Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Royal Government of Cambodia Ministry of Health Pre-Service Training for Health Workers Project P169629 Draft Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Version of February 5, 2020 0 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery TABLE OF CONTENTS Executive Summary ............................................................................................................................................................... 5 A. Introduction and Background .................................................................................................................................. 9 A.1 Objectives...................................................................................................................................... 9 A.2 Project Description........................................................................................................................ 9 A3 Brief relevant country, sectoral and institutional context .......................................................... 10 A.3.1 Country Context .................................................................................................................. 10 A.3.2 Sectoral and Institutional Context ...................................................................................... 11 A.4 Project stakeholders and beneficiaries ....................................................................................... 12 A.5 ESF standards applied for the project and summary of relevant national environmental and social laws ............................................................................................................................................... 14 A.7 Project Location .......................................................................................................................... 16 B. Assessment ..................................................................................................................................................................... 17 B.1 Focus Groups Discussions and Key Informants Interviews ....................................................... 17 B.2 Analysis of health student’s enrollment data by gender, ethnicity, age and other demographic parameters.............................................................................................................................................. 19 B.2.1 Medical students by gender in Cambodia. Year 2019 ........................................................ 19 B.2.2 Medical students by ethnicity in Cambodia. Year 2019...................................................... 20 B.2.3 Number of health students versus the population in Cambodia. SY 2018-2019................ 21 B.3 Quantitative and qualitative analysis of the current public health workforce by gender, ethnicity, age and other demographic parameters ................................................................................ 22 B.3.1 Public health workforce by gender in Cambodia. Year 2019 .............................................. 22 B.3.2 Public health workers by age bracket in Cambodia. Year 2019 .......................................... 23 B.3.3 Health workforce by ethnicity in Cambodia. Year 2019 ..................................................... 24 B.3.4 Number of Public Health Workers versus Population in Cambodia. Year 2019 ................. 25 B.4 Analysis of current practices and the most relevant current health sector curricula from an environmental and social perspective. ................................................................................................... 25 C. Plan for Inclusive Service Delivery ....................................................................................................................... 27 C.1 Recommendation to promote the enrollment and inclusion of disadvantaged groups ............ 27 1 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery C.2 Recommendations to imbedding social inclusion and environmental sustainability in the health sector in Cambodia. ................................................................................................................................ 28 C.2.1 Promoting the equitable access to project benefits to Ethnic Peoples and other socially vulnerable groups ............................................................................................................................... 29 C.2.2 ............................................................................................................................................. 29 D. Occupational and Community Health and Safety ........................................................................................... 29 E. Hazardous and clinical waste management...................................................................................................... 30 D.1 Health Care Waste Management Plan........................................................................................ 32 D.1.1 Waste Segregation .............................................................................................................. 32 D.1.2 Waste Handling ................................................................................................................... 33 D.1.3 Interim storage of waste ..................................................................................................... 34 D.1.4 Treatment and Disposal of healthcare waste ..................................................................... 34 D.1.5 Waste Water from laboratories and training facilities .............................................................. 35 F. Environmental Risks Management Process...................................................................................................... 35 E.1 Mitigation Measures for Facilities Renovation Activities ........................................................... 36 G. Project’s Labor Management Procedure ............................................................................................................ 36 F.1 Assessment of Key Potential Labor Risks .................................................................................... 38 F.1.1 Project Activities and Key Labor Risks..................................................................................... 38 F.1.2 Overview of the Labor Legislation: Terms and Conditions ..................................................... 39 F.1.3 Overview of the Labor Legislation: Occupational Health and Safety ..................................... 40 F.2 Responsible Staff......................................................................................................................... 40 F.2.1 Occupational, Health and Safety............................................................................................. 41 F.2.2 Policies and Procedures .......................................................................................................... 42 F.2.3 Age of Employment................................................................................................................. 43 F.2.4 Terms and Conditions and equal opportunities ..................................................................... 43 F.3 Grievance Mechanism ................................................................................................................ 43 F.3.1 Communications ..................................................................................................................... 43 F.3.2 Process .................................................................................................................................... 43 F.3.3 Contractor Management ........................................................................................................ 45 F.3.4 Gender Based violence prevention ......................................................................................... 45 H. Implementation arrangements of the Plan for Inclusive Service Delivery .......................................... 46 I. Annex ................................................................................................................................................................................ 48 2 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.1 Cambodia Population 2019......................................................................................................... 48 H.2 Health Students........................................................................................................................... 49 H.2.1 UHS Student Data ............................................................................................................... 49 H.2.2 Battambang RTC Student Data ........................................................................................... 50 H.2.3 Stung Treng RTC Student Data ............................................................................................ 50 H.2.4 Kampot RTC Student Data................................................................................................... 51 H.2.4 Kampong Cham RTC Student Data...................................................................................... 52 H.3 Public Health Workforce ............................................................................................................. 53 H.3.1 Health Workers by Gender ................................................................................................. 53 H.3.2 Health Workers by Age Bracket .......................................................................................... 56 H.4 FGD UHS ...................................................................................................................................... 60 H.5 FGD Stung Treng RTC .................................................................................................................. 65 H.6 FGD Khmer-Soviet Friendship Hospital ....................................................................................... 71 H.7 FGD PPCIL (PWD) ........................................................................................................................ 74 H.8 FGD MRI (LGBT)........................................................................................................................... 76 H.9 Environmental Codes of Practices (ECOP) ................................................................................. 78 H.10 Environmental risk screening checklist ....................................................................................... 81 H. 11 Outline of Sample ESMP ................................................................................................................ 84 Figures Figure 1: Location Map ............................................................................................................................... 16 Tables: Table 1: Stakeholders and Beneficiaries ..................................................................................................... 12 Table 2: ESF Standards ................................................................................................................................ 15 Table 3: Medical Students by Gender ......................................................................................................... 19 Table 4: Medical Students by Ethnicity ....................................................................................................... 20 Table 5: Medical Students versus Population ............................................................................................. 21 Table 6: Public Health Workforce by Gender ............................................................................................. 23 Table 7: Public Health Workforce by Age Bracket ...................................................................................... 24 Table 8: Public Health Workforce by Ethnicity ........................................................................................... 24 Table 9: Number of Public Health Workers versus Population .................................................................. 25 Table 10: Health Sector Curricula ............................................................................................................... 27 Table 12: Health care waste characteristics and hazards profile ............................................................... 31 Table 13: Proposed project workforce ....................................................................................................... 38 Table 14: Potential labor Risks related to the proposed project activities................................................. 39 Table 15: Grievance Redress Mechanism ................................................................................................... 41 Table 11: Health Sector Curricula ............................................................................................................... 46 3 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery LIST OF ABBREVIATIONS BTB Battambang province DHR Department of Human Resource DHS Department of Hospital Services EQHA Enhancing Quality of Health Care Activity ESCOP Environmental and Social Code of Practice ESCP Environment and Social Commitment Plan ESF Environment and Social Framework ESS Environment and Social Standards GBV Gender Based Violence GRM Grievance Redress Mechanism HC Health Center HCW Health Care Waste H-EQIP Health Equity and Quality Improvement Project IP Indigenous People Group (Ethnic Minority) KfW German Development Bank KPC Kampong Cham Province KPT Kampot Province LGBT Lesbian Gay Bi-sexual Transgender MoH Ministry of Health MRI Micro Rainbow International Foundation OD Operational District PHD Provincial Department of Health PIU Project Implementing Unit PMD Department of Preventive Medicine PMT Project Management Team PPCIL Phnom Penh Center for Independent Living PWD Person/s with Disability RGC Royal Government of Cambodia RH Referral Hospital RTC Regional Training Center SEP Stakeholder Engagement Plan SOGIE Sexual Orientation on Gender Identity and Expression STR Stung Treng Province UHS University Health Sciences WBG World Bank Group WHO World Health Organization 4 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Executive Summary This “Human Resource Development Readiness Assessment and Plan for Inclusive Delivery” (HRDRAP) is one of the Environmental and Social Framework (ESF) tools prepared, consulted and disclosed by the Ministry of Health (MoH) of the Kingdom of Cambodia for the “Pre-Service Training for Health Workers” in Cambodia. This project is expected to be financed by the World Bank. The main objective of this HRDRAP is to assess and propose specific recommendations for: a) promoting the enrollment and inclusion of disadvantaged groups as medical students in Cambodia, and b) imbedding social inclusion and environmental sustainability aspects in the project activities, in line with WB’s ESF standards. The proposed project focus on the primary health care students which include medical doctors, nursing and midwifery. The students’ data are taken from the government health schools which include UHS, Battambang RTC, Kampot RTC, Kampong Cham RTC and Stung Treng RTC. The data collected cover the school year 2018-2019. The data for Public Health Workers used by this assessment was taken from the five major public hospitals at Phnom Penh, also from the provincial hospitals, referral hospitals and commune health centers from 24 provinces of Cambodia. Data collected covers the year 2019 and data collection was facilitated through the Provincial Health Departments and supplemented by the Personnel Department of MoH. The proposed actions for health curricula and ESF inclusion are derived from the focus group discussions (FGDs) with health students, faculty teaching staff and decision makers of UHS and Stung Treng RTC, also from FGDs with medical staff (doctors, nurses and midwives) and management team of Khmer- Soviet Friendship Hospital, PPCIL (PWD sector) and Micro Rainbow International (LGBT sector). A consultation meeting with the project stakeholders on the initial draft of HRDRAP provided additional input and refinement of the proposed actions and recommendations. Assessment results: 1. Inclusion of Disadvantaged Groups Primary Health Care Students in Cambodia. Year 2019 Ethnic Minority Medical Number of Women Students PWD Students Students Course Student Number Percent Number Percent Number Percent Doctor 2,812 1,056 38% 0 0% No data Nursing 1,998 1,178 59% 9 0.45% No data Midwifery 1,453 1,453 100% 10 0.69% No data Total 6,263 3,687 59% 19 0.30% Source: Own elaboration Overall, the majority of the current health students in Cambodia are women, however there is gender imbalance in the doctor and the midwifery students. Doctor students has only about a third women and midwifery has all women students. 