HEALTH POLICY AND PLANNING; 14(3): 229–242
© Oxford University Press 1999
Rehabilitating health services in Cambodia: the challenge of
coordination in chronic political emergencies
STEVEN LANJOUW,1 JOANNA MACRAE2 AND ANTHONY B ZWI1
1Health Policy Unit, London School of Hygiene and Tropical Medicine, UK and 2Humanitarian Policy Group,
Overseas Development Institute, London, UK
The end of the Cold War brought with it opportunities to resolve a number of conflicts around the world,
including those in Angola, Cambodia, El Salvador and Mozambique. International political efforts to negotiate peace in these countries were accompanied by significant aid programmes ostensibly designed to
redress the worst effects of conflict and to contribute to the consolidation of peace. Such periods of political transition, and associated aid inflows, constitute an opportunity to improve health services in countries
whose health indicators have been among the worst in the world and where access to basic health services
is significantly diminished by war. This paper analyzes the particular constraints to effective coordination of
health sector aid in situations of ‘post’-conflict transition. These include: the uncertain legitimacy and competence of state structures; donor choice of implementing channels; and actions by national and international
political actors which served to undermine coordination mechanisms in order to further their respective
agendas. These obstacles hindered efforts by health professionals to establish an effective coordination
regime, for example, through NGO mapping and the establishment of aid coordinating committees at
national and provincial levels. These technical measures were unable to address the basic constitutional
question of who had the authority to determine the distribution of scarce resources during a period of transition in political authority. The peculiar difficulties of establishing effective coordination mechanisms are
important to address if the long-term effectiveness of rehabilitation aid is to be enhanced.
Introduction
In the wake of peace settlements in countries from Bosnia to
Mozambique, and from Cambodia to the Lebanon, the 1990s
has seen a growing interest internationally in the concept of
‘post’-conflict rehabilitation. This interest has been marked
by, for example, the creation of a new Post-Conflict Unit
within the World Bank responsible for monitoring and influencing the policy response in situations of ‘war–peace transition’ (World Bank, 1997a; Holtzman, 1997),1 and within the
United Nations, where an Executive Committee on Peace
and Security (ECPS) has been established and is responsible
for coordinating the efforts of specialized agencies in ‘post’conflict situations (United Nations, 1997). Debates regarding
the role of aid in ‘post’-conflict situations can be seen as part
of a wider concern within the aid community to enhance the
links between relief and development aid (see, for example,
European Commission, 1996; Development Assistance Committee, 1997).
Countries emerging from periods of violent political conflict
typically face a number of substantive health and health
system challenges. The negative effects of conflict on health
and health systems have been documented elsewhere (see
Zwi & Ugalde, 1989; Zwi 1996; Levy & Sidel, 1997). The
effects of injury and increased exposure to disease as a result
of increased poverty and displacement are not quickly
reversed. Addressing the direct and indirect effects of war on
health and health systems therefore represents a major challenge for those concerned with ‘post’-conflict rehabilitation.
Alongside these challenges are also potential opportunities.
International political support for negotiated settlements,
such as that in Cambodia, is typically accompanied by pledges
of significant financial support. However, while this may be of
great value in the aftermath of so much destruction and economic disruption, this aid is disbursed in a highly charged and
unstable political environment.
In such settings, attempts to coordinate aid for the health
sector, a complex issue at the best of times (see Buse & Walt
1997), are simultaneously more pressing than is usual and
confront particular difficulties. They are especially urgent and
necessary given that the needs are particularly acute, the total
volume of resources small (although they often represent a
substantial increase over prior resource flows) and, as
described below, the channels for implementing aid are more
diffuse and complex. They are more difficult to manage
because of the competing political agendas and the lack of a
mandated authority to mediate these political decisions and
enforce policy coherence.
This paper examines the context and process of health aid
coordination in Cambodia between 1991–1993. It focuses on
the relationship between national political actors and the
many international agencies who came to work in the country
230
Steven Lanjouw et al.
during this period. It complements other analyses, including
those from key actors, regarding the experiences faced by
Cambodia during this period (see Heng & Key, 1995, for
example). The case study highlights two key issues. First,
political factors influenced greatly the type of aid provided to
the country during the period 1991–1993, and the way in which
it was managed. These structural, political factors constrained
the scope for health professionals to establish effective coordination mechanisms. Second, the limited capacity of technical
coordination mechanisms to influence resource allocation
contributed to the emergence of a pattern of rehabilitation
investment which was highly fragmented, did not correspond
fully with national health priorities, and has proved difficult to
sustain. Overcoming such difficulties in other similar situations will depend upon donor organizations, in particular,
adopting more coherent strategies and appropriate aid instruments to support rehabilitation measures.
The remainder of the paper is divided into three main sections: a brief historical overview of Cambodia and the transition period; a description of the main mechanisms of aid
coordination operating in the Cambodian health sector
during the transition period; and, finally, an assessment of the
implications of these findings for other ‘post’-conflict settings.
The context: a political history of aid 1954–1991
Historical overview
Cambodia’s turbulent and destructive history over the past
few decades is summarized in Figure 1. The Kingdom of Cambodia (1954–1970) under Prince Sihanouk was replaced by
that of Lon Nol following a coup with the support of the USA.
Throughout this period, Cambodia was dragged inexorably
into the Vietnam war, suffering widespread carpet-bombing,
which led to massive displacement and contributed to the
country’s own political instability. The Khmer Rouge overthrew the Lon Nol regime and introduced a radical attempt
to return Cambodia to its early forms of agriculture and traditional society. During this infamous period of the killing
fields, intellectuals and minority groups were systematically
annihilated. Many others died as a result of disease, malnutrition and summary violence. At least half a million people,
up to as many as two million, are estimated to have died
during this period.
The Khmer Rouge was overthrown in 1979 with the support of
the Vietnamese who established the People’s Republic of
Kampuchea (PRK), which lasted for 10 years. During this
period Vietnamese style governance and development were
introduced and substantive support from the Eastern Bloc was
obtained. War continued with the Khmer Rouge, the Royalists
and other factions opposed to the Vietnamese-backed regime,
seeking to destabilize the country through low-intensity incursions and guerilla warfare. These factions, based in the refugee
camps along the Thai-Cambodian border, were actively supported by the USA, China and Thailand, among others.
It was these factions, under the heading of the Coalition
Government of Democratic Kampuchea, who occupied
Cambodia’s seat in the United Nations from 1982 onwards,
constituting an effective government in exile. The Vietnamese-backed regime in Phnom Penh, which controlled the
vast amount of territory and redeveloped the machinery of
state (such as the public administration), was recognized by
very few governments, mostly those associated with the
Eastern Bloc from whom it drew financial and political
support. Otherwise, the PRK, as the country was known, was
subject to international sanctions, blocking aid and trade
relations with the country (Mysliwiec, 1988).
In 1990, marking an internal process of economic and political liberalization, the PRK became the State of Cambodia
(SOC). With the backing of the Permanent Members of the
United Nations Security Council, negotiations were initiated
to end the conflict and facilitate Cambodia’s re-entry into the
international community. These negotiations culminated in
the signing of the Paris Peace Accords on 23 October 1991.
Aid and war
Since independence in 1954, successive Cambodian states had
relied upon aid for their survival. Reflecting its political
history, the source of aid has swung from the West (particularly from the US) to the East (predominantly Vietnam and
the USSR) and back to the West again, in different periods of
its political economy.
