Assessment of Quality of and Access to Friends Help

Assessment of Quality of and Access to Friends Help


Assessment of quality of and access to Friends Help

Friends (MMM and mmm) Interventions and services in Cambodia


UNICEF Cambodia

Table of Contents

1.Background and context

2.UNICEF Cambodia Programme area and specific project involved

3.Purpose and objectives

4.Scope of the study

5.Criteria and guiding questions


7.Work Assignment


9.Management arrangements, roles and responsibilities in the study process

10.Required qualifications

11.Ethical principles and premises

Annex I: Outline of the inception report

Annex II: Outline of the draft and final reports

Annex III: List of mmm and MMM Referral Hospitals

Annex IV: Package of activities for mmm and MMM as per SOP


1.Background and context

According to the Ministry of Health’s latest HIV estimates report (October 2011), the national HIV sero-prevalence in Cambodia has declined from its peak of 2% in 1998 to an estimated 0.7% in 2013. In 2012, 74,572 adults (aged 15 years and over) and 7,585 children (aged 0-14 years) were estimated to be living with HIV. Following the dramatic expansion of care and treatment, Cambodia is now one of the first developing countries with over 80% antiretroviral treatment (ART) coverage of adults and 90% coverage of children in need (56,546 adults and 4,997 children). This represents a substantial increase from only 38% in 2005.

Cognizant of the holistic care needs of people living with HIV (PLHIV), the Ministry of Health of Cambodia approved the Operational Framework for Continuum of Care (CoC) for People living with HIV in April 2003. Comprehensive care and support for PLHIV was approved for implementation and has been strengthened and gradually expanded. As of September 2005, 12,355 PLHAs, including 1,071 children, were receiving pre-ART care (for the management of opportunistic infections) and anti-retroviral treatment (ART) services provided by 35 referral and national hospitals. In contrast, by the end of 2012, 61 hospitals provided ART and pre-ART care for adults and 35 hospitals provided ART and Pre-ART care for children and adolescents (see Annex III). Data from these clinics showed that by the end of 2012 - 44,318 adults (>15) and 4,595 children (< 15) were receiving antiretroviral therapy (ART). In addition, 4,482 adults and 1,383 children were receiving pre-ART care.

In tandem, collaboration between different national programmes (HIV/AIDS, TB and Maternal and Child Health (MCH)) was strengthened. Community and home-based care services, support groups for PLHAs, and Voluntary Confidential Counselling and Testing (VCCT) were also expanded to provinces and Operational Districts (OD) nationwide.


MondolMithChuoyMith (mmm or MMM) is one of the essential elements of the Operational Framework of Continuum of Care for PLHA. This is despite universal treatment coverage in a resource poor country such as Cambodia, where people living with HIV/AIDS (PLHA), including children, experience many challenges in regularly accessing and adhering to treatment (including financial, social and psychological challenges). The mmm/MMM intervention was therefore developed to help mitigate these challenges.

The “mmm/MMM” is a monthly or bi-monthly forum whereby children (and their caregivers), adolescent, youth and adults affected with HIV can regularly come together to receive HIV care and support services such as adherence support, individual and group counselling on OI and ART, peer support, and health education for affected children and family on self-care, home care, nutrition and prevention of HIV transmission. In addition to the medical care provided, this forum can catalyse social support and community education and act as an incubator for local innovation, leadership and partnerships.Activities and interventions provided through mmm and MMM are described at SOPs and varied at different sites. For the list of mmm and MMM activities refer to Annex IV.

Objectives of the mmm/MMM are to:

-reduce stigmatization and discrimination of children (and their caregivers), youth and adults living with HIV; and

-empower children (and their caregivers) youth and adults to optimally manage and adhere to their treatment regimens through monthly interventions[2].

Standard operating procedure (SOP) was developed in 2006 to implementing “MMM” activities for adults and in 2009 for children (“mmm”).SOP aimed to guide public health care providers and other concerned stakeholders, especially The Cambodia People Living with HIV/AIDS Network (CPN+), who are responsible for putting into practice the MMM/mmm concept laid down in the Operational Framework on Continuum of Care for PLHAs in Cambodia as part of the scaling-up towards universal access to prevention, care, treatment and support initiative. It lays out the practical steps to establish an mmm/MMM group at the OD, and specifies the concrete package of activities that can be provided by mmm/MMM.

UNICEF has provided technical and financial support to National Centre for HIV/AIDS, Dermatology and STD to implement “mmm” interventions since 2008 starting with supporting small scale interventions that led and have contributed to the development of SOP in 2009, which was also supported by UNICEF. Currently, UNICEF supports 22 out of 35 hospitals, among which 9 have playgrounds in it. There are number of NGOs that also support various mmm and MMM interventions, based on the SOP but using different models.