5 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Based on the collected data, there is a very low number of students from ethnic minority groups (IP) and they are mostly concentrated at Stung Treng RTC. The four other medical schools surveyed were not able to give the data on ethnicity. All the medical schools surveyed did not provide the data of students with disability, however, it was observed during the orientation of “National Exit Exam Passers” held at MoH in October 2019, that at least two nursing student passers were PWD. On the other hand, the data for Public Health Workers were collected from five of the major public hospitals at Phnom Penh, Provincial Hospitals, Referral hospitals and Commune Health Centers from 24 provinces of Cambodia. Public Health Workforce in Cambodia. Year 2019 Ethnic Age Bracket Medical Number of Women Minority/Cham Professionals Workforce Number Percent Number Percent 20-30 30-40 40-50 50-60 Doctor 2,141 415 19% 1 0.05% 14% 40% 30% 16% Nursing 8,176 2,855 35% 51 0.6% 33% 26% 23% 18% Midwifery 5,963 5,963 99% 22 0.4% 51% 24% 15% 10% Total 16,280 3,687 59% 74 0.5% 37% 27% 21% 15% Source: Own elaboration Doctors are mainly working in the hospitals with high concentration among the major public hospitals at Phnom Penh (average of 144 Doctors/hospital). It is relevant to highlight that only a limited number of Doctors work in the rural health centers (160 doctors among the 1,220 health centers). More than half of public primary health workers of Cambodia are women, however only less than a fifth are women doctors, a third are women nurses and midwives are almost all women. Based on official data coming from Ministry of Planning (Yr 2019), there are about 24 different types of IP in Cambodia, totaling approximately 200,216 people or about 1.2% of Cambodia’s total population of 16.5 million. However, this assessment reports that public health workers from ethnic minorities are minimal comprising only a half of one percent of the total workforce. More than a third of all public health workers are young of ages 20-30, the number decreases as the age bracket goes up. There is however only 14 percent of young doctors while more than half of midwives are young (age bracket 20-30). 2. Inclusion of Environment and Social topics in Health Curricula Current pre-service education has some courses on infection control which are partially relevant to occupational health and safety, and hazardous waste management in year one and two. Those courses are in line with National Guidelines for Infection Prevention and Control for Healthcare Facilities (2017). The safeguard trainings for health workers conducted by MoH through the Department of Preventive Medicine (PMD), has limited contents in relation to the environment and social risk management. Practices and management procedures which are in line with the National Guidelines for Infection 6 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Prevention and Control for Healthcare Facilities (2017) are integrated as part of training courses and the guidelines of the laboratories. However, it is generally focused or has an emphasis on the hospital context. Application of appropriate personal protection equipment (PPEs), segregation of wastes, and sterilizing of wastes and glassware including autoclaving methods are being practiced. The analysis of the existing curricula shows that there are not in the country cultural competence training for students at medical schools, focusing on skills and knowledge that values diversity, understand and respond in a culturally-appropriate manner to social diversity: gender, ethnic minorities, disabled people, SOGIE, etc. There is also a lack of content related to topics like how to prevent gender- based violence and work with survivors, work with very vulnerable social groups (street children, impoverished elderly, etc.). 3. Proposed actions for Health curricula and ESF inclusion. On Health Curricula:  Include in the behavioral science subject, topics on “social inclusion and environmental sustainability” and/or soft skills courses (behavioral science courses) for medical students for having the right attitude in dealing and treatment of the vulnerable people group;  Promote public awareness raising activities among medical students for better understanding and responding (in a culturally-appropriate manner) on ethnic minorities, PWD and SOGIE- related elements so that future health workers won’t discriminate PWD, LGBT patients. (details on the process ad how to carry it out will be further discussed with the concerned group);  Include in the medical outreach program, visits to PWD homes/communities, interact and hear from PWDs, see their situation.  Include in the curricula or imbed in the subject “Organizational Structure and System of MoH, its departments, health institutions from national, provincial, district and commune level, in order to help new medical professionals understand the system and know how and where to refer patients. On ESF Inclusion:  Promote actions to increase the number of women enrollees for doctor students like providing equal number of quota for male and female passing the National Entrance Exam or at least increase the quota for women entering the doctor course at UHS;  Provide equal access to opportunity for female doctors in the government hospitals. MoH to give priority to female doctors for future hiring until the gender balance among the government doctors is reached, or increase the number of women doctors by at least 35 percent from the current 19 percent in government health facilities by the end of the project period;  Provide special support to actively promote the enrolment of disadvantaged groups (ethnic minorities, PWD, women). This is to ensure that the disadvantaged groups are provided the opportunity to enroll in medical course and are not left out. The component of the support provided to students from the disadvantage groups shall be “tailored fit” to their need, i.e. responding to their physical, psychological and cultural circumstances; 7 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery  Promote Stung Treng RTC as a focal center in the country for health professional’s education with ethnic minorities through: o Information dissemination among high schools at the provinces with many ethnic minorities about Stung Treng RTC program and medical courses offered and to encourage the ethnic minorities’ students to enroll; o Developing specific training materials and training activities to reach better and work with ethnic minorities in Cambodia, similar to other centers in countries like Vietnam. Promoting better understanding and responding in a culturally-appropriate manner to the needs of the patients with an ethnic background. On improving health and safety of health workers:  Health facilities to follow the healthcare waste management process including: sorting, handling, storage and final disposal of solid HCW outlined in good international practices and relevant guidelines and regulations including National Guideline on Health Care Waste Management, Infection Prevention and Control Guidelines for Health Care Facilities, etc;  Improve and strengthen the public participation and Grievance Redress Mechanism among project implementing units, making the GRM accessible and responsive, making the workplace safe place for all, especially or vulnerable group such as women and children. On improving the documentation and record keeping of HTIs and PIUs:  Health Training Institutions (UHS and RTCs) to include in their record, documentation of student, faculty and staff coming from ethnic minorities, PWDs, LGBTs  Project implementing units (MoH Departments, PHDs, ODs, Hospitals, Health Centers, Professional Councils, and National Exam Committee) to include in their documentation, students and personnel coming from the ethnic minorities, PWDs, LGBTs.  National Entrance Examination and National Exit Examination to include in the documentation of applicants and passers, the number of women, ethnic minorities, PWDs.  For baseline data on number of PWDs and ethnic minorities involved the health education and public health service, a follow up survey should be conducted at the start of project implementation. 8 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery A. Introduction and Background The Royal Government of Cambodia (RGC), through the Ministry of Health (MoH) and with financial assistance from the World Bank Group (WBG) is proposing the “Pre-Service Training for Health Workers” project. The project’s goal is to improve the quality of education for health professionals entering the workforce in Cambodia. The project aims to strengthen the quality of education for health professionals will be through introducing competency-based education (CBE). CBE emphasizes skill-building following the acquisition of accurate, foundational knowledge about a subject. Traditional knowledge-based education alone tends to focus on what the learner is taught and less on whether learners can use learning to solve problems, perform procedures, communicate effectively, or make good clinical decisions. It targets two priority areas. Component 1 strengthens competency-based teaching and learning capacity in selected health schools. Component 2 seeks to improve the governance of health professionals’ education in Cambodia. MoH agreed to apply the new World Bank’s Environmental and Social Framework (which came into effect in October 2018) for the proposed project as part of an appraisal tool. The following two ESF instruments were prepared, consulted and disclosed prior appraisal stage (February 2020):  Human Resource Development Readiness Assessment and Plan for inclusive Service Delivery (HRDPAP); and  The project’s Stakeholder Engagement Plan (SEP). This HRDRAP for inclusive service delivery is one of ESF tools needed, in order to provide the practical input for environmental sustainability and social inclusion component of the proposed project. A.1 Objectives The main objectives of this Human Resource Development Readiness Assessment and Plan for Inclusive Service Delivery (HRDRAP) is to review, assess, and propose recommendations for: (a) Promoting the enrollment and inclusion of disadvantaged groups as students in health schools and medical training institutions, and encourage their joining the medical workforce, (b) Embedding social inclusion and environmental sustainability aspects in the project activities, in line with WB’s ESF standards. A.2 Project Description The proposed project’s goal is to improve the health of the Cambodian people. To achieve this transformational change, it is aimed to create a new foundation for the training of a competent health care workforce. The project will address the root causes of the inadequacies of the present system and tackle institutional and systemic barriers to successful reform. It will have a lasting impact on the 9 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery educational system, as well as a positive effect on generations to come from doctors, nurses, midwives, pharmacists, and dentists. Project objectives are to transform the outdated pre-service curriculum to one that is competency-based, train core faculty in up-to-date methods of teaching; add new curriculum in primary care, and define new structural frameworks for student assessment and program quality assurance. Major systemic and institutional barriers identified as outdated regulation of health education, lack of basic standards for training programs, and ineffective coordination of training institutions with hospitals and health centers will be addressed. Considering the broad sweep of change required, and the many years of training of doctors (7 years) and other health care workers, the true impact of this project will not be realized for a decade or more. The project’s ultimate goal is to build a strong foundation and institutional framework that will set the stage for continuous improvement far into the future. A.3 Brief relevant country, sectoral and institutional context A.3.1 Country Context Cambodia has experienced remarkable political and economic transition over the past four decades. The country has transformed itself from a conflict-torn country to a peaceful one. Since 1993, Cambodia has focused on maintaining peace and stability, rebuilding infrastructure and institutions, fostering economic growth, and improving living standards of the population. Over the past 20 years, the Cambodian economy has maintained a steady and robust growth rate at 8.0 percent per annum, ranking among the top seven fastest-growing economies in the world. Growth has largely been driven by the export of goods and services, which grew 15.3 percent a year during the same period. As a result, Cambodia’s per capita Gross National Income (GNI) increased almost fourfold, from US$320 in 1997 to US$1380 in 2018. Strong economic growth has also led to a dramatic decline in poverty. Poverty incidence under the national poverty line decreased from 47.8 percent in 2007 to 13.5 percent in 2017. However, Cambodia's economic growth is subject to emerging risks that may challenge this trajectory. In short to medium-term, risks have intensified due to uncertainty over preferential access to the European Union market under the Everything But Arms agreements as well as the ongoing slowdown in the Chinese economy and the potential adverse impact of Chinese foreign direct investment and tourism to Cambodia. A prolonged construction and property boom as well as the increase of credit provided to the construction and real estate sectors alongside rising indebtedness—where combined bank and microfinance credit now accounts for over 100 percent of GDP—also present a downside risk for Cambodia. In the longer term, emerging challenges include the erosion of external competitiveness within the context of rapidly rising wage rates. In addition, persistent gaps in human and physical capital constrain Cambodia’s ability to make a quicker shift towards more diversified and higher value-adding economic activities. For example, 12 percent of firms reported poorly educated workers as a constraint to doing business. There are acute constraints in human capital. Significant gaps in health, early childhood nutrition, education, and skills constrain the productivity of Cambodia’s future labor force. Cambodia’s score on a recently developed Human Capital Index (HCI) is 0.49, which is far lower than the regional average (0.65 in 2017), meaning that—based upon the status of health and education outcomes—children born today 10 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery will only be 49 percent as productive when they grow up as they could be, if they had enjoyed complete education, good health, and a well-nourished childhood. Lack of access to good quality health services, especially in remote and rural areas and high levels of stunting among children under-five are significant remaining challenges to human capital development. Quality of education remains a concern. When years of schooling are adjusted for quality of learning, there is a learning gap of 2.7 years among Cambodian school children. This has knock-on effects on the health workforce. Inconsistencies in secondary schooling have led to a low quality of applicants and intake of students to health professionals’ training programs. A.3.2 Sectoral and Institutional Context Cambodia’s health outcomes have improved steadily over the past 20 years, surpassing several better- off countries. Progress and innovation in health service delivery have contributed to the achievement of most health-related Millennium Development Goals (MDGs). Life expectancy has increased, while mortality rates for infants, children, and mothers have recorded a significant decline. Despite these improvements, maternal mortality remains unacceptably high, and neonatal mortality has not declined proportionately to total child mortality – still accounting for nearly half of all under-five deaths in 2014. At 32 percent in 2014, stunting prevalence in under-five children remains 'high' according to the World Health Organization public health thresholds. There have been significant improvements in key public health service coverage over the past two decades. These include a dramatic increase in facility-based deliveries (10 percent in 2000 to 83 percent in 2014), uptake of antenatal care (10 percent to 80 percent), and coverage of other maternal and child health services, such as polio-3 immunization rates (45 percent in 2000 to 80 percent in 2014).1 Access to health care for the most vulnerable groups also improved between 2004 and 2014, with a two-fold increase in the proportion of care-seeking behavior at public health centers. By 2014, all populations had higher than 80 percent access rate to care regardless of the place of residence. However, gaps remain in access to care, and there are persistent and growing disparities in maternal, newborn, nutrition, and communicable disease outcomes. The country’s rural, remote, ethnic minorities, and socioeconomically challenged women and children remain disproportionately affected by poor health and nutritional status. The wealth gap in child mortality has remained unchanged since 2005 at roughly three times higher for poor and rural children compared to wealthy and urban. Household wealth is one of the strongest determinants of neonatal mortality, followed by dwelling in rural areas. The stunting prevalence in the poorest wealth quintile (42 percent) is more than double that in the richest (18 percent). Full immunization of children is at 61 percent in the poorest quintile compared to 90 percent in the wealthiest. Demand-side barriers for priority services and low community awareness must be addressed to achieve sustainable improvements in access. Distance and low community awareness have been fundamental barriers. 