerment of women. Allof this has been done in a very effective andsustainable way and at relatively low-cost (USD 5per household during their first year in the

program and less thereafter). Data from thisprogram in Cambodia show that availability/access to vitamin A-rich foods is a limiting factorto consumption. When availability is increased,consumption is also increased. Monitoring datashow that the frequency of consumption ofvegetables per week has increased in children 12-59 months of age, since program start-up. And,more than 90% of income generated fromhousehold gardens is used to purchase other high-quality foods.

Nutrition education is also an importantcomponent of programs aimed at improvingdietary intake of vitamin A. By having foodsavailable locally, there is greater likelihood thatthey can/will be consumed. However, data from aqualitative study conducted by HKI in 1997showed that there are many food taboos,especially for young infants during the weaningperiod.11 It is for mothers of infants (under oneyear of age) where nutrition education can play animportant role. Many NGOs and other agenciesare providing nutrition education as part of theiron-going activities in agriculture (homegardening, animal raising) and in other sectors aswell (health). Although most do not conductextensive nutritional assessments of their targetpopulation, qualitative assessments are common.NGOs expressed that these qualitativeassessments show that by increasing people’sknowledge of proper feeding practices, peopleexperience improvements in their general wellbeing and level of energy.

Fortification

Fortifying foods with vitamin A and othermicronutrients has also been shown to be aneffective and sustainable way to increase theintake of essential vitamins and minerals forspecial sub-groups of the population (e.g. infantfoods and fortified oil for household members).The first step is to identify potential foods thatcan be fortified and a viable food industry.Currently, in Cambodia, there are no initiatives tofortify foods with vitamin A or multiple nutrients.However, UNICEF, in collaboration with the RGCis investigating this possibility. Because Cambodia



relies heavily on neighboring countries forprocessed foods, regional initiatives will berequired. However, in the short- to medium-term,fortified foods (apart from iodized salt) will mostlikely still be inaccessible to many ruralCambodians.

Iron deficiency is the major cause of anemia anda serious public health problem. It is a result of

the amount of dietary iron absorbed beinginsufficient to meet iron requirements. Irondeficiency has been shown to increase the risk ofmorbidity and mortality. Among children, irondeficiency anemia (IDA) is associated withimpaired cognitive and motor development andgrowth, lower school performance and, increasedmorbidity from infectious diseases. It is also amajor cause of morbidity and mortality amongpregnant women, and greatly reduces workproductivity. Iron deficiency anemia can affect theentire population; however, those most at riskinclude low birth-weight infants, infants, pregnantwomen and their fetus.

Prevalence

Children. Results from the CNMS revealalarmingly high rates of anemia among preschool-aged children. Overall, 54% of children underfive years of age were found to be anemic(hemoglobin concentration, Hb, <11 g/dL).Figure 4 shows the prevalence of anemia,distinguishing different levels of severity(indicated by Hb level), for different age groups.Anemia prevalence among children 6-11 monthsof age was 79% and nearly 20% had a Hb <9 g/dL. This level of severity more or less persistedinto the second year of life and then declined after24 months of age but was still very high.

Figure 5 shows that although there weredifferences in the prevalence of anemia amongprovinces, the problem exists everywhere. Theprevalence of anemia, including more severeanemia, was highest in Rattanakiri and OtarMeanchey. In Rattanakiri, the prevalence ofmalaria infestation among children was found tobe more than 40%, which may explain part of theanemia found. In the other provinces surveyed,prevalence of malaria infestation was much lower,with <10% in Preah Vihear and <5% in all others.In provinces where the prevalence of malaria islow, iron deficiency is the main cause of anemia.

Iron Deficiency Anemia

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Figure 4. Prevalence of anemia among preschool-agedchildren in rural Cambodia, distinguishing different levels ofHb, by age group. (n=1762)Bars indicate 95% Confidence Interval (CI) corrected fordesign effect.

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Figure 5. Prevalence of anemia among children aged 6-59months, distinguishing different levels of Hb, by province.(n=1762)Bars indicate 95% CI corrected for design effect.


In Cambodia, socio-economic status and malaria(in some provinces) are factors contributing toanemia. As described previously, in Cambodiathere are poor infant and child feeding practices.Complementary foods are often of poor qualityand rarely contain sufficient iron. In addition,methods to increase the bioavailability of iron-rich foods and meals, both from plant and animalsources, are not known by most people. Animalfoods are the best sources of iron and othermicronutrients, and these foods are expensive,therefore less accessible to many. Thus, very earlyin life a child is already anemic. Insufficientintake is not only the case for infants and childrenbut also for other segments of the populationthroughout the lifecycle. While pregnant womenhave increased needs for iron, they most oftenbegin pregnancy with low iron stores, makingthem even more anemic during pregnancy andincreasing their risks of pregnancy-relatedcomplications and risk to have a low birth weightinfant.

In some parts of Cambodia, especially the heavilyforested areas, malaria is also a problem. Malariaparasitemia is a contributing factor to anemia.However, while it is a contributing factor, becausethe prevalence of anemia is so high due to a lowintake of iron-rich foods, most of the anemia iscaused by iron deficiency.13 In addition,hookworm could play a role in anemia. In a studyof school-aged children conducted by GTZ,hookworm infestation was associated withanemia.14

Strategies to address iron deficiency anemia

The main strategies for addressing the problem ofiron deficiency anemia are supplementation tohigh risk groups (preschool-aged children, school-aged children and pregnant women), dietarydiversification and improvement of ironbioavailability through diet, fortification, andparasitic disease control.

Supplementation

Iron supplementation, which involves theprovision of iron in capsule, tablet or elixir form


Women. Anemia is also a problem among womenof reproductive age. In non-pregnant womenanemia prevalence ranged from 45-65%. Theprevalence of anemia was highest in Rattanakiri,Preah Vihear and Kampong Thom. In all three ofthese provinces malaria is also a problem,suggesting that it could also be contributing to thehigh rates of anemia. However, anemia rates arealso high in other provinces as well. Amongpregnant women, anemia prevalence ranged from50-80% and the provinces with the highestprevalence were Rattanakiri, Kampot andKampong Thom. Figure 6 shows prevalence ofanemia among mothers by province,distinguishing different levels of Hb. It can beseen that severe anemia (Hb <9 g/dL) is prevalentacross provinces.

Causes of iron deficiency anemia

Iron deficiency anemia is largely caused by thefollowing factors: poor bioavailability ofconsumed iron, insufficient intake in relation toneed, increased requirements at certain stages inthe life cycle (pregnancy, early childhood andadolescent growth) and blood loss throughmenstruation, child birth, and worm infestation.In addition, chronic diarrhea, malaria and HIVcan contribute to anemia.12

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Figure 6. Prevalence of anemia among mothers, byprovince, distinguishing different levels of Hb (g/dL).(n=1,545)Bars indicate 95% Confidence Interval (CI) corrected fordesign effect.



is the most common strategy for the control ofiron deficiency anemia. Currently, the MOH has astrategy of provision of 90 iron/folatesupplements each containing 187mg of ferroussulfate (60mg elemental iron) and 3.5mg of folicacid to pregnant women. However, results fromthe Cambodia Demographic and Health (CDHS)show that less than 38% of women (urban andrural) received any antenatal care from anytrained personnel. Furthermore, the CNMS foundthat 88% of women during their last pregnancywere never given or never bought iron tablets.Thus, only a very small proportion of pregnantwomen take iron and, most likely few, if any, takethe entire recommended 90 tablets provided bythe MOH. Often times health center staff do notgive enough tablets to women. Another problemassociated with the iron/folate supplements iscompliance. When women do receive theirsupplements, they often do not comply in takingall of the 90 tablets. Reasons for this are becausewomen are rarely advised on how to take thesupplement (which time of day, and with a mealto reduce side effects) and they are usually notinformed that they are likely to experience side-effects, which are unpleasant but not harmful.This results in women taking only a fraction ofthe supplements compared to what they shouldtake.

A pilot project is underway to supplement femalegarment factory workers, aged 15-49 years, with aweekly dose of iron (187mg of ferrous sulfate and3.5mg of folic acid). This pilot project is beingimplemented by the RGC and supported by WHO.The MOH and WHO also have recently launchedanother iron supplementation pilot project foradolescent girls over 12 years old, in secondaryschools of some districts in Kampong Speu, andfor women of reproductive age. The same weeklyiron supplement, as described above, is beingdistributed through a peer sellers system. Leaders(female) in each school are selected to receivetraining on the specifics of the pilot project, theirrole in the distribution of the iron/folatesupplement on a monthly basis, and will betrained about anemia and iron. A mass educationcampaign will be conducted at the launch of theproject and on a monthly basis thereafter aroundthe time the supplement is distributed. The

supplement is to be sold at a very low cost (300-400 Riels/packet of four pills)15 by the sellers,where 100 Riel goes to the seller and the rest goesinto a revolving fund for community healthemergencies or activities.

However, no programs exist for ironsupplementation to preschool-aged children,which is a group at high risk of iron deficiency.Because rates of anemia among underfives inCambodia are very high, and because it will notbe possible to increase iron intake adequatelythrough the diet in the short run, there is an urgentneed to explore whether iron supplements can beeffectively delivered to reduce anemia among thishigh-risk group. However, since very little workhas been done worldwide with ironsupplementation among preschool-aged children,there is little information available on effectivestrategies, programs, or lessons to be learned fromcountries facing a similar problem. There is thusan urgent need, both for Cambodia as well as forother countries, to explore possible deliverymechanisms for this age group in particular,through pilot projects to study the most efficientdelivery channels and mechanisms to be appliedfor the future for this age group.

Dietary Diversification

Dietary diversification is primarily a strategy forimproving either the amount of iron-rich foodconsumed or its bioavailability. While dietarychanges alone, without fortified foods, cannotbridge the gap between current intake and thehigh needs for iron, especially for pregnantwomen and young children, it is worth closingpart of the gap by using strategies such ashomestead food production to improve iron-richfood consumption. As in the case with vitamin A,iron-rich foods are often too expensive. Bymaking foods available at the household level,through homestead food production activities, thiscan help contribute to alleviating the problem.More specifically, the production of poultry, meatand fish, and using culturally acceptable andpractical strategies to improve the bioavailabilityof iron from staples and commonly consumedfoods, together with nutrition education, can

1 0 An Overview of Nutrition Sector Activities in Cambodia 2002


result in improved consumption of iron-rich foodsand absorption of iron by the body.16 InCambodia, the strong food taboos especially forinfants in the weaning period and pregnantwomen, put these groups at even higher risk ofiron deficiency. Consequently, any dietarydiversification initiative should take these factorsinto consideration and aim to change foodconsumption behaviors in order to address theproblem of IDA.

Fortification

There are currently no programs in Cambodia tofortify foods with iron. However, the feasibility offortifying fish sauce and/or wheat flour is beingexamined. A UNICEF consultant report iscurrently being written.

Parasitic Disease Control

Parasitic disease control is an importantcomplement to other strategies to combat anemia,especially in a country like Cambodia wherehookworm and malaria are endemic in certainareas. The National Malaria Center, inconjunction with WHO and various NGOs, iscurrently implementing periodic de-worming andproviding insecticide-treated bednets topopulations in malaria-endemic areas.

Failure to consume adequate amounts of iodinethrough the diet can result in iodine deficiency

disorders (IDD). It affects human health in manyways. It may cause a variety of problemsincluding mental and growth retardation (maylead to cretinism), lethargy, increased childhoodmortality, reproductive failure, miscarriage andstillbirths.17 The most noticeable physical sign ofIDD is an enlarged thyroid gland, which results inwhat is known as goiter. The most vulnerablegroups are pregnant women and their fetuses, andpreschool and school aged children. The mostdevastating consequences of IDD are on thedeveloping human brain, as neural cells multiplymainly in utero and in the first two years of life.

IDD not only affects the individual, it also hasnegative effects on the development process of asociety in general. In places where there are long-term severe IDD problems, this may delay socialand economic development; children and adults inthe community may become slower mentally andless energetic, which may make it difficult tomotivate them to participate in developmentactivities.

Prevalence

The 1997 national goiter prevalence rate among8-12 year olds was found to be approximately12%, with some areas having goiter rates as highas 45%.18 Consumption of adequate levels ofiodized salt, the most common and cost-effectiveway to address the problem of IDD, are low. TheCNMS measured whether households hadadequate iodized salt (>=25ppm) or not. In allsurvey provinces, less than 10% of householdshad adequate levels of iodized salt except forKandal and Rattanakiri (Figure 7). Theproportion of households with adequate salt inKandal was about 15%; it could be higher inKandal because of the proximity to Phnom Penh,where iodized salt is more accessible. Rattanakirihas the highest proportion of households withadequate iodized salt (65.6%) and this is becausethe salt in Rattanakiri is from Vietnam and Laos,which is mostly all iodized.

Iodine Deficiency Disorders

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Figure 7. Proportion of households with adequately iodizedsalt (>=25ppm), by province. (n=14,861)

An Overview of Nutrition Sector Activities in Cambodia 2002 1 1


Causes of iodine deficiency disorders

IDD is caused by a lack of iodine in the diet.Goiter and cretinism is most common in areaswhere there is little iodine in the soil, water orfoods (crops and domestic animals). Theseproblems are also common in areas with highamounts of rainfall, which leads to naturallyoccurring iodine to be leached from the soil andin river basin areas where there is high erosion.This is the case for many areas in Cambodia,especially those along major rivers such as theMekong river basin, which gets flooded on anannual basis. Presently, in Cambodia, only adozen small-scale industries are fortifying saltwith iodine. However, the proportion of thepopulation that has access to iodized salt is verysmall and therefore most of the population is stillat risk of IDD.

Strategies to address iodine deficiencydisorders

Strategies to address the problem of IDD includesupplementation with iodized oil capsules and saltfortification.

Supplementation

Supplementation with oral iodized oil capsules isnot an MOH policy or national program.However, in late 2000 through May 2001, theMOH distributed iodized oil capsules to areas thatwere identified as having high goiter rates andthat are most at risk of IDD. These areas aremainly concentrated in the northeast part of thecountry namely in the Provinces of Rattanakiri,Mondulkiri, Stung Treng, Kratie and in onedistrict of Siem Reap. The distribution of iodizedoil capsules was performed through measlescampaign activities and reached up to 76,000women of reproductive age. Otherwise, capsulesare not available through the health centers. Forwomen of childbearing age, the recommendeddosage, as per WHO, for one oral iodized oilcapsule is 480 mg (1.0 mL) of iodine every 12-18months. The distribution campaign, done in the 5provinces mentioned above, was conducted as an“emergency effort” and may or may not beconsidered again by the MOH in the future.

Fortification

Fortification of salt with iodine is a proven cost-effective strategy to address IDD. In Cambodia,salt iodization efforts have been on-going sincethe early 1990’s. Plans for a national program toreach Universal Salt Iodization by the end of 1998were pursued with the support of UNICEF.However, to this date, several operationalproblems have contributed to the failure inachieving this objective. While iodized salt fromimports (Vietnam and Laos) and from small-scaleproduction plants in Phnom Penh is starting toreach remote areas, availability at household levelremains low. Where iodized salt may be available,cost remains higher than non-iodized salt and thuspoor households will tend to purchase the cheaperproduct. Knowledge of the general populationabout IDD and the benefits of iodized salt is lowand this could also be a reason why householdsdo not purchase iodized salt. However, inRattanakiri, where most of the salt is iodized dueto imports from Vietnam and Laos, householdconsumption of iodized salt is highest, evenwithout social mobilization. Thus, making theproduct available, where few or no other choice isavailable, could be one strategy to improveconsumption of iodized salt. For this, legislationrequiring that all salt for human consumption beiodized needs to be put in place. Meanwhile, inorder to increase awareness about IDD anddemand for iodized salt, the Nutrition Unit/MOH,in cooperation with the National Sub-Committeefor IDD, have been involved in training,education and promotion of the use of iodized saltin select provinces where goiter prevalence ishigh. These efforts have focused on improving theknowledge, attitude and practices of health staffabout IDD and its prevention.

The term ‘malnutrition’ is used here to refer tothe syndrome of inadequate intake of protein,

energy, and micronutrients, combined withfrequent infections, that result in poor growth andsmall body size. The term protein-energymalnutrition (PEM) is still widely used today but

Malnutrition



the shift to ‘malnutrition’ occurred as scientificevidence began accumulating that the high ratesof stunting could not be overcome by providingmore protein and energy from more of the samefoods. Rather, certain micronutrients wereidentified as playing a key role in linear growthand infection. Specifically, vitamin A and iron,and more recently zinc, have been suggested askey nutrients for growth.19

Malnutrition is a problem that affects largesections of the population in the developingworld. There are multiple causes of malnutrition,which are intertwined and contextual. Theproblem of malnutrition often starts very early onin life. Consequences of malnutrition onindividuals and societies are devastating, long-lasting and often irreversible. Children who aremalnourished suffer more severe episodes ofinfectious diseases, and more frequently, thanthose who are well-nourished. Their growth isimpaired which contributes to delayed motor andintellectual development. If the malnutritioncontinues later on in life (even mild or moderate),damage may be irreversible, which results inweak and less productive adults, with decreasedlearning capabilities and worse reproductiveoutcomes. Also, malnutrition can have negativeeffects, not only on those afflicted, but also ontheir offspring. All of these consequences canhave a negative impact on the social andeconomic development of a society, especially ifthe problem of malnutrition affects large segmentsof the population.