In the wake of the genocidal Khmer Rouge regime, a major
emergency operation was initiated by the West in September
1979. In early 1982, the United Nations declared that the
emergency was over, effectively suspending Western aid
flows as development aid was subject to the embargo,
pending the withdrawal of the Vietnamese from the country.
The only exception to this was a small group of Western
NGOs and UNICEF which continued their advocacy work
and some development work in the country, funded from
private and, in the case of UNICEF, assessed contributions to
the UN (Mysliwiec, 1994). Between 1981 and 1989, Vietnam
and the USSR were the major financial backers of the Cambodian state.
As the peace negotiations progressed, and the process of
political and economic liberalization continued within Cambodia, so the scope for international aid action increased.
Externally, donor agencies such as the European Commission and USAID started to fund NGO-led work inside Cambodia. Internally, the Phnom Penh Government allowed
NGOs to move out of the capital and in to the regions. International organizations, such as UNHCR, UNDP and WHO,
sent numerous fact-finding missions to the country in the lead
up to the deployment of the United Nations Transitional
Authority.
In search of legitimate coordination: UNTAC,
SNC, TAC and other good intentions
The legitimacy dilemma
The concept of public policy implies the presence of an authority with the authority and the legitimacy to represent (or at
least claim to represent) the interests of a population, and
Coordination in ‘post’-conflict Cambodia
231
Figure 1. Cambodia’s political evolution since independence
with the technical and administrative competence to implement that policy. In terms of national health policy, this
implies control over territory, usually defined in terms of
internationally accepted borders. In other words, national
policy, specifically national public health policy, implies the
existence of a competent and legitimate state, if not to
provide services at least to finance and regulate them
(Macrae, 1998; Cassels, 1992).
This idealized ‘strong state’, with its functioning Ministry of
Health firmly in control of policy-making, resource allocation
and regulation of the sector, is increasingly absent in many
parts of the Third World. Instead, many developing countries,
particularly in Africa, are characterized by states which lack
the capacity, and in some cases the political will, to function
as sovereign states (Clapham, 1996). The weakness of public
policy in these countries, together with the current preference
of official aid organizations for policy-based lending
(LaFond, 1995), means that the locus of health policy-making
is increasingly internationalized – with decisions regarding
major elements of the content of health policy in recipient
countries frequently being made in Washington, Copenhagen
and London, rather than in national capitals (Duffield, 1991;
Clapham, 1996; Okounzi & Macrae, 1995).
Steven Lanjouw et al.
In situations of ongoing conflict, and in situations of ‘post’conflict transition, the legitimacy and authority of the state
may be contested by national and international actors. This
presents particular problems for aid actors who wish to
neither support nor reinforce existing state structures which
are also seen as belligerent parties to a conflict. For this
reason, it is rare that development aid is provided by the
international community; rather, relief aid, delivered outside
state structures, is the primary tool of engagement in countries such as Sudan, Somalia and Afghanistan.
In situations of ‘post’-conflict transition, such as that in Cambodia between 1991–1993, the problem of finding a legitimate
interlocuter for aid is somewhat different. Here, there was a
political process, marked by the signing of a peace accord,
demobilization of troops and culminating in an election. Until
the elected government was in place there was a vacuum in
terms of the political authority recognized by the international powers. Coinciding with the political ‘continuum’
from war to peace was an aid continuum. Prior to the signing
of the Paris Accords, relief had been the only form of aid not
subject to the embargo, and this had been virtually suspended
after 1982. During the interim period of the transition,
rehabilitation aid was provided. It was only after the elections
that normal development-aid relations could be resumed,
marked most importantly by the establishment of World
Bank and IMF lending.
As indicated above, there is currently considerable debate
internationally regarding the need to link relief and development aid, and in particular to ensure that relief measures
achieve developmental objectives and contribute to longterm sustainability. A problematic dimension to effecting a
transition from relief to rehabilitation to development,
however, is that one key condition for the resumption of
development aid is an engagement by the aid community with
the very state whose legitimacy is in question. When the legitimacy and authority of the state remains contested nationally
and internationally, it is unclear who has the mandate and
power to set priorities and to distribute scarce resources.
In Cambodia, the Paris Peace Accords established a framework which sought to respond to this dilemma of legitimacy,
and to establish what Meier (1993) has called a constitution
for decision-making, a mechanism for deciding how decisions
should be made regarding the use of international rehabilitation assistance. Constructing such a mechanism was not
simply a diplomatic nicety, but rather had important practical
implications. At stake was how the US$800 million of aid
pledged in June 1992 by the international community would
be spent over the coming 18 months.
In the health sector in particular, the stakes were high. In
4
3.5
3
2.5
2
1.5
1
0.5
1989
1990
1991
1992
1993
1994
1995
Figure 2. Cambodian Ministry of Health recurrent expenditure
1989–1995 in billions of riels in 1989 constant prices
1991, levels of government public-health expenditure were
less than half their value in 1989 (see Figure 2). No reliable
figures exist to report accurately international aid expenditure on health during the period 1989–1992, however, data
from 1992–1995 provide an indication of the absolute and
relative value to the Cambodian health sector. Figure 3 shows
that aid expenditures exceeded government expenditures
nearly four-fold in 1992 and more than seven-fold in 1993.
How these funds were invested had important implications
for determining access to quality care by most of the population.
UNTAC, SNC and the TAC: the tangled web for decisionmaking
The establishment of the United Nations Transitional Authority in Cambodia (UNTAC) was designed to address the
‘constitutional’ vacuum which existed between the signing of
30
25
US$ millions
While the capacity of national governments to manage international pressures on health policy may be diminishing in
many countries, the fact that they are sovereign and recognized internationally matters (Clapham, 1996; Reno, 1999).
At least in theory, states remain the final arbiter of public
policy, since they alone have the legal power to determine
who operates within the confines of their national borders.
billions of riels - constant 1989 prices
232
20
15
10
5
0
1992
1993
1994
1995
year
Cambodian Govt
Aid
Figure 3. Total health expenditures: government and aid
Coordination in ‘post’-conflict Cambodia
the peace accords and the formation of the elected government. Unique in international law, UNTAC drew its legitimacy from a body comprising the four Cambodian factions –
the Supreme National Council (SNC).
The SNC comprised 12 members representing the four factions; Prince Sihanouk, Head of State 1954–1970, was an
additional member and served as its President. The SNC
embodied the legitimate sovereign state recognized by the
United Nations. The SNC delegated all powers necessary to
implement the Paris Peace accords to the United Nations,
represented by the Special Representative of the Secretary
General, Yasushi Akashi. The mandate of UNTAC drew on
233
the peace accords, and comprised seven components: military (including disarming and demobilizing the factions),
civilian policing, electoral, civil administration, repatriation
(focused on facilitating the return of 370 000 refugees from
Thailand), human rights, economic affairs and rehabilitation
(Charney, 1992). The constitutional arrangement set up in
Cambodia effectively created a UN Trusteeship, allowing in
principle for the United Nations to act as the government of
the country.