11 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery At the same time, Cambodia is facing demographic and epidemiological transitions that change the health needs of the population and the skills required to deliver health services. The burden of disease (BoD) has shifted away from one with a high prevalence of communicable diseases to a high prevalence of non-communicable diseases (NCDs). Between 1990 and 2016, communicable diseases (including vaccine-preventable diseases), maternal and neonatal disorders, and nutritional deficiencies declined from 64 percent to 34 percent of the BoD, with NCDs accounting for the majority (55 percent) in 2016. Simultaneously, from 2030, declining fertility is projected to yield rapid increases in the elderly population. This continues to have considerable implications on the health needs of the population and, correspondingly, the skills needed within the health workforce to deliver services that are appropriate to the needs. Health services in Cambodia are delivered through a vast network of public facilities organized by administrative level, but equally by private providers that have proliferated in the country over the past few decades. Provincial Health Departments (PHDs) are responsible for health service delivery. The PHD is responsible for supervising Operational Districts (ODs), including their OD offices, Referral Hospitals (RHs), Health Centers (HCs), and Health Posts (HPs).2 Cambodia’s Minimum Package of Activities (MPA) and a Comprehensive Package of Activities (CPA) outline clinical service delivery guidelines for facilities at each level though provider adherence and service availability are variable across geographies and by type of services within the same facility. A.4 Project stakeholders and beneficiaries Based on the project’s Stakeholder Engagement Plan (SEP), the key stakeholder's beneficiaries of this project are outlined in the table below. Key Stakeholders Implementing Agency Ministry of Health Top Decision Making Body Health Sector Steering Committee (HSSC) Top Management Level Project Director and Project Manager Team Leaders (3) For CBE, FMP and ES Safeguards Implementing Units  Public Health Training Institutions (HTI) o University of Health Sciences (UHS) o Regional Training Centres (RTCs)  Project Focal Points for CBE o Department of Human Resource (DHR) o Department of Hospital Services (DHS) o Department of Preventive Medicine (PMD)  Budget and Finance (DBF) Independent Bodies Independent Verification Agency (IVA) Payment Certification Agency (PCA) 12 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Professional Council for Nursing, Midwifery Other stakeholders and Medical Doctors Student and professor representatives Other Stakeholders Entities Implementing WHO, DFAT Australia, JICA, KfW, H-EQUIP, similar project/activities EQHA USAID, MOE, MOEYS Private Medical schools Private medical schools Public Hospitals, Health Centres Health Institutions Private Hospitals and clinics Groups representing women, disable NGOs people, ethnic minorities, LGBT Project Beneficiaries Poor women and children Ethnic People Vulnerable Groups Persons with Disability LGBT Group General Public Cambodian People Table 1: Stakeholders and Beneficiaries The key stakeholder of the proposed project is the Ministry of Health of Cambodia and its project implementing departments, including the implementing health schools. Other stakeholders with interest on the proposed projects are various development institutions with similar projects plus civil society and professional groups. 13 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery A.5 ESF standards applied for the project and summary of relevant national environmental and social laws The following Environmental and Social Standards (ESS) of the WB’s Environmental and Social Framework (ESF) are going to be applied to this project: Relevant ESF’s Rationale of relevance Related Cambodia ES Laws Standards ESS1. Environmental Sharing development benefits The EIA Sub-decree (1999) and EIA Guidelines and Social with disadvantaged and (2009) require project proponents to address Assessment and vulnerable groups (e.g., public health issues as part of their analysis of Management women, children, elderly, socio-economic risks and impacts. ethnic minorities, sexual and The 2008 Organic Law requires councils to gender identity (SOGI), consider the “needs of women, men, youth, disabled people, etc.) children and vulnerable groups, including poor people and ethnic people” and rejects “any bylaw which discriminates against an individual, or a specific group of persons, based on factors of race, religion, sex, age, color, nationality, nationality at birth or mental or physical disability." The 2009 Law on the Protection and the Promotion of the Rights of Persons with Disabilities further define the principle of non-discrimination of these persons. ESS2. Labor and Promote safety and health at The Labor Law, which dates back to 1997, Working Conditions work; equal opportunity in the remains the key document governing the workplace regulatory framework for labor in Cambodia. The 1997 Labor Law defines non- discrimination in employment and wages. It establishes a minimum wage level, which may vary among regions. It also establishes labor inspection and prohibits labor from paying off debts or compulsory purchases by workers from company stores. Working hours are limited to 8 hours per day, 6 days a week. A whole chapter in the Law is dedicated to health and safety in the workplace. National Guidelines for Infection Prevention and Control for Healthcare Facilities (2017) states basic guidelines to be followed 14 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery regarding the hygiene, health, and safety at the healthcare facilities. ESS3. Resource Avoid or minimize the Resource efficiency and pollution management Efficiency and generation of hazardous is addressed through the 1994 Law on Pollution waste, and ensure the Investment and 1996 Law on Environmental hazardous waste are managed Protection and Natural Resource Management properly (NRM), along with other sector-specific laws on preventing pollution from agriculture runoff, wastewater, solid and hazardous wastes, and air emissions ESS4. Community Prevent community exposure The EIA Sub-decree (1999) and EIA Guidelines Health and Safety to health and safety issues (2009) require project proponents to address and hazardous materials and public health issues as part of their analysis of promote gender-based socio-economic risks and impacts. violence prevention, an The 2008 Organic Law on Gender-Based improvement on the health Violence (GBV) relates to the prevention of and domestic violence within the family, and of safety conditions of the health human trafficking workers, and hazardous and clinical waste management ESS7. Indigenous Equitable access to project The guiding document to address ethnic Peoples benefits; benefits delivered in peoples' issues in Cambodia is the National a culturally appropriate Policy on the Development of Ethnic Peoples. manner The document, prepared to start in 1994 and formally issued in 2009, recognizes the need for specific policies for ethnic peoples’ communities. The 2008 Organic Law recognizes ethnic peoples’ vulnerability ESS10. Stakeholder Enhance stakeholder Cambodia’s regulations, which include the Engagement participation (faculty staff, Constitution, the EIA Sub-decree (1999), and students, patients); the 2001 and 2008 Organic Laws, broadly information disclosure; support public participation. Public disclosure grievance management; and grievance redress are less well covered by accountability laws and regulations. Table 2: ESF Standards 15 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery A.7 Project Location Figure 1: Location Map The “Pre-Service Training for Health Workers” project will be implemented by the Ministry of Health (MoH) through its implementing departments, the Department of Human Resource (DHR) which will oversee the overall implementation of the project, the Department of Budget and Finance (DBF), the Department of Preventive Medicine (PMD) which is in-charge with the Environment and Social Framework aspects of the project and, the Department of Hospital Services (DHS). This project is expected to be implemented nation-wide. The implementing units for pre-service training are the government medical schools lead by the University of Health Service (UHS) located at the capital city of Phnom Penh and the four Regional Training Centers (RTCs) covering a cluster of provinces in four regions, shown in the location map above. The Battambang Regional Training Center (pink region) covers the six northwestern provinces, Kampot RTC (green region) covers six southwestern provinces, Kampong Cham RTC (yellow region) covers seven provinces including the newly established province of Tboung Khmum and Stung Treng RTC which covers the five northeastern provinces (blue region) with large population of various ethnic minorities. 16 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery B. Assessment B.1 Focus Groups Discussions and Key Informants Interviews For the preparation of this HRDRAP, different focus groups and interviews with key informants were carried out in December 2019 by the ESF team from MoH as qualitative assessment. The following table illustrates the total numbers of participants and numbers of focus group discussions (FGD) conducted in Stung Treng and Phnon Penh. Focus Groups discussions # of Institution Location Sub-groups with: Participants Nursing Students (5 sub- 2 10 groups) Regional Training Center Midwifery Students 5 21 Stung Treng (RTC ) Teachers for Nursing 2 10 Teachers for Midwifery 2 10 Interview - RTC Director 1 Provincial Health Director and Department Stung Treng 1 6 Department (PHD) heads Referral Hospital Stung Treng Department Heads 1 8 Phnom Penh Center for Independent Living Phnom Penh People with Disability 1 6 (PPCIL) Medicine Students 2 10 Nursing Students 4 20 Midwifery Students 4 20 University for Health Combined Teachers 4 20 Phnom Penh Decision Makers (Vice Sciences (UHS) Rector and department 1 10 Heads) Interview with Student 1 Affair Dir. Micro Rainbow Phnom Penh LGBT Group 1 2 International Foundation Total Number of 155 Participants Table 3: Focus groups and interviews carried out for the preparation of the HRDRAP Based on the limited resources available for the preparation of this HDRAP, focus groups and interviews were only carried out in Phnom Penh and Stung Treng. The capital city was selected since most of the medical schools are located here. Stung Treng RTC was selected as well since it is a strategic health training school to reach out and provide health training to potential and deserving ethnic minority high school graduates. 17 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery In addition, five government medical schools were selected as a sample for the quantitative analysis of health students. Only courses for medical doctors, nursing and midwifery, are considered in this survey. Data forms were given out to the “sample” schools to collect data on the number of students enrolled for the school year 2018-2019, gender, ethnicity, students with a disability, students coming from the LGBT group. A consultation workshop carried out on January 27th, 2020, in Phnom Penh, in order to present and discuss with key stakeholders this project and plus draft versions of the ESF tools . For details, the consultation report has been attached as an annex of the propect’s Stakeholder Engagement Plan (SEP). Twenty people joined the meeting. As a summary, the main conclusions of the consultations were: On Health Curricula: - Include in the health curricula or health activities the awareness of medical students on PWD; - Awareness of health students on SOGIE to better understand LGBT community and medical practitioners provide health services with a sense of tolerance and acceptance and not to discriminate members of LGBT; - Recommend including in the curricula or imbed in the subject “organizational structure and system of MoH, its departments, and health institutions from the national, provincial, district, and commune levels. On Health Students Enrolment: - Enrolment quota for increasing female doctor students. At national entrance exam are determined by the decision-makers at MoH; - Enrolment of male midwifery students could be considered, but it may need more work and more time for the Khmer culture to accept or be comfortable with having male midwives; - No discrimination on enrolment among disadvantaged as long as they qualify with the required criteria. On Accreditation of health professional and clinics: - The Accreditation of health professionals is the same for both public and private health practitioners. They have to register with their respective professional council; - Accreditation of small clinics such as for hormone treatment is not yet regulated, and patients, primarily the LGBT, are at risk. The main issues raised at the consultation workshop have been considered at the project’s HDRAP and SEP. 18 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery B.2 Analysis of health student’s enrollment data by gender, ethnicity, age and other demographic parameters Based on the data collected for the preparation of this HDRAP, the following tables provide the summary results of the number of students (sample size for the analysis), gender, and ethnicity. Details are provided in the annexes. The number of students with disabilities and the students coming from LGBT are not documented in the school records. However, they were mentioned in the qualitative survey at the focus group discussions carried out for this assessment. B.2.1 Medical students by gender in Cambodia. Year 2019 Doctor of Medicine Nursing Midwifery TOTAL Name of Medical Femal School Male Female Total Male Female Total Female Total Male Total e UHS including TSMC 1,756 1,056 2,812 181 432 613 311 311 1,937 1,799 3,736 RTC Battambang 172 221 393 394 394 172 615 787 RTC Kampot 171 241 412 331 331 171 572 743 RTC Kampong Cham 218 240 458 352 352 218 592 810 RTC Stung Treng 78 44 122 65 65 78 109 187 Total 1,756 1,056 2,812 820 1,178 1,998 1,453 1,453 2,576 3,687 6,263 Percentage Female 38% 59% 100% 59% Source: Own elaboration Table 3: Medical Students by Gender The University of Health Sciences (UHS) operates in Phnom Penh, and it offers the courses for medical doctor, nursing, midwifery, dentistry, pharmacy, postgraduate degrees, and other related medical courses. All four regional training centers (RTC) offer courses for nursing and midwifery. The number of doctor students at UHS are coming from the eight-year course Diploma Degree in Medicine and from the four-year course in Specialized Doctor Diploma. Among all the 2,812 doctor students, only more than a third or 38 percent are women. For nursing students, the overall result shows that more than half of the students are women. Looking closely at the data, UHS has 70 percent, female nursing students. The other three RTCS have more than half female students but Stung Treng RTC has only a third or 36 percent women students for nursing. Midwifery students are mainly female: 100 percent of the enrolled students. All the medical schools are open to accepting the male students for midwifery, but no male students have so far enrolled for the course. The overall enrollment for the three identified medical courses has more women (59 percent). This is because of all women enrollment for the midwifery course. 