Prevalence

Children. Indicators for nutritional status ofchildren include height-for-age (stunting), weight-for-height (wasting) and weight-for-age(underweight). Stunting reflects long-term,cumulative effects of inadequate nutrition andhealth. Wasting represents the failure to receiveadequate nutrition during the period immediatelybefore the assessment or recent episodes ofillness. Being underweight could mean that thechild is stunted, wasted or both.

Figure 8 shows child stunting by age. By thesecond year of life, nearly half of Cambodianchildren are already malnourished (demonstratedby stunting rates). Figure 9 shows stunting among12-23 month olds by province. Preah Vihear,Rattanakiri and Kampong Thom all have stuntingprevalence rates over 50%. However, otherprovinces also have high prevalence rates withstunting being over 35%. A similar pattern is seenfor underweight by age and province. Thesefindings show that there is both short- and long-term food shortages and also food is of poorquality. Other findings from the CNMS show thatillness, including diarrhea is also a contributingfactor to malnutrition.

Women. The Body Mass Index (BMI) indicatorwas used to determine a woman’s nutritionalstatus. The index uses both weight and height and

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provides a measure of “thinness”. Figure 10shows wasting (i.e BMI <18.5 kg/m2) amongmothers by province. The percentage of womenwith low BMI ranges from about 13 – 25%.Contributing factors to maternal malnutrition arepoverty, limited food availability, poor dietaryquality and low meal frequency.

Causes of malnutrition

Malnutrition is an outcome of various biologicaland social processes for which three types ofcauses have been identified, the immediate, theunderlying and the basic causes. The immediatecauses of malnutrition relate to poor diet and toillness. These are themselves caused by theunderlying factors, which are associated withfamily accessibility to food, maternaland child caring practices, access tohealth services and hygiene andsanitation. These underlying factorsare affected by basic factors whichinclude the socioeconomic andpolitical situation within whichfamilies live (Figure 11).

In Cambodia, as in many developingcountries, poor infant and childfeeding practices put infants at risk ofmalnutrition very early on in life.While breastfeeding is very common– nearly all women are stillbreastfeeding their child at 12 monthsof age and almost 50% are stillbreastfeeding their 24 months oldchild (Figure 12, p14) – few womeninitiate exclusive breastfeeding andthose that do, start complementaryfoods early (before 6 months of age).The CDHS found that only 18% ofchildren less than two months of agewere exclusively breastfed in the 24hours prior to the interview. This willmost likely result in poor nutrientintake since complementary foods arepoor in energy and nutrients, andfeeding frequency is low at only 2-3times per day. These infants are alsoat increased risk of infection.

Figure 10. Wasting among mothers (BMI <18.5 kg/m2). (n=13,440)

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Immediatecauses

Underlying causesat household/family level

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(human,economic, and organizat ional) andway they are control led

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Inadequatedietary intake Disease

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Figure 11. UNICEF conceptual framework for malnutrition.Source: UNICEF. State of the World’s Children 1998. Oxford:Oxford University Press, 1998.


Family access to food is also often a problem. Thenumber of households that are food insecure ishigh in some geographic areas, especially duringthe rainy season, when flooding is common inmany parts of the country, and where entire cropsare often destroyed.

Strategies to address malnutrition

Over the past quarter of a century, variousstrategies have been used to alleviate the problemof malnutrition in developing countries. Becauseproblems relating to malnutrition are verystrongly context specific, any nutrition programshould be tailored to the particular problems,level of knowledge of the target group, culturalconditions, resource availability and constraintsof a given target group.20 In addition, by tailoringa program to a specific environment and context,the chances of making this interventionsustainable are greatly increased. Effortsconcentrated on alleviating malnutrition must bedone in conjunction with programs to reduce theprevalence of common infectious and parasiticdiseases within the population, as these alsocontribute to the “vicious” cycle of malnutritionand infection. Finally, household and individualfood security needs to be addressed. One way todo this is through homestead food productionprograms. HKI’s experience has shown thatimproving household production of fruits andvegetables leads to increases in consumption of

these food items and contributes to incomegeneration; this income is then used to purchasehigh-quality food items.

While better access to food items is essential,nutrition education is also important, especiallyfor mothers of young children (less than 12months of age) for whom food taboos are strongin Cambodia. Nutrition education can beaddressed alongside growth monitoring. Afterplotting a child’s growth, the health worker candiscuss possible ways for preventing or furtherslowing down the child’s growth. Growthmonitoring also makes the mother more aware ofhow her child is doing. Because of the importanceof growth monitoring as a “tool” to providenutrition education/counseling, this is part of theIntegrated Management of Childhood Illnesses(IMCI) package that is currently being piloted intwo operational districts in Cambodia. The“Feeding Recommendations During Sickness andHealth” of the IMCI guidelines was developed byHKI.

Programs to address malnutrition also need toensure that high risk groups, especially pregnantwomen and children, receive sufficientmicronutrients. This can be through foods, asdescribed above, but also through supplementsand/or fortification. Currently trials are underwayfor supplementation of pregnant women andchildren with a multiple micronutrientsupplement. There is increasing evidence thatmultiple micronutrient supplements havenumerous benefits for pregnancy outcomes, moreso than those seen with only iron/folic acidsupplementation, and on child growth anddevelopment. More research is being conducted toexamine this and UNICEF, WHO and HelenKeller International/Indonesia, among others, areat the forefront of this research.

Thus, integrated approaches targeted topopulations most at risk of suffering frommalnutrition, pregnant women and children underthe age of three, are necessary in order toovercome the devastating consequences ofmalnutrition on individuals and on society as awhole.

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Figure 12. Proportion of children currently breastfeeding,by child age. (n=9,483)


HIV/AIDS is the single leading infectiouscause of death in developing countries. In

Cambodia the HIV Sentinel Surveillance Projectindicated that approximately 169,000 adults aged15-49 are living with HIV.22 As expected, thehighest prevalence of HIV was seen amongstcommercial sex workers (31.1%) and frequentclients. In response to this, the national AIDSprevention program has focused primarily onreducing sex-worker-client transmission througheducation and condom use. However, increasingnumbers of HIV/AIDS cases are being seen innon-sex worker women and infants. The women,generally infected through their husbands orpartners, have fewer options to protectthemselves. If they become pregnant, their childfaces the risk factors associated with a severely illmother; these include poor fetal development, lowbirth weight, and once born, poor caring practices.The child also faces the risk of becoming HIV+.In order to prevent or slow the progression of HIVin these non-sex worker women, development ofprogrammatically effective interventions areneeded to complement the current HIV/AIDSprevention strategies.

Potential role of specific micronutrients inHIV/AIDS

Several studies over the last 5 years indicate thatcertain, but not all, micronutrient deficienciesmay compromise host immunity to HIV andassociated infections, and hasten the clinicalprogression of HIV/AIDS. More specifically,deficiencies in vitamin A, zinc, B12, vitamin E,and selenium have been associated with greatermorbidity in HIV+ persons and/or increasedmother-to-child transmission.23 Clinical trialsinvolving supplementation of HIV+ individualswith vitamin A, zinc, and vitamin E have beenassociated with reduced infectious diseasemorbidity or improved immunological status,24

and a large-scale trial in Tanzania indicated thatprenatal multiple micronutrient supplementsreduced low-birth weight and fetal death bynearly half in HIV+ women.25 In Cambodiadeficiencies in vitamin A and other micronutrientsare widespread amongst adult women as indicatedin the recent countrywide survey conducted byHKI in collaboration with the Cambodiangovernment.26 Although multivitamins areadvocated by several HIV care facilities inCambodia, their distribution is not systematic orwidespread and, most importantly, theformulations generally lack those nutrients moststrongly associated with reduced HIV burden.

III. Nutrition and Infectious Diseases

Human ImmunodeficiencyVirus Infection

Poorly nourished people are more susceptible to infectious diseases than well-nourished people. Poornutrition, or selective nutrient deficiencies, does not simply suppress immune function but causes

dysregulation of a normally coordinated host response to infections. This leads to the development of anineffective response. In addition, some evidence indicates that undernutrition may enhance the severityof infections. At the same time, infections affect nutritional status by reducing dietary intake and nutrientabsorption, and by increasing the utilization and excretion of protein and micronutrients. This is part ofthe “vicious cycle” of malnutrition and infection. Recent observations indicate more than ever thatnutritional status is a predominant factor determining immune competence and plays a central role ininfectious disease outcome.21

In Cambodia, infection with human immunodeficiency virus (HIV), tuberculosis (TB), and malaria, areserious public health problems. Malnutrition may play a role in worsening the health and nutritionsituation of HIV infected individuals and may contribute to the development and/or worsening of TB.Micronutrient interventions can help to strengthen the immune system and reduce the severity andimpact of opportunistic infections in people living with HIV/AIDS (acquired immunodeficiencysyndrome) and TB. In addition, nutrition plays a strong role in modulating malaria morbidity andmortality.


with HIV are 20 to 30 times more at risk forcontracting tuberculosis. Globally, it is estimatedthat one third of the increase in incidence of TBin the last five years is attributable to HIV and,TB is the leading cause of death among peoplewho are HIV positive. While data is not available,local authorities suggest that this is also true inCambodia. Common conditions associated withthe risk of developing active TB are diseasesassociated with immunosuppression such as HIVinfection, measles and malnutrition. Hostnutritional status may influence the risk of aninfected individual developing activetuberculosis.

Role of specific micronutrients in tuberculosis

The association between malnutrition and TB iswell known, especially among adults. Although itwas found that children with severe proteinenergy malnutrition are at a higher risk ofdeveloping TB, less is known about thenutritional status of children with TB.30 Clinic-based studies using different indicators of vitaminA status suggest that vitamin A deficiency is notuncommon among adults and children living withtuberculosis. And, it has been postulated thatvitamin D deficiency is associated withtuberculosis. Other studies suggest thatdeficiencies in iron, B12, and zinc couldcompromise immune response. The CNMS foundthat in Cambodia deficiencies in vitamin A andother micronutrients are widespread amongstadult women and children. At the same time, inCambodia, nutritional rehabilitation is notconsidered in the control/treatment strategy forTB patients, except for some patients that may berecipients of a package of goods from the UnitedNations World Food Programme (WFP) whichconsists of rice, canned fish, cooking oil and cornsoy blend (CSB).

Malaria is a widespread parasitic disease andremains a major cause of morbidity, anemia,

and mortality worldwide. It has long been

Malaria

Section III: Nutrition and Infectious Diseases

There are different nutrition-relevant actionsaimed at preventing and/or mitigating HIV/AIDSimpacts.27 For people living with HIV/AIDS,nutritional care and support is critically importantin preventing, or forestalling nutritional depletion.This could include improving quantity and qualityof the diet, building or replenishing body stores ofmicronutrients, and speeding recuperation fromHIV-related infections. Nutritional support cantarget communities with the objective ofpreventing and/or mitigating impacts throughreducing the interactions of HIV/AIDS withmalnutrition. Any nutrition intervention shouldtake into consideration the three mainpreconditions of good nutrition, i.e. food security,health and environment services, and care. Suchprograms could include nutrition counseling inhealth facilities, community settings or at home tochange dietary habits. This should be inconjunction with homestead food productionactivities so that foods and additional income aremore readily available at the household level.Programs addressing breastfeeding promotion andcomplementary feeding will need to furtheremphasize the dissemination of clear informationto policy makers, health providers, andcommunities about mother-to-child transmissionfacts, including risks and benefits of breastfeedingas well as all aspects associated with a decisionnot to breastfeed. Support for breastfeedingwomen will need to be established, throughMothers Groups or other support means.

Tuberculosis remains one of the most deadlyhealth problems in East Asia, causing more

deaths than any other infectious disease, includingAIDS. In Cambodia, TB is a serious public healthproblem. Sixty four percent (64%), or more than 7million people, are infected with M. Tuberculosis.Incidence of all forms of TB is 539 per 100,000per year, the death rate due to TB is 90 per100,000 per year28 and, co-existence of HIV andTB is high. Data from the HIV/AIDS SentinelSurveillance show that approximately 6% of TBpatients are infected with HIV.29 People living

Tuberculosis


Section III: Nutrition and Infectious Diseases

acknowledged that populations residing inmalarious areas generally live under conditionsleading to poor nutritional status. The groups athighest risk for the adverse effects of malaria,children and pregnant women, are also mostaffected by poor nutrition.31 In Cambodia, malariaremains one of the primary causes of morbidityand mortality and is mostly found in the hilly,forested areas bordering Thailand, Laos andVietnam. In 2001, there were 50,284 confirmedcases of malaria (4.2 per 1000 population); inhigh-risk provinces the range was 31/1000 to 132/1000. Overall, there were 412 recorded deaths;the case fatality rate for severe cases was 9.2%and it was as high as 33.33% in Svay Rieng.32 Anestimated 3,636,303 persons are considered at riskfor contracting malaria.

Currently, malaria control in Cambodia and in thewhole South-East Asia Region generally focuseson the early treatment of clinical malaria.However, the emergence of multi-drug resistantstrains has stimulated the search for alternativemethods of malaria control and prevention.Mosquito bed nets, impregnated every 6-12months with pyrethroid insecticides are aneffective (and cost-effective) intervention. Whenused regularly, insecticide-treated nets (ITNs)were very effective in reducing morbidity andmortality. A meta-analysis of trials using ITNsshowed overall reductions in malaria morbidityby 48% and mortality by 20-40%.33 At the presenttime there are a number of projects in Cambodiainvolving the distribution and sale of ITNs. Theseservices are being provided through NGOs, andthe National Malaria Control Programme withsupport from the EU and WHO.

Role of specific micronutrients in malaria

Nutrition plays a strong role in modulatingmalaria morbidity and mortality. A placebo-controlled study in preschool-aged children inPapua New Guinea showed that zincsupplementation reduced by 38% the frequency ofhealth center attendance owing to P. falciparummalaria. And, that zinc was even more protectiveagainst heavy malaria infections.34 In anotherstudy in Papua New Guinea, it was shown that

vitamin A supplementation reduced the frequencyof P. falciparum episodes by 30% in preschool-aged children.35 The observation that selectivenutrient supplementation with vitamin A or zinccan substantially lower malaria attack ratessuggest that targeted micronutrientsupplementation interventions can serve as usefuladjuncts to malaria-control programs. At US$0.12 for 1-yr supply, vitamin A supplementationfor children under five years of age, andespecially for children one to three years of age,would rank among the more cost-effectiveinterventions for malaria.36

In Asia and Africa, a significant reduction inmorbidity and mortality has been achievedthrough vitamin A supplementation. Similarly,there is sufficient evidence that suggest aconsiderable reduction in malaria morbidity andmortality among children protected by insecticidetreated nets. Both interventions are proven to becost effective and both target children under five.In addition, the delivery mechanisms may becomplementary, with the scheduling of netretreatment and vitamin A capsule distributiontraditionally being approximately every sixmonths. Malaria and vitamin A deficiencies areoften found in the same populations. InCambodia, both ITN distribution and vitamin Acapsule distribution are being conducted.However, these programs are not in tandem andthere is a need to maximize health benefits bydelivering them both effectively and efficiently.Furthermore, delivery of other micronutrientsthrough the bednet distribution program should beinvestigated, especially since this synergisticapproach to disease control could maximizeresources and have the greatest impact.


The National Council for Nutrition (NCN),housed in the Ministry of Planning, was

established in early 1998. Various governmentministries (including the MOH), UN agencies andNGOs are members of the NCN. The NCN isresponsible for nutrition policy, monitoring andevaluation of nutrition programs, coordinationwith line ministries and research. It is the inter-ministerial coordinating body for activities innutrition. To date, little of the proposed activitiesof NCN have been realized. Coordination hasbeen limited, and funding for the secretariat ispractically non-existent. However, recently, theNCN finalized a draft “Nutrition Investment Plan2002-2007” (6 February 2002, Final Draft) and isseeking donors to assist with financial support.The objectives and strategies of this plan, whichfollow MOH nutrition objectives, are outlinedbelow:

Objectives

– To reduce the levels of malnutrition in childrenunder 5 years of age by 20% from the currentlevel of 45% (underweight);

– To virtually eliminate deficiencies of iodineand vitamin A over five years;

– To reduce by 20% the current levels of anemiain children under 5 (63%, CDHS), childrenunder two (70%, CNMS – HKI), women ofchildbearing age (57%) and pregnant women(77%), joint WFP/UNICEF baseline surveyconducted in 1998;

– To increase coverage of antenatal care (ANC)so that weight gain during pregnancy can bemonitored and to increase by 20% the numberof women gaining 9 kg or more duringgestation;

– To reduce levels of low birth weight from thecurrent estimated 20%, to 15% in 5 years;

– To reduce the levels of malnutrition of womenof reproductive age from 20% to 15 % asmeasured by BMI <18.5 kg/m2.

Strategies directly related to actions innutrition

The overall strategy, as outlined in the NutritionInvestment Plan (2002-2007) should be acommunity-based approach emphasizing actionsat the commune and household level withsupportive national level approaches. The Plansuggests that inputs should be directed to existingprograms, and working community mobilizationschemes, such as those from Seth Koma(UNICEF), other UN programs and many NGOs.The strategy favors expansion and scaling-up ofthese existing community-based projects andother activities, specifically the following:

– Locally, the focus should remain at theunderlying and basic causes of malnutrition. Itshould take into consideration caring practicesof children and women, household foodsecurity (access to food), health, sanitation,family planning, pre-natal care, incomegeneration, education and literacy for women.