The Paris Peace Accords, included a Declaration on the
Rehabilitation and Reconstruction of Cambodia (Box 1). The
Rehabilitation Component of UNTAC, with its own Director,
Declaration on The Rehabilitation and Reconstruction of Cambodia
1. The primary objective of the reconstruction of Cambodia should be the advancement of the Cambodian nation and people, without
discrimination or prejudice, and the full respect for human rights and the fundamental freedom for all. The achievement of this
objective requires the full implementation of the comprehensive political settlement.
2. The main responsibility for deciding Cambodia’s reconstruction needs and plans should rest with the Cambodian people and the
government formed after free and fair elections. No attempt should be made to impose a development strategy on Cambodia from any
outside source or deter potential donors from contributing to the reconstruction of Cambodia.
3. International, regional and bilateral assistance to Cambodia should be coordinated as much as possible, complement and supplement
local resources and be made available impartially with full regard for Cambodia’s sovereignty, priorities, institutional means and
absorptive capacity.
4. In the context of the reconstruction efforts economic aid should benefit all areas of Cambodia, especially the more disadvantaged,
and reach all levels of society.
5. The implementation of an international aid effort would have to be phased in over a period that realistically acknowledges both
political and technical imperatives. It would also necessitate a significant degree of cooperation between the future Cambodian
Government and bilateral, regional and international contributors.
6. An important role will be played in rehabilitation and reconstruction by the United Nations system. The launching of an
international reconstruction plan and an appeal for contributions should take place at an appropriate time, so as to ensure its success.
7. No effective programme of national reconstruction can be initiated without detailed assessments of Cambodia’s human, natural and
other economic assets. It will be necessary for a census to be conducted, developmental priorities identified, and the availability of
resources, internal and external, determined. To this end there will be scope for sending to Cambodia fact-finding missions from the
United Nations system, international financial institutions and other agencies, with the consent of the future Cambodian Government.
8. With the achievement of the comprehensive political settlement, it is now possible and desirable to initiate a process of rehabilitation,
addressing immediate needs, and to lay the groundwork for the preparation of medium and long-term reconstruction plans.
9. For this period of rehabilitation, the United Nations Secretary-General is requested to help coordinate the programme guided by a
person appointed for this purpose.
10. In this rehabilitation phase, particular attention will need to be given to food security, health, housing, training, education, the
transportation network and the restoration of Cambodia’s existing basic infrastructure and public utilities.
11. The implementation of a longer-term international development plan for reconstruction should await the formation of a
government following the elections and the determination and adoption of its own policies and priorities.
12. This reconstruction phase should promote Cambodian entrepreneurship and make use of the private sector, among other sectors, to
help advance self-sustaining economic growth. It would also benefit from regional approaches, involving, inter alia, institutions such as
the Economic and Social Commission for Asia and the Pacific (ESCAP) and the Mekong Committee, and Governments within the
region; and from participation by non-governmental organizations.
13. In order to harmonize and monitor the contributions that will be made by the international community to the reconstruction of
Cambodia after the formation of a government following the elections, a consultative body, to be called the International Committee
on the Reconstruction of Cambodia (ICORC), should be set up at an appropriate time and be open to potential donors and other
relevant parties. The United Nations Secretary-General is requested to make special arrangements for the United Nations system to
support ICORC in its work, notably in ensuring a smooth transition from the rehabilitation to reconstruction phases.
Box 1. The Declaration on the Rehabilitation and Reconstruction of Cambodia
234
Steven Lanjouw et al.
was responsible for this, and was to work according to three
key principles laid out in the Declaration to guide the international assistance for the rehabilitation and reconstruction of
Cambodia. These were:
• Sovereignty – the Cambodian people and the government
to be elected should be primarily responsible for delivering
reconstruction assistance;
• Respect for local capacity – external assistance should complement and supplement local resources;
• Balance – assistance should benefit all areas, especially the
most disadvantaged.
The counterpart to the Rehabilitation Component of
UNTAC in the SNC was the Technical Advisory Committee
(TAC). The TAC, chaired by the UNTAC Director of
Rehabilitation, solicited approval from the factions for all
proposed projects and mission proposals, with the exception
of those implemented by NGOs.
The public administration, highly politicized under the preUNTAC regime, nominally fell under the control of UNTAC.
The Paris Accords had stipulated that all existing ministries
and departments would continue to function during the transition period. UNTAC had responsibility for overseeing the
civil service. Its capacity to do so was limited, not only by the
ratio of UNTAC personnel to Cambodian civil servants
(there were 400 of the former and 200 000 of the latter), but
by the linguistic obstacles facing the international civil servants attempting to shadow and control a bureaucracy effectively run by one of the factions (CPP).
This complex machinery provided the backdrop against
which coordination in the health sector was to take place. In
a context of continued hostility (including military action)
and distrust between the factions and their respective political and financial backers, delegating responsibility to a third
party (the United Nations) potentially provided a means of
neutralizing decision-making. An impartial UN, acting
according to the provisions and principles of the Paris
Accords, offered a way for deciding how decisions could be
made regarding rehabilitation priorities, among other things.
UNTAC’s capacity to do so in practice was limited, however.
Coordination in practice
UNTAC did not work as a transitional government, capable
of setting and enforcing systemic policy. It did not do so for
three main reasons.
First, the leadership of the UN mission in Cambodia interpreted its mandate differently. Rather than acting as a temporary sovereign power, which would then hand over power
to a newly established regime (rather as had the colonial
powers), the Special Representative of the Secretary General
(SRSG) sought a more consensual and pragmatic approach.
The SRSG saw UNTAC’s legitimacy as contingent upon
achieving consensus in the SNC. This interpretation assumed
both that the SNC could achieve such consensus and that the
SNC itself was seen as legitimate by the political factions
themselves and could claim to be representative of the interests of the Cambodian people.
Second, the factions did not allow UNTAC to function effectively. The Khmer Rouge left the UNTAC/SNC framework
early in the proceedings, refusing to comply with the processes of demobilization and preparations for the elections.
Other factions, namely FUNCIPEC and the KPNLF were
acutely sensitive to the risk that aid might serve to reinforce
the advantage of the communist-led State of Cambodia,
which remained as the de facto government in much of the
country. For example, they blocked agreement on a World
Bank loan, despite the fact that this was not to come into force
until after the elections. Thus, the Technical Advisory Committee was unable to achieve consensus and thus to provide a
practicable focus for aid decision-making during the transitional period.
Finally, donor countries did not want to establish a rigorous
coordination regime. In principle, UNTAC provided a
mechanism for such coordination, and the Paris Accords
established criteria for it to allocate resources. That both the
UNTAC rehabilitation component and the TAC were weak
reflected the (deliberate) under-investment by donors of the
financial and political capital which could have provided a
competent coordination regime.
The questionable legitimacy of the interim administration in
Cambodia, dominated as it was by the former government,
led many donors to by-pass the existing public administration
structures. In the health sector, UNTAC faced an awesome
task of getting a sometimes hostile donor community, which
wanted to identify its own priorities and the groups to whom
aid would be distributed, to prioritize critical needs, prevent
duplication, share information and avoid concentrating
resources in certain geographic areas of the country. With
close to 70 external organizations involved in the health
sector by late 1993, some with little or no official recognition
and no obligations to locally account for how resources were
disbursed, this uncontrolled environment was, to take a
common phrase, a ‘free for all’.
Major donors, in particular the United States and to a lesser
extent the European donors, including the European Commission, sought to maximize their room for manoeuvre by
working outside the coordination regime they themselves had
worked to establish. Specifically, they sought to direct aid to
the non-communist factions and to avoid engaging with the
State of Cambodia.