19 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery B.2.2 Medical students by ethnicity in Cambodia. Year 2019 Doctor of Nursing Midwifery TOTAL Name of Medical Medicine School Ethnic Ethnic Ethnic Khmer Khmer Total Khmer Total Khmer Total Minority Minority Minority UHS 2,812 613 - 613 311 - 311 3,736 - 3,736 RTC Battambang 393 - 393 394 - 394 787 - 787 RTC Kampot 412 - 412 331 - 331 743 - 743 RTC Kampong 458 - 458 352 - 352 810 - 810 Cham RTC Stung Treng 113 9 122 55 10 65 168 19 187 Total 2,812 1,989 9 1,998 1,443 10 1,453 6,244 19 6,263 Percentage of 0% 0.45% 0.69% 0.30% ethnic minorities Source: Own elaboration Table 4: Medical Students by Ethnicity Based on official data coming from Ministry of Planning (Yr 2019), there are about 24 different types of IP in Cambodia, totaling approximately 200,216 people or about 1.2% of Cambodia’s total population of 16.5 million3. The majority of the ethnic minorities are in the provinces of Ratanakiri, Mondolkiri, Stung Treng and Kratie. In relation to the medical students, all the medical schools surveyed do not have the official data on the ethnicity of the students. Among all the schools surveyed, only Stung Treng RTC that has identified 19 students from the ethnic minority. The data is not from the school records but from the results of the focus group discussions carried out for this project with the students and teachers. They identify the ethnic minority student based on the name/s and the community the student/s come from. Looking closely at the Stung Treng RTC, the ethnic minority students account for 10 percent of the student population. However, based in the focus groups and interviews carried out for this project, 3 The official definition of Indigenous People/Ethnic Minority group done by the Government of Cambodia differs from the WB’s definition. For the WB, based on para 8 of ESS7, the term Indigenous People (IP) is used in a generic sense to refer exclusively to a distinct social and cultural group possessing the following characteristics in varying degrees: (a) Self-identification as members of a distinct indigenous social and cultural group and recognition of this identity by others; and (b) Collective attachment to geographically distinct habitats, ancestral territories, or areas of seasonal use or occupation, as well as to the natural resources in these areas; and (c) Customary cultural, economic, social, or political institutions that are distinct or separate from those of the mainstream society or culture; and (d) A distinct language or dialect, often different from the official language or languages of the country or region in which they reside. 20 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery some ethnic minority students prefer to do not self-identify as minority since they feel ashamed. Based on that fact, the proportion may be higher. There are Cham students4 at UHS, but the number was not determined during the survey. UHS has set up a prayer room for the Muslims inside the campus. There could be some ethnic minority students among the other schools surveyed. However, some ethnic minorities have been assimilated by the mainstream Khmer culture and identify themselves as Khmer, in the same manner as the Chinese and Vietnamese born and/or living in Cambodia for a long time who consider themselves Khmer. Some do not identify themselves as ethnic minorities to avoid social discrimination. B.2.3 Number of health students versus the population in Cambodia. SY 2018-2019 Medical Students Enrolled (SY 2018-2019) Ratio 1 Health Provinces Population RTC Region Medical student vs. Covered 2019 Nursing Midwifery Total Doctor population Battambang RTC 7 4,124,000 - 393 394 787 5,240 Kampot RTC 6 2,832,852 - 412 331 743 3,813 Kampong Cham RTC 6 5,125,848 - 458 352 810 6,328 Stung Treng RTC 5 1,076,418 - 122 65 187 5,756 Phnom Penh 1 2,129,371 2,812 613 311 3,736 570 TOTAL 25 15,288,489 2,812 1,998 1,453 6,263 2,441 Source: Own elaboration Table 5: Medical Students versus Population Overall, the ratio of medical students attending public medical school versus the national population is 1 for every 2,441 people. The region covered by Kampong Cham RTC has the highest population and has the highest ratio of 1 student for every 6,328 people. Stung Treng RTC covers the lowest number of population; however, the number of medical students is low; thus, the student ratio versus population is high at 5,756 people per 1 student. The capital city of Phnom Penh is the convergence place for the medical students primarily for the doctor students. These doctor students, however, come from various provinces and the resulting ratio of 570 people per student may not be reflective of the real condition.- Random interview with the five interns from Year 6 doctor students of UHS showed that out of 5 students four are from the provinces of Prey Veng, Pursat, Battambang and Kampong Cham, only one student is from Phnom Penh. Doctor students from the provinces would prefer to enroll at UHS and compete to enter the UHS program because of the scholarship top 10 percent of the National Entrance Exam are free of school fees. In addition, with the allowance from the government through MoH, the tuition fee is lower than 4 Cham group does not fulfill the four criteria stated in para 8 of ESS7 to be considered as an Indigenous People (IP) group for WB. 21 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery the private medical school. Additional incentives for students to enroll UHS are: the school is known as most of the doctors in the provinces graduated from UHS, prestige, all students enrolled at UHS are screened and passed the national entrance exam, international program for best students who study with international teachers, better chance to pass the National Exit Exam and better chance to get job from government health facilities. Stung Treng RTC has a declined enrollment according to the information reported by the school senior management. Nursing and midwifery course has become less attractive as a significant part of students get no job after they graduate, there is limited recruitment of government health workforce, and competition among nurses and midwives is high. Students from Stung Treng are at disadvantages in terms of access to opportunity in the cities, high demand of nursing, and midwifery graduates among private clinics, but the salary is low at $120/ month for 20-hours duty/day (below the minimum wage and exploitative). It has been reported that no strict enforcement for minimum wage standards among private clinics. B.3 Quantitative and qualitative analysis of the current public health workforce by gender, ethnicity, age and other demographic parameters The data for public health workers were collected in December 2019 for all the 24 provinces of Cambodia through the Provincial Health Departments (PHDs). The public health institution surveyed includes the provincial hospital at the provincial level, referral hospitals at the operational districts (OD), and rural health centers at the commune/Sangkat level. Similar data were also collected from the five major public hospitals in the capital city of Phnom Penh. Only data for doctors, nurses, and midwives were collected for this study. The data for public health workers for Phnom Penh is not yet exhaustive; only 5 out of 7 major hospitals provided the data, health centers and referral hospitals have also not provided the data. B.3.1 Public health workforce by gender in Cambodia. Year 2019 Public Doctors Nurses Midwives Total Workforce Units Hospitals Male Female Total Male Female Total Male Female Total Male Female Total Phnom Penh 5 556 146 702 509 654 1,163 - 185 185 1,065 985 2,050 Hospitals Provincial 24 574 128 702 810 600 1,410 - 705 705 1,384 1,433 2,817 Hospitals Referral 72 461 116 577 795 399 1,194 1 840 841 1,257 1,355 2,612 Hospitals Health 1,119 135 25 160 3,207 1,202 4,409 57 4,175 4,232 3,399 5,402 8,801 Centers Total 1,220 1,726 415 2,141 5,321 2,855 8,176 58 5,905 5,963 7,105 9,175 16,280 Percentage 19% 35% 99% 56% Female 22 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Source: Own elaboration based on data provided by Provincial Health Departments, MoH Personnel Department Table 6: Public Health Workforce by Gender Among the three government health professions surveyed, Nurses account for half of the total number. Midwives account for 37 percent and doctor's 13 percent. Doctors are mainly working in hospitals with high concentration among the major public hospitals at Phnom Penh (average of 144 Doctors/hospital). It is relevant to highlight that only a limited number of Doctors work in rural health centers (160 doctors among the 1,220 health centers). The ratio of female doctors working in public hospitals and health centers accounts for less than a fifth only. Female nurses, on the other hand, accounts for a third of the nurse workforce. Midwives are mostly women. While there are no male midwifery students, the health centers at Ratanakiri province employed male midwives. There is also one male midwife working at the referral hospital at Prey Veng province. These male midwives could be good examples to promote male enrollment for midwifery. During the discussions with the medical students and teachers at Stung Treng RTC for the preparation of this HRDRAP, they considered that men could be competent midwives as they are strong to assist and carry mothers giving birth, especially in times of emergency. The resulting ratio of women working in the government health facilities shows that there is a gender imbalance. Data shows that the male health workforce dominates the hospital at the national, provincial, and district levels, while female health workers primarily midwives dominate the health centers at the commune level. B.3.2 Public health workers by age bracket in Cambodia. Year 2019 Nurses Midwives Government Age Bracket Age Bracket Hospitals 20- 50- 20- 30- 50- 30-40 40-50 Total 40-50 Total 30 60 30 40 60 Phnom Penh 390 387 176 210 1,163 64 59 26 36 185 Hospitals Provincial Hospitals 378 302 368 362 1,410 261 124 174 146 705 Referral Hospitals 467 310 276 141 1,194 496 177 107 61 841 Health Centres 1,452 1,088 1,072 797 4,409 2,244 1,060 568 360 4,232 TOTAL 2,687 2,087 1,892 1,510 8,176 3,069 1,420 875 603 5,967 Percentage/bracket 33% 26% 23% 18% 100% 51% 24% 15% 10% 100% Doctors Total Medical Staff Age Bracket Age Bracket Provinces 20- 50- 20- 50- 30-40 40-50 Total 30-40 40-50 Total 30 60 30 60 Phnom Penh 13 298 222 169 702 467 744 424 415 2,050 Hospitals 23 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Provincial Hospitals 94 278 224 106 702 733 704 766 614 2,817 Referral Hospitals 165 239 132 41 577 1,128 726 515 243 2,612 Health Centres 32 47 57 24 160 3,728 2,195 1,697 1,181 8,801 TOTAL 304 862 635 340 2,141 6,060 4,369 3,402 2,453 16,280 Percentage 14% 40% 30% 16% 100% 37% 27% 21% 15% 100% Source: Own elaboration Table 7: Public Health Workforce by Age Bracket Among all the public health workforce, the number of younger staff (ages 20-30) account for more than a third of the whole workforce, and the number goes down as the age increases. The number of the senior workforce or those of reliable age is 15 percent. More than half of the midwives are young (ages 20-30), most of them (73 percent) work at the health centers in the rural areas. About 10 percent of the midwives are retriable (age 50-60). Only 14 percent of doctors are young (age bracket 20-30), this could be because doctors study 8 long years in the medical school. Two-fifths of the doctors are of middle age (30-40), these age bracket could have enough experience in medical practice, while 30 percent are adults (ages 40-50) they could already have substantial experience in medical practice. The retirable age doctors account to 16 percent. B.3.3 Health workforce by ethnicity in Cambodia. Year 2019 Doctors Nurses Midwives Total Medical Staff Public Hospitals Khme Ethnic Khme Ethnic Khme Ethnic Khme Ethnic Total Total Total Total r Minority r Minority r Minority r Minority Phnom Penh 1,16 702 - 702 1,163 - 185 - 185 2,050 - 2,050 Hospitals 3 1,41 Provincial Hospitals 701 1 702 1,407 3 704 1 705 2,812 5 2,817 0 1,19 Referral Hospitals 577 - 577 1,194 - 841 - 841 2,612 - 2,612 4 4,40 4,23 Health Centres 160 - 160 4,361 48 4,211 21 8,732 69 8,801 9 2 2,14 8,17 5,96 16,20 16,28 TOTAL 2,140 1 8,125 51 5,941 22 74 1 6 3 6 0 Percentage Ethnic 0.05% 0.6% 0.4% 0.5% Minorities Source: Own elaboration Table 8: Public Health Workforce by Ethnicity Like the medical schools, hospitals and health centers do not record the ethnicity of the staff, or if they do, most of the staff will put their ethnicity as Khmer, with the view that they are born and live in Cambodia, and therefore, they are Khmer. Discussion with teachers and students at Stung Treng RTC revealed that some people from the ethnic minority assimilate with Khmer culture and society and would identify themselves as Khmer to avoid social discrimination. The ethnic minorities column in Table 8 includes the ethnic minorities and the Cham people. 24 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Overall, there is a very minimal number of ethnic minorities among the public health workforce. It has been reported that there is only one doctor of Cham ethnicity working at the provincial hospital at Ratanakiri. B.3.4 Number of Public Health Workers versus Population in Cambodia. Year 2019 Public Health Workforce Ratio of Provinces Health Region Population Covered Doctor Nurses Midwives Total Workers vs. Population Battambang RTC 7 4,124,000 407 2,203 1,765 4,375 943 Kampot RTC 6 2,832,852 329 1,582 1,302 3,213 882 Kampong Cham 6 5,125,848 568 2,293 1,937 4,798 1,068 RTC Stung Treng RTC 5 1,076,418 135 935 774 1,844 584 Phnom Penh 1 2,129,371 702 1,163 185 2,050 1,039 TOTAL Cambodia 25 15,288,489 2,141 8,176 5,963 16,280 939 Source: Own elaboration. PHDs, Personnel Department of MoH, Population is taken from the 2019 National Census. Table 9: Number of Public Health Workers versus Population Overall, the ratio of the public health workforce with respect to the population of Cambodia is 1 health worker versus 939 people. Stung Treng RTC region has the lowest ratio. This region has a lesser population but is distributed in a large geographical area, and the proximity of the communities to the hospital and health centers are far. The remoteness of the communities needs more health workers to be able to respond to the health needs of the people in the communities. B.4 Analysis of current practices and the most relevant current health sector curricula from an environmental and social perspective. The following table shows the relevant current practices and training courses related to environmental and social perspectives. Relevant ESF’s Health School Curricula DHR/PMD Training Curricula Standards ESS1. Environmental  Not included in the medical  Environment and Social Safeguards and Social curricula, but all the health schools for the construction of new health Assessment and have the waste management centers Management system in place. Social assessment  Not included in the training curricula may be limited to the assessment courses on cultural competence of the patient's health training to understand and respond  There are not in the country to social diversity cultural competence training for  PMD is still developing the ES students at medical schools, assessment guidelines for the 25 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery focusing on skills and knowledge construction of new health centers that values diversity, understand and other MoH future construction and respond in a culturally- projects, the new WB Environment appropriate manner to social and Social Standards used for the diversity: gender, ethnic Pre-Service Training for Health minorities, disabled people, Workers could be the starting point SOGIE, etc. for this initiative.  Health and Hygiene environment (water and sanitation improvement initiatives)) ESS2. Labor and  Current pre-service education has  DHR provides the orientation Working Conditions some courses on infection control, seminar on 1997 Labor Law of which are quite relevant to Cambodia and its implementing occupational health and safety, guidelines for the human resource and hazardous waste management officers of all offices under MoH, in year one and two. Those including the RTCs ESS3. Resource courses are in line with National  Training course on Arsenicosis Efficiency and Guidelines for Infection Prevention Management Pollution and Control for Healthcare ESS4. Community Facilities (2017).  