– As relates to micronutrients, vertical programsfor IDA, VADD, and IDD will be the focus.Programs will be responsible for technicalsupport to improve community education, and

IV. Inventory of Nutrition Interventions in Cambodia

The main objectives in conducting this nutrition sector review were to better understand currentnutrition programming in Cambodia— to assess what is being done, where, and by whom and based

on that, identify the programmatic gaps, and prioritize areas of need for future actions in the field ofnutrition. This was done by documenting, describing and analyzing the different nutrition interventionsunderway in Cambodia. A total of 58 organizations were interviewed in order to identify their objectivesand activities in nutrition program/s, their target groups and geographical areas. A summary of theinterventions that each organization is conducting is presented in the table in Appendix II. This was thenused to identify gaps and priorities in programming, in accordance with government objectives.

Summary of governmentobjectives & strategies in

nutrition


Section IV: Inventory of Nutrition Interventions in Cambodia

knowledge and use of fortified foods andmicronutrient supplements.

– Nutrition training and capacity building isessential. The greatest need is the short-termtraining to central and mid-level technicalcadres in public health nutrition, breastfeeding,appropriate complementary feeding practices,growth monitoring promotion, andmicronutrient deficiencies. Their role astrainers for volunteers and community leadersneeds to be strengthened to match the pace ofthe rapidly growing demand for community-based programs.

– Development of a national sentinelsurveillance system to capture nutrition trendsover the years by using the CDHS 2000 as thebaseline information to follow-up trends.

Based on interviews for this review, the mainnutrition interventions can be grouped as

follows:

Nutrition education: The program attempts,through various education sessions/training andactivities, to improve the knowledge of the targetpopulation on one or many aspects/topics ofnutrition.

Food supplementation: Foods such as rice, oil,sugar, fish, or nutrient- and energy-dense blends(eg: corn-soya blend (CSB)), are distributed to themost vulnerable target groups, or, distributionoccurs following emergency response to naturaldisasters such as flooding.

Vitamin/Mineral distribution: The program aimsto alleviate micronutrient deficiencies bydistributing vitamin and/or mineral supplementsto the target group (eg: iron/folate supplements towomen of childbearing age).

Growth monitoring: The program conducts, on aregular basis, weighing sessions for children

under the age of 5 years to monitor the progress inchild growth. In some cases, individual childgrowth is pooled to form a community picture ofthe nutrition situation.

Breastfeeding promotion: The program promotesthe National Breastfeeding Policy througheducation/training sessions. This includespromotion of— initiation of breastfeeding withinthe first hour following birth (colostrum),exclusive breastfeeding up to six months of age,timely introduction of complementary foods, etc.

Nutritional assessment: The program conductsregular nutritional assessment to measureprogress in the nutritional status of the targetgroup and changes in their food related practices.

Homestead food production: The programinvolves the promotion of home gardening,especially for production of nutrient-rich fruitsand vegetables; animal raising may/may not be acomponent. These activities contribute tohousehold food security by making foodsavailable for consumption and for sale. The saleof these items generates additional income that ismost often used to purchase other food items.

In general, there are many programs andactivities with nutrition-relevant components;

however, their scope and scale is often limited.There is a lack of coordination among programsand between organizations, and nutrition is oftennot addressed explicitly as an outcome. It is mostoften a small part of much larger programs with afocus other than nutrition. There are someexceptions to this as some large-scale integratedprograms have explicit nutrition goals and coverlarger geographical areas. The majororganizations, working in one or more districts offive to nine provinces, include the MOH,UNICEF, WHO, WFP, HKI, and WV-C. Otherimportant contributors are those agencies workingin one to five districts of one to three provincesand these include, ADRA, CARE, FAO, GTZ,

Description of nutrition-relatedinterventions

Summary of findings of nutritioninterventions in Cambodia



HU, LWS, PFD, RACHA, SC-A, and SC-F.Following is an overview of the main nutritioninterventions being conducted in Cambodia, andto what extent the interventions are beingaddressed.

Nutrition education

All organizations included in this review havenutrition education as an integral part of theirprogram/s, regardless of program size. Althoughall organizations are performing nutritioneducation in one form or another, the majority aresmall organizations working within a smallgeographical area. For half of these smallerorganizations, the nutrition education activitiesinclude very basic nutrition concepts (foodgroups, foods rich in vitamin A and iron, etc.)because nutrition is a minor objective of theirlarger homestead food production program. Asmentioned by many organizations, the level ofknowledge of the population about nutrition isvery low and therefore any type of nutritioneducation was expressed to be a step forward.

The main organizations conducting nutritioneducation have much larger-scale programs thathave more explicit nutrition objectives, focusingon the reduction of micronutrient deficienciesand/or malnutrition. Such programs includebreastfeeding promotion and the timelyintroduction of complementary foods, homesteadfood production, national programs such as VACdistribution, and others. These programs coverlarger geographical areas and may or may not bethrough government systems. If they are, theyinclude work at different levels (national,provincial, etc.). Otherwise, most programs havea community-based component that often timesinvolve village health volunteers (VHVs) andother volunteers. These organizations include theMOH, UNICEF, WHO, WFP, FAO, HKI and HKIpartner NGOs (ADRA, CCK, KWCD, PFD, VSG,WOSO), SC-A, SC-F, WV-C.

The majority of agencies interviewed mentionedthat they use some, or all, nutrition educationmaterials developed by Helen KellerInternational. These include the HKI Nutrition

Reference Manual, posters, leaflets, songs,training curricula for growth monitoring, etc. Atthe same time, many have requested technicalassistance from HKI for training their staff inbasic nutrition and have also sought guidance formonitoring of their nutrition programs. HKI hasprovided this training to its’ partner NGOs;however, due to limited resources, HKI has notbeen able to provide the technical assistance to allNGOs as requested. In addition, agencies felt thatadditional nutrition education materials should bedeveloped and requests for this have been made toHKI by various NGOs, UNICEF, WFP, andvarious government ministries, including healthand rural development

Food supplementation

The main agency conducting foodsupplementation is WFP. Based on findings fromthe 1998 UNICEF/WFP baseline survey showinghigh rates of malnutrition, WFP mobilizedresources for a supplementary feeding program.This was viewed, at the time, as emergency reliefand was launched in 2000 with 7 NGO partners(ADRA, LWS, CARE, ANS, WVI, CARITAS,PFD) in one to two districts of 6 provinces. It nowcovers 28 health centers, has been going on for 18months, and is being conducted by health centerstaff with assistance of village volunteers. PartnerNGOs provide technical support andgovernmental agencies conduct routinemonitoring. Supplementary food is provided byWFP in the form of corn-soya blend (CSB), whichis fortified with vitamins and minerals. The targetgroups are children 6-59 months, pregnant women(2nd and 3rd trimester) and lactating women up tosix months postpartum. Children receive amonthly ration of 6kg of CSB, while pregnant andlactating women receive 3kg. WFP also providesvitamin A fortified oil (0.3 kg to households) andsugar (0.75kg to children). This activity ishappening on a monthly basis, where growthmonitoring and nutrition education sessions areconducted.

HKI was invited by WFP to develop the trainingcurriculum for growth monitoring and to thenprovide the training to WFP partner NGOs. This



curriculum will now also be used to updateModule 10 in the MOH “Minimum Package ofActivities”. At the same time, because of HKI’sdemonstrated expertise in nutrition surveys/surveillance in Cambodia and other countries inthe Asia-Pacific Region, WFP was interested inhaving HKI conduct the monitoring of the foodsupplementation program, in partnership with theRGC. However, due to limited funding, this wasnot possible.

Other organizations, such as SC-A, SC-F andGTZ are also conducting food supplementationactivities within a whole district of one province.The remaining organizations (approximately 9)are conducting food supplementation on a muchsmaller scale— a couple of communes and a fewvillages in one province. They are providing one,or a few, of the following food items - rice, fish,soy milk, oil, sugar, milk formula.

Vitamin/Mineral distribution

Currently, there are two main national vitamin/mineral distribution programs. These are theMOH national vitamin A capsule distributionprogram targeting under fives and postpartumwomen, and, the MOH “Safe Motherhood”initiative which includes the provision of iron/folate to pregnant women (90 tablets/woman perpregnancy).

The main agency currently working with thenational VAC distribution program is HKI. To tryto improve VAC coverage, HKI is working withthe MOH on a pilot project in three operationaldistricts, in three different provinces. The pilotaims to improve VAC coverage by providingtechnical and logistical support to the MOH,health center staff, VHVs and partner NGO’s staffworking in these pilot ODs. Efforts have focusedon development of training curricula for healthcenter staff and VHVs, provision of training toprovincial and operational district-level staff,development of mass media materials (posters,stickers, TV and radio spots, etc). The effortsinclude a strong monitoring and evaluationcomponent so that lessons learned can then beapplied to other operational districts. UNICEF has

provided financial assistance in the past. Fundingfor VAC activities have been erratic, thus makingit difficult for the national program to implementactivities, especially since the MOH budget forthis activity is limited. Program enhancement isrequired and for this, additional funds are alsoneeded.

The provision of iron/folate to pregnant womenconducted through the health system is notfunctioning very well. The MOH would like toimprove coverage of iron/folate to pregnantwomen; however, those interviewed mentionedthat there are limited resources to focus on this.Other target groups being addressed by the MOHare non-pregnant female garment factory workersof reproductive age and school girls 12 years andolder (as described earlier). This project is beingdone with support from WHO. The garmentfactory pilot project provides a weekly iron/folatetablet to target women in seven factories nearPhnom Penh. The school girls component willalso provide weekly iron/folate supplements andwill be done in collaboration with UNICEF in 2districts of Kampong Speu Province. This isdescribed more fully under the section: Strategiesto address iron deficiency anemia.

Other international organizations that conductvitamin/mineral distribution (vitamin A, iron/folate) on a fairly large scale (a few districts of afew provinces) are UNICEF, RACHA, ADRA,WV-C, GTZ-IFSP and SC-F. Finally, about 12more organizations conduct vitamin/mineraldistribution activities on a smaller scale withintarget communes and villages.

Members from the National MicronutrientWorking Group expressed that resources forvitamin/mineral supplementation are limited.There are gaps in current activities addressingVAC supplementation among preschool childrenand postpartum women and in iron/folatesupplementation among pregnant women. At thesame time, no efforts address the urgent need ofsupplementing preschool children with iron/folatesupplements.



Growth monitoring

Growth monitoring is being performed by 22 outof 58 organizations, as part of their nutritionprogram. The MOH in collaboration with theWHO is currently reviewing and updating itsnational training module for nutrition and growthmonitoring. The main goals are to standardize theapproaches used for growth monitoring, toexplain the use of the new growth cards, and toimprove the training of health workers for thefuture. The training curriculum developed by HKIfor the WFP supplementary feeding program (seeabove) is being used to update the nationaltraining module. Once the module is completed, atraining session on growth monitoring for healthcenter staff will be conducted in the provinces ofKampong Chamn, Kampong Chhnang and SvayRieng.

Results from interviews show that onlyinternational organizations conduct growthmonitoring activities. No local NGOs were foundto include this activity as part of their nutritionprogram. WFP as well as UNICEF, with theMOH, have the largest geographical coverage forthis activity where they cover a few districts of 6provinces. In other areas, the MOH has yet toimplement growth monitoring activities— in fact,few health centers even have weighing scales.While most organizations value the importance ofconducting growth monitoring on a regular basisfor children under five years of age, few werefound to have a component that includesrehabilitation of malnourished children. Due tothe lack of knowledge of health workers andvolunteers, and the lack of national protocol/guidelines to follow once malnutrition is detected,often only basic nutrition and health counseling(increasing consumption of nutrient-rich foods,preparing proper complementary foods, hygieneand sanitation practices) is provided tomalnourished children. The more severe cases ofmalnutrition are referred to the nearest hospital,where often times health staff cannot manage thecases.

Breastfeeding promotion

Nearly half the organizations interviewed includebreastfeeding promotion in their nutritionprogram. The extent of the promotion and itscontent depends on the objectives of the nutritionprogram. Currently, the MOH has a NationalBreastfeeding Program, which aims to promoteand protect infant and child feeding practices. Atthe onset of the program in early 2000, aBreastfeeding Technical Working Group wasformed what is composed of major agencies innutrition and breastfeeding in Cambodia: theMOH, UNICEF, WHO, RACHA, WV-C, andHKI. A National Infant Feeding Policy has beendeveloped to serve as the protocol/guidelines forthe promotion of proper infant feeding practicesand a policy on infant feeding and HIV has alsobeen developed. The National BreastfeedingProgram has also provided training to healthworkers, midwives, nurses and doctors throughthe Regional Training Centers in Battambang,Kampong Speu, Kampot and Svey Rieng as wellas in Phnom Penh. A few organizations, such asWHO, UNICEF, RACHA, WFP, HKI and WV-Care covering large areas with their nutritionprograms, which include breastfeedingpromotion. The programs from theseorganizations cover one or more districts within3-8 provinces. RACHA is piloting a “WatGrannies” program where elderly women monksare involved in breastfeeding promotion. This hasbeen successful within the RACHA program areasand should be tested elsewhere. Otherorganizations that conduct breastfeedingpromotion activities work on a smaller scale—within one district of one province or within a fewcommunes and villages in one district of one ortwo provinces. The main topics which arepromoted in this activity are: initiation ofbreastfeeding within 1 hour after delivery(provide colostrum), exclusive breastfeeding up toaround six months of age and timely introductionof nutrient-rich complementary foods.

Interviews showed that not all organizationspromote the same breastfeeding messages to theirtarget population. Some organizations wereunaware of the guidelines recommended by the



National Infant Feeding Policy. Also, almost noagencies are addressing the issue of breastfeedingand HIV/AIDS (or mother-to-child transmission).Training on breastfeeding by the variousorganizations is most often given to TBAs, VHVs,other volunteers, nurses and health center (HC)staff in order to disseminate breastfeedingmessages at the community level, which wasfound to be most often done through mother’sgroups and/or household visits.

Nutritional assessment

Nutritional assessment is most often conducted bythe main organizations working in the area ofnutrition in Cambodia; these are the RGC (MOHand Ministry of Planning), UNICEF, WFP, andHKI. WHO has also done some assessment on asmaller-scale. For these organizations, nutritionalassessment is done mainly to measure theprogress and the impact of specific programsconducted. In 1998, UNICEF and WFP conducteda baseline survey and a follow-up survey wasconducted in 2000 to measure their programimpacts. In 2000, HKI, in partnership with theRGC, conducted a national micronutrient surveyand assessment of the national VAC distributionprogram and iron supplementation activities.Results from the survey and assessment weresubsequently used to design the current VAC pilotproject (described previously) and is also beingused for advocacy for additional resources innutrition. In addition, the micronutrient surveywill also be a good baseline for future suchsurveys. HKI/Cambodia hosted a MicronutrientWorkshop in 2001, where preliminary resultsfrom the CNMS were launched. In addition,regular Nutrition Bulletins are published to raiseawareness about the nutritional situation inCambodia. These bulletins are widely distributedto governmental agencies, donors, UN agencies,NGOs and others working in the field of nutrition.

To date, nutritional assessment has mostly beendone through baseline and follow-up surveys.However, ongoing nutritional assessment orregular surveillance is not presently conducted.One of the objectives of the Nutrition InvestmentPlan of the RGC (2002-2007) is to develop a

sentinel surveillance system for nutrition trendswithin the 5 years of the Plan. HKI is the mainorganization in Cambodia that has the technicalexpertise to assist the RGC to set up nutritionalsurveillance. In the Asia-Pacific Region, HKI hasestablished extensive surveillance systems inBangladesh and Indonesia, that provide qualitydata that governmental and non-governmentalorganizations can use for program planning.

Many other organizations (14) interviewed forthis nutrition sector review conduct some form ofnutritional assessment within their smaller scaleprojects. The assessments range from gatheringinformation on rates of night blindness andconsumption of vitamin A-rich foods tomeasuring rates of anemia within a certain targetgroup. However, these activities are localized andsmall-scale.

Homestead food production

Homestead food production activities are beingconducted by over 50% of NGOs interviewed.The main objective of homestead food productionactivities is almost always to improve householdfood security. Other objectives are to increaseconsumption of nutrient-rich foods and togenerate income. The table in Appendix II showsthat most small organizations conductinghomestead food production programs generallyonly conduct one other nutrition activity, namelynutrition education. However, larger organizationsare conducting various nutrition activities inaddition to homestead food production. Theseinclude HKI and its’ partner NGOs (ADRA,CCK, KWCD, PFD, WOSO, VSG), FAO, WV-C,CARE, UNICEF and GTZ-IFSP. Other smallerorganizations (20) are also conducting homesteadfood production activities, but these programs areoften small-scale and scattered in pockets ofCambodia. One of the more sustainable strategiesfor homestead food production activities is theHKI program. The model used is based on thesuccessful program being implemented by HKI/Bangladesh. This model focuses on developing asystem at the community-level whereby inputs,such as seeds, seedlings and saplings, are madeavailable year-round for households to access.