They did so in two ways. First, they bypassed the United
Nations by sub-contracting NGOs directly, rather than
working through the UN. Importantly, NGO projects were
not subject to scrutiny by the TAC. Donors argued that channelling aid directly through NGOs was necessary in a context
where there was a critical lack of institutional capacity and
skilled personnel (USAID, 1994). One of Cambodia’s
primary and perhaps most influential donors, USAID, articulated this approach in May 1994 by stating,
‘Cambodia’s unique circumstances dictate the need for
an innovative USAID post-crisis transition strategy. The
critical lack of institutional capacity, skilled personnel,
and local financing dictates an interim USAID strategy
Coordination in ‘post’-conflict Cambodia
of relying largely on NGOs for much of the project
implementation’ (USAID, 1994).
235
In addition to the primary, statutory coordination mechanisms, a number of ad hoc coordination bodies were established. These included the Donor Consultative Group, a
permanent donor consortium for Cambodia (ICORC) which
met outside the country, and the Joint Support Unit (JSU).
The latter body, chaired by UNHCR and UNDP, was established to coordinate overall humanitarian and rehabilitation
assistance, and specifically repatriation and resettlement
assistance. It included representatives of bilateral governments, UN specialized agencies and three NGO representatives. Supporting the JSU was a Joint Technical Management
Unit, which provided the Secretariat for the JSU and a
network of offices at the Provincial level, primarily in the
north-west. These Provincial Support Units (PSUs) comprised technical and management staff able to launch, at district or community level, projects of simple and standard
design having immediate and quick impact. PSUs aimed to
raise the capacity of district and provincial authorities to
respond to the needs of repatriated refugees. The first PSUs
were financed by UNDP and UNHCR, and were to be the
forerunners of the later UNICEF and WHO-financed provincial health advisors (see Hirono, 1992). The JSU and PSUs
worked closely with the growing NGO community. The latter
had its own coordination mechanism, the Cooperation Committee of Cambodia (CCC).
Although USAID describes Cambodia’s circumstances as
unique, donor reliance on NGOs to disburse rehabilitation
aid funds is common practice (see Macrae et al., 1995). In the
Cambodian case, bilateral relations (or indeed relations with
the international financial institutions) could not be resumed
until the elected government was in place. At the same time,
those multilateral agencies with a major involvement in
rehabilitation, such as UNHCR, had limited operational
capacity, sub-contracting NGOs to deliver particular services.
This strategy led to a mushrooming of international NGOs
(see Table 1). In 1991 there were approximately 60 international NGOs in Cambodia. This rose to 87 in 1992 and to
105 in 1993, with many nearly doubling their number of staff
in those years. Much of the assistance from these agencies was
directed towards Phnom Penh and the north-west provinces,
to which the majority of the refugees sought to return. This
expansion in the number and activity of NGOs heightened
the coordination challenge, as each came with its own assessment of need, strategy for implementation and, in some cases,
political agenda.
In the health sector, many activities, such as malaria control
and essential drugs, remained critically underfunded, while
others, such as infrastructure rehabilitation, were funded generously, with pledges exceeding the amounts stated in the
appeal. The time-frame for the rehabilitation period was
designed to coincide with that of the political process – some
18 months. The short project cycle placed pressures on NGOs
to identify projects that could deliver visible outputs quickly.
While many NGOs undertook training initiatives, these were
developed in an ad hoc way. Thus one senior WHO official in
Phnom Penh described the training approach adopted by
many agencies as ‘highly prescriptive’ (Lanjouw, 1997).
Donors and agencies involved in training often determined
the costs in advance of an assessment of training needs, as
these training costs were inexorably linked to short-term
monies and budgets.
Aiding recovery? Health coordination
mechanisms, 1991–1993
The mechanisms developed for health sector coordination
largely mirrored that for overall aid coordination. Thus,
WHO and UNICEF established replicas of the JSU and PSUs
primarily in the north-west provinces. Similarly, international
NGOs active in the Cambodian health sector had in August
1989 established an informal coordinating mechanism at
national level called MEDICAM, which sought to forge a
closer relationship with the Ministry of Health and constituted a sub-committee of the CCC.2 MEDICAM gained
momentum in 1991 when the MOH designated a representative to MEDICAM, and in April 1991 three NGO representatives were voted in to join CoCom (see below) for an initial
six months. Subsequently MEDICAM, with substantial
support from MSF, also gained representation and participated in the numerous technical sub-committees of CoCom.
A second donor strategy to circumvent the UNTAC/SNC
structure was to negotiate directly with individual factions for
access, rather than through the TAC. In so doing, they jeopardized not only the principles of neutrality and impartiality
of the Accords, but also the mandate of the United Nations
to uphold such principles.
The UN, WHO and CoCom
Of particular interest, however, is the health corollary of
UNTAC itself. Until 1991, UNICEF had been the lead agency
Table 1. Number of NGOs working in Cambodia, 1988–1995
International NGOs
Local NGOs
1988
1989
1990
1991
1992
1993
1994
1995
23
0
31
0
45
1
60
5
87
18
105
78
145
119
164
160
Sources: Cooperation Committee for Cambodia, for international NGOs; Ponleu Khmer for local NGOs.
236
Steven Lanjouw et al.
in the health sector in Cambodia. At least until the 1990s,
UNICEF’s mandate was unique within the UN family in its
ability to work with non-state entities, and states such as Cambodia which were not internationally recognized (Richardson,
1995). The signing of the Paris Accords provided for the beginnings of a normalization of relations beween the UN specialized agencies and Cambodia. UNDP, WHO, UNFPA,
although lacking permanent representation in Phnom Penh,
started to provide technical support to the health sector in
1991.
Such normalization was tentative and conditional, a fact which
was to have implications for the UN’s ability to provide a
leadership role in the coordination of aid for health. During
the transitional period, the WHO office was not fully accredited, and was run instead by a Special Envoy of the Organization’s Secretary-General. Health development assistance
provided by the Organization had to be provided through a
humanitarian assistance programme, and to steer clear of the
‘. . . usual WHO development terminology for the time being
for political and mandate reasons’ (Kreysler, 1991).
The implications of ‘relief’ rather than ‘development’ funding
have been described elsewhere (Macrae, 1997; Macrae et al.,
1995). The key distinction between these two forms of aid lies
not in their particular content, but in the fact that in contrast
to development aid, relief is politically unconditional and
does not confer legitimacy on the incumbent regime. WHO’s
emphasis on the humanitarian nature of its intervention,
reflected the essentially political distinction between relief
and development aid.
The ability to preserve the neutrality of a humanitarian actor,
whilst also striving to provide a focus for a coordinated
approach to rehabilitation inevitably placed strains on WHO,
and the Coordinating Committee (CoCom) it helped to
establish and maintain. As indicated earlier, the nature of
working in a situation of contested legitimacy meant that the
developmental approach it adopted required engaging with a
state administration. WHO justified this engagement on
humanitarian grounds, in other words, arguing that the longterm development of effective health services required
working with professional staff in relevant ministries and
provincial authorities. However, the majority of donors questioned the legitimacy of these bodies, and allocated resources
outside of them.