Training course on Occupational Health and Safety  The practice of utilizing Health appropriate personal protection  Public Disaster Management in equipment (PPE) for laboratory Disaster for Health Center classes and clinical practice. Not  PMD provides a seminar for the discussed in class lectures but PHDs on the Disaster and risk students develop the habit with management for natural disaster practical application (learning by (flooding, hurricane) and epidemic doing and applying the PPE) diseases such as the African Swine  Lack of content related to topics Flu (ASF) like how to prevent gender-based violence and work with survivors, work with very vulnerable social groups (street children, impoverished elderly, etc.). ESS7. Indigenous  There are not in the country  Not included in the training curricula Peoples cultural competence training for courses on cultural competence students at medical schools, training to promote better focusing on skills and knowledge understanding and responding in a that values diversity, understand culturally-appropriate manner to the and respond in a culturally- needs of the patients with an ethnic appropriate manner to the special background 26 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery needs of ethnic minorities. ESS10. Stakeholder  Not included in the teaching  No training on Stakeholder Engagement curricula but included in the Engagement but is being practiced in school system the participation of many of the MoH projects. students and teachers in the school’s strategic planning. There is also available for students a grievance system Table 10: Relevant current health sector curricula from an environmental and social perspective From the site visits of some laboratories and facilities under UHS during the preparation of HRDRAP, it was observed that clinical and hazardous waste management and occupational health and safety are considered as important. Appropriate practices and management procedures, which are in line with the National Guidelines for Infection Prevention and Control for Healthcare Facilities (2017), are integrated as part of training courses and the guidelines of the laboratories. However, it is generally focused or has an emphasis on the hospital context. Application of appropriate personal protection equipment (PPEs), segregation of wastes, and sterilizing of wastes and glassware, including autoclaving methods, are currently practiced. For the clinical and hazardous wastes, UHS has contracted with the Red Cross for collection and final disposal of sterilized wastes while the UHS campus for nursing and midwifery sent them to the incinerator of the nearby hospital. To further improve on the practices of the clinical and hazardous waste management, pollution prevention, and improvement of the occupational health and safety, appropriate measures are included as part of HRDRAP of the project. However, regardless of the length of training, education, and practices on environment, health and safety remain limited in the regional training centers (RTCs). C. Plan for Inclusive Service Delivery Pre-service training may be specific to individual professional disciplines such as medicine, nursing, and midwifery. Still, concepts on environmental sustainability and social health and safety should be introduced early in the curriculum for all. Under Component 1, which is strengthening competency- based teaching and learning capacity of the project, which will support the development and delivery of competency-based training programs in health professions, the following are the recommendations for project implementation. C.1 Recommendation to promote the enrollment and inclusion of disadvantaged groups  Promote actions to increase the number of women enrollees for doctor students like providing equal number of quota for male and female passing the National Entrance Exam or at least increase the quota for women entering the doctor course at UHS;  Provide equal access to opportunity for female doctors in the government hospitals. MoH to give priority to female doctors for future hiring until the gender balance among the government 27 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery doctors is reached, or increase the number of women doctors by at least 35 percent from the current 19 percent in government health facilities by the end of the project period;  Provide special support to actively promote the enrolment of disadvantaged groups (ethnic minorities, PWD, women). This is to ensure that the disadvantaged groups are provided the opportunity to enroll in medical course and are not left out. The component of the support provided to students from the disadvantage groups shall be “tailored fit” to their need, i.e. responding to their physical, psychological and cultural circumstances. C.2 Recommendations to embedding social inclusion and environmental sustainability in the health sector in Cambodia.  Include in the Health Curricula the behavioral science subject, topics on “social inclusion and environmental sustainability” and/or soft skills courses (behavioral science courses) for medical students for having the right attitude in dealing and treatment of the vulnerable people group;  Soft skills course (behavioral science course) for medical students to have the right attitude in dealing and treatment of the vulnerable people group;  Promote public awareness raising activities among medical students for better understanding and responding (in a culturally-appropriate manner) on ethnic minorities, PWD and SOGIE- related elements so that future health workers won’t discriminate PWD, LGBT patients;  Include in the medical outreach program, visits to PWD homes/communities, interact and hear from PWDs, see their situation;  Health facilities to follow the healthcare waste management process including sorting, handling, storage and final disposal of solid HCW outlined in good international practices and relevant guidelines and regulations including National Guideline on Health Care Waste Management, Infection Prevention and Control Guidelines for Health Care Facilities, etc;  Develop/improve standardized policies and frameworks on (i) occupational health and safety environment, (ii) hazardous and clinical waste management, pollution prevention, and resource efficiency, and (iii) community health and safety in line with relevant good practices of WHO standards such as Safe management of wastes from health-care activities and Prevention of hospital-acquired infections , and applicable national guidelines;  Improve and strengthen the public participation and Grievance Redress Mechanism among project implementing units, making the GRM accessible and responsive, making the workplace safe place for all, especially or vulnerable group such as women and children;  Review the existing curriculums related to the above-mentioned items;  Revise or developing appropriate courses consistent with the standardized frameworks and integrating those into pre-service curricula;  Ensure that relevant, reliable facilities and agencies are in place by the National regulations and World Bank’s Environment Safeguards Standards. For instance, having incinerators and contracting qualified hazardous waste handling agencies are in place to accept the final hazardous waste disposal;. 28 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery C.2.1 Promoting the equitable access to project benefits to Ethnic Peoples and other socially vulnerable groups  Promote Stung Treng RTC as a focal center in the country for health professional’s education with ethnic minorities through: o Information dissemination among high schools at the provinces with many ethnic minorities about Stung Treng RTC program and medical courses offered and to encourage the ethnic minorities’ students to enroll; o Developing specific training materials and training activities to reach better and work with ethnic minorities in Cambodia, similar to other centers in countries like Vietnam. Promoting better understanding and responding in a culturally-appropriate manner to the needs of the patients with an ethnic background.  Support activities for ethnic minority medical students, to include support for “remedial or tutorial classes in order to improve their academic competencies at the time of entry to the RTC;  Right for the students and patients to express their sexual preference, Medical Forms on Gender (Male, Female, Others);  Build health facilities that are PWD friendly, with wheelchair ramp and rails, reachable counters, provide “PWD” signs to help easy mobility for PWDs. . D. Occupational and Community Health and Safety According to WHO5, health workers working at health care facilities and laboratories are exposed to a complex variety of health and safety hazards every day, including:  biological hazards, such as TB, Hepatitis, HIV/AIDS, SARS;  chemical hazards, such as glutaraldehyde, ethylene oxide;  physical hazards, such as noise, radiation, slips trips and falls;  ergonomic hazards, such as heavy lifting;  psychosocial hazards, such as shift work, violence, and stress;  fire and explosion hazards, such as using oxygen, alcohol sanitizing gels; and  electrical hazards, such as frayed electrical cords. Due to these, health workers need protection from these workplace hazards when they enter their workplace. Unsafe working conditions contribute to health worker attrition in many countries due to work-related illness and injury and the resulting fear of health workers of occupational infection, including from HIV and Tuberculosis. Infections caused by accidental blood exposure are generally preventable if health workers use appropriate protective wear such as gloves and eye protection, spills of body fluids are cleaned up promptly, and biomedical waste is disposed of correctly. Protecting the occupational health of health workers is critical to having an adequate workforce of trained and healthy health personnel. 5 https://www.who.int/occupational_health/topics/hcworkers/en/ 29 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Health and safety issues of the community, including patients and visitors related to the health care facilities and laboratories, are similar to those issues exposed to the health care workers. Thus, it is important to recognize shared health and safety risks between health care staff and patients and identify opportunities to integrate patient and worker safety activities across departments and programs. Without basic health and safety guidelines and the ability to implement them, health workers, patients, and visitors to health care facilities and laboratories are vulnerable to accidents and exposure to infectious diseases. Following are some recommended steps to be adopted for the safe environment for healthcare-related facilities:  Develop the capacity and policy tools  Adopt appropriate measures for a safe work environment  Initiate and reinforce a safe work environment  Setting up regularly auditing system  Developing appropriate curricula and educational resources in line with relevant good practices of WHO standards such as Safe management of wastes from health-care activities 6 and Prevention of hospital-acquired infections7, and applicable national guidelines to be integrated into the pre-service training to ensure that all health workers are properly trained for a safe environment Gender focus: the health services sector is a major employer of women. Special emphasis should be placed on the particular challenges faced by them in the health care working environment. The program, education, and training initiatives should ensure that both men and women understand their rights within the workplace and outside it. E. Hazardous and clinical waste management Health care waste (HCW) includes all wastes generated in the delivery of health care services. WHO (1999a) estimates that 75-90% of the waste produced by the health care facilities originates from non- risk or general sources (e.g., janitorial, kitchens, administration) and is comparable to domestic waste. The remaining 10-25% of HCW are classified as hazardous and poses a variety of potential health risks. Categories of health care waste, as defined in WHO (1999a), which are considered of most concern in Cambodian health care facilities, are summarized in Table 1. Exposure to hazardous healthcare waste can result in disease or injury. All individuals exposed to hazardous healthcare waste are potentially at risk, including those within healthcare establishments and those outside these sources. The main groups at risk are health staff (doctors, nurses, technicians, auxiliary and maintenance staff, janitors); patients, their relatives and visitors; workers at waste disposal sites including scavengers; and nearby communities. 6 Safe management of wastes from health-care activities / edited by Y. Chartier et al. – 2nd ed. WHO 2014 7 Prevention of hospital-acquired infections. A practical guide – 2nd edition. WHO 2002 30 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Pathogens in infectious waste may enter the human body by a number of routes: through a puncture, abrasion, or cut in the skin; through the mucous membranes; by inhalation; or by ingestion. Sharps may not only cause cuts and punctures but also infect wounds if they are contaminated with pathogens. Sharp injuries are the most popular accidents in health facilities. Sharp injury is the main transmission way of several dangerous infectious diseases. Unless healthcare wastes are managed strictly, they easily cause pollution of the environment and health impacts. Classification Characteristics/Associated Hazards Infectious Comprises waste that is suspected of containing pathogens including laboratory cultures, surgery and autopsy waste from patients with infectious diseases, bodily wastes from patients in infectious disease wards, and miscellaneous waste such as disposable gloves, tubing, and towels generated during the treatment of infectious patients). Pathogens from infectious waste may enter the human body through puncture of skin cuts, mucous membranes, inhalation or ingestion. Pathological Consists of tissue, organs, body parts, blood and body fluids. Pathological wastes are considered a sub-category of infectious wastes and pose the same hazards. Sharps Describes items that could cause cuts or puncture wounds, including hypodermic needles, scalpel, and broken glass. Because sharps can not only cause cuts and punctures but also infect these wounds if they are contaminated with pathogens, this sub-category of infectious wastes is considered very hazardous. Chemical Consists of discarded solid, liquid and gaseous chemicals with toxic, corrosive, flammable, reactive, and genotoxic properties. Chemicals most commonly used in HCF include formaldehyde, photographic chemicals, heavy metals such as mercury from broken clinical equipment, solvents, organic and inorganic chemicals, and expired, used or spilt pharmaceuticals. Hazards from chemical and pharmaceutical waste include intoxication as a result of acute or chronic exposure from dermal contact, inhalation or ingestion and contact burns from corrosive or reactive chemicals. Radioactive Includes solid, liquid and gaseous materials contaminated with radio nuclides; produced as a result of procedures such as in-vitro analysis of body tissue and fluid, in-vivo organ imaging and various investigative and therapeutic practices. Because radioactive waste is genotoxic, health workers in handling active sources and contaminated surfaces must take extreme care. Table 11: Health care waste characteristics and hazards profile 31 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery To address clinical and hazardous waste issues, several regulations and guidelines have been prepared by the MOH, including a national guideline on healthcare wastes management for use by health care facilities. The guideline is intended to supplement WHO's comprehensive health care waste management guidelines (WHO, 2000; 1999a) and focus on practical aspects of safe hospital waste management, including waste minimization, collection, segregation, storage, transportation, and disposal. Additional guidelines on injection safety have also been developed by the MOH to provide specific guidance to health care facilities on the distribution, use, collection and safe destruction of disposable syringes and safety boxes. A system has been established to safely collect sharp wastes from health facilities for incineration in the designated high temperature incinerators (Sicsim). However, weak management at the health facility level hinders the implementation of the guidelines for health care waste management, including proper waste segregation and storage and maintenance of incinerators. Recognizing that sanitary or engineered landfills are unlikely to be available in remote locations, another option is the safe burial of health care waste on health care facility and training center premises. On-site disposal represents an acceptable disposal option only if certain requirements are met as follows: - Restricted access to disposal site by authorized personnel only - The lining of burial site with a material of low permeability such as clay to prevent groundwater pollution - Limit use to hazardous materials that cannot safely be incinerated to maximize the lifetime of a landfill. Notwithstanding the availability of health care waste management guidelines, it is apparent that there is considerable scope for adopting more rigorous health care waste management practices in health centers and training centers. D.1 Health Care Waste Management Plan Health facilities will follow a healthcare waste management process, including sorting, handling, storage, and final disposal of solid HCW outlined in good international practices and relevant guidelines and regulations, including the National Guideline on Health Care Waste Management, Infection Prevention and Control Guidelines for Health Care Facilities, etc. The following section briefly describes guidance for health care wastes segregation, handling, storage, and final disposal indicated in the MOH guidelines and good international practices. D.1.1 Waste Segregation Segregation of health care waste is intended to ensure that wastes are properly identified and separated and that different waste streams are handled and disposed of correctly. It typically involves sorting different wastes into color-coded plastic bags or containers at the source. Recommended handling and disposal practices for different categories of health care waste will vary according to the resources 32 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery available to health care facilities. Examples of WHO (1999a) recommended health care waste handling practices appropriate for health care facilities that apply minimal waste management programs are:  General health care waste (in black bags or containers) should join the domestic refuse stream for disposal.  