Capacity building is a key component; training andfollow-up technical support is provided to partnerNGO staff, provincial departments of agricultureand community members. Many NGOs haverequested technical assistance/training forhomestead food production activities; but HKI hasnot been able to provide support because oflimited resources.

In general, there is no geographical coordinationfor homestead food production. It was also foundthat homestead food production activities do nothave a common objective. Strategies vary byagency and there is no government departmentinvolved with standardizing guidelines forhomestead food production initiatives.

Other findings

Organizations that work in the field of HIV/AIDS,and include some form of nutrition activitieswithin their program, were also contacted andinterviewed. Only a few such organizations areoperating in Cambodia. The main ones, in termsof program scope and geographical coverage, areKHANA, CARITAS, WV-C, CARE, andMaryknoll. The nutrition activities integratedwithin the HIV/AIDS programs of theseorganizations were found to be basic and quitesimilar between organizations. These activitiesare: multi-vitamin supplementation as part of thepacket of medicine that organizations usuallyprovide to their target group, foodsupplementation such as rice, canned fish, andsome vegetables and, some basic nutritioneducation along with health and hygieneeducation.

Most organizations working in the field of HIV/AIDS mentioned that they find nutrition a veryimportant component of their program becausepeople living with HIV/AIDS have a betterquality of life if they are well-nourished.However, all organizations mentioned the lowlevel of knowledge of their staff about HIV/AIDSand nutrition and the lack of information availableregarding this. Most organizations showedinterest in learning more about the relationshipbetween HIV/AIDS and nutrition and how this

could potentially help improve the status of theirtarget groups. Also, it was mentioned thathouseholds living with HIV+ persons faced moreproblems with food security and thus, it would beimportant to set up homestead food productionprograms targeting communities at high risk forHIV, so that families could become more selfsufficient.

Many organizations face the same types ofconstraints in their efforts to conduct nutritionactivities. These include limited human, materialand financial resources. This limits the scope andgeographic focus of nutrition-related activities.Another constraint that was expressed by many isthe low level of education, and the lack ofknowledge of target populations about health/nutrition-related topics. Agencies find itchallenging and time consuming to attempt toovercome this constraint to achieving behaviorchange, especially because of the strongtraditional beliefs people have towards food-related practices. The lack of trainingopportunities in nutrition for health staff of NGOsand for government staff is another majorconstraint mentioned. This low level in staffknowledge was reported as an obstacle thatresults in reduced capacity to conduct extensivetraining and expand nutrition interventions at thecommunity level.

Main constraints in conductingnutrition activities


V. Gaps and Priorities for Future Programmingin Nutrition

This table describes the gaps and priorities as identified in this review according to the activitiespresently conducted by organizations that were interviewed, and in relation to the nutrition

objectives, and the priority sectors, of the MOH/RGC.

NUTRITIONAL ISSUES GAPS PRIORITIES

Vitamin A Deficiency (VAD) - Poor VAC coverage among all target groups: underfives and postpartum women

- Poor coordination between different levels of the MOH relating to VAC distribution program

- Lack of a system for supervision, monitoring and evaluation of the VAC program activities

- VAC supply erratic - Low level of knowledge among health

workers about the VAC Policy - Poor knowledge among health workers

and community members in relation to the benefits of vitamin A, and VAC distribution

- Lack of knowledge among NGO staff about the VAC Policy

- Lack of resources/poor distribution of resources to support efficient VAC distribution through outreach activities (limited budget)

- Small-scale (sporadic coverage) homestead food production programs

- Lack of sustainable approaches to homestead food production activities

- Lack of nutrition education materials for national distribution

- No fortified foods available at the community-level

Short-term: - Improve VAC supplementation coverage

across the country - Support training for health center staff and

VHVs - Support health center outreach activities - Provide support for activities, including a

feedback system, supervision and education to the HC staff and VHVs in relation to vitamin A and VAC distribution

- Support community mobilization efforts by production of mass media-type materials

- Improve coordination efforts through the National Micronutrient Working Group

Medium-term: - Improve access to vitamin A rich food by

such initiatives as homestead food production (animal and plant foods)

- Nutrition education for improved feeding practices

Long-term: - Food fortification with vitamin A

Iron Deficiency Anemia (IDA)

- Very few interventions to address IDA in target groups most at risk (pregnant women, preschool-aged children and school-aged children)

- Poor knowledge of health workers and the general population on the signs and consequences of IDA and its prevention

- Lack of knowledge among health workers and the population about the National Safe Motherhood Policy on distribution of iron supplements to all pregnant women (90 iron/folate tablets during pregnancy)

- Lack of a National Policy on IDA (treatment and prevention)

- Lack of promotion of iron-rich food consumption and iron absorption enhancers (vitamin C rich food, protein-rich foods)

- Few efforts focused on parasitic disease control

- Lack of fortification initiatives

Short-term: - Immediate interventions in the form of pilot

projects, to find the best ways to address the severe problems of IDA by providing iron supplements and education to high risk groups (particularly pregnant women and young children)

- Mass education campaigns about the causes, consequences and prevention of IDA. This should be linked with pilot programs

- Control of parasite infestation in children and pregnant women by mass distribution of anti-parasite medicines

- In malaria endemic regions, ensure widespread coverage of impregnated bednets and system for re-impregnation

Medium-term: - Development of a National Policy on IDA

to support field efforts and based on pilots recommended above

- Expansion of homestead food production programs (especially animal foods)

- Development and implementation of a nutrition education strategy

Long-term: - Fortification of food items with iron - Environmental sanitation initiatives


Infectious Diseases - The relationship between micronutrient status and morbidity and mortality during HIV infection is not well-known

- It is unknown whether nutritional interventions (supplementation, dietary education, fortification) will improve morbidity and mortality during HIV infection

- Lack of information on whether nutritional interventions will help prevent individuals infected with TB from developing active disease

- No information on whether micronutrient supplementation could affect clinical outcomes of individuals with co-infection (TB and HIV)

- Lack of information for health center staff, NGOs staff, and others on mother-to-child transmission of HIV

- No integration of micronutrient supplementation with malaria control programs

- Lack of programs addressing food security issues for households with HIV+ persons

Short-term: - Conduct sound operations research

related to relationships between HIV and nutrition and TB and nutrition

- Develop strategy for the delivery of vitamin A with bednet distribution

- Examine possible deliver strategies for other micronutrients through the bednet distribution program

- Develop training package for health center staff, NGO staff and others on mother-to-child transmission of HIV, taking into consideration the most suitable option for women in different situations (urban vs. rural, socio-economic status, etc)

Medium-term: - Modify/develop programs based on

operations research recommended in short-term priorities

- Development of homestead food production program targeting communities at high risk for HIV

Section V: Gaps and Priorities for Future Programming in Nutrition


As can be seen from the overview presentedherein, there are many gaps in the area of

nutrition programming in Cambodia. At the sametime, there are many priorities in nutrition thatneed to be addressed if reductions in maternal andchild morbidity and mortality are to be realized.Programs that are likely to have the mostsignificant impact on reducing malnutrition arethose that are targeted at the populations forwhich inadequate nutrition has its largest effects,namely pregnant women and children under 3years of age. It is in these populations and duringthese ages that nutritional interventions have thegreatest potential for benefit.

In general, programs to improve the nutritionalsituation of women and children must start earlyon in the lifecycle. Pregnant women must receiveadequate dietary intake during pregnancy (andeven pre-pregnancy) in order for her fetus to growand develop properly. This is difficult to achieve,even in more industrialized countries and thus,supplementation with iron/folate should be apriority and with multiple micronutrients in thefuture. At the same time, dietary diversificationshould be promoted through homestead foodproduction programs and nutrition education.These types of programs can make micronutrient-rich foods more accessible to the household andthus have the potential for improving dietaryintake.

Promotion of exclusive breastfeeding up untilaround six moths of age with appropriate (highquality) complementary feeding thereafter will beimportant. Supplementation with vitamin A, iron,and in the future multiple micronutrients is alsovery important for preschool-aged children.Vitamin/mineral supplementation for children isalso common or recommended in industrializedcountries, even when children have better dietaryintakes. School-aged children and especiallyadolescent girls are also vulnerable, and programsto address their needs should not be neglected.These girls are the future mothers and theirnutritional status pre-pregnancy is an importantdeterminant of pregnancy outcome. Ironsupplements for school children could be oneimportant intervention. Thus, nutrition throughout

the lifecycle is important for the overall wellbeing of the individual and future generations.

To address these issues one needs to look atsuccessful efforts within Cambodia and in othercountries with a similar situation. Depending onthe intervention, there will be a need to strengthenhealth system delivery, and also strengthencommunity-based initiatives. Efforts will requirestrong local and political commitment, clearpolicies and guidelines, and initiatives fromgovernmental agencies, UN agencies and localand international NGOs. The followingrecommendations are made, based on findingsfrom this nutrition sector review. They areorganized as general recommendations andspecific program recommendations. The specificrecommendations are further broken down asthose that could be addressed in the short-,medium- and longer-term, bearing in mind thatbecause nutritional deficiencies often do notoccur in isolation, addressing one will likely havean impact on others.

a. Due to the heavy workload and budgetconstraints, some aspects of the nationalnutrition program, such as development ofnutrition-related policies, strategic planningand supervision from the national level, havenot received the attention needed. In addition,the Nutrition Unit/MOH is understaffed. Whilethe National Nutrition Unit receives technicaland financial support from some internationalorganizations, additional support is required inorder to build capacity of this Unit toimplement its strategy.– additional qualified staff are required to

work in the Nutrition Unit;– consideration should be given to sending

key staff abroad for further training;– trainings in-country, by international

organizations, could be organized to furtherenhance Nutrition Unit staff capacity;

– the RGC should consider the developmentof a nutrition curriculum to be used at the

VI. Recommendations

General recommendations


University of Phnom Penh for futurequalified human resources in the field ofnutrition.

b. Health center staff knowledge about nutritionand MOH nutrition-related policies (e.g.vitamin A policy, breastfeeding policy andSafe Motherhood Initiative) is limited. Healthcenter staff receive little training aboutnutrition, and continuing education is sporadic.In order to push nutrition programmingforward, health center staff will need trainingand refresher training on different aspects ofnutrition. Agencies working with health centerstaff should include training and refreshertraining on nutrition in their programs.However, trainings will eventually need to beinstitutionalized (see point #3 below).

c. A one-time training for health center staff ontopics such as the VAC program, ironsupplementation, breastfeeding, etc. is notsufficient as there is a high staff turn-over athealth centers. Thus, a system needs to be in-place for trainings to be on-going (periodic). Agroup of trainers responsible for this activity atthe provincial and operational district levelswill need to be identified, as will initialtrainers from the national level. Some nutritioncurricula are already in place, but others needto be developed in line with the MOHMinimum Package of Activities.

d. On-going program monitoring and supervisionis required. Agencies, whether NGOs orgovernmental should set up, if not alreadypresent, a systematic monitoring system thatwill collect information to help improveprogram activities. This can be done through asurveillance system (described below).

e. It is important for a nutritional surveillancesystem to be established. Surveillance can beused to map problems geographically and, itcan map interventions that are beingconducted. At the same time, data from thesurveillance system can be used to assess theimpact of program interventions. In addition,communicating findings from nutritional

surveillance can lead to mobilization of fundsfor nutrition programs, whether they are short-term disaster relief or longer-term initiatives.

f. Because surveillance may not be nationallyrepresentative or representative at theprovincial-level, periodic population-basednutrition surveys will need to be conductedevery 10 years to evaluate progress of nutritioninterventions. Results from these surveys willbe important for national programming andpriority setting.

g. Because Cambodia is still recovering frommany years of civil war, it is expected thatexternal assistance to the health system willneed to be provided for some time. Thus,external agencies should work in accordancewith MOH or RGC policy in order that thetransition can happen gradually and smoothly.

h. The NCN needs to become more active in its’coordinating role and, support should beprovided so that the new Cambodia NutritionInvestment Plan (2002 – 2007) can be realized.

Vitamin A Deficiency

Strategies to address the problem of VAD includesupplementation, dietary diversification andfortification. In the short-term, VAC coverageneeds to be improved nationwide, in the medium-term, access to micronutrient-rich foods should beconsidered and in the longer-term fortification offoods with vitamin A should be addressed.

Short-term

a. National scale-up of on-going pilot activitiesto improve VAC coverage among preschool-aged children and postpartum women shouldbe done. Efforts need to continue to focus onstrengthening the health care system byproviding training to health center staff andsupport for outreach activities. At the same

Specific program recommendations

Section VI: Recommendations


time, demand creation for VAC needs tocontinue. Current efforts in this area need to beevaluated and recommendations need to bemade for project scale-up.

b. Shortage of VACs at the health center level isoften a problem. This is particularly the casefor the newer 100,000 IU dose of vitamin A forchildren 6-11 months of age. Bettercoordination between agencies working withthe national VAC program needs to occur toensure that adequate VACs are available.Stocks should be maintained at the operationaldistrict level to improve accessibility for massdistribution months (March and November)and for measles outbreaks.

c. While there is a new policy for the provisionof an 8000 Riels (approximately US$2) perdiem per health center staff per day foroutreach activities, health center staff often donot know if they will receive the funds and ifthey do, it often comes many months after theoutreach session. Also, health center stafffrequently need to use some of this per diemfor transport and/or lodging when traveling tovillages far from the health center. Because ofthese limitations, staff may not be motivated togo out for outreach sessions. This needs to beexplored through various channels includingMEDICAM and UNICEF, together with theMOH. Meanwhile, agencies supporting healthcenters could help support outreach activitiesuntil the government system is in place.

Medium-term

a. Dietary diversification is an important strategyfor addressing VADD. Programs to increasethe production and availability ofmicronutrient-rich foods, both animal andplants, should be expanded. And, monitoringof these activities should be an integral part ofprograms.

b. Once foods are available, nutrition educationcan play an important role in improving intake.This is especially important during the stagewhen infants are being introduced

complementary foods and during pregnancyand lactation. Thus, homestead foodproduction programs should have a nutritioneducation component.

c. Nutrition education materials have beendeveloped by Helen Keller International andare being used widely throughout Cambodia.An assessment of additional needs for nutritioneducation materials is required. Also, thesustainability of reproduction of materialsmust be looked into.

d. NGO, and most MOH/Nutrition Unit staff,lack knowledge on basic nutrition. An agency,governmental or non-governmental, should beidentified that can provide the training neededfor staff to be able to carry out their programs.

Long-term

While efforts have begun to look at thepossibilities of fortification of foods with vitaminA, this needs further exploration.

Iron Deficiency Anemia

Strategies to address the problem of IDA includesupplementation, dietary diversification,fortification and parasitic disease control. In theshort-term, supplementation efforts should beimproved, or in the case of children, initiated,and, parasitic disease control efforts should beimproved and/or expanded. At the same time, inthe medium-term, dietary diversification,including homestead food production andnutrition education should be considered and inthe longer-term, food fortification andenvironmental sanitation.

Short-term

a. Programs to improve iron/folatesupplementation to pregnant women need to bestrengthened. Current delivery channels needto be examined and evaluated as does supplyof iron/folate tablets to health centers. Trainingshould be provided to health center staff aboutnational policy on supplementation to pregnant



women and educational materials will need tobe developed. In addition an educational “massmedia type” marketing of iron supplementstargeting pregnant women needs to bedesigned and implemented. However, becausethere are so few effective programs, it wouldbe important to conduct a pilot that takes intoaccount the many lessons learned in otherplaces.

b. Because many pregnant women do not attendthe health center regularly for prenatal check-ups, it is important for health center staff toprovide the recommended 90 tablets of iron/folate to the woman if/when she does show atthe health center. Health center staff arereluctant to do so because they would preferfor women to return. However, staff need toreceive training on this “Safe Motherhood”initiative and should be able to provide follow-up and support to pregnant women.

c. Provision of iron supplements to childrenshould be undertaken to prevent irondeficiency anemia in children. Because littlehas been done globally on this, a pilot projectshould be designed and piloted to examinedifferent delivery systems of an ironsupplement specially designed for preschool-aged children.

d. Programs that provide iron supplements toschool children should continue with improvedcoordination between the Ministry ofEducation and Health.

e. Control of parasitic diseases (such as malariaand hookworm) is also important for theprevention and control of anemia. Efforts bythe National Malaria Center and others in thisfield should be expanded and be bettercoordinated. In particular, regular massdeworming should be put in place andinsecticide-treated bednet coverage should beexpanded to all high-risk areas.

Medium-term

a. Currently there is no national policy on ironsupplementation or control of IDA, except for

pregnant women. The National MicronutrientWorking Group needs to develop guidelinesfor anemia control and treatment so that healthcenter staff, NGOs and other agencies workingin this field can know what to do. This shouldbe in line with the Integrated Management ofChildhood Illness package that will be pilotedshortly by the MOH, in collaboration with theWHO.

b. Iron supplies should be re-examined. Currentlythere are sufficient stocks and in fact, there areso many supplements that often times theyexpire soon after delivery to the health centers.This is another reason why health center staffmay not be giving pregnant women the 90recommended tablets of iron/folate.

c. Dietary diversification to improve intake oriron-rich foods is required. This could be donethrough homestead food production activities(described under VADD). But, the significanceof animal foods is even more important in thiscase.

d. Nutrition education materials describing ironabsorption inhibitors and enhancers should bedeveloped. These materials can be used byhealth center staff, NGO staff and others whenconducting nutrition education activities andwill be important for use with homestead foodproduction activities.