While the MMM and mmm SOP was in place since 2006 and 2009 respectively, support to interventions has been scattered in different time periods and by different agencies, including UNICEF and civil society organisations. This study will be a timely and useful exercise to learn from existing practices, lessons learned and challenges in mmm/MMM implementation and its outreach to the most vulnerable population. It will help mapping the stakeholders that are accountable and responsible for providing the services and those providing support and implementing the mmm/MMM interventions. The study will help further improving the services and approaches to mmm/MMM interventions with better and more coordinated model responding to the actual needs of the target population, including worst-off and most vulnerable groups.

2.UNICEF Cambodia Programme area and specific project involved

This study is part of the Annual Work Plan 2013 signed between Ministry of Health and Maternal and Newborn Child Health & Nutrition programme of UNICEF. It is under the Intermediate Result 3 (IR3), Strengthened multi-disciplinary health sector response in HIV prevention, treatment, and care and support services to women and children.

3.Purpose and objectives

The purpose is to generate relevant and comprehensive evidence, good practices, lessons learned as well as challenges on mmm/MMM interventions that can inform National Centre for HIV/AIDS, Dermatology and STD (NCHADS), Ministry of Health, UNICEF and other relevant stakeholders to inform future on decisions of the interventions and directions that UNICEF and other relevant stakeholders may support.

Specific objectives are:

-To determine the extent to which the mmm and MMM interventions have addressed the rights, needs and problems of children, adolescents, youth and adults.

-To assess to what extent the mmm/MMM interventions are feasible and efficient in its current model compare with other existing models.

-To review institutional set-up and assess the effectiveness and quality of the interventions against the objectives of the SOPs.

-To identify and draw lessons from different mmm/MMM models and practices used by various stakeholders.

-To formulate recommendations for decisions on future of mmm/MMM interventions for more effective, cost efficient and standardised implementation of the interventions.

The knowledge and evidence generated will be used by:

-National Center for HIV/AIDS, Dermatology and STD (NCHADS) and Ministry of Healthof Cambodia as an important source of information for further sustainability and quality of the services and possible policy work.

-UNICEF for future support to NCHADS to further strengthen and enhance the mmm/MMM services.

-Other relevant stakeholders (civil society organisations, development partners) for better and coordinated planning of Paediatric AIDS Care and continuum of care (CoC) interventions

The findings and recommendations will be shared with all relevant stakeholders at national and subnational leveland presented and discussed at the national round table or conference in the first quarter of 2014.

4.Scope of the study

The study should coverthe mmm/MMM interventions supported by UNICEF and other non-governmental organisations from 2008 to August 2013 in the hospitals at national and subnational levels. At least 10 hospitals offering services for children, adolescents and youth, and 15 hospitals offering services for adults, including one hospital that provides services to adolescents separately from children should be covered. The list of the hospitals and their location are provided in Annex III.

The studyshouldassess and analyse the gaps through equity lenses and promote social inclusion for the most marginalized children, youth and adults and their caregivers and families.

5.Criteria and guiding questions

This following criteria and questions will be utilised to guide the study. Human rights-based approach, equity, gender and relevant cross-cutting issues should be considered throughout the study.


a)To what extent the mmm/MMM objectives and interventions aligned with and have contributedto the achievement of the national priorities and policies related to Paediatric AIDS Care and continuum of care (CoC)?

b)To what extent the mmm/MMM interventionsare responding to the needs of stakeholders and beneficiaries?

  • How relevant are the interventions in a local (low-resource economic and health) context in rural and urban areas?


a)To what extent the mmm/MMM SOPs (i.e. implementation, location, guidelines; human and technical resources; organizational structure; decision-making in management) were efficient to the objectives and planned results?

  • To what extent the mmm/MMM models and interventions were cost-effective with respect to operational costs?
  • Which mmm/MMM model is most cost-efficient compared to other models and how does the cost-efficiency vary with other SOPs?


c)To what extent the mmm/MMM interventions have contributed in implementation or revision of the relevant existing policies or to the development of new ones?

d)To what extent the children and youth (and their caregivers) and adults manage and adhere to their treatment regimens due to mmm/MMM interventions?

  • To what extent the institutional set-up contributes to effectiveness and access to services.

e)To what extent have mmm/MMM interventions contributed in reducing the stigmatization and discrimination of the most vulnerable children, adolescent and adults living with HIV?