Sharps should be collected together into puncture-proof yellow safety boxes and held for high- temperature incineration. Encapsulation and disposal to a secure landfill is a suitable alternative for sharps.  Highly infectious waste should be sterilized by autoclaving as soon as possible. For other infectious waste, disinfection is sufficient to reduce microbial content. Treated infectious waste should then be deposited in yellow bags and containers marked with the international infectious substance symbol. Incineration is the preferred method for disposal of infectious waste, although landfilling is also appropriate. Blood should be disinfected before discharge to the sewer system or wastewater treatment plant, if available, or maybe incinerated.  Large quantities of chemical wastes should be packed in chemical-resistant containers and sent to specialized treatment facilities. Small quantities of chemical waste can be held in leak-proof containers and enter the infectious waste stream for incineration or landfilling. It is noted that incineration at low temperatures may be insufficient to destroy thermally-resistant pharmaceuticals. Small quantities of chemical waste or drug waste can be collected together with the infectious waste per exception in the Infection prevention and control guideline provides.  Waste containing high heavy metal concentrations should be collected separately in brown containers and sent to specialized treatment facilities.  Low-level radioactive waste should be collected to yellow bags or containers for incineration. High-level radioactive waste must be sent to specialized disposal facilities. It is important to train all healthcare workers, including physicians, to keep contaminated and non- contaminated waste separate. Only a small percentage of the waste generated by a healthcare facility is clinical and hazardous waste that must be specially handled to reduce the risk of infections or injury. Segregation of the waste at the point where it is generated can conserve resources by greatly reducing the amount of waste that needs special handling. Poor separation of waste at the point where it is generated leads to large amounts of waste that must be handled especially – which can overwhelm the disposal system, lead to improper disposal of clinical and hazardous waste, and put everyone at risk. D.1.2 Waste Handling Staff and students should handle medical and hazardous waste as little as possible before storage and disposal. The more waste is handled, the greater the chance for accidents. Special care must be taken when handling used needles and other sharps, which pose the greatest risk of accidental injury and infection. Emptying waste containers 33 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Waste containers that are too full also present greater opportunities for accidents. Waste should be removed before the containers become completely full. Dispose of sharps containers when they are 3/4 full. (When sharps-disposal containers become too full, people may push sharps into the container, causing injury.) Staff should wear utility gloves, heavy-duty apron, and boots when collecting waste. Do not collect clinical and hazardous waste from the storage areas by emptying it into open carts or wheelbarrows, as this may lead to spills and contamination of the surroundings, may encourage scavenging of waste, and may increase the risk of injury to staff, patients, and visitors. Handle clinical and hazardous waste as little as possible. D.1.3 Interim storage of waste If possible, the final disposal of waste should take place immediately, but it is often more practical to store waste briefly in the facility before final disposal. Interim storage should be short-term. If it is necessary to store clinical and hazardous waste on-site before final disposal: - Place waste in a closed area that is minimally accessible to staff, patients, visitors and animals. As few people as possible should come into contact with stored clinical and hazardous waste. - All containers should have lids to prevent accidental contamination, spillage, and access by insects, rodents, and other animals. - Contaminated clinical and hazardous waste poses serious health threats to the community. Never store clinical and hazardous waste in open containers & never throw waste into an open pile. D.1.4 Treatment and Disposal of healthcare waste Health facilities, laboratories and training centers can apply one or several treatment options as below: - Transportation to the nearest approved disposal site; - Handling of waste immediately by friendly environment methods such as needle shredder machine, concrete tank, labeled bin; Although the national guidelines on health care waste management and infection control reflect best practices and deem adequate and training on the guidelines has been provided, attention should be given to ensuring their proper application by health care facilities. Weak management at health facility level hinders the implementation of the guidelines for health care waste management, including proper waste segregation storage and disposal, and maintenance of incinerators. To address this weakness, it is recommended that capacity building be provided to improve site-specific waste management practices at health facilities. Capacity-building should comprise both training and technical support. Training in best health care handling and disposal practices is expected to create 34 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery more awareness of HCWM issues and foster responsibility among health care facilities staff in an effort to prevent occupational exposure to hazardous HCW. Training should be provided to all health care facility staff – both health care personnel and auxiliary and support staff. Recognizing that sustaining adequate waste management practices at health care facilities ultimately depends on auxiliary staff, it is highly recommended that waste management responsibilities be clearly defined and linked with performance-based monitoring and evaluation. Adequate waste handling and disposal infrastructure and management systems should be put in place at health care facilities. A standard health care waste management package intended to improve health care waste handling at health care facilities would encompass: (i) color-coded waste plastic bags and containers; and (ii) safety boxes for disposal of used needle and syringes. The segregation of waste at source to minimize mixed waste must be practiced as it would improve the waste disposal system. Therefore an appropriate system and management should be put in place to ensure waste segregation at the point of generation itself. D.1.5 Waste Water from laboratories and training facilities Safe disposal practices for wastewater as specified in the MOH’s Waste Management Guidelines should be followed in handling of sanitary wastes from laboratories and training centers. Specific mitigation measures to ensure environmentally-safe disposal of wastewater from health care facilities are also described in WHO (1999a). Recommended practices include:  Where possible, facilities should be connected to municipal WWTP.  Facilities that are not connected to municipal WWTP should install compact on-site sewage treatment (i.e., primary and secondary treatment, disinfection) to ensure that wastewater discharges meet applicable permit requirements. This should continue to be monitored by the project. F. Environmental and Social Risks Management Process This section is developed for those proposed project's activities, which involves the facilities renovation activities. This section describes the environmental and social risks management processing guidance of the project. The following guidance shall serve to ensure that potential impacts and practical mitigation measures are identified and prepared early on in the planning and development of subprojects, in order to avoid or mitigate the potential impact that may be generated by subprojects financed under the project. The project will adopt a simplified three-step process, as follows: First step – Eligibility screening of all proposed subprojects, particularly infrastructure-related subprojects, to determine the eligibility of subprojects for support under the project. The investment financed by this project will not include:  Activities that have the potential to cause any significant loss or degradation of critical natural habitats whether directly or indirectly; 35 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery  Activities that could affect forest and forest health;  Activities requiring land acquisition;  Activities causing directly or indirectly physical or economic displacement;  Activities that could harm Indigenous Peoples/ethnic minorities;  Activities that could affect sites with archeological, paleontological, historical, religious, or unique natural values;  Activities that have potential establishment of new buildings or extension of new infrastructures. Second step – Environmental and Social Risks Screening. If the subproject is deemed eligible, the subproject, especially infrastructure subproject, is screened using the Environmental and Social Checklist (Annex I.10) to determine potential environmental risks and categorization. Third Step – Preparation of ESF Instrument. Based on the results of risks screening described above, subprojects that are not required additional measures/instruments will follow the ESCOPs prepared as part of this document. Subprojects, especially infrastructure-related subprojects that need additional instruments or measures, subproject specific instruments such as site-specific Environmental and Social Management Plan (ESMP) will be prepared before the start of any civil work/activities. The sample outline of the ESMP is mentioned in Annex H.11. E.1 Mitigation Measures for Facilities Renovation Activities Prior to the execution of minor civil works or facilities renovation activities, the participating facilities will ensure to prepare and review the design for minor works, building renovation where applicable. The designs for these works shall be approved by facility management and or competent local agencies in line with the relevant legislation. During construction, the facility staff shall be responsible for ensuring implementation of the Environmental and Social Code of Practices (ESCOPs) (see Annex H.9). The ESCOPs will also be incorporated into the project Operations Manual (OM) and where applicable included in contractor contract. Overall implementation of these ESCOPs and ESMP will be supervised and monitored by the PMD. G. Project's Labor-Management Procedure Labor Management Procedures (LMP) are mandated by ESS2 – Labor and Working Conditions of the World Bank Environmental and Social Framework (ESF) to identify the main labor requirements and risks associated with the project and to determine the resources necessary to address project labor issues. The LMP is a living document to be reviewed and updated throughout the development and implementation of the project. The LMP applies to all project workers, irrespective of the contract being full-time, part-time, temporary, or casual. 1. The World Bank ESS2 defines four categories of project workers: Direct workers - people employed or engaged directly by the Borrower (including the project proponent and the project implementing agencies) to work specifically in relation to the project 36 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Contracted workers - people employed or engaged through third parties to perform work related to core functions of the project, regardless of location. These could be either international or national workers. Primary supply workers - people employed or engaged by the Borrower’s primary suppliers (primary supply workers); Community workers - people employed or engaged in providing community labor, generally voluntarily. There will be no community workers engaged on the project. Civil Servant- those employed directly by the Government. Overview of Labor Use on the Project 2. This project will only engage staff from the Ministry of Health (Government Civil Servants), the public University of Health Sciences (UHS) and consultants (contracted workers). Some workers may be contracted through a firm for the minor works required for the upgrading of some physical facilities -the nature and location of those minor works are unknown at this stage of project preparation-. In this project, there are no expected primary supply workers or community workers. 3. This section describes the expected labor use on the project, based on available information. As the project progresses and more information becomes available, this information will be revised. Migrant workers are not expected as a result of this project. Project Number of Characteristics of Timing of Labor Contracted Workers Component Project Project Workers Requirements Workers Component 1: Approx. 30 National and Project Consultancy contracts Strengthening direct or international skilled implementation are likely to be competency- contracted consultants are tendered to individual based teaching workers expected to consultants. and learning strengthen the Minor works for the capacity teaching and upgrading of physical learning capacity in facilities (clinical skill the UHS and the laboratories, libraries, four public Regional lecture halls, class- Training Centers rooms) are likely to (RTCs). be tendered to a Works for the private firm. upgrading of Number of contracted physical facilities and sub-contracted may require workers is unknown national and at this stage. international skilled and unskilled workers. 37 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Component 2: Health professionals education governance and project management Subcomponent Approx. 15 Combination of Project Consultancy contracts 2.1: Health direct or International and implementation are likely to be Professionals contracted national skilled tendered to individual education workers consultants consultants. governance Number of contracted and sub-contracted workers is unknown at this stage. Subcomponent Approx. 6-10 Mostly national, but Project Unknown at this 2.2: Project direct or also international implementation stage. management contracted skilled consultants workers Table 12: Proposed project workforce F.1 Assessment of Key Potential Labor Risks F.1.1 Project Activities and Key Labor Risks 4. Activities under this project are not expected to have any significant negative impact related to labor and working conditions. 5. The key labor risks that have been identified associated with the project activities include Occupational Health and Safety (OHS) due to the minor works for the upgrading of physical facilities (clinical skill laboratories, libraries, lecture halls, class-rooms) under Component 1. 6. Minor renovations under Component 1 are the only ones involving physical works, whilst the remaining components are consultancy and technical assistance activities. Project Component Activities Key Labor Risks Component 1: Strengthening (a) Strengthen the teaching OHS for activities (a), including competency-based teaching and learning capacity in the a. Ground transportation; and learning capacity UHS and the four public Regional Training Centers b. Air travel; (RTCs). c. Sedentary work. (b) Works for the upgrading of OHS for activities (a), including physical facilities may d. Operating machinery; require skilled and unskilled workers e. Working in enclosed spaces (trenches); 38 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery f. Working at heights’; g. Traffic management hazards; and h. Electrical hazards; Subcomponent 2.1: Health Support MoH in the OHS, including: Professionals education establishment of regulations i. Ground transportation; governance and standards for health professional’s education; j. Air travel; external review and quality k. Sedentary work. assessment of health professional’s education programs; and development and operation of the national licensing examination system Subcomponent 2.2: Project Support the implementation, OHS, including: management coordination, and management l. Ground transportation; of project activities on planning and execution, financial m. Air travel; management (FM), n. Sedentary work. procurement, supervision and reporting, internal and external audits, environmental and social standards management, and monitoring and evaluation Table 13: Potential labor Risks related to the proposed project activities F.1.2 Overview of the Labor Legislation: Terms and Conditions 7. Cambodia has national legislation that outlines worker’s rights. The Labor Law (1997) remains the key document governing the regulatory framework for labor in Cambodia. 