Long-term

a. While efforts have begun to look at thepossibilities of fortification of foods with iron,this needs further exploration.

b. Environmental sanitation and related educationwill be required in the longer-term to addressthe problem of hookworm, and schistosomiasis(in select areas). Water supply in remote areasis required and, educational materials aboutprevention of these diseases needs to bedeveloped.



Iodine Deficiency Disorders

IDD can be controlled through salt iodizationefforts. Additional attention is required so thatiodized salt become more accessible to allCambodians. These efforts should happen in theimmediate future.

Short-term

a. Universal salt iodization for humanconsumption needs to be realized. Legislation,long in the making, needs to be finalized andapproved. Iodized salt production efforts needto continue and need to be expanded.

b. While there is some distribution of iodized saltto the provinces, additional efforts are neededand expansion to all provinces is essential. Forthis, demand creation of the product at theprovincial-level is required and this can bedone through a social marketing campaign.

c. The MOH should examine whether there is aneed to continue to provide iodized oilcapsules to women of reproductive age in highrisk areas.

Medium-term

Once iodized salt reaches the provinces, efforts tomake it available at the lower level are alsorequired. Social marketing will also be useful atthese levels as well, especially when non-iodizedsalt is also available on the market (since non-iodized salt is cheaper than iodized salt).

Malnutrition

Malnutrition is a result of a complexity ofimmediate and underlying causes. In the short-term, malnutrition strategies should focus onimproving infant and child feeding practices aswell as maternal nutrition. At the same time,efforts to control micronutrient deficiencies(described above) will also have an impact onmalnutrition. Longer-term efforts should focus onnutritional surveillance and program evaluation.

Short-term

a. Programs to improve breastfeeding practicesand to improve the quality and timelyintroduction of appropriate foods for infantsare needed. Technical assistance to theNational Breastfeeding Program is required inorder that program objectives are being met atthe different levels. Programs will not onlyneed to focus on strengthening health workerknowledge about breastfeeding, but also willneed to focus on community-based initiativesto improve breastfeeding and complementaryfeeding practices. For these activities and forbreastfeeding promotion in general, it will beimportant to have a women-centered approachto learn of constraints to breastfeeding andhow best the woman can feed her child.

b. Dietary diversification to improve dietaryintake is required. This could be done throughhomestead food production activities(described under VADD). Accompanyingnutrition education materials should bedeveloped. Making foods available is requiredbefore mothers can learn more aboutimproving quality of complementary foods.

c. While there is a policy on HIV/AIDS andinfant feeding, dissemination of informationhas hardly been conducted. Materials shouldbe developed and counselors should be trainedto be able to provide mothers who are HIVpositive with information on possibilities forinfant feeding.

Medium-term

Training programs for health center staff, NGOstaff and others will need to be developed in asystematic way so that messages are consistentand in line with MOH policies. This should alsoinclude the use of the Child Health Card and thenewly revised module on growth monitoring.

Long-term

After results of the trials on maternal and childsupplementation with multiple micronutrients,



efforts should focus on determining whethersupplementation with multiple micronutrients is afeasible option in Cambodia and then determinepossible channels for distribution to thesedifferent target groups.

Infectious Diseases

Poorly nourished people are more susceptible toinfectious diseases than well-nourished peopleand evidence indicates that undernutrition mayenhance the severity of infections. Thus, it will beimportant in the short-term to focus on thepotential role that micronutrients can play inprogression of HIV and TB. This operationsresearch will contribute to global knowledge onthe subject and will be useful for adapting on-going programs. In the medium-term, programsshould focus on food security issues for thosecommunities at high-risk for HIV.

Short-term

a. Due to the important role that multiplemicronutrient supplements can play inreducing the progression of HIV and TBinfections, especially in countries likeCambodia where the nutritional status of thepopulation is poor, operations research shouldbe conducted to examine the role ofmicronutrients in disease progression. HKIhas the technical expertise, and experience, forsuch operations research.

b. Efforts to coordinate vitamin Asupplementation with bednet distributionprograms should be considered. Any suchefforts require the participation of the NationalMalaria Center, the National MicronutrientTechnical Working Group and others workingin this area (such as NGOs).

c. Other micronutrients, besides vitamin A, canalso play a role in reducing malaria morbidityand mortality. Thus, operations research toexplore distribution mechanisms of othermicronutrients with on-going activities shouldbe considered.

d. Because health center staff, NGO staff andothers have little knowledge of Mother-To-Child-Transmission, a training program shouldbe developed that is in line with governmentpolicy on infant feeding. An agency withexpertise in nutrition should work with theMOH on such a training program, that wouldeventually be integrated with other MOHtraining programs. Special emphasis onappropriate counseling is necessary.

Medium-term

a. Based on operations research examiningmicronutrients and HIV/AIDs and TB (seeabove), programs should be adaptedaccordingly.

b. Food security programs targeting communitiesat high risk for HIV/AIDS should be initiated.Improving access to and consumption ofmicronutrient-rich foods would benefit thevery poor and food insecure areas. Anapproach such as homestead food production(both plants and animal products) could beused, as this is a sustainable way to makenutrient-rich foods available at the householdlevel, with minimum inputs.



1. National Institute of Statistics, DirectorateGeneral for Health (Cambodia), and ORC Macro.2000. Cambodia Demographic and Health Survey2000. Phnom Penh, Cambodia and Calverton,Maryland USA: National Institute of Statistics,Directorate General for Health, and ORC Macro.

2. BASICS. Improving Child Health ThroughNutrition: The Nutrition Minimum Package.BASICS, 1997.

3. HKI/Cambodia. The need for increasing coverageof vitamin A capsule program to reduce vitamin Adeficiency among young children in Cambodia.HKI/Cambodia Nutrition Bulletin, Vol. 2, Iss. 2,November 2000.

4. West KP, Jr., Chirambo M, Katz AJ, Sommer A,Malawi Survey Group. Breast-feeding, weaningpatterns, and the risk of xerophthalmia inSouthern Malawi. Am J Clin Nutr 1986; 44:690-697.

5. GTZ-IFSP – Health Component – ActivitiesReport for 1 January 2000 to 31 December 2000,Kampot, Cambodia.

6. West CE, Eilander A, van Lieshout L.Consequences of revised estimates of carotenoidbioefficacy for the dietary control of vitamin Adeficiency in developing countries. J Nutr 2001,in press.

7. West K Jr, and Darnton-Hill, I. Vitamin ADeficiency, in Semba RD and Bloem MW, eds.Nutrition and Health in Developing Countries,Humana Press, Totowa, NJ, USA 2001.

8. HKI/Cambodia. The need for increasing coverageof vitamin A capsule program to reduce vitamin Adeficiency among young children in Cambodia.HKI/Cambodia Nutrition Bulletin: Vol.2, Iss. 2,Nov. 2000.

9. As per the MOH/Cambodia VAC Policy that hasnot yet been updated to include that postpartumwomen should receive two high dose VACs.

10. West K Jr, and Darnton-Hill, I. Vitamin ADeficiency, in Semba RD and Bloem MW, eds.Nutrition and Health in Developing Countries,Humana Press, Totowa, NJ, USA 2001.

11. HKI/Cambodia. Study on Infant FeedingPractices: Colostrum, Breastfeeding andWeaning. 1997.

12. Gillespie S. Major Issues in the Control of IronDeficiency. MI and UNICEF 1998.

13. Yip R. Iron Deficiency and Anemia in Semba RDand Bloem MW, eds. Nutrition and Health inDeveloping Countries, Humana Press, Totowa,NJ, USA 2001.

14. Longfils P, IFSP-Health Component: SchoolProgramme Activities Report and SchoolAnthropometric, Hemoglobin and Stool Survey in1999 and Follow up Survey in 2000. GTZ-IFSP/Kampot. Cambodia.

15. Exchange rate: US$1 = 4,000 Riels

16. Allen H.L. and Alhuwalia Namanjeet. 1997.Improving Iron Status Through Diet – Theapplication of knowledge concerning dietary ironbioavailability in human populations. John SnowInc./OMNI Project. Arlington, VA, USA.

17. Semba RD. Iodine Deficiency Disorders in SembaRD and Bloem MW, eds. Nutrition and Health inDeveloping Countries, Humana Press, Totowa,NJ, USA 2001.

18. National Sub-Committee for IDD, 1997.

19. Allen LH. Nutrition Bulletin. European Journal ofClinical Nutrition 1994; 48:S75-S89.

20. Schroeder, DG. Malnutrition in Semba RD andBloem MW, eds. Nutrition and Health inDeveloping Countries, Humana Press, Totowa,NJ, USA 2001.

21. Shankar AH. Nutritional Modulation of ImmuneFunction and Infectious Disease, in PresentKnowledge in Nutrition, 8th Edition, ILSI, 2001.

22. Ministry of Health/National Center for HIV/AIDS, Dermatology and STD. Report on HIVSentinel Surveillance in Cambodia 2000. MOH,2001.

23. Semba RD and Gray GE. HumanImmunodeficiency Virus Infection, in Semba RDand Bloem MW, eds. Nutrition and Health inDeveloping Countries, Humana Press, Totowa,NJ, USA 2001.

24. Ibid.

25. Fawzi WW, et al. Randomised trial of effects ofvitamin supplements on pregnancy outcomes andT-cell counts in HIV-1-infected women inTanzania. Lancet. 1998 May 16;351(9114):1477-82.

Endnotes


26. HKI. Initial findings from the 2000 CambodiaNational Micronutrient Survey. Supportingdocument to the Micronutrient Workshop held onFebruary 20, 2001, in Phnom Penh, Kingdom ofCambodia.

27. Gillespie S, Haddad L and Jackson R. HIV/AIDS,Food and Nutrition Security: Impacts and Actionsin Nutrition and HIV/AIDS, United NationsAdministrative Committee on Coordination, Sub-committee on Nutrition. Nutrition Policy Paper#20, Report of the 28th Session Symposium held3-4 April 2001, Nairobi, Kenya.

28. Ministry of Health/National TB Program/Kingdom of Cambodia. 1999. Use “DOTS” toSave our People. Tuberculosis Report.

29. Ministry of Health/National Center for HIV/AIDS, Dermatology and STD. Report on HIVSentinel Surveillance in Cambodia 2000. MOH,2001.

30. Whalen C and Semba RD. Tuberculosis, in SembaRD and Bloem MW, eds. Nutrition and Health inDeveloping Countries, Humana Press, Totowa,NJ, USA 2001.

31. Shankar, AH. Malaria, in Semba RD and BloemMW, eds. Nutrition and Health in DevelopingCountries, Humana Press, Totowa, NJ, USA 2001.

32. Malaria indicators for 2001. National MalariaCenter, Ministry of Health, Cambodia.

33. Lengeler C. Insecticide treated bednets andcurtains for malaria control. Cochrane Review.In: The Cochrane Library, Issue 4. Oxford:Update Software, 1998.

34. Shankar AH, Genton B, Baisor M, Paino J, TamjaS, Adiguma T, Wu L, Rare L, Bannon D, TielschJM, West KP Jr, Alpers MP. The influence of zincsupplementation on morbidity due to Plasmodiumfalciparum: a randomized trial in preschoolchildren in Papua New Guinea. Am J Trop MedHyg. 2000 Jun;62(6):663-9.

35. Shankar AH, Genton B, Semba RD, et al. Effect ofvitamin A supplementation on morbidity due toPlasmodium falciparum in young children inPapua New Guinea: a randomized trial. Lancet1999; 354:203-209.

36. Graves PM. Comparison of cost-effectiveness ofvaccines and insecticide impregnation ofmosquito nets for the prevention of malaria. AnnTrop Med Parasitol 1998; 92:399-410.

Endnotes


Local NGOs, in alphabetical order:

• Bantey Srei• Buddhism for Development• Cambodian Association for the Development of

Economy Together (CADET)• Cambodian Development and Relief Centre for the

Poor (CERCP)• Cambodian Health Education Development

(CHED)• Cambodian Women’s Development Association

(CWDA)• Chamroeun Cheat Khmer (CCK)• Chivith Thmey• Community for Rural Development (CRD)• Cooperation for a Sustainable Cambodian Society

(CSCS)

• Khmer HIV/AIDS NGO Alliance (KHANA)• Khmer Human Resources for Development

Organizations (KHReDO)• Khmer Rural Development Association (KRDA)• Khmer Women’s Cooperation for Development

(KWCD)• Kratie Women’s Welfare Association (KWWA)• Minority Organization for the Development of

Economy (MODE)• Rachana• Sovann Phoum• Village Support Group (VSG)• Women’s Service Organization (WOSO)

Appendix I. List of organizations interviewed

International NGOs, in alphabetical order:

• Action Against Hunger (AAH)• Adventist Development and Relief Agency

(ADRA)• Asian Outreach Cambodia (AOC)• Assemblies of God (AOG)• Cooperation, Assistance, Relief Everywhere

(CARE)• CARITAS• Christian Outreach Relief and Development

(CORD)• Church World Service (CWS)• Coopération Internationale pour le Développement

et la Solidarité Programme in Cambodia (CIDSE)• Food for the Hungry International (FHI)• GTZ – Integrated Food Security Program (IFSP)• Handicap International (HI)• HealthNet International (HNI)• Health Unlimited (HU)

• Helen Keller International (HKI)• International Cooperation Cambodia (ICC)• International Volunteers of Yamagata (IVY)• Lutheran World Service (LWS)• Malteeser Germany (MHD)• Maryknoll• Médecins du Monde (MDM)• Partners for Development (PFD)• Reproductive and Child Health Alliance (RACHA)• Save the Children – Australia (SCA)• Save the Children – France (SCF)• Save the Children – UK (SCUK)• SERVANTS• 24-Hour Television Charity Committee – Cambodia• World Relief – Cambodia (WR-C)• World Vision – Cambodia (WV-C)• ZOA Refugee Care

Government Organizations/Programs:

• National Breastfeeding Program – Ministry ofHealth

• National Centre for Health Promotion (NCHP),Ministry of Health

• National Nutrition Program, Ministry of Health

UN Organizations, in alphabetical order:

• Food and Agriculture Organization (FAO)• UNICEF• World Food Program (WFP)• World Health Organization (WHO)


Appendix II: Summary table – Organizational profile and interventions

36

Appendix II.Sum

mary Table – O

rganizational profileand interventions

CURRENT INVOLVEMENT IN THE NUTRITION SECTOR &MAIN DONORS

Programs: Food Security Program – Focuson homestead food production, improvementof rice production, income generation, andincreased consumption of nutrient-rich food.Four trainers conduct education with villagevolunteers via nutrition workshops, women’sgroups, and cooking practices.

Donors: European Union

Programs: Support WFP’s SupplementalFood Program (SNAP) – Involves support toHC staff to conduct monthly growthmonitoring, food ration distribution forchildren under 5, pregnant/ lactating women,nutrition education.Child Survival Program – Strong nutritioncomponent: improve nutritional status ofchildren under 3 years; Improve BF andyoung child feeding practices; decreaseanemia; includes the Hearth Program (torehabilitate malnourished children); educationon nutrition is done via Mother’s Clubs, homegardening activities and Hearth Program.

Donors: USAID, ADRA-Australia, VASS NewZealand, WFP

Programs: Primary Health Care TeachingProgram – Weekly mobile medical clinicwhere nutrition activities are performed.Informal education in groups, children’s funactivities, growth monitoring sessions.Mothers of malnourished children receivecounseling and a food supplement (soyamilk); BF counseling is done and milk powderis distributed as a last resort if the mothercannot BF.

Donors: Rattanak Foundation and individualdonations

ORGANIZATION

1. Action Against Hunger(AAH)

Year of establishment inCambodia: 1989

2. Adventist Developmentand Relief Agency (ADRA)


3. Asian Outreach Cambodia(AOC)


GEOGRAPHIC REGION

Province:Prey Vihear

Districts:Chom Ksan and Kulen(24 villages, 600families)

Province:Siem Reap, KampongThom

District: Baray andSantuk OD in KampongThom; Angkor ChoeungOD in Siem Reapprovince.

Province: Kandal

District: Viet Haim

X X

FUTURE PLANS

The program is expected toremain the same. No futureplans yet as it is too early intothis new program.

In the very near future, theHearth Program will beimplemented within the ChildSurvival Program (started inOctober 2001), in which theyplan to train VHVs to supportthe program and disseminateinformation through theprogram.

No future plans.

NE FS VMD GM BFP NA HFP

TARGET POP.

Family as awhole; fornutritionobjectives –women andchildren

Women 15-49y. old; U5children

Women andchildren ingeneral (about500 peopleweekly)

X X X X X

X X X X X X X

NOTE: NE = Nutrition Education; FS = Food Supplements; VMD = Vitamin/Mineral Distribution; GM = Growth Monitoring;BFP = Breastfeeding Promotion; NA = Nutritional Assessment; HFP = Homestead Food Production

ORGANIZATION CURRENT INVOLVEMENT IN THE NUTRITION SECTOR& MAIN DONORS

GEOGRAPHIC REGION TARGET POP. FUTURE PLANSNUTRITION INTERVENTIONS



37

CURRENT INVOLVEMENT IN THE NUTRITIONSECTOR & MAIN DONORS

Programs: Community Health EducationProgram (CHE) – Health, hygiene andnutrition education is given by CHE TrainingTeams to members of VDCs who perform thetraining at the community level, using groupdiscussions, practice, IEC materials such asimages and pictures to stimulate discussions.Each community decides what they want toknow in nutrition, health and other sectors ofthe CHE program. From one community toanother the subjects may be different. Alsothrough animal husbandry, home gardeningand fruit tree planting activities, somenutrition education is given. Trainers alsolearn how to recognize and preventmalnutrition.