CoCom
The capacity of the Ministry of Health to coordinate health
sector aid was extremely limited. At precisely the time when
more international assistance than ever before was coming in
to the country, the public administration was in crisis. There
were few officials with expertise or training in planning and
coordinating humanitarian or basic health care assistance
programmes and salaries were plummeting. Even if it had
been functioning, the public administration was identified
with the Communist Party and thus not seen as a legitimate
partner by the majority of donors.
As a result, coordination initiatives at central and provincial
level were left largely to the international community itself.
WHO, and to a lesser extent UNICEF, sought to fill the
vacuum left by the erosion (de facto and de jure) of the state.
In an attempt to build a coherent management framework for
health services rehabilitation, in 1992 WHO started to
actively bolster CoCom, which by then drew on senior-level
representation from the existing SOC health administration
and from other international agencies.
The Committee was chaired by an Under-Secretary of
Health, and its membership included representatives of the
MOH, WHO, UNICEF, the International Committee of the
Red Cross (ICRC), UNDP, bilateral agencies and three
NGO representatives. CoCom was supported by a Secretariat and Executive Committee which was chaired by a
Director of Cabinet and included the Director General of
Health, the Director of Policy and Planning, and the Director of International Relations (see Figure 4). Technical
assistance was provided by WHO, whose representatives,
along with other senior officials of the MOH, and representatives of some of the bilaterals, participated in CoCom Secretariat meetings.
The terms of reference and working practices of CoCom
helped define the relationships between the transitional
national authority and the range of actors in the health sector.
CoCom’s objectives were: to monitor and evaluate all health
activities by international aid agencies working in the health
sector; to provide advice; and to make recommendations to
the MOH in order to support the planning, coordination and
implementation of health sector activities in Cambodia. In
addition, it was to ensure the continued generation and evaluation of health information and health activity mapping with
a view to identifying priorities and constraints, and to recommend national policies and plans; review public health sector
human and financial resource needs; undertake studies and
reviews (through sub-committees and working groups) and
facilitate the most appropriate use of technical advice to the
Ministry; provide information on current and planned activities of all international, multilateral, bilateral and nongovernment organizations working in the health and
health-related sectors; and to review all externally funded
health proposals to ensure they were consistent with national
health policy.
The establishment of CoCom at national level was followed
by a number of provincial coordination committees (ProCoComs), set up to coordinate international assistance at the
province and district level. ProCoComs were chaired by
provincial directors of health, supported by a secretariat
which convened meetings, prepared agendas, and took
minutes of meetings between the MOH authorities and international organizations working in the provincial health
sector. Support for this process came from both UNICEF and
WHO.
Four ProCoComs were established in 1992, and two in 1993.
By 1994 there were eight ProCoComs in the 21 provinces/
cities throughout the country. The overall objective of the
ProCoComs was to facilitate the implementation of national
health programmes and policies via provincial health plans
Coordination in ‘post’-conflict Cambodia
237
Figure 4. Coordination Committee of the Ministry of Health
through the coordination of NGOs, international organizations and provincial health resources to avoid duplication
and to maximize health impact. The ProCoCom mechanisms
also sought to disseminate information from the CoCom level
to the provinces but do not appear to have functioned well as
information collecting institutions which fed insights and
material up to the national level. Even in Battambang
province, one of the better functioning and resourced, ProCoComs had real difficulties getting problems addressed and
in Svey Rieng, a province along the Vietnamese border, for
example, there was little movement of information in any
direction.
WHO and UNICEF also supported the establishment of a
number of CoCom sub-committees and technical working
groups to assist in advising the MOH on the implementation
of specific health services (see Figure 4). Each sub-committee
had its own specific terms of reference, which were reviewed
and updated annually; they were supposed to meet regularly
and to feed information to the MOH, through CoCom, on
heath policy and planning issues. Membership reflected the
composition of the CoCom, and included one or two NGO
representatives with particular experience in the issue concerned, who were identified through MEDICAM. By 1994
there were eight sub-committees in existence.3
238
Steven Lanjouw et al.
Coordination of repatriation and reintegration activities
A second important focus of health coordination during the
transition period placed emphasis on efforts to repatriate
refugees, notably those from the Thai border camps, and to
reintegrate returnees into local structures. In relation to the
health sector, a key element of reintegration was to ensure
that health workers trained through different systems and,
working with the different political factions, could be
absorbed and utilized within the health system.
Although final responsibility for the repatriation and reintegration of refugees lay with UNHCR, implementation of a
health component for the integration of refugees into the
existing health services was to be coordinated by WHO and
UNICEF. Based on the findings of the UN interagency
humanitarian needs assessment (United Nations, 1991) and
the UN Secretary-General’s Consolidated Appeal of June
1992 (UNTAC, 1992), it was agreed that WHO would act as
the coordinator for the health component, with UNICEF
responsible for implementation.
Thus ahead of a newly mandated government in Cambodia in
November 1993, WHO, along with the interim health
administration, and in collaboration with senior personnel of
the four political factions which together made up the SNC,
undertook to develop and support the health services reintegration and unification of three of the four factions into the
existing SOC (government) health services (Hun Chun et al.,
1993). These activities were concentrated in the north-west
provinces of the country to which the majority of refugees
aimed to return, and as bilateral donor support for the health
services of the former factions (FUNCIPEC and KPNLF)
ended in October 1993, this undertaking paved the way for
the emergence of a civilian health system.
It was proposed that this would take place through the integration of factional health staff and health programmes into
the national district and provincial health management
system. It was supported by a technical planning and working
group which considered policy recommendations regarding
the strengthening of provincial and district level management
capabilities, issues regarding the private sector health services
and health facilities, and human resources development. In
Banteay Meanchay and Siem Riep, staff from a variety of
hospitals, infirmaries and MCH clinics were ‘rationalized’ in
order to reduce operating costs, reduce the number of health
workers employed, especially those with questionable training, and reduce the number of hospital beds from 415 to 270.
In addition, the Health Worker Qualification Equivalencies
Paper was produced in February 1993 and agreed by the SNC
factions, collapsing the number of different health worker
diplomas nation-wide from 59 to 23.
NGO mapping
In May 1991 the MOH prepared a country-wide NGOmapping exercise to determine the exact type and quantities
of aid flowing in from external sources to Cambodia in order
to facilitate coordination of NGO medical assistance. For a
number of reasons, including the fact that there was no
mechanism to enforce compliance, this information was not
collected and it was not until March 1992, with support of
CoCom and WHO, that this initiative really got underway.
Subsequently general information about each NGO operating in the Cambodian health sector, and some information
about bilateral and multilateral support, was collected, listing
projects by geographic area and activity, human resources,
budgets, and the level of health system intervention. Thus by
mid 1992 there were 55 NGOs (including the international
Committee of the Red Cross and other Red Cross societies)
working in the health sector, 15 of which worked with
returnees, 14 with internally displaced. Thirty-nine were
based at provincial level, 26 at district level and another 26 at
central level in Phnom Penh. Total funds budgeted for NGOs
in 1991 were US$16.6 million, rising to US$28.8 million in
1992 (Lanjouw et al., 1998).4
Alongside the establishment of a data base informing the
allocation and distribution of NGO health resources and
activities, it was hoped that this information would help
attract NGOs to underserved areas of the country, notably
those to the north-east and south-west. Moreover, after
national elections it was hoped that this exercise would be
repeated regularly and that it would encourage organizations
in the health sector to submit project proposals and reports
on their activities to the proper departments in the MOH.