8. The 1997 Labor Law defines non-discrimination in employment and in wages. It establishes a minimum wage level, which may vary among regions. Working hours are limited to 8 hours per day, 6 days a week. There are strong regulatory provisions against discrimination in the work place, enhancing from a legal point of view fair treatment, non-discrimination and equal opportunity, special protection and assistance to vulnerable workers. A whole chapter in the Law is dedicated to health and safety in the workplace. The Law also covers those who work for subcontractors. 9. Child labor remains a noticeable gap in the legal framework despite many years of participation in related international programs. The Labor Law defines 12 years old as the minimum working age for children. This is in contradiction with the international standards in which the minimum working age is 15 years, or countries with special weaknesses being allowed to lower this age limit to 14. In 39 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery addition, the Labor Law does not cover domestic helpers who are likely to include very young workers. Types of work that are allowed for 12 to 18 years old are defined in additional documents but in a rather lose manner. The Prakas on the Prohibition of Hazardous Child Labor (2004) allow hazardous work for well-trained children above 16, provided it is not night work. F.1.3 Overview of the Labor Legislation: Occupational Health and Safety 10. The Labor Law (1997) includes provisions on Occupational Health and Safety (OHS) mostly consistent with ESS2 of the World Bank’s Environmental and Social Framework (ESF). F.2 Responsible Staff 11. This section identifies the functions and/or individuals within the project responsible for oversight mechanisms. 12. Engagement and Management of Contractors/Subcontractors. The Ministry of Health (MoH) is responsible for contractor engagement and compliance with contract conditions (payment of invoices). The MoH will address all LMP aspects as part of procurement for works and consultancy/technical assistance activities. The responsible implementing agency for contractor management will be a Project Implementation Unit (PIU) to be established in MoH, who will be responsible for overseeing all aspects of implementation of the project, including compliance and contractor induction. 13. The contractor is subsequently responsible for management in accordance with contract specific Labor Management Plans (LMP). Implementation of which will be supervised by MoH as defined by specific Plans. The detailed approach is described in the following sections. 14. Occupational Health and Safety. Contractors must designate a minimum of one safety representative to ensure day-to-day compliance with specified safety measures and records of any incidents. Minor incidents and near misses are reported to MoH on a monthly basis, serious incidents are reported immediately. Minor incidents are reflected in the quarterly reports to the World Bank, major issues are flagged to the World Bank immediately. 15. Labor and Working Conditions. Contractors will keep records in accordance with specifications set out in this LMP. MoH may at any time require records to ensure that labor conditions are met. MoH will review records against actuals at a minimum on a monthly basis and can require immediate remedial actions if warranted. A summary of issues and remedial actions will be included in quarterly reports to the World Bank. 16. Training of Workers. Contractors are required to, at all times, have a qualified safety officer on board. If training is required, this will be the contractor’s responsibility. The safety officer will provide instructions to contractor staff. The contractor will be obligated to make staff available for any mandatory trainings required by MoH, as specified by the contract. 17. Addressing Worker Grievances. The Contractors will be required to implement a Grievance Redress Mechanism (GRM) for Project staff. Contractors will be required to present a worker grievance redress mechanism which responds to the minimum requirements in this LMP. The MoH’s ESF Focal 40 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Point Team will review records on a monthly basis. MoH will keep abreast of GRM complaints, resolutions and reflect in quarterly reports to the World Bank. Responsibility Organization Function Individual Engagement of project MoH MoH’s ESF Focal Point To Be Determined workers. (TBD) Management of MoH MoH’s ESF Focal Point To Be Determined project workers. (TBD) Occupational Health Contractor(s) Designated Safety TBD and Safety. Representative(s) Training of Workers. Contractor(s) Designated Safety TBD Representative(s) Addressing Worker Contractor(s) Management TBD Grievances. MoH MoH’s ESF Focal Point TBD Table 14: Grievance Redress Mechanism F.2.1 Occupational, Health and Safety 18. The project implementing agencies will: o. Comply with Cambodia legislation, WB’s ESS2 requirements and other applicable requirements which relate to OHS hazards; p. Enable active participation in OHS risks elimination through promotion of appropriate skills, knowledge and attitudes towards hazards; q. Continually improving the OHS management system and performance; r. Communicate this policy statement to all persons working on the project with emphasis on individual OHS responsibilities; and s. Make this policy statement available to all interested parties. 19. Contractors will be required to have at least one designated Safety Officer on each site. The Safety Officer will be responsible for: t. Identification of potential hazards to project workers, particularly those that may be life threatening; u. Provision of preventative and protective measures, including modification, substitution, or elimination of hazardous conditions or substances; v. Training of project workers and maintenance of training records; w. Documentation and reporting of incidents; 41 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery x. Emergency prevention and preparedness and response arrangements to emergency situations; and y. Remedies for adverse impacts such as occupational injuries, deaths, disability and disease. 20. The contractor(s) will be required to: z. Develop and implement procedures to establish and maintain a safe working environment, including that workplaces, machinery, equipment and processes under their control are safe and without risk to health; aa. Actively collaborate and consult with project workers in promoting understanding and methods for implementation of OHS requirements; bb. Provide OHS training to all employees involved in works or site supervision; cc. Provide laminated signs of relevant safe working procedures in a visible area on work sites, in English and local language as required; dd. Provide PPE as suitable to the task and hazards of each worker, without cost to the worker; ee. Put in place processes for project workers to report work situations that they believe are not safe or healthy and to remove themselves from situations they have reasonable justification to believe are unsafe; ff. Confirm appropriate measures are in place for working in communities with known risk of conflict / violence; gg. Ensure availability of first aid boxes in all work locations; hh. Provide employees with access to toilets and potable drinking water; and ii. Properly dispose of solid waste at designated permitted disposal/landfill sites. 21. Further to enforcing the compliance of environmental and social management, contractors are responsible and liable for the safety of site equipment, labors and daily workers attending to the construction site and safety of citizens for each subproject site, as mandatory measures. F.2.2 Policies and Procedures 22. Most environmental and social impacts of the project resulting from activities directly under the control of contractors will be mitigated directly by the same contractors. As such, the approach is to ensure that contractors effectively mitigate project related impacts. MoH will incorporate standardized environmental and social clauses in the tender documentation and contract documents in order for potential bidders to be aware of environmental and social performance requirements that shall expected from them, are able to reflect that in their bids, and required to implement the clauses for the duration of the contract. MoH will enforce compliance by contractors with these clauses. 23. As a core contractual requirement, the contractor is required to ensure all documentation related to environmental and social management, including the LMP, is available for inspection at any time by 42 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery the MoH. The contractual arrangements with each project worker must be clearly defined. All environmental and social requirements will be included in the bidding documents and contracts. 24. Under no circumstances will contractors, suppliers or sub-contractors engage forced labor. F.2.3 Age of Employment 25. For this project, the minimum age will be 18 years. This rule will apply for both national and international workers. 26. Workers will be required to provide proof of their identity and age before commencing any works on site. 27. If any contractor employs a person under the minimum age, that contractor be required to undertake relevant management measures to ensure the safety of the worker and implement immediate measures no repeat action is taken. F.2.4 Terms and Conditions and equal opportunities 28. All terms and conditions as outlined in the World Bank Environmental and Social Framework (ESF) ESS2, paragraphs 10 to 15 apply to contracted workers. 29. In line with national law, the maximum working hours are limited to 8 hours per day, 6 days a week. 30. Employment opportunities will be available to all. F.3 Grievance Mechanism 31. A formal Grievance Redress Mechanism (GRM) will for project workers is as per the process outlined below. This takes into account culturally appropriate ways of handling the concerns of direct and contracted workers. Processes for documenting complaints and concerns have been specified, including time commitments to resolve issues. 32. In addition, this GRM has been and will continue to be communicated to all stakeholder groups during each planned engagement activity. Special communications will be held with the vulnerable groups identified at each location. F.3.1 Communications All project workers will be informed of the Grievance Mechanism process as part of their contract and induction package. F.3.2 Process 33. The process for the Worker GRM is as follows: jj. The Aggrieved Person/Party may report their grievance in person, by phone, text message, mail or email (including anonymously if required) to the Contractor in the first instance, as the initial focal point for information and raising grievances; 43 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery kk. For complaints that were satisfactorily resolved by the Aggrieved Person/Party or Contractor, the incident and resultant resolution will be logged and reported to the MoH’s ESF Focal Point. ll. Where the Aggrieved Person/Party is not satisfied, the Contractor will refer the aggrieved party to the MoH’s ESF Focal Point. Grievances may also be referred or reported to the MoH if deemed suitable. mm. The MoH’s ESF Focal Point endeavors to address and resolve the complaint and inform the Aggrieved Person/Party. For complaints that were satisfactorily resolved by the MoH’s ESF Focal Point, the incident and resultant resolution will be logged by the MoH’s ESF Focal Point. Where the complaint has not been resolved, the MoH’s ESF Focal Point will refer to the general manager of the MoH’s PIU for further action or resolution; nn. If the matter remains unresolved, or the Aggrieved Person/Party is not satisfied with the outcome, the general manager of the MoH’s PIU refers the matter to the Project Steering Committee for a resolution. The MoH’s ESF Focal Point will log details of issue and resultant resolution status; oo. If it remains unresolved or the complainant is dissatisfied with the outcome proposed by the Project Steering Committee, the Aggrieved Person may refer the matter to the appropriate legal or judicial authority. A decision of the Court will be final; and pp. Feedback must be provided to the lodger of each step no less than weekly, or more often if suitable. 34. Steps a through e should be undertaken immediately. Where the matter is referred to the MoH’s ESF Focal Point, a resolution should be sought within two weeks. If unsuccessful and the matter is referred to the Project Steering Committee, this should occur within a month 35. Each record is allocated a unique number reflecting year and sequence of received complaint (for example 2019-01, 2019-02 etc.). Complaint records (letter, email, record of conversation) should be stored together, electronically or in hard copy. The MoH’s ESF Focal Point will be responsible for undertaking a regular (at least monthly) review of all grievances to analyze and respond to any common issues arising. The MoH’s ESF Focal Point is also responsible for oversight of the GRM. 36. These steps should be undertaken immediately. Where the matter is referred to the MoH’s ESF Focal Point, a resolution should be sought within two weeks. If unsuccessful and the matter is referred to the Project Steering Committee, this should occur within a month 37. Each record is allocated a unique number reflecting year and sequence of received complaint (for example 2019-01, 2019-02 etc.). Complaint records (letter, email, record of conversation) should be stored together, electronically or in hard copy. 38. Any grievance related to corruption or any unethical practice should be referred immediately to the Cambodia Supreme Court. 44 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery F.3.3 Contractor Management 39. The tendering process for contractors will require that contractors can demonstrate their labor management and OHS standards, which will be a factor in the assessment processes. 40. Contractual provisions will require that contractors: qq. Monitor, keep records and report on terms and conditions related to labor management; rr. Provide workers with evidence of all payments made, including benefits and any valid deductions; ss. Keep records regarding labor conditions and workers engaged under the project, including contracts, registry of induction of workers including Code of Conduct, hours worked, remuneration and deductions (including overtime); tt. Record safety incidents and corresponding Root Cause Analysis (lost time incidents, medical treatment cases), first aid cases, high potential near misses, and remedial and preventive activities required (for example, revised job safety analysis, new or different equipment, skills training, etc.); uu. Report evidence that no child labor is involved; vv. Training/induction dates, number of trainees, and topics; and ww. Details of any worker grievances including occurrence date, grievance, and date submitted; actions taken and dates; resolution (if any) and date; and follow-up yet to be taken. Grievances listed should include those received since the preceding report and those that were unresolved at the time of that report. 