Donors: AOG – Finland, USA, Philippines;Government of France and Finland.

Programs: Nutrition activities are conductedthrough the home gardening program.Objectives are to improve the nutritionalstatus of the whole family and increaseincome. Activities consist of basic nutritioneducation and cooking demonstrations ingroups or individual households, using IECmaterials.

Donors: CAFOD, AUSAID, NOVIB

ORGANIZATION

4. Assemblies of God (AOG)


5. Banteay Srei


GEOGRAPHIC REGION

Province:Kg. Speu, Kandal, Kg.Cham

District:Cbaar Mon in Kg. Speu,Kieng Svay and Saangin Kandal, Dambae inKg. Cham(18,338 people)

Province:Siem Reap

District: 3(13 villages)

X X

NUTRITION INTERVENTIONS FUTURE PLANS

Future plans are to continue toexpand to more villages everyyear using the same approachand add more training lessonsto the program in some villagesas needed.

They plan on keeping thesame approaches for the futurehowever they would like toexpand their program to morevillages and provide training toVHVs in home gardening andnutrition.


TARGET POP.

Adults ingeneral;women aremore involved

Poor andvulnerablewomen (350households)

X X

ORGANIZATION CURRENT INVOLVEMENT IN THE NUTRITION SECTOR& MAIN DONORS

GEOGRAPHIC REGION TARGET POP. FUTURE PLANSNUTRITION INTERVENTIONS



38 CURRENT INVOLVEMENT IN THE NUTRITION

SECTOR & MAIN DONORS

Programs: Community DevelopmentProgram - Health promotion activities throughthe mobile health unit: health and nutrition(child feeding practices, nutrient-rich foods,prevention of micronutrient deficiencies)information is disseminated using posters,engaging into discussions through monthlymeetings for children’s program, women’sgroups, household visits. The staff trainVHVs and support them in conducting theseactivities.

Donors: PACT, Enfants du Mekong

Programs: Food for Preschool Children andNutrition Education – This program isimplemented through the food securityprogram – home gardening. Nutritioneducation activities occur via sessionsorganized by VDC members who are trainedby CADET’s staff. Basic nutrition informationis disseminated using posters and flip charts

Donors: CIDSE

ORGANIZATION

6. Buddhism forDevelopment


7. Cambodian Association forDevelopment of EconomyTogether (CADET)


GEOGRAPHIC REGION

Province: Battambang

District: Sangkai

Commune: 7

Province: Takeo

District:Prey Kabas

Commune: Kampengand Prey Phdao(6 villages)

X X

FUTURE PLANS

Plan to reinforce the nutritioneducation activities by usingmore and better IEC materials.

No future plans for expansionor modifications to thisprogram.


TARGET POP.

Women of allages, with aspecialemphasis onpregnantwomen

Population ingeneral withemphasis onwomen 15-49and children(220households)

X X

NUTRITION INTERVENTIONSORGANIZATION GEOGRAPHIC REGION TARGET POP. FUTURE PLANSNUTRITION INTERVENTIONSCURRENT INVOLVEMENT IN THE NUTRITION SECTOR& MAIN DONORS



39


Programs: Support WFP’s SNAP program inBantey Meanchey province. Support HCstaff, VHVs for monthly growth monitoring,CSB suppl. to U5 children, pregnant/lactatingwomen, conduct nutrition education andother health activities.- In all provinces, CARE provides assistanceand strengthens HCs to improve servicedelivery at HC level and outreach activities- CARE conducts home gardening activitiesin all the provinces they are present.- HIV/AIDS program (Koh Kong, BanteyMeachey): food suppl. (rice, fish) to HIV+people; multi-vitamin supplementation, or justiron and B complex vitamins; education onnutrition, hygiene and sanitation.

Donors: USAID, WFP

Programs: Supports WFP’s SNAP (foodsupplemental program) – Assists HC staffand volunteers in monthly GM sessions, CSBration distribution to U5 children,pregnant/lactating women, nutrition educationand other health activities.Community Development Program – Incomegeneration through home gardening; credit;agriculture; infrastructure; water, etc.;distribute multi-vitamin supplements, rice andmeat through the HIV/AIDS Home CareProgram, and also conduct basic health,hygiene and nutrition education for HIV/AIDSpeople and their family.

Donors: Various CARITAS around the world,WFP

ORGANIZATION

8. Cooperation, Assistance,Relief, Everywhere (CARE)


9. CARITAS


GEOGRAPHIC REGION

Province: BanteyMeanchey, OddarMeanchey, Koh Kong,Pursat, KampongChhnang

District: P. Net Preah inBantey Meanchey;Somrong in OddarMeanchey; Sre Ambel inKoh Kong; SampovMeas and Bakan inPursat; Kg. Chhnang inKg. Chhnang.

Province:Siem Reap

District: Siem Reap(7 HCs)

X X X X X


Plan to become involved in thenear future in strengtheningVAC distribution to children andpostpartum women bysupporting HC staff andvolunteers (training, methods ofreporting) at the HC andcommunity levels.

Programs are expected toremain the same for the nearfuture.


TARGET POP.

Pregnant/lactatingwomen,children under5

Emphasis onwomen and U5children;community ingeneral;people livingwith HIV/AIDS

X X X X X X




40 TARGET POP.

Women andpoor families(40 families)

Healthworkers,health careeducators

Poor women inthecommunity;youth groups


Programs: Through their agricultureprogram, the goal is to improve knowledge offarmers about nutrition and how to grownutrient-rich foods. Communityrepresentatives receive training onagriculture, how to choose appropriatenutrient-rich crops; supported by project staffthey distribute seeds, conduct nutritioneducation in households and through creditgroups.

Donors: Partner NGO Sor Sor Trong

Programs: The program is to improve thehealth of Cambodians by designing effectivehealth education interventions, produceappropriate IEC materials, and train primaryhealth care educators. This organizationdoes not work directly in nutrition but isrequired from time to time to develop IECmaterials in nutrition for variousorganizations.

Donors: Information not available

Programs: As part of their Credit BankProgram, some health and nutritioneducation is provided regularly during creditgroup meetings in villages. CWDA staffconduct the education sessions, which covervarious topics of nutrition such as nutrient-rich food consumption, prevention ofmicronutrient deficiencies, and proper infantfeeding practices. These educational sessions are conducted using posters,leaflets, open discussions, question andanswer period, and problem solving.


ORGANIZATION

10. Cambodian Developmentand Relief Center for thePoor (CERCP)


11. Cambodian HealthEducation Development(CHED)


12. Cambodian Women’sDevelopment Association(CWDA)


GEOGRAPHIC REGION

Province:Kampot

District: Kampong Trach

Commune: KampongTrach Khang Khoeun

Village:Koh Tachan


Province:Phnom Penh area

Commune: 20(5-6 villages in eachcommune)

X X


From the request of the districtauthorities, the nutritioneducation program willcontinue. Topics will cover:growing nutrient-rich vegetablesin household garden, andnutrition for preschool-agedchildren in 20 villages of thedistricts of Kampong Trach andDang Tong.

No future plans for the programon IEC materials developmentin the field of nutrition.

No future plans for this programfor now.


X

X




41


Programs: In their Primary Health CareProgram, nutrition, VAD prevention andhome gardening are promoted. Training isgiven to VHVs and village model gardenfarmers. Information is disseminated througheducational sessions (posters, leaflets,discussion cards) and real fooddemonstrations. Nutritional assessment ofthe target groups is conducted regularly,supported by HKI.

Donors: HKI and Oxfam

Programs: Save the Poor Children Program– Promote health of poor families, orphans,disabled people and widows. Train VHVs andsupport them in disseminating info. throughsmall discussion groups, schools, and houseto house by using posters, leaflets and videoshows. Conduct some nutrition activitieswithin food security program, homegardening program.

Donors: AusAID, APSO, CWS

Programs: Community DevelopmentAssistance Project – Health and nutritioneducation in primary schools for children (andfor teachers). Education done using IECmaterials and activities. Some nutritioneducation is being conducted within thehome gardening program. Some foodproduction and preservation is done in PreyVeng and basic nutrition education is part ofthis program. Through the Primary HealthCare Program in Prey Veng, nutrition is partof the training and capacity building of healthstaff for maternal and child health.

Donors: Tear Fund Holland and UK; ZOARefugee Care.

ORGANIZATION

13. Chamroeun Cheat Khmer(CCK)


14. Chivith Thmey


15. Christian Outreach Reliefand Development (CORD)


GEOGRAPHIC REGION

Province: Takeo

District:Koh Andeth

Communes: Rominh,Phlea Prochum, PreyKhla, Kra Pom, Chok,Borei Challusa(12 villages)


District: Banan, Bovel

Communes: 3

Villages: 9

Province:Kampong Speu,Prey Veng

District:Baseth in Kg. Speu(23 villages); andKamchey Mear inPrey Veng

X X


Plan to expand to four newvillages in the future, and trainthe VHVs in these villages.

Will expand the program to upto 200 families in order for themto improve their quality of life.

Expand to 21 more villages inthe near future because theprogram is successful. Plan todevelop a Parent-Teacherassociation within their schoolprogram to sensitize parents tothe importance of good nutritionfor good school performance.Would like to develop a schoolfood program and distributeVACs and iodized salt inaddition. Plan to develop ananimal husbandry program.


X X

X X

TARGET POP.

Pregnant andlactatingwomen,mothers of U5children

Poor families,women andchildren

Women15-49;preschool andprimary schoolaged children






Programs: Through their home gardeningprogram, established in 1997, they conductnutrition and health education activities.Simple nutrition messages are disseminatedby VHVs and HC staff (trained by CWS staff)through self-help groups, savings and creditgroups and mother’s groups.

Donors: CWS New York, EED, Christian Aid,DIA, ECHO

Programs: The nutrition activities are donevia the Farming and Animal HusbandryProgram (started Feb. 2001). The objectivesare to raise animals and promote homegardening for income generation andincrease nutrition knowledge. They trainpeople house by house in farming techniquesand they disseminate nutrition information atthe same time, using posters, videos andfood demonstrations.

Donors: Local donors (Cambodia)

Programs: Community-Based EducationProgram – Objectives are to increaseawareness on proper nutrition practices,reduce micro-nutrient deficiencies,encourage BF, promote home gardening andseed distribution. Nutrition educationactivities are done by CSCS staff , healthcenter staff and some members of women’sgroups, who receive nutrition training.Activities consist of a school program (5minute blip/week on nutrition), discussionswith school teachers, community leaders,women’s groups, support VAC distributionthrough outreach activities and referrals toHCs, encourage pregnant women to receiveANC and demand iron tablets (90tablets/pregnant woman) from HCs.

Donors: UNICEF, CIDA

ORGANIZATION

16. Church World Service(CWS)


17. Community for RuralDevelopment (CRD)


18. Cooperation for aSustainable CambodianSociety (CSCS)


GEOGRAPHIC REGION

Province: Kandal,Kampong Thom andSvey Rieng

District: 1 in each ofKandal and Kg. Thomand 3 in Svey Rieng(36 villages)

Province: KampongSpeu

Commune: 1(300 households)

Province:Kampong Speu

District:Basedth(21,288 families, 34schools)

X X


They want to conduct anevaluation of their nutrition andhealth activities to assess theimpact of these activities andmodify their approach asneeded. They want to expandthe promotion of homegardening to increase people’spurchasing power for nutritiousfoods.

In the future, they plan to trainthe community to betterunderstand the advantages ofhomestead food production andhealth education, so they canchange their family situationpositively.

The program is expected toremain the same as it has onlyvery recently started.


X X X

X X

TARGET POP.

Pregnant,lactatingwomen andchildren

Whole familybut especiallyfarmers whoparticipatein the program

Population as awhole withan emphasison women andchildren




43


Programs: Integrated CommunityDevelopment Program – Includes foodsecurity, credit, income generation, healtheducation in which some nutrition educationon basic concepts and food sanitation isperformed as well as promotion of vegetableproduction and consumption. VHVs andTBAs are trained to disseminate thisinformation.


Programs: Empowerment of women throughmanagement of water resources, improvedhousehold food security, nutrition and healthproject (WIN). Training of National staff fromthe MOH, provincial level, O.D. staff, healthcenter staff and farmers. The nutritioneducation is done through demonstrationgardens, group sharing of experiences,practical activities to increase knowledge andconsumption of foods rich in nutrients suchas VAC and iron.

Donors: The United Nations

Programs: Through the Child DevelopmentProgram, nutrition activities are conducted.The community decides what they want toknow about nutrition and health. Basicnutrition concepts (food groups,micronutrients, food hygiene) are taught ingroups gathered in the community. Their goalis to fill the gaps that teachers do not fill inmost schools regarding health and nutritioneducation.

Donors: Canada, Germany and Japan(donations), USAID

ORGANIZATION

19. CoopérationInternationale pour leDéveloppement et laSolidarité Programme inCambodia (CIDSE)


20. Food and AgricultureOrganization of the UnitedNations (FAO)


21. Food for the HungryInternational (FHI)


GEOGRAPHIC REGION

Province: Kandal

District:Muk Kampol

Communes: 5(17 villages)

Location:Samrong and PreyKabas districts in TakeoProvince; Mleach andChum Kiri districts inKampot Province; Poukand Prasath Bakorngdistricts in Siem ReapProvince.(10 villages, 30household/village; 291people)

Province: Kampot

District: Chouk(1600 children)

X X


Plan to conduct a needsassessment survey in the targetarea to focus interventions inthe future.

Plan to collaborate with WFPon the nutrition program; toimprove the knowledge ofgovernment staff in the field ofnutrition; to collaborate withWHO in the field of foodhygiene and sanitation.

Plan to increase the number ofnutrition activities in the schoolprogram especially.


TARGET POP.

All people inthe targetarea;emphasis onwomen andchildren

Schools,farmersespeciallywomen

School-agedchildren;community asa whole

X X

X




44 FUTURE PLANS

The program is expected toremain the same in the future.

No future plans for thisprogram.


Programs: IFSP – Consists of 6components: village infrastructure, agricultureand homestead food production, incomegeneration, credit, community developmentand health. Within the health componentnutrition plays a big role. School HealthProgram every 6 months: education, vitaminsA and B complex are distributed,mebendazole for deworming, iron therapy ifanemia is detected, anthropometricmeasurements for nutritional ststus.Provincial staff, HC staff and VHVs aretrained to work together during monthlyoutreach activities to conduct growthmonitoring, education sessions, provide ANCto pregnant women and nutrition education,etc. Distribute food to children during monthlynutrition activities, helps to attract mothers toparticipate in activities.

Donors: GTZ

Programs: Health and Nutrition Program –Support to WFP’s SNAP (supplemental foodprogram) for HC staff for monthly GMsessions, food ration distribution (CSB) forchildren, pregnant/lactating women, nutritionand health education, practice to preparecomplementary food, BF promotion. VHVsalso receive training to help in conductingthese activities. These monthly activities alsoinclude vaccination and other health care tomothers and children, which are not part ofthe SNAP.

Donors: Canadian Cooperation Office(CCO), RACHA, WFP

ORGANIZATION

22. German TechnicalCooperation-Integrated FoodSecurity Program(GTZ – IFSP)

Year of establishment inCambodia: 1995 (GTZHealth Projects)

23. Handicap International(HI)


GEOGRAPHIC REGION

Province:Kampot

District: Chum Kiri,Angkor Chey, Dang tungand Kampong Trach(90,000 people, cover 4HCs)

Province:Siem Reap

District: Kralanh

Commune: 11(92 villages, 6 HCs)

X X X X X X

NUTRITION INTERVENTIONS


X X X X

TARGET POP.

Children under5, school-agedchildren andwomen ofreproduct. age

Pregnant/lactatingwomen;children under5




45


Programs: - Nuns and Wat GranniesProgram - Training is given to volunteers(Nuns and Grannies) by HNI and governmenthealth staff on BF and treatment for diarrheawith ORS. Volunteers go house to house toteach women about these subjects. HNI visitvolunteers regularly for problem shootingsessions.- The Antenatal Care Program – includesnutrition education relating to anemia and itsprevention in pregnancy. The training is givento feedback committees who conducteducation with community members.Distribution of VAC to postpartum womenand iron to pregnant women.

Donors: RACHA

Program: Support to the development ofhealth services – Support WFP’s SNAPProgram (supplemental food program) in 2HCs out of 5. Support HC staff in monthlygrowth monitoring of U5 children, Corn-SoyaBlend (CSB) ration distribution to childrenand mothers, nutrition education and otherhealth related activities. In the remaining HCsand villages around these HCs, generalhealth and nutrition education is performedby VHVs who are supported by HNI staff andHC staff, practical cooking lessons are oftendone with target group.