  • To what extent the objectives of mmm/MMM SOPs have been achieved and what are the major influencing factors and challenges?
  • To what extent have the interventions been able to reach the most vulnerable and disadvantaged group of population?


a)To what extent the relevant legislative framework and policies provide a ground for sustainable development of quality Paediatric AIDS Care and continuum of care services and interventions, particularly in less developed provinces?

b)To what extent the relevant knowledge and skills are integrated into regular activities of professionals and service providers working with children, adolescents, youth and adults and their families?

c)To what extent the interventions and its impact on children, adolescents and adults (including the worst-off/most vulnerable groups) likely to continue when external support is withdrawn?

  • What are the major factors that influence the achievement or non-achievement of sustainability (ownership and leadership) of the mmm/MMM (by National Center for HIV/AIDS, Dermatology and STD (NCHADS) of Ministry of Health)?
  • How likely will the interventions be replicated or scaled up to other areas with referral hospitals?

d)To what extent and in which way does the involvement of communities, pagoda and civil society (and any other stakeholders, including local authorities) may contribute further to the future sustainability of mmm/MMM?


a)To what extent the interventions contributed to achievement of children’s rights and how the interventions contributed in addressing key cross-cutting issues?

  • Whether and how the interventions contribute to the promotion of human and especially child rights?
  • To what extent and how the interventions ensure an equity focus?
  • To what extent the interventions reflect gender mainstreaming issues?


This study should be conducted in seven provinces and cover least 10 hospitals offering services for children, adolescents and youth, and 15 hospitals offering services for adults, including one hospital that provides services to adolescents separately from children. The approach shall combine qualitative and quantitative methods of data collection and analysis relying on primary and secondary data.The overall approach to be applied shall have an equity focus and assess direct and indirect beneficiaries, including children (including with disability), adolescents, youth and adults of different backgrounds (from rural and urban areas, children living in the poorest communities, of parents with different education, economic status). Whenever possible the study should provide disaggregated data (basic socio-economic status, urban/rural, sex, age etc.), but not necessarily at representative levels.

In addition to the relevant staff from MoH, NCHADS and UNICEF the interviews should be conducted with the following:

  • Key stakeholders, partners

-General directorate of planning, Ministry of Planning responsible for National Strategic Development Plan.

-Cambodia National Committee for Children (CNCC).

-NGO partners (AHF, CPN+) that have supported mmm/MMM in some hospitals. This will include a comparison of mmm/MMM interventions in Paediatric AIDS Care sites with playgrounds and without playgrounds.

-Other civil society organisations.

-Province and district authorities.

-Social welfare professionals or social workers.

-Communities and community leaders in the areas of target groups

-Faith-based leaders

  • Beneficiaries

-Children (0-14 years old and > 14 years old) (and their caregivers), and adults of mmm/MMM interventions who are on pre-ART and ART care, their caregivers and families

  • Service providers

-physicians/nurses (at paediatric wards), playground facilitators, selected home based care teams that are involved in the mmm/MMM interventions.

The guiding questions against defined criteria shall be further elaborated and used as a basis for development of the main data collection instruments (interviews and focus groups). The tools need to be developed by the consultant/contractor.

Methodologies and techniques should be developed and used to meet specific needs for information and the questions set out in the TOR and the availability of resources. The consultant is expected to analyse all relevant information sources, such as reports, records from the hospital, programme documents, internal and external review reports, programme files and any other documents that may provide evidence on which to form judgments. All relevant documents, together with a contact list of all the relevant stakeholders, implementing partners will be provided to the consultant once a contractual agreement has been made.

The methodology and techniques to be used should be described in details in the proposal and revised during the inception phase, if necessary.

7.Work Assignment

This study will be carried out by consultant under the oversight of relevant UNICEF HIV/AIDS Specialistand Evaluation Specialist (Managers). The consultant will be responsible for the following specific activities:

Conduct desk reviewand submit an inception report(in Cambodia and by distance if required, maximum 5 working days):

Inception report should include preliminary findings based on stakeholder interviews, desk review, approach and methodology with detailed breakdown of draft work plan for the entire process. It should also include proposed scale and data collection methodology and approach that will be used responding to the scope and criteria of the study.

Field work preparation (in Cambodia, maximum 4 working days)

Based on the final inception report and feedback from the managers, the consultant should submit the final sampling, including target groups, number of interviews and tools to be used. Tools will have to be reviewed by the managers and Ministry of Health, before preparation and submission of all the necessary documents for the National Ethics Committee for Health Research of the MoH. Approval by the National Ethics Committee might take up to 10 days.

Data collection and initial analysis: (in Cambodia, maximum 15 working days)

Continue desk review by reviewing additional documents, reports and records. Convene consultations with stakeholders and conducting interviews in Phnom Penh and provinces based on the approved methodology, sampling and tools. Prepare for and make a presentation on initial findings.