Other coordination mechanisms
Outside of governmental mechanisms, health coordination
also took place in a variety of other forms. Notable among
these were the Memoranda of Understanding (MoUs)
between UN agencies, which established inter-UN coordination mechanisms. UNDP and WHO, for example, established an MoU for a project on hospital infection control;
another between UNICEF and WHO covered collaboration
around the Expanded Programme on Immunization/Polio
eradication, the pharmaceutical sector, strengthening health
services, maternal and child health and nutrition; and one
between UNHCR and WHO covered the joint appointment
of provincial health advisors.
Coordination in practice
The UNTAC period ended in December 1993 with Cambodia still plagued by a low-intensity war. In particular, the
Khmer Rouge continued its battle to undermine the emergent state, which remained weakened by political (and not
occasionally, military) in-fighting. Some preparations for the
post-election period had been made by the UNTAC
Rehabilitation Directorate, including hastily designed efforts
for demining, emergency and rehabilitation support such as
food security for repatriated and resettled populations,
investment planning, and a structure to continue the mobilization of donor assistance. It was hoped that the ICORC
mechanism would assist the new government and its administrative bodies to coordinate international assistance, and to
oversee the continuation of the reconstruction and development process.
During the period 1989–1993 the size of the international aid
Coordination in ‘post’-conflict Cambodia
programme in Cambodia increased eighteen-fold from
US$17.3 million to US$317 million. No reliable figures exist
that detail the precise allocations to the health sector during
this period. That such figures are not readily available is worrying in terms of accountability and in terms of subsequent
planning of health expenditure. What is clear, however, is that
by 1993, international aid accounted for 88.6% of total public
health expenditure in the country (CDC database, see also
Lanjouw et al., 1998). Aid then was a critical resource for the
Cambodian public health system. Yet, as described above, the
capacity of the public administration to coordinate this aid
was limited.
Lacking a clear national counterpart, and reflecting the
sophisticated political mechanisms put in place to provide an
interim ‘state’, a strikingly large number of bodies emerged
which sought to coordinate aid generally and health aid in
particular. In addition to their number, what is also striking is
that, with the exception of ICORC which met only rarely,
none of the coordination mechanisms which emerged were
linked to resource allocation. So, for example, the UNTAC
rehabilitation component, itself underfunded, had no operational responsibility. Similarly, WHO, which had its own
resources for technical assistance, had no operational budget.
MEDICAM represented NGOs, the majority of whom relied
on official funding for the bulk of their work.
It is bilateral allocations to operational agencies which shape
aid responses. It is they who decide the overall scale and pace
of the response, the type and distribution of aid instruments
and projects, and the timeframe of the project cycle. While
some of the detail of planning may be delegated to an intermediary multilateral body, such as UNHCR for refugee repatriation, through the choices they make regarding which
projects to fund, bilaterals clearly have a key role in shaping
sectoral policy.
Bilaterals lacked a coherent strategy for sectoral rehabilitation in Cambodia, and nominally delegated responsibility
to the UN and its specialized agencies to guide policy in the
absence of a functioning state. However, the ability of the UN
to play this role was undermined by national and international actors who worked consistently outside the UNTAC
framework, damaging its capacity to monitor and coordinate
aid. In the process, its ability to ensure that the principles for
rehabilitation laid out in the Charter (Box 1) were adhered to
was also undermined, as was the ability of specialized agencies to promote technical standards.
In the case of the health sector, efforts by health professionals
– national and international – to establish effective mechanisms for coordination were undermined to a considerable
extent by structural features of the aid system, and by the particular political problems it confronted working in a situation
of contested legitimacy.
Coordination is clearly a means, rather than an end in itself.
It is a means by which the sum of collective efforts can be used
to maximize health gain through the establishment of an
effective and sustainable health system. Bilateral bodies were
largely unwilling and unable to work with and through the
239
public administration then in place. The international aid
system could only become operational by channeling funds
through NGOs. While NGOs offer important advantages, not
least their capacity to act as competent interlocuters, they also
suffer from a number of limitations.
In particular, NGOs could not (nor would they claim to) substitute for the presence of an effective state, nor could they
develop and implement policy through a national network of
public health professionals. While bodies such as WHO
sought to re-establish the capacity of central policy-making
institutions, the pattern of resource allocation tended in the
opposite direction, namely to invest in disparate project
activities, implemented by many different NGOs. Such an
approach was unable to address key structural problems
facing the sector, in particular the problems of acute underfinancing and problems of very low public sector pay.
In real terms, the value of government health spending in
1993 was half that of 1989. While salaries comprised a relatively large part of this expenditure, in absolute terms, health
worker wages were below subsistence levels, forcing them
to leave the sector, seek alternative employment or to unofficially charge their patients.
In a context where the bulk of aid resources were channelled
outside the public administration, donors could not adopt a
coherent, policy-based approach to health sector development, relying rather on a project-based approach. It is not surprising that efforts to coordinate these initiatives were at best
partially successful, since the mechanism for aid disbursements was inherently fragmented rather than coherent.
While CoCom and MEDICAM provided important vehicles
for information exchange, and for much vigorous discussion
regarding options for the development of the Cambodian
health system, these were not juridical bodies with the authority to determine the location, content or duration of projects. Rather, they relied upon establishing consensus
between different agencies, each with their own mandate,
organizational style and existing commitments to their
donors.
Delinked from resource allocation mechanisms, the valuable
technical guidance they sought to provide was undermined by
the effects of the wider political context, which in turn influenced the choice of aid instruments. In particular, rehabilitation was designed as a stop-gap measure ‘between’ relief
and development aid. While claiming developmental objectives, in contrast to development aid the project cycle was
short, thus limiting the range of activities which could be
undertaken. Also inherent was a donor preference to invest
in infrastructure.
This combination of factors resulted in strategies which were
unlikely to prove sustainable in the medium term, and which
arguably decapacitated the already weak public health
service in the country. So, for example, under-financing of
essential drugs probably increased the problem of underutilization of public facilities. Similarly, no funds were formally targeted towards a strategy to address the very low
240
Steven Lanjouw et al.
wages of health workers, exacerbating the problem of trained
staff leaving the sector or diversifying their activities outside
the public health system.
Aid coordination in a chronic political emergency:
issues and implications from the Cambodia case
This study can be situated within a wider context of international reflection on the role and modality of international
aid in unstable situations. In a report to the former SecretaryGeneral of the United Nations, Margaret Anstee commented
that the issue of ‘post’-conflict rehabilitation and peace-building ‘. . . is a (and probably the) major growth industry for a
large number of components of the UN system and is likely
to remain so for the next few years’ (Anstee, 1996, emphasis
in the original). Similarly, a recent evaluation highlighted that
the World Bank’s portfolio of projects to so-called ‘post’-conflict countries increased by over 800% between 1980 and 1997
(Kreimer et al., 1998). In this period, a total of US$6.2 billion
was loaned to ‘post’-conflict countries by the Bank (ibid).
This paper has sought to describe and analyze the particular
difficulties facing international aid actors working in situations of ‘post’-conflict transition. It highlights a number of
key issues which merit consideration by policy-actors
working in other similar settings.