Donors: MSF – Australia, MSF –Switzerland, HNI - Dutch

ORGANIZATION

24. HealthNet International(HNI)


24 a. HealthNet International(HNI)


GEOGRAPHIC REGION

Province:Svey Rieng

District:Romeas Hek(reaching parts of the219 villages)

Province: Kratie

District: Kratie(support to 5 HCs)(28 villages for SNAP)

X X X X


Try to work in nutrition at thereferral hospital in Svey Riengfor malnourished children whoneed to be admitted at thehospital.

The program is expected toremain the same.


X X X X X

TARGET POP.

Women15-49 and theirchildren







Programs: Community Health Programwhich includes some nutrition education viahealth activities; to enhance the capacity ofvillagers to improve their own health and thequality of health services.

Donors: ECHO and DFID

Programs: Indigenous Women andChildren’s Health and Nutrition Project(Ratanakiri) – Assessment of nutritional andhealth status; preventive and curativeservices as MOH outreach guidelines;improvement of knowledge and practices inhealth and nutrition.

Donors: ECHO

ORGANIZATION

25. Health Unlimited(HU)


25 a. Health Unlimited (HU)


GEOGRAPHIC REGION

Province:Preah Vihear

District: TbengMeanchey, SangkumThmey, Koulen, andChom Ksan(24 villages)

Province: Ratanakiri

Districts:Oyadao, Lumphat,Andong Meas, Kun Mumand O’Chum. (150villages, 49,000 people)

X


Preah Vihear – Discuss withPHD about expanding thecommunity health program toother villages via increasedcapacity of the PHD healtheducation department,provincial MCH program andhealth centers.

Ratanakiri – The project is for a9-month period as a semi-emergency program. Hope toobtain more funds to extend itas a development programincluding identifying anddeveloping food sources anddiet diversification.


X X X X X

TARGET POP.

14,170 peoplein 24 villages,4 healthcenters

Women 15-49y. old, U5children




47


Programs: Pilot program on VAC distribution(working with MOH) to improve VACcoverage by creating awareness anddemand among households/communitiesthrough improving training of HC staff andVHVs, and providing supervision, logisticsand other essential support activities to theVAC/EPI outreach program.- Homestead Food Production (gardening,animal husbandry) – Aims to improveavailability, access and consumption ofmicronutrient-rich foods. Works with 6 partnerNGOs in 7 provinces. Technical assistanceand training in nutrition education is providedto NGO staff and VHVs who disseminateinformation to community members.- Regular monitoring and evaluation, staffcapacity building and IEC materialdevelopment in nutrition are importantcomponents of HKI’s programs.- Additional activities: HKI developed“Recommendations for feeding practices forthe sick child” for WHO’s IMCI Pilot Program;HKI is involved in national policydevelopment for micronutrients (VA, iron,iodine); is part of the IEC Working Group; isinvolved in the development of the NationalBreastfeeding Policy; is part of the NationalMicronutrient Working Group.

Donors: USAID

ORGANIZATION

26. Helen Keller International(HKI)


GEOGRAPHIC REGION

Province: Takeo,Kampot, Kratie,Kampong Thom,Kampong Speu,Kampong Som,Battambang, Kandal andPhnom Penh.

District: VAC PilotProgram - Chhlong ofKratie Province;Prey Kabas of TakeoProvince; Kampot ofKampot Province.

X X X X X


Plans for expansion of the VACdistribution program at thenational level; expansion of thehomestead food productionprogram to more districts andprovinces; plans to address thehigh IDA problem amongchildren and pregnant womenin Cambodia.


TARGET POP.

Pregnant/lactatingwomen, U5children






Programs: Rattanakiri IntegratedDevelopment and Education (RIDE) – Health,nutrition and food security. Communitymembers develop a plan for their own healthand nutrition priorities, which are addressedby the project. Training is given to VHVs inbasic health and nutrition and to TBAs in BF.Information is disseminated throughdiscussion groups, women’s groups, andcooking lessons. Growth monitoring sessionsare done and counseling and follow-up isdone with malnourished children. IECmaterials are developed or adapted fromother sources for these ethnic minority groups.

Donors: SIDA, DFID

Programs: The nutrition activities areconducted through the home gardeningprogram. The IVY staff train the homegardening volunteers who in turn train thefarmers in the program. The activities consistof basic nutrition education sessions withfarmers and cooking demonstrations.

Donors: Japanese Organizations

ORGANIZATION

27. International CooperationCambodia (ICC)


28. International Volunteersof Yamagata (IVY)


GEOGRAPHIC REGION

Province:Rattanakiri

District: Tah Veng andOchum

Province:Svey Rieng

District:Svey Thram

Commune: Chuteo

X X X


- Videos on basic health andnutrition practices will bedeveloped in the dialect usedby the people of Rattanakiri, asthis type of IEC is very popularand an effective educationaltool among this group.

- A new program will start inMondolkiri and Kampong Chamwhich will include growthmonitoring and food security.

No future plans for expansion ofcurrent nutrition activities or anew nutrition program.


X X

TARGET POP.

Wholepopulation withemphasis onwomen and U5children

Women – thefarmers andchildren’s caretakers




49


Programs: HIV/AIDS Home Care Project:This project is being implemented by partnerNGOs in 3 provinces. It consists of homecare, which is provided to people living withHIV/AIDS. The home-based kit is composedof HIV/AIDS medicine, referral to the nearesthospital, multi-vitamin supplements; they alsoprovide some supplemental food (rice,vegetables), some nutrition, hygiene andsanitation education, and social andpsychological support. They also conduct acommunity development program which aimsat generating income for families affected byHIV/AIDS.

Donors: USAID

Programs: The nutrition activities are part ofa program which includes clean water wells,poultry credit and fish ponds. The activitiesconsist of educating the community aboutnutrition and increasing their intake ofnutrient-rich food. Extra food is distributed toindividuals with HIV/AIDS. CommunityAdvisors are trained to conduct activities withthe target group to raise their awareness.


ORGANIZATION

29. Khmer HIV/AIDS NGOAlliance (KHANA)


30. Khmer HumanResources for DevelopmentOrganizations (KHReDO)


GEOGRAPHIC REGION

Province: Battambang (2ODs), Kampong Cham(2 ODs), and Siem Reap(1 HC)

Province: KampongChhnang

District: KampongChhnang, Roleapa Ear,and Kampong Tralach

Communes: 3

X X X


No future plans for now for thisprogram.

No future plans


X X X

TARGET POP.

Adults andchildren livingwith HIV/AIDS

Children,pregnantwomen, poorand vulnerablepeople, andpeople withHIV/AIDS






Programs: Home Gardening Program –Provision of health and nutrition education inthe community – conduct nutrition and healtheducation about mother and child health, howto establish a home garden, to increasenutrient-rich food consumption from thegarden, and how to prepare nutritiouscomplementary foods. The information isdisseminated through project staff usingposters and leaflets in group discussions,farmers’ groups and household visits.

Donors: Inter-Church CooperationOrganization (ICCO)

Programs: Nutrition Education Programwithin Homestead Food Production Program– Objectives: to improve knowledge ofpregnant/lactating women and mothers ofchildren under 5 y/ old on nutrition, reducenight blindness, malnutrition and otherdiseases. VHVs are trained in disseminatingnutrition information. via IEC materials,songs, food demonstration and study tours tomodel gardens.

Donors: Helen Keller International andCanada Fund

Programs: Nutrition and health education(for primary health care): Provide nutritionand health education to women for betterfood and health care related practices.Encourage pregnant women to receivetetanus vaccine and to bring their children toimmunization sessions, including to receivetheir VAC for U5 children. Through the use ofposters, VHVs and other trainers,disseminate information to the community indiscussion groups and house to house.


ORGANIZATION

31. Khmer RuralDevelopment Association(KRDA)


32. Khmer Women’sCooperation for Development(KWCD)


33. Kratie Women’s WelfareAssociation (KWWA)


GEOGRAPHIC REGION

Province:Battambang

District:Mong Resei

Commune: 9(52 villages; 1,336families)

Province: Kandal,Sihanoukville

District: 4

Communes: 7

Villages: 48(3700 people)

Province: Kratie

District: Kratie

Commune: ThmorAndeth, Kanthot, RonResei(5 villages, over 2000women, over 1000children)

X X


Plan to increase to number offamilies in the program a littleeach year, to increase thecoverage and introduce newvillages.

Would like to expand thishomestead food productionprogram and nutritioneducation program to morevillages in the near future.Would like to train morenutrition staff who areresponsible only for nutrition.

Continue the program as it is, toencourage women to bringtheir children for immunizationand provide nutrition and healtheducation.


X X X X

TARGET POP.

Female headof households,female andmale farmers.

Pregnant andlactatingwomen,mother of U5children andthose whohave a modelgarden.

Women withan emphasison pregnantwomen, U5children

X




51


Programs: Support to WFP’s SNAP(supplemental food program) for HC staff formonthly GM sessions, food ration distribution(CSB) for children, pregnant/lactatingwomen, nutrition and health education , BFpromotion. LWS staff (CommunityDevelopment Workers) train VHVs andsupport them in conducting activities on amonthly basis through the SNAP program.Other community development activities areintegrated into WFP’s monthly fooddistribution program, namely home gardeningpromotion. A technical team supports thoseinterested in starting a home garden.

Donors: LWS member churches around theworld, WFP

Programs: Health promotion and curativeprogram – They do not conduct specificnutrition activities. They support newlyestablished infrastructure – new PHD,referral hospital, 3 government healthcenters, direct support to temporary healthpost (border with Thailand) for malaria andHIV/AIDS cases.- MHD recently conducted a health survey,which included some nutritional assessment(anemia, VA rich food consumption) andGMP. For the remaining of their program(about 6 months), they will conduct iron andB complex vitamin distribution to children andpregnant women and nutrition education,including cooking practices.

Donors: ECHO

ORGANIZATION

34. Lutheran World Service(LWS)


35. Malteeser Germany(MHD)


GEOGRAPHIC REGION

Province: KampongSpeu, Battambang

District: Aoral andPhnom Sruoch in Kg.Speu (10,000 people);Bavel in Battambang(7000 people)

Province: OddarMeanchey

Districts: Samrong andBanteay Ampil(6 communes)

X X X X X


Plan to integrate nutritionactivities and education withinall other agriculture andcommunity developmentprograms in the otherprovinces they work in (Kandaland Takeo).

Highly interested in nutritionalissues so would like to do morein the near future, but alldepends on funding.


X X X X

TARGET POP.

Women andchildren;community asa whole.

Population ingeneral –(40,000)emphasis onmothers andchildren






Programs: Community Health and EducationProgram – Assist children to complete 6grades of schooling. Increase awarenessabout basic health and nutrition and providebasic health care. Health clinic receivesroughly 40 patients/week including mothersof children in the school program andpregnant women. Extra food to schoolchildren – soy milk in class and 10 kg ofrice/month/child for their family. Through theclinic, pregnant women receive multi-vitamins, very poor families, and those with aHIV+ members receive rice, sometimes fishand oil in addition to vitamins.- Home Care HIV/AIDS Program - Seedlingof Hope: provide support in groups to HIV+people, education on hygiene and sanitation,distribute medicine and vitamin supplements,in addition to some money, which is mainlyspent on food. (2 communes of Mean Cheydistrict, Phnom Penh, reaching about 400people).

Donors: Maryknoll – US-based

Programs: Primary Health Care Program –Reaching population via HCs, health posts,mobile clinics, and immunization campaigns.TBA training includes some nutrition lessonsand BF practices. Training of staff on childhealth issues include nutrition and preventionof malnutrition and micronutrient deficiencies.Support is given to outreach teams during VAdistribution

Donors: ECHO

ORGANIZATION

36. Maryknoll


37. Médecins du Monde(MDM)


GEOGRAPHIC REGION

Province:Suburb of Phnom Penh

District:Mean Chey

Province:Mondolkiri

District: Kaoh Neck,Kaoseima, Oreang,Pichrada, Sen Monorom

X X X


Future plans are to addresswomen’s health issues throughworking with older girls enrolledin their education program.

Plan to conduct a TOT at theend of February 2002 for allMDM staff (HealthCoordinators) in the districtswhere they work, on themanagement of the sick childwhich will include manylessons in nutrition, especiallythose related to infant and childfeeding practices andmalnutrition.


X X

TARGET POP.

Boys and girls8-12 years old,mothers ofthese children,pregnantwomen

Children andpregnantwomen; healthworkers andTBAs




53


Programs: Their nutrition program aims atreducing micronutrient deficiencies in U5children and pregnant women. This is donethrough training of VHVs: informationsessions in groups, household visits,distribution of IEC materials and videoshows.

Donors: PACT and ICCO

Programs: Breastfeeding Technical WorkingGroup supports the initiatives of the Program.A National Infant Feeding Policy has beendeveloped to protect and promote infantfeeding practices and standardize guidelines.TOTs on BF have been conducted in the 4Regional Training Centers in the Provincesand the Technical School for Medical Care inPhnom Penh. Training is continuous for the 2Hospitals planned to become Baby Friendly.

Donors: UNICEF, WHO

Programs: IEC development – collaboratewith MCH, some NGOs and donors (AusAID)in developing IEC materials related to healthand nutrition, as needed.Healthy City Program – Street food safety in5 major markets of Phnom Penh. Campaignsare run to raise awareness among streetvendors, health workers about food safety, byusing T.V./radio spots, pamphlets, posters.Monitor and evaluate food safety in the city.

Donors: WHO, AusAID

ORGANIZATION

38. Minority Organization forthe Development ofEconomy (MODE)


39. National BreastfeedingProgram, Ministry of Health(MOH)


40. National Centre forHealth Promotion (NCHP),Ministry of Health (MOH)


GEOGRAPHIC REGION

Province: KampongThom

District: San Dan

Commune: 3(10 villages)

National program –training has been donein Regional TrainingCenters of Battambang,Kampong Speu, Kampotand Svey RiengProvinces, and in PhnomPenh.

Nationwide

X X


Plan to expand the nutritionactivities to 10 more villages inthe 3 communes and reinforceand improve VHVs’ knowledgein 10 previous villages.

Future plans includeconductinga TOT in Romea Hek andKampong Trabek Districts ofSvey Rieng and KampongChhnang Provinces,respectively. This TOT will traindoctors involved with IMCI , whowill in turn train the healthcenter staff.

If funds permit, may expandHealth City Program to majorcities around Cambodia, notjust focus on Phnom Penh.


X X

TARGET POP.

Pregnantwomen andmothers of U5children

Healthworkers,midwives,doctors,women15-49,pregnant andlactatingwomen

Generalpopulation X






Programs: - National Vitamin A Program –Support and provide training to MOH staff,HC staff, VHVs to improve knowledge andefficiency in VAC distribution in order toimprove VAC coverage.- National BF Program – support planning,implementation and evaluation of programactivities.- IDD Program – Training of HC staff onincreasing awareness and treatment of IDD,training of VHVs in education on IDD, anddistribution of subsidized iodized salt in someareas; IEC materials development; promoteproduction of iodized salt; monitoring ofprogram activities.- IDA Program – Routine supplementation ofiron/folate for pregnant women via ANC (90tablets/pregnant woman).; Pilot program onweekly iron/folate suppl. to women factoryworkers around Phnom Penh and secondaryschool girls (over 12 y. old) in 2 districts ofKg. Speu, including rural women ofreproductive age.- Growth Monitoring Promotion (GMP) –Update and standardize the nutrition andGMP Module for training of HC staff; adaptmodule to new child health card.

Donors: The MOH, WHO, UNICEF

ORGANIZATION

41. National NutritionProgram, Ministry of Health(MOH)

Year of establishment of theprogram: 1993

GEOGRAPHIC REGION

Province: - VA Program– National level;

- National BF Program –Battambang, Kg. Speu,Kampot and Svey RiengProvinces, and in PhnomPenh.

- IDD Program – 5provinces;

- IDA Program – Nationallevel for SafeMotherhood Program;Phnom Penh and Kg.Speu for distribution ofiron/folate to women 15-49;

- GMP – 1 district of Kg.Cham, Kg. Chhnang andSvay Rieng for training.

X X X X X


- IDD Program: plan for 2002 todevelop IEC materials, promoteproduction of iodized salt, putmonitoring system in place;plan to pilot a program: trainingof VHVs to disseminateinformation on IDD house byhouse and provide subsidieson iodized saltin 1 district of Kandal province.

- GMP: Plan a training of all HCstaff in 1 district of Kg. Chamand Kg. Chhnang on how toconduct proper GMP with newstandards, and distributescalesto health centers which do nothave any.


TARGET POP.

MOH staff atvarious levels;Pregnant/lactatingwomen,mothers ofchildren under5 years.




55


Programs: - Child Survival Program: needsassessments are conducted to select prioritynutrition interventions. This year the mainsubjects will relate to BF and complementaryfoods. The Hearth Program will beimplemented within this Program.- Northeast Cambodia CommunityDevelopment Program (NCCDP): generalnutrition education is widely disseminatedamong the community.- Support WFP’s SNAP supplementaryfeeding program (Kratie) – support HC staffand village volunteers during distribution offood rations (CSB) to U5 children andmothers, GM sessions, nutrition educationand other health activities.- Home gardening and nutrition educationprogram as partners with HKI (Kratie)- HKI’s Partner in the Pilot Project on VACdistribution in Chhlong OD. Support fortraining of HC staff and VHVs, duringpreparation and distribution of VAC, andmonitoring and evaluation.

Donors: USAID and Allen Foundation, HelenKeller International, WFP

Programs: Primary Health Care Program –nutrition activities consist of educationalsessions conducted by VHVs, supported bythe program staff and IEC materials. Cookingdemonstrations are also done. Subjects suchas nutrition during pregnancy, feedingcolostrum and BF, complementary feeding,and growth monitoring are covered.

Donors: Ter Desone (Head Office inIndonesia)

ORGANIZATION

42. Partners for Development(PFD)


43. Rachana


GEOGRAPHIC REGION

Province: Kratie, StungTreng

Districts: Kratie andChhlong in KratieProvince - 21 villages, 67schoolsStung Treng - 25 villages

Province: Takeo

District:Koh Andeth

Commune:Sre Ronaong(17 villages)

X X X X X X X


Expansion of NCCDP to 14more villages in Stung Treng.They would also like to expandthe Animal Husbandry PilotProject in Chhlong O.D. TheHearth Program will beimplemented starting early2002 as a pilot project in somevillages of Chhlong O.D., up to30 villages.

The program is expected toremain the same in the nearfuture.


TARGET POP.

Women 15-49and U5children

Women15-49 X X






Programs: - The Nuns and Wat GranniesProgram – Training is given to volunteers byRACHA and government health staff on BFand treatment for dehydration with ORS.Volunteers go house to house, to teachwomen about these subjects.- The Antenatal Care Program – nutritioneducation related to anemia and itsprevention during pregnancy. The training isgiven to feedback committees who conducttraining with community members. They oftendistribute iron/folate supplements to pregnantwomen and those who are able to visit thehealth centre are encouraged to request theirsupplements.

Donors: USAID

Programs: - Malnutrition Monitoring &Supplementary Feeding Project (MMSF) –(April-Dec. 2001): Monitoring of nutritionalstatus of children 9 mo.-5 years old afterflood 2000. Done on monthly outreachsessions. Food distribution to families ofchildren with height-for-weight of 80% or less,pregnant/lactating mothers and siblings alsoreceive food. HC staff are trained andconduct activities.- Basic Health Services Project (BHS) –1999-Dec. 2002: Nutrition education: infantfeeding practices, weaning foods,micronutrients; 6 monthly VAC distribution tochildren 6-59 months and postpartum women(within 2 months after delivery). VHVs andTBAs are trained, do monthly outreachactivities, supported by SCA staff.

Donors: Save the children UK (MMSFProject); Asia Development Bank (BHSProject)

ORGANIZATION

44. Reproductive and ChildHealth Alliance (RACHA)


45. Save the Children –Australia (SCA)


GEOGRAPHIC REGION

Province: Siem Reap,Pursat, Kampot

District: O.D. of SiemReap in Siem ReapProvince SompomeasO.D. of Pursat Province;Angkor Chey O.D. ofKampot Province

Province:Kampong Cham

District:MMSF – Cheung Prey/Batheay OD(154 villages);

BHS – CheungPrey/Batheay andMemot ODs(328 villages)

X X X


They constantly expand theNuns and Wat GranniesProgram, by going from oneHC catchment to the next. Theyplan to start a new TBA trainingprogram to teach about earlyBF initiation, exclusive BF,complementary foods andnutrition in pregnancy. Willdevelop a new program toincrease awareness amongmidwives about moth-to-childtransmission in HIV.

For the BHS Project, futureplans are to plantdemonstration gardens at allhealth centers. Provide anutrition manual to each healthcenter and provide training innutrition to health center staff.


TARGET POP.

Pregnant andlactatingwomen

Mothers ofchildren 9mo-5yrs (MMSF);pregnant andlactatingwomen (BHS)

X X X X X




57


Programs: MOH/ADB Basic Health ServicesProject – SC-F is doing “Contracting-In” – Incharge of management and finances of thewhole OD. Main activities of the project:integrated identification of malnourishedchildren by mid-upper arm circumference andconfirmed by weight/height (children <80%w/h receives ration card for foodsupplementation). this ration comes fromWFP’s SNAP Program (Corn-Soy blend); six-monthly deworming and vitamin Asupplementation for primary schools and out-of-school children; IEC campaigns on feedingpractices using pagoda volunteers for peereducation; assessment of householdmechanisms during loss of harvest; formationof self-help groups to formulate appropriateresponses to flood-related food shortages.Pagoda volunteers help to target the mostvulnerable groups in the community,disseminate health/ nutrition information, andmobilize them for outreach activities.

Donors: SC-UK, CIDA-Health and NutritionInitiatives Fund

ORGANIZATION

46. Save the Children –France (SC-France)


GEOGRAPHIC REGION

Province: Takeo

District: Kirivong OD (20HCs, 213,000 people)

X X X X X X


Plan to include a schoolfeeding program if thisproposed activity is acceptedby the Ministry of Education’sauthorities in theOD of Kirivong.


TARGET POP.







Programs: - SC-UK’s mandate is to respondto emergency situations anywhere in thecountry. During emergencies they providesome food and logistics supplies to targetpopulations.- Life Opportunity Program in Kratie – Mainobjective is food security: includeshomestead food production, agriculturaltechniques, primary health care with basicnutrition education.- Support to SC-France and SC-Australia inKampong Cham through projects aiming tostrengthen health services – SC-UK runs thenutrition approach of these two organizations:growth monitoring, anthropometrics, foodsupplement distribution and nutritioneducation.

Donors: EU, Save the Children UK HeadOffice

Programs: Nutrition Program – Focus is onchildren under 5 years who are disabledand/or malnourished. A weekly clinicprovides care to women and children. Food isdistributed once/week (nutrient and energydense mix), 1 packet/child/ week via theclinic. Malnourished kids are given milkformula (10-12 months) or soy milk (over 12months). Food from WFP (rice, oil and fish) isgiven to destitute households withmalnourished children. Home visits are done2-3 times per week for severely malnourishedcases and twice/ month for mildlymalnourished cases. Lessons are taught tomothers (nutrition, ORS, hygiene) and theyare encouraged to use low cost resourcesaround their house. Treat about 40malnourished children at any one time.

Donors: Tear Fund Holland & UK

ORGANIZATION

47. Save the Children – UK(SC-UK)


48. SERVANTS


GEOGRAPHIC REGION

Province: Kratie andKampong Cham

District: Kratie in KratieProvince(56 villages, 4000families)Memot in Kg. Champrovince

Province: Phnom Penhoutskirts

District:Mean Chey(80,000 people in thedistrict but only targetingunder 5 children)

X X X X


The program will remain thesame for the near future.

Plan to start the implementationof the Hearth Program in thenear future and zincsupplementation to childrenunder the age of 5 years.


TARGET POP.

Children under18 years old

Children underthe age of 5years, women15-49

X X X X X X




59


Programs: Social Assistance and HealthEducation Program: Support children frompoor and vulnerable families; rehabilitatechildren with moderate malnutrition; trainmothers to prepare nutritious food for theirchildren. Growth monitoring sessions forchildren under 5 years; training to VHVs whodisseminate nutrition information throughposters and group discussions

Donors: Save the Children France

Programs: Supplemental Food Program –Address maternal and child health, foodsecurity through home gardening, water andsanitation. Nutrition education is done byVHVs who receive training by program staff,and consists of discussion groups, cookingdemonstrations, mother’s groups, monthlygrowth monitoring (malnourished childrenreceive bean porridge, eggs, milk powder,and mother receives seeds for homegarden). Follow-up of these children is donehouse by house.

Donors: Private Japanese T.V. Company(run a yearly telethon that provides a stablesource of funds for this organization)

ORGANIZATION

49. Sovann Phoum


50. 24-Hour TelevisionCharity Committee –Cambodia


GEOGRAPHIC REGION

Province:Outskirts of Phnom Penh

District: Mean chey

Communes:Stung Mean chey(7 villages)and Dangkor(6 villages)

Province:Kandal

District:Kandal Stung

Commune: Danrous(1300 households in 14villages)

X X


Plan to educate mothersthrough cookingdemonstrations on methods offood preparation using nutrient-rich foods to feed youngchildren.

Future plans are to expand thenutrition approach to morevillages.


TARGET POP.

Pregnant/lactatingwomen,children under5.

Mothers andchildren under5

X X X X






Programs: Strategic and technicalleadership for development of the NationalNutrition Plan of Action.- Set Koma Program (UNICEF’s CommunityDevelopment Project): Enhance the capacityof community through Village DevelopmentCommittees (VDCs), civic organizations andNGOs. The Set Koma Program addressesthe 3 main underlying determinants ofnutritional status: household food security;care for children and women; and healthwater and sanitation.- UNICEF assists in interventions at thenational level in areas such as micronutrientdeficiencies, BF promotion and the Baby-Friendly Hospital Initiative.- UNICEF develops IEC materials for thevarious national programs (BF, VA, IDD, etc.)- UNICEF also assists in the National IDDprogram in the development of policy andplanning for salt iodization and IEC materials.

Donors: UN organizations, variousgovernments and donor agencies.

Programs: Nutrition Education Programthrough Homestead Food ProductionProgram – Objective is to reduce VADD, IDAand IDD via training and education andincreased production and consumption ofnutrient-rich food. VHVs receive training todisseminate information to target groupsusing IEC in mother’s groups, withindividuals, and population in general.

Donors: Helen Keller International

ORGANIZATION

51. United Nations Children’sFund (UNICEF)


52. Village Support Group(VSG)


GEOGRAPHIC REGION

Province: Set KomaProject – Kampongspeu, Kampong Thom,Prey Veng, Svay Rieng,Oddar Meanchey, StungTreng.

District: 18

Commune: 120 (1,130villages)


Districts: Ek Phnom,Sang Kei, Tmor Kuol

Villages: 13(665 people)

X X X X X X


Plans in the near future are toaddress the alarming problemof iron deficiency anemiaamong children and pregnantwomen in Cambodia.

Would like to provide technicaltraining to beneficiaries onanimal husbandry and providethem with credit scheme.


TARGET POP.

Women andchildren under5 yrs.

Women15-49especiallypregnant/lactatingwomen,mothers ofchildren under5 y. old

X X X X




61


Programs: Home Gardening and AnimalHusbandry Program – nutrition activitiesconsist of training VHVs in basic nutritionconcepts and in prevention of vitamin Adeficiency, to conduct education sessionsthrough IEC materials, role plays, games andmusic. Nutritional assessment of the targetgroups is conducted regularly, supported byHKI.

Donors: Helen Keller International, Save theChildren France

Programs: In general, WFP contributes toincrease knowledge of food insecurity andnutritional issues, supports a variety ofactivities to address these; providesassistance to vulnerable groups (includingduring emergencies like floods) in the form offood aid which serves as a nutritionalsupplement for beneficiaries.- Supplementary Nutrition Action Program(SNAP) – HC staff implement the programwith support from 7 partner NGOs in 6provinces. The supplementary food isdistributed to U5 children andpregnant/lactating women; this includesfortified CSB and vitamin A fortified oil andsugar. This occurs monthly with growthmonitoring, nutrition education, and otherhealth-related activities.- School Feeding Program – Primary schoolsin three provinces. Children receive a dailybreakfast of rice, canned fish, oil and salt,sometimes vegetables if community canprovide it Also every 6 months they conduct adeworming campaign in all participatingschools.

Donors: WFP Headquarters – Depends ondonations

ORGANIZATION

53. Women ServiceOrganization (WOSO)


54. World Food Program(WFP)


GEOGRAPHIC REGION

Province: Kandal,Kampong Speu

District: Kandal Stoengin Kandal; Kang Pisei inKampong Speu

Communes: 7(21 villages)

Province: SNAP -Battambang, BanteayMeanchey, Siem Reap,Kampong Thom,Kampong Speu andKratie(28 Health Centers)(35,000 U5 children and6500 pregnant/lactatingwomen benefit eachmonth)

School Feeding Program– Takeo (130 schools),Kampot (45 schools) andKampong Cham (35schools)(Total=125,802 children)

X X X X


They plan to expand to 12 newvillages in the near future andtrain VHVs to conduct nutritionactivities.

Planning is underway for thedevelopment of a program toaddress nutritional problems ofpeople living with HIV/AIDS inCambodia by addressing foodsecurity, food aid andHIV/AIDS.


TARGET POP.

Pregnantwomen, U5children,women15-49


X X X X X






Programs: WHO supports programs beingimplemented by the Nutrition Unit of theMOH.- Women Iron/Folate Supplementation PilotProject (WIF) – Prevention of anemia amongwomen factory workers (18-45 years old) bydistributing a monthly iron/folate supplement(4 pills/packet); also WIF (for schoolgirls) –same supplement sold by school peerleaders to girls over 12 yr. old in 4 secondaryschools of Kampong Speu and to women ofreproductive age in the community; ed.awareness raising in community and schools.- Growth Monitoring Program (GMP) –support to the Nutrition Unit forstandardization of the training module ongrowth monitoring; TOT at the national levelon principles of GM.- Support to the National BreastfeedingProgram – planning, policy development,training.- Integrated Management of ChildhoodIllnesses (IMCI): Pilot Program underdevelopment. Implementation in 1 district of2 provinces and will include major nutritiongoals – growth monitoring, rehabilitation ofmalnourished children, education oninfant/child feeding practices, guidelines forfeeding of sick child.

Donors: WIF – Japanese govt.; GMP –SIDA; National BF Program – UNICEF

ORGANIZATION

55. World HealthOrganization (WHO)


GEOGRAPHIC REGION

Location:WIF – Phnom Penh andKampong Speu (2districts, 139 villages);

GMP - Kampong ChamO.D. (11 Health Centers)Kampong ChamProvince

X X X X X


Plans for the near future for theWIF program are to develop avideo as a social marketing toolfor village level to inform peopleabout anemia, benefits ofiron/folate supplements and abalanced diet. Will developapproaches such as drama toreach more women; within thefactories, they are difficult toreach since owners fear theywill be distracted from theirwork and decrease theirproductivity.


TARGET POP.

Women18-45,pregnant andlactatingwomen,children




63


Programs: Child Survival Program: Goalsare to decrease morbidity and mortality ratesamong children, build capacity of MOH indelivering child survival services, strengthenTBAs and drug selling and delivery systems,diarrhea control, micronutrient deficiencyprevention and BF promotion. Health stafftrain VHVs in conducting health and nutritionactivities via discussion groups, house tohouse visits, cooking demonstrations, use ofbasic IEC materials. World Relief teamsconduct puppet shows and drama. Support isgiven to HC staff and VHVs during VACdistribution months and outreach activities.

Donors: USAID

ORGANIZATION

56. World Relief – Cambodia(WR-C)


GEOGRAPHIC REGION

Province:Kampong Cham

District: Ponthea Krieck(Reach 50% ofpopulation)

X X X


Plans are to expand theprogram to cover the wholedistrict starting in 2002 with agreater focus on nutrition byintroducing the HearthProgram.


TARGET POP.

Women15-49 andchildren






Programs: Child Survival Project (Kandal) –support to local health services in delivery ofa range of reproductive and child healthinterventions. Immunization, casemanagement of illnesses, nutrition includingBF promotion, vitamin A deficiencyprevention (VAC distribution), feeding of sickchildren, complementary foods – MOH stafftrain HC staff and VHVs who conductactivities in HCs and outreach sessions(facilitated by WV staff).- Area Development Program (ADP; 6provinces) – Community developmentprogram in general, with a health component.Includes home gardening, nutrition/healtheducation, deworming, VAC distribution;special night blindness prevention program inKampong Thom province.- HIV/AIDS Home Care Program – Providemedicine, multi-vitamins, nursing/basictreatment, health/nutrition and hygieneeducation, social support, community-basedshelter for orphans (reach about 1000 adults,and about 600-1000 children).

Donors: Donations from other World Visionoffices, USAID, CIDA

Programs: Integrated relief programs andcommunity reintegration programs-Basichealth education program on hygiene andsanitation, preventable diseases and nutritionthrough the life cycle. Improve food securityvia home gardening, animal and fish raising.

Donors: ECHO, ICCO

ORGANIZATION

57. World Vision – Cambodia(WV-C)


58. ZOA Refugee Care


GEOGRAPHIC REGION

Province: Battambang,Kampong Thom, Kandal,Takeo, Kampong Speu,Kampong Chhnang

District: Child SurvivalProgram: Kean Svay andLeuk Dek OD in Kandalprovince

ADP: 1-9 HCs in 1-4districts of each 6province.

HIV/AIDS Program:along National Road 1 –PP, Kandal, Prey Veng;National Road 2/3, and4/5 – PP, Kandal, Kg.Speu, and Takeo.

Province:Oddar Meanchey

District: Samrong

Commune: Bos Sbov,Kok Mon, Kok Kpoh(32 villages)

X X X X X X


Plan to implement the HearthProgram in Kampong Thom orKandal province. Would like tostart integrating somesuccessful approaches of theChild Survival Program into theADPs to make the nutrition andhealth components moreimportant in these programs.

Focus more on special groupsin the community (pregnantwomen, infants), and workmore closely with agriculturesector to ensure farmersimprove their nutritionknowledge.


TARGET POP.

Community ingeneral, forADPs, mothersand childrenunder 2 forCSP. Familiesaffected byHIV/AIDS(children)

Population ingeneral.Emphasis onmothers,children,adolescents&teachers

X X


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