First, conflict affected countries are among the most health
deprived. The combination of war, superimposed on structural poverty, means that access to health services is often
extremely limited for these populations. The process of
‘post’-conflict transition, such as that in Cambodia, is often
accompanied by substantial pledges of international assistance. While these may be slow in being translated into real
disbursements (see, for example, Peou et al., 1998), relative
to national public resources aid represents a crucial resource.
Establishing mechanisms for coordination in order to ensure
that resources are used effectively might therefore be seen as
particularly important in these environments.
A complex array of mechanisms existed to effect coordination in Cambodia during this time. These were concerned
to ensure coherence between the different elements of the
UNTAC mission: aid, political and military; for interventions
targeted at particular groups, particularly returning refugees;
for particular types of organization, such as NGOs; and for
specific sectors, such as CoCom in health.
Borton (1996) defines four types of coordination: information
coordination, in other words the sharing of basic information;
coordination through common representation (for example,
to negotiate funding or brief the media); framework coordination (requiring a shared sense of priorities); and
management/directive coordination (implying a hierarchy of
authority and/or a degree of leverage over the actions of one
body by another).
In the Cambodian context, coordination for health comprised
largely ‘information coordination’. CoCom, for example, provided a forum for the collection, collation and exchange of
information between different actors. This was a valuable
role to play, arguably contributing to the development of the
long-term capacity of the Ministry of Health in the coordination sphere, providing not only information, but methods
and systems for information collection, such as the NGO
mapping exercise.
The capacity of CoCom to move beyond this type of coordination to a higher level of intensity was limited as much by
differences in the style, mandates and personalities associated
with agencies, as by structural factors. Away from interagency politics, WHO provides a useful and less politicized
space for the different factions to meet to discuss the
incorporation of their health workers into the national public
health system. In this capacity, it facilitated framework
coordination, which resulted in common guidelines for
accreditation of different health workers. While as yet unimplemented, this initiative was important in enabling the
different factions to talk to each other.
What the coordination mechanisms could not, and did not,
achieve was a coherent analysis of the primary problems
facing the health sector, nor did they have the power to influence the allocation of resources according to that need.
One might argue further that the coordination mechanisms
were necessarily limited in their impact because the real
decisions regarding the allocation of funds had already been
determined prior to reaching Cambodia. Donor agencies
such as the European Commission had already set their strategy for rehabilitation, and relied upon implementing agencies
to present proposals, rather than working to agreed policy
objectives. The short project cycle and donors inherent
preference to support capital costs further undermined
attempts to promote ‘rational’ allocation of resources in
support of sustainable health development.
Thus the political context of transition, in which donors
wanted to avoid engaging with state institutions, meant that
donors deployed aid instruments which were inherently difficult to coordinate. The primary implementing channel was
through NGOs, and thus rehabilitation assistance was delivered by many different agencies, implementing relatively
small, but numerous projects according to their different
mandates, organizational cultures and political objectives.
Lack of political and financial support for the rehabilitation
component of UNTAC, and political manoeuvring with the
SNC, meant that these mechanisms, like their more technical
counterparts, also had a limited impact on the allocation of
aid resources during the transition period. The fact that NGO
projects lay outside the scope of the TAC meant that these
would not, in any case, have been considered by it.
In situations of chronic instability, and specifically where the
legitimacy of the state is contested, international aid is
increasingly delivered outside governmental structures, by
international and non-government organizations. Such strategies enable donor governments to avoid being seen to
endorse governments in recipient countries who are also
party to the conflict. With multiple donors working with multiple partners, the need for coordination in the sense of
Coordination in ‘post’-conflict Cambodia
having a combined strategy and clear criteria for resource
allocation is clearly important. However, no such mechanism
existed in the Cambodian context. While bilateral donors
delegated responsibility for technical implementation to
specialized agencies and NGOs, they did not delegate the
power to these actors to determine how resources were spent.
This disconnect meant that resource allocation was driven
more by the political and bureaucratic priorities of donors,
NGOs and the Cambodian factions, than an analysis of need.
While such a state of affairs is not uncommon, the opportunity costs in the case of Cambodia were particularly high.
Endnotes
1 It is significant too that in his first speech as President of the
World Bank, James Wolfensohn highlighted the particular needs of
countries making the transition from war to peace (Holtzman, 1997).
2 Among the first 13 members of MEDICAM were AFSC
(American), Enfants de Cambodge (French), HI (French) MCC
(American), MSF (Dutch-Belgian), Redd Barna, (Swedish-Norway)
Save the Children, (UK) World Vision (International), with substantial support from UNICEF.
3 These were: Maternal and Child Health; Mental Health;
Health Information Systems; Pharmacy; Hospital Planning and
Management; Primary Health Care; Prevention of Blindness; and
District Health Strengthening. The establishment of sub-committees was influenced by the enthusiasm of particular actors (individuals and organizations) and in some cases reflected the interests
of particular NGOs (for example, MSF in relation to health information systems) in promoting nationally models they had developed at local level. It is not clear, however, whether all key areas of
activity, for example, communicable disease control, received the
attention they deserved at this point in time. It was notable, for
example, that control of tuberculosis in the early days of transition
suffered greatly given the unavailability of drugs and lack of further
training and support for pre-existing systems of diagnosis, treatment
and care.
4 Best estimate; although it should be noted that considerable
discrepancies exist in the data on NGO funding in relation to
amounts budgeted, dispensed, and spent (see Lanjouw et al., 1998).
References
Annear P. 1995. Case study of Cambodia 1954–1995. Economic and
Political Development, Poverty and Health Care. Deakin University, Australia; pp.1–95.
Anstee M. 1996. The United Nations role in ‘post’-conflict peacebuilding: Report to the Secretary General. New York: United
Nations.
Borton J. 1996. An account of coordination mechanisms during the
international response to the 1994 crisis in Rwanda. Disasters
20(4): 305–24.
Buse K, Walt G. 1997. An unruly melange? Coordinating external
resources to the health sector: A review. Social Science and
Medicine 45: 449–63.
Cassels A, Janovsky K. 1998. Better health in developing countries:
are sector-wide approaches the way of the future? Lancet 352:
1777–9.
Cassels A. 1992. Implementing health sector reform. Report prepared for the Health and Population Division, Overseas
Development Administration, UK.
Charney J. 1992. NGOs and the rehabilitation and reconstruction of
Cambodia. Report on behalf of the Cooperation Committee for
Cambodia. Phnom Penh.
Clapham C. 1996. Africa and the international system: the politics of
state survival. Cambridge: Cambridge University Press.
Development Assistance Committee. 1997. DAC guidelines on conflict, peace and development cooperation. Paris: OECD.
241
Duffield M. 1991. The privatization of public welfare, actual adjustment and the replacement of the state in Africa. Paper presented at the conference on ‘International privatization:
strategies and practices’, St Andrews, 12–14 September 1991.
European Commission. 1996. Communication from the Commission
to the Council and Parliament on Linking Relief, Rehabilitation
and Development. Brussels: European Commission.
Heng MB, Key P. 1995. Cambodian health in transition. British
Medical Journal 311: 435–7.
Hirono R (ed.). 1992. Comprehensive paper on Cambodia: A UNDP
mission. Phnom Penh: UNDP.
Holtzman S. 1997. Post-conflict reconstruction. Washington DC:
World Bank, Social Policy and Resettlement Division.
Hun Chun Ly et al. 1993. The working paper for the unification of
health administrations. A report of the CoCom unification of
health services sub-committee’s planning team. November.
Phnom Penh, Ministry of Health.
Kreimer A, Eriksson J, Muscat R, Arnold M, Scott C. 1998. The
World Bank’s experience with post-conflict reconstruction.
Washington DC: IBRD.
Kreysler JV. 1991. Draft report on Cambodia. Meeting in
WHO/WPRO, Manila, November 1991. CAM/REP/4. Phnom
Penh, WHO.
LaFond A. 1995. Sustaining Primary Health Care. London: Save the
Children Fund and Earthscan.
Lanjouw S. 1997. Turmoil and confusion. Health Exchange February:
6–8.
Lanjouw S, Macrae J, Zwi A. 1998. The role of external support for
health services rehabilitation in ‘post’-conflict Cambodia. Draft
report London School of Hygiene and Tropical Medicine/Overseas Development Institute. London.
Levy BS, Sidel VW. 1997. War and public health. New York and
London: Oxford University Press.
Macrae J. 1995. Aid policy in transition: a preliminary analysis of
‘post’-conflict rehabilitation of the health sector. Journal of
International Development 7: 669–84.
Macrae J. 1997. Dilemmas of legitimacy, sustainability and coherence: rehabilitating the health sector. In: Kumar K (ed.).
Rebuilding civil societies after civil war: critical roles for international assistance. Boulder, USA and London: Lynne Rienner.
Macrae J. 1998. Purity or political engagement?: issues in food and
health security in complex political emergencies. Journal of
Humanitarian Assistance http: /www-jha.
Macrae J, Zwi A, Forythe V. 1995. Post-conflict rehabilitation: preliminary issues for consideration by the health sector. Report
for the Overseas Development Administration. London:
London School of Hygiene and Tropical Medicine.
Meier G. 1993. The new political economy and policy reform.
Journal of International Development 5: 381–9.
Mysliwiec E. 1988. Punishing the poor: the international isolation of
Kampuchea. Oxford: Oxfam.
Mysliwiec E. 1994. Cambodia: NGOs in Transition. In: Utting P
(ed.). Between Hope and Insecurity: the social consequences of
the Cambodian peace process. pp. 97–142. Geneva: UNRISD.
Okounzi S, Macrae J. 1995. Whose policy is it anyway?: International
and national influences on health policy development in
Uganda. Health Policy and Planning 10: 122–32.
Peou S, Yamada K, Macrae J. 1998. Foreign aid for peace in Cambodia: explaining unfulfilled pledges. Draft report to New York
University ‘Pledges of aid project’.
Reno W. 1999. Sovereignty matters: the local politics of government
recognition. Unpublished mimeo. University of Florida, Miami.
Richardson J. 1995. UNICEF’s emergency response: based on staff
perspectives. New York: UNICEF.
United Nations. 1991. Inter-Agency Report of the UN Inter-Agency
Humanitarian Mission to Cambodia. New York: United
Nations.
United Nations. 1997. Renewing the United Nations: A programme
for reform. Report of the Secretary-General. New York: United
Nations.
242
Steven Lanjouw et al.
United Nations Secretary General. 1992. Report of the SecretaryGeneral on the Implementation Plans of the Agreements
S/23613, February 19, paragraphs 150–157.
UNTAC. 1992. The Secretary-General’s Consolidated Appeal for
Cambodia’s Immediate Needs and Rehabilitation. UNTAC.
USAID. 1994. Assistance Strategy for Cambodia, FY1994–97.
Washington DC, USAID.
World Bank. 1997a. War to Peace Transition. Institutional and Social
Policy, Africa Region. Information Brief. Washington: World
Bank.
World Bank. 1997b. A framework for World Bank involvement in
post-conflict reconstruction. Mimeo, Washington: World Bank.
April 25.
Zwi AB, Ugalde A. 1989. Towards an epidemiology of political violence in the Third World. Social Science and Medicine 28:
633–42.
Zwi AB. 1996. Numbering the dead. Counting the casualties of war.
In: Bradby H (ed.). Defining violence. Understanding the
causes and effects of violence. Aldershot, UK: Avebury Press;
99–124.
Acknowledgements
The research work upon which this paper was based was funded by
the UK Overseas Development Administration (now Department
for International Development, DFID); and was a joint project
between the London School of Hygiene and Tropical Medicine, the
Overseas Development Institute, and the National Institute for
Public Health, Phnom Penh. The project team comprised Steven
Lanjouw, Joanna Macrae and Anthony Zwi, who worked with the
support of Dr Oum Sophal, Director of the National Institute for
Public Health, and Dr Ivek Navapol, who assisted with gathering
materials for the project. Charlotte Benson of ODI assisted in the
collation of financial flow data. Anthony Zwi was a member of the
DFID-funded Health Economics and Financing Programme when
this work was undertaken; the views presented here are those of the
authors and do not reflect those of any organizations. This paper
has drawn extensively from the draft report by Lanjouw S, Macrae
J and Zwi A, ‘The role of external support for health services
rehabilitation in ‘post’-conflict Cambodia’ (London School of
Hygiene and Tropical Medicine, and Overseas Development Institute, London, 1998). The comments of Gill Walt and of an anonymous referee on earlier versions of this manuscript were of value in
refining the paper.
Biographies
Steven Lanjouw has an MA in Political Science from the University
of Amsterdam and a MSc in Health Policy, Planning and Finance
from the London School of Hygiene and Tropical Medicine
(LSHTM). He has spent much of the last 8 years working in conflict
induced environments of Southeast Asia with a number of humanitarian and academic organizations. He has conducted health policy
related research in Cambodia and Myanmar/Burma. His current
research interests include health provision for indigenous people,
health systems research and health and migration.
Joanna Macrae is a Research Fellow at the Overseas Development
Institute working as part of the Humanitarian Policy Group.
Together with colleagues at LSHTM and elsewhere, she has conducted a number of studies regarding health policy in situations of
‘post’-conflict transition, including Uganda, Cambodia and Ethiopia.
Her primary research interest is in the politics and practice of international aid in chronic political emergencies. She has written extensively on the issue of linking relief and development aid for the UK
Department for International Development, UNOCHA and
UNHCR, and on the role of aid as a tool for conflict management.
Anthony Zwi trained in medicine in Johannesburg, South Africa,
and subsequently in public health and epidemiology in the UK. He
has a longstanding interest in the impact of political violence and
conflict on health and health systems. He has co-edited a special issue
of Social Science and Medicine on Political Violence and Health in
the Third World (1989 Volume 28 (7)) and worked with Joanna
Macrae on exploring the role of international aid to the health sector
in countries emerging from conflict. He currently heads the Health
Policy Unit, LSHTM, and is actively involved in the Conflict and
Health working group. He is particularly interested in facilitating
linkages between academics and the health-related NGO and donor
communities.
Correspondence: Steven Lanjouw, P.O. Box 258, CMU Post Office,
Chiangmai 50202, Thailand. Email: [email protected]
Joanna Macrae, Humanitarian Policy Group, Overseas Development Institute, Portland House, Stag Place, London SW1E 5DP, UK.
Email: [email protected]
Anthony B. Zwi, Health Policy Unit, LSHTM, Keppel St, London
WC1E 7HT, UK. Email: [email protected]