41. Monitoring and performance management of contractors will be the responsibility of MoH. MoH will be responsible for oversight of labor management provisions as well as contract supervision. F.3.4 Gender Based violence prevention 42. Gender based violence (GBV) is an assault that is directed at individual based on his or her biological sex or gender orientation. It includes physical, sexual, verbal, emotional, and psychological abuse, denial of resources or access to services, threats, coercion, and economic or educational deprivation, whether occurring in public or private life. 43. GBV is a human rights violation, a public health challenge and a barrier to civic, social, political and economic participation. It undermines not only the safety, dignity and overall health status of individuals who experience it, but also the public health, economic stability and security of the country. Forms of Gender Based Violence: Sexual Harassment A behavior characterized by the making of unwelcome and inappropriate sexual remarks or physical advances in a workplace or other professional or social situation. Sexual harassment by employer is a form of illegal employment discrimination 45 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Rape A type of sexual assault usually involving sexual penetration carried out forcibly or under threat of injury against the person’s will Acid throwing Is a form of violent assault involving the act of throwing acid or similarly corrosive substance onto the body of another “with the intention to disfigure, maim, torture Table 15: Health Sector Curricula Gender Based Violence Prevention  Increase awareness of the scope of the GBV problem and its impact  Partner and/or coordinate with the Ministry of Social Affairs and with NGOs such as LICHADO,  GBV to be included Grievance Redress Mechanism of the proposed project  Strengthen prevention effort by adopting and promoting WHO’s RESPECT Women Framework to prevent violence against women and girls: - R-elationships skills strengthened - E-mpowerment of women - S-ervices ensured - P-overty reduced - E-nvironments made safe - C-hild and adolescent abuse prevented - T-ransformed attitudes, beliefs and norms H. Implementation arrangements of the Plan for Inclusive Service Delivery Institutional implementation arrangement The “Pre-Service Training for Health Workers” will be implemented by the MOH over a period of six years. The Minister of Health will appoint a Secretary of State for Health as the Project Director, and a senior expert on professional health education as the Program Manager. Thee relevant senior government officials will be appointed as Team Leaders; one to oversee technical aspects related to the introduction of competency-based training, one to oversee financial management and procurement, and the third one to oversee the implantation of HRDRAP, including gender mainstreaming. The project activities will be carried out by (a) the project focal points in this and relevant MOH departments who will be responsible for development or updating all frameworks and documents related to competency-based education. Various working groups will be established to support the project focal point to develop or update all CBE framework documents and decrees/sub-decrees, regulations, Prakas, and standards. the Department of Preventive Medicine (PMD) is responsible to implement and monitor the project activities in compliance with social, environmental commitment plan, implementation of HRDRAP, and gender mainstream framework. To ensure that the implementation of this instrument for the project is effective, MoH has assigned an ESF Focal Point in the Project Implementation Unit -under the PMD- to provide ongoing support, advice and monitoring to all the institutional stakeholders. In addition, it may be required to recruit part 46 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery time/full time consultants to support the stakeholder engagement processes, technical advisory work and (in case it is required) supervise the improvement of physical facilities/equipping the existing facilities. Hiring suitable staff has been included in the ESCP as one of the commitments. A Health Sector Steering Committee (HSSC) will be established as the apex decision making body in the MOH. The HSSC will be chaired by His Excellency the Minister of Health and its members would include relevant Secretaries of State and Under-secretaries of State, Director Generals from the MOH, and senior representative from the Ministry of Economy and Finance (MEF). It will provide leadership, guidance, oversight, and strategic direction to the project management and implementation teams. The Project Director will appoint an Independent Verification Agency (IVA) to verify achievement reported by the project implementing units, including PMD. Monitoring and Reporting The ESF Focal at PMD will be the main responsible for the monitoring the implementation of the plan and expected outcomes. The PMD will have the overall responsibility for data collection, monitoring, and analysis across the various components, as part of the Project’s M&E efforts. To attain the effectiveness and sustainability of the HRDRAP during implementation of Pre-Service Training for Health Workers Project, PMD with the support of hired qualified ES Specialist will monitor the implementation of environmental and social performances, and the recommendations of the HRDRAP, and the requirements stated in the ESCP. The ES monitoring report will be reviewed submitted regularly to the HSSC/MoH. Then HSSC/MoH will submit the ES monitoring report together with the project’s reports to the World Bank. 47 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery I. Annex H.1 Cambodia Population 2019 Region No Province HH male Female Total 1 Battambang 218,584 458,902 528,498 987,400 2 Banteay Meanchey 177,526 426,104 433,441 859,545 3 Odor Meanchey 56,331 134,350 126,902 261,252 4 Siem Reap 218,659 491,568 514,944 1,006,512 Battambang RTC 5 Pursat 102,253 200,392 211,367 411,759 6 Kampong Chhnang 122,925 251,895 274,037 525,932 7 Pailin 16,833 36,151 35,449 71,600 Sub-Total 913,111 1,999,362 2,124,638 4,124,000 1 Kampot 138,374 280,537 312,308 592,845 2 Sihanouk 51,983 153,255 149,632 302,887 3 Koh Kong 26,716 62,304 61,314 123,618 4 Kep 9,347 20,615 21,183 41,798 Kampot RTC 5 Takeo 199,362 432,649 466,836 899,485 6 Kampong Spue 187,835 424,039 448,180 872,219 Sub-Total 613,617 1,373,399 1,459,453 2,832,852 1 Kampong Cham 215,923 428,481 467,282 895,763 2 Kampong Thom 154,458 327,013 350,247 677,260 Kampong Cham RTC 3 Tboung Khmum 169,281 377,205 398,091 775,296 4 Prey Veng 227,008 501,346 556,082 1,057,428 5 Svay Rieng 131,937 249,446 275,108 524,554 6 Kandal 273,111 580,129 615,418 1,195,547 Sub-Total 1,171,718 2,463,620 2,662,228 5,125,848 1 Stung Treng 34,627 83,093 76,472 159,565 2 Kratie 86,137 185,429 187,396 372,825 Stung Treng RTC 3 Mondolkiri 19,609 45,533 43,116 88,649 4 Preah Vihear 56,331 126,624 124,728 251,352 5 Ratanakiri 47,417 102,325 101,702 204,027 Sub-Total 244,121 543,004 533,414 1,076,418 Phnom Penh 399,203 1,039,192 1,090,179 2,129,371 Total 3,341,770 7,418,577 7,869,912 15,288,489 48 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.2 Health Students H.2.1 UHS Student Data UNIVERSITY HEALTH SERVICES (UHS) Number of Students Ethnic Composition (2018-2019) Year No Courses Ethnic Level Khme Cha Male Female Total Minorit r m y Diploma degree in 1 1st Year 155 143 298 298 Medicine 2nd Year 156 127 283 283 3rd Year 149 113 262 262 4th Year 171 103 274 274 5th Year 180 92 272 272 6th Year 209 116 325 325 7th Year 135 85 220 220 8th Year 120 65 185 185 Total 1275 844 2119 2119 2 Specialized Doctor Diploma 1st Year 78 38 116 116 2nd Year 100 55 155 155 3rd Year 167 90 257 257 4th Year 136 29 165 165 Total 481 212 693 693 3 Bachelor in Nursing 1st Year 29 69 98 98 2nd Year 28 67 95 95 3rd Year 21 44 65 65 4th Year 10 25 35 35 Total 88 205 293 293 4 Bachelor in Midwifery 1st Year 0 60 60 60 2nd Year 0 58 58 58 3rd Year 0 40 40 40 4th Year 0 16 16 16 Total 0 174 174 174 5 Assoc. degree in Nursing 1st Year 29 79 108 108 2nd Year 30 72 102 102 3rd Year 34 76 110 110 Total 93 227 320 320 6 Assoc. Degree in Midwifery 1st Year 0 37 37 37 2nd Year 0 49 49 49 3rd Year 0 51 51 51 Total 0 137 137 137 TOTAL 1,937 1,799 3,736 3,736 49 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.2.2 Battambang RTC Student Data BATTAMBANG REGIONAL TRAINING CENTER Number of Students Year Ethnicity No Courses (2018-2019) Level Male Female Total Khmer 1 Bachelor degree in Nursing and Midwifery 1st Year 0 39 39 39 Total 0 39 39 39 2 Associate degree in Nurse 1st Year 43 78 121 121 2nd Year 26 41 67 67 3rd Year 58 80 138 138 Total 127 199 326 326 3 Continue Primary Nurse to Associate degree 1st Year 0 0 0 0 2nd Year 2 8 10 10 3rd Year 43 14 57 57 Total 45 22 67 67 Continue Primary Midwife to Associate 4 1st Year 0 0 0 0 degree 2nd Year 0 50 50 50 3rd Year 0 100 100 100 Total 0 150 150 150 5 Associate degree in Midwifery 1st Year 0 37 37 37 2nd Year 0 48 48 48 3rd Year 0 120 120 120 Total 0 205 205 205 TOTAL 172 615 787 787 H.2.3 Stung Treng RTC Student Data STUNG TRENG REGIONAL TRAINING CENTER Number of Students Ethnic Composition (2018-2019) No Courses Offered Year Level Ethnic Male Female Total Khmer Minority 1 Associate degree in Nursing 1st Year 8 10 18 2nd Year 16 13 29 113 9 3rd Year 54 21 75 Total 78 44 122 113 9 2 Associate degree in Midwifery 1st Year 0 13 13 2nd Year 0 14 14 55 10 3rd Year 0 38 38 50 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Total 0 65 65 55 10 TOTAL 78 109 187 168 19 H.2.4 Kampot RTC Student Data KAMPOT REGIONAL TRAINING CENTER Number of Students (2018- Ethnicity No Courses Offered Year Level 2019) Male Female Total Khmer Bachelor degree in Nursing and 1 1st Year Midwifery 2nd Year 3rd Year 4th Year 0 54 54 54 Total 0 54 54 54 2 Associate degree in Midwifery 1st Year 0 43 43 43 2nd Year 0 78 78 78 3rd Year 0 71 71 71 3rd Year up- 0 85 85 85 grade Total 0 277 277 277 3 Associate degree in Nursing 1st Year 31 74 105 105 2nd Year 43 61 104 104 3rd Year 65 90 155 155 Total 139 225 364 364 4 Associate Degree in Dental Nursing 1st Year 12 8 20 20 2nd Year 12 5 17 17 3rd Year 8 3 11 11 Total 32 16 48 48 TOTAL 171 572 743 743 51 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.2.4 Kampong Cham RTC Student Data KAMPONG CHAM REGIONAL TRAINING CENTER Number of Students Year Ethnicity No Courses Offered (2018-2019) Level Male Female Total Khmer 2 Associate degree in Nursing 1st Year 22 14 36 36 2nd Year 18 12 30 30 3rd Year 34 8 42 42 Total 74 34 108 108 3 Primary Midwife to Associate degree in 1st Year 34 34 34 Midwifery 2nd Year 89 89 89 3rd Year 174 174 174 55 55 55 Total 352 352 352 6 Primary Pharma to Assoc. D in Nursing 1st Year 43 73 116 116 2nd Year 52 60 112 112 3rd Year 49 73 122 122 Total 144 206 350 350 TOTAL 810 810 52 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.3 Public Health Workforce H.3.1 Health Workers by Gender Provincial Hospitals - Health Workers by Gender Doctors Nurses Midwives Total Staff No Name of Hospital Male Female Total Male Female Total Male Female Total Male Female Total 1 Battambang 54 8 62 89 51 140 0 76 76 143 135 278 2 Banteay Meanchey 23 5 28 29 22 51 0 47 47 52 74 126 3 Otdar Meanchey 12 2 14 26 7 33 0 10 10 38 19 57 4 Siem Reap 51 6 57 49 34 83 0 45 45 100 85 185 5 Pursat 21 3 24 27 14 41 0 27 27 48 44 92 6 Kampong Chhnang 23 8 31 31 43 74 0 39 39 54 90 144 7 Pailin 12 8 20 26 12 38 0 19 19 38 39 77 8 Kampot 22 5 27 43 40 83 0 33 33 65 78 143 9 Sihanouk Ville 26 3 29 31 29 60 0 32 32 57 64 121 10 Koh Kong 14 3 17 20 5 25 0 12 12 34 20 54 11 Kep 12 0 12 6 5 11 0 10 10 18 15 33 12 Takeo 41 5 46 73 63 136 0 42 42 114 110 224 13 Kampong Speu 30 1 31 24 27 51 0 14 14 54 42 96 14 Kampong Cham 48 12 60 70 54 124 0 55 55 118 121 239 15 Kampong Thom 30 13 43 22 28 50 0 21 21 52 62 114 16 Tboung Khmum 12 3 15 16 8 24 0 17 17 28 28 56 17 Prey Veng 14 4 18 13 13 26 0 23 23 27 40 67 18 Svay Rieng 24 3 27 38 28 66 0 20 20 62 51 113 19 Kandal 37 14 51 28 58 86 0 36 36 65 108 173 20 Stung Treng 14 4 18 31 12 43 0 34 34 45 50 95 21 Kratie 10 9 19 45 24 69 0 20 20 55 53 108 22 Ratanakiri 17 3 20 29 7 36 0 26 26 46 36 82 23 Mondolkiri 11 2 13 18 10 28 0 12 12 29 24 53 24 Preah Vihear 16 4 20 26 6 32 0 35 35 42 45 87 Total 574 128 702 810 600 1410 0 705 705 1384 1433 2817 Percent Women 22% 43% 100% 51% 53 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Referral Hospitals _ Health Workers by Gender Doctors Nurses Midwives Total Staff No Name of Hospital Male Female Total Male Female Total Male Female Total Male Female Total 1 Battambang 13 13 26 68 35 103 0 50 50 81 98 179 2 Banteay Meanchey 42 5 47 88 29 117 0 86 86 130 120 250 3 Otdar Meanchey 5 0 5 11 5 16 0 8 8 16 13 29 4 Siem Reap 23 5 28 33 23 56 0 27 27 56 55 111 5 Pursat 6 4 10 23 5 28 0 21 21 29 30 59 6 Kampong Chhnang 13 2 15 14 24 38 0 0 0 27 26 53 7 Pailin 0 0 0 0 0 0 0 0 0 0 0 0 8 Kampot 23 5 28 48 32 80 0 32 32 71 69 140 9 Sihanouk Ville 0 0 0 0 0 0 0 0 0 0 0 0 10 Koh Kong 8 0 8 10 3 13 0 11 11 18 14 32 11 Kep 0 0 0 0 0 0 0 0 0 0 0 0 12 Takeo 37 4 41 92 30 122 0 70 70 129 104 233 13 Kampong Speu 22 7 29 27 19 46 0 67 67 49 93 142 14 Kampong Cham 38 10 48 60 26 86 0 65 65 98 101 199 15 Kampong Thom 22 8 30 20 14 34 0 15 15 42 37 79 16 Tboung Khmum 47 11 58 61 31 92 0 69 69 108 111 219 17 Prey Veng 48 11 59 80 38 118 1 118 119 129 167 296 18 Svay Rieng 26 5 31 39 17 56 0 42 42 65 64 129 19 Kandal 61 18 79 60 57 117 0 104 104 121 179 300 20 Stung Treng 0 0 0 0 0 0 0 0 0 0 0 0 21 Kratie 11 5 16 35 7 42 0 24 24 46 36 82 22 Ratanakiri 7 1 8 8 1 9 0 12 12 15 14 29 23 Mondolkiri 6 0 6 9 2 11 0 8 8 15 10 25 24 Preah Vihear 3 2 5 9 1 10 0 11 11 12 14 26 Total 461 116 577 795 399 1194 1 840 841 1257 1355 2612 Percentage Female 20% 33% 100% 52% 54 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Health Center - Health Workers by Gender No. of Doctors Nurses Midwives Total Staff No Name of Hospital HC Male Female Total Male Female Total Male Female Total Male Female Total 1 Battambang 79 13 3 16 244 90 334 0 355 355 257 448 705 2 Banteay Meanchey 66 1 0 1 203 50 253 0 238 238 204 288 492 3 Otdar Meanchey 34 10 1 11 113 19 132 0 116 116 123 136 259 4 Siem Reap 89 3 1 4 193 90 283 0 264 264 196 355 551 5 Pursat 40 2 1 3 105 26 131 0 157 157 107 184 291 6 Kampong Chhnang 41 2 1 3 120 73 193 0 157 157 122 231 353 7 Pailin 6 1 1 2 23 36 59 0 23 23 24 60 84 8 Kampot 59 10 1 11 164 117 281 0 257 257 174 375 549 9 Sihanouk Ville 13 10 4 14 60 28 88 0 67 67 70 99 169 10 Koh Kong 12 6 0 6 42 17 59 0 67 67 48 84 132 11 Kep 4 1 0 1 14 9 23 0 29 29 15 38 53 12 Takeo 79 13 3 16 206 62 268 0 349 349 219 414 633 13 Kampong Speu 54 11 2 13 173 63 236 0 210 210 184 275 459 14 Kampong Cham 87 2 0 2 174 62 236 0 260 260 176 322 498 15 Kampong Thom 52 10 1 11 126 70 196 0 190 190 136 261 397 16 Tboung Khmum 63 4 2 6 127 52 179 0 217 217 131 271 402 17 Prey Veng 103 10 1 11 305 65 370 0 276 276 315 342 657 18 Svay Rieng 43 0 0 0 127 61 188 0 150 150 127 211 338 19 Kandal 99 17 2 19 138 107 245 0 258 258 155 367 522 20 Stung Treng 12 0 0 0 84 21 105 0 89 89 84 110 194 21 Kratie 30 3 0 3 146 40 186 0 210 210 149 250 399 22 Ratanakiri 16 1 0 1 123 9 132 57 27 84 181 36 217 23 Mondolkiri 11 0 0 0 47 22 69 0 67 67 47 89 136 24 Preah Vihear 27 5 1 6 150 13 163 0 142 142 155 156 311 Total 1,119 135 25 160 3207 1202 4409 57 4175 4232 3399 5402 8801 Percentage Female 19% 27% 100% 61% 55 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.3.2 Health Workers by Age Bracket Provincial Hospital - Health Workers by Age Bracket Doctors Nurses Midwives No. of Age Bracket Age Bracket Age Bracket No Provinces Provincial Hospitals 20- 30- 40- 50- Total 20- 30- 40- 50- Total 20- 30- 40- 50- Total 30 40 50 60 30 40 50 60 30 40 50 60 1 Battambang 1 6 17 27 12 62 26 14 63 37 140 17 5 32 22 76 2 Banteay Meanchey 1 2 10 8 8 28 11 8 26 6 51 25 4 16 2 47 3 Otdar Meanchey 1 4 7 2 1 14 14 8 8 3 33 4 6 0 0 10 4 Siem Reap 1 4 14 27 12 57 26 6 30 21 83 9 9 10 17 45 5 Pursat 1 3 5 14 2 24 11 9 8 13 41 4 4 4 15 27 6 Kampong Chhnang 1 6 15 7 3 31 29 12 9 24 74 21 4 11 3 39 7 Pailin 1 4 15 1 0 20 14 9 13 2 38 11 6 1 1 19 8 Kampot 1 6 15 3 3 27 16 15 17 35 83 9 14 5 5 33 9 Sihanouk Ville 1 1 13 11 4 29 7 16 10 27 60 11 2 11 8 32 10 Koh Kong 1 5 9 2 1 17 9 9 3 4 25 3 1 6 2 12 11 Kep 1 2 7 3 0 12 10 1 0 0 11 9 0 1 0 10 12 Takeo 1 5 15 17 9 46 34 37 35 30 136 20 7 12 3 42 13 Kampong Speu 1 1 11 13 6 31 11 8 14 18 51 4 2 5 3 14 14 Kampong Cham 1 9 18 14 19 60 43 31 24 26 124 16 13 10 16 55 15 Kampong Thom 1 6 11 23 3 43 12 6 10 22 50 7 3 5 6 21 16 Tboung Khmum 1 1 7 3 4 15 8 8 2 6 24 8 3 4 2 17 17 Prey Veng 1 3 7 8 0 18 4 1 8 13 26 6 2 9 6 23 18 Svay Rieng 1 4 12 8 3 27 19 15 14 18 66 8 1 2 9 20 19 Kandal 1 9 14 20 8 51 23 20 18 25 86 18 10 3 5 36 20 Stung Treng 1 3 13 2 0 18 12 15 11 5 43 19 4 10 1 34 21 Kratie 1 2 11 4 2 19 13 19 26 11 69 4 8 5 3 20 22 Ratanakiri 1 3 12 2 3 20 10 14 7 5 36 13 6 2 5 26 23 Mondolkiri 1 3 9 1 0 13 10 5 7 6 28 4 3 4 1 12 24 Preah Vihear 1 2 11 4 3 20 6 16 5 5 32 11 7 6 11 35 Total 94 278 224 106 702 378 302 368 362 1410 261 124 174 146 705 Percentage per bracket 13% 40% 32% 15% 100% 27% 21% 26% 26% 100% 37% 17% 25% 21% 99% 56 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Referral Hospitals (RH)_Health Workers by Age Bracket Doctors Nurses Midwives No. No Provinces of Age Bracket Age Bracket Age Bracket RH 20- 30- 40- 50- 20- 30- 40- 50- 20- 30- 40- 50- Total Total Total 30 40 50 60 30 40 50 60 30 40 50 60 1 Battambang 3 8 8 6 4 26 28 20 48 7 103 15 12 13 10 50 2 Banteay Meanchey 5 15 19 10 3 47 20 20 55 22 117 42 13 25 6 86 3 Otdar Meanchey 1 5 0 0 0 5 7 3 4 2 16 6 1 1 0 8 4 Siem Reap 4 7 15 6 0 28 19 16 12 9 56 11 5 9 2 27 5 Pursat 3 4 5 1 0 10 8 9 7 4 28 9 4 1 7 21 6 Kampong Chhnang 2 3 9 3 0 15 19 12 4 3 38 0 0 0 0 0 7 Pailin 0 0 0 0 8 Kampot 4 8 10 7 3 28 25 17 25 13 80 17 12 3 0 32 9 Sihanouk Ville (No RH) 0 0 0 0 10 Koh Kong 1 2 3 2 1 8 6 5 0 2 13 6 2 0 3 11 11 Kep (No RH) 0 0 0 0 12 Takeo 5 14 16 10 1 41 47 58 11 6 122 40 19 5 6 70 13 Kampong Speu 3 8 11 4 6 29 14 9 13 10 46 41 14 9 3 67 14 Kampong Cham 6 13 14 18 3 48 41 19 21 5 86 34 18 10 3 65 15 Kampong Thom 2 10 8 10 2 30 15 9 8 2 34 0 5 6 4 15 16 Tboung Khmum 5 8 40 9 1 58 53 25 11 3 92 42 20 3 4 69 17 Prey Veng 9 18 19 17 5 59 53 29 23 13 118 87 14 14 4 119 18 Svay Rieng 4 8 19 3 1 31 29 7 6 14 56 35 4 1 2 42 19 Kandal 10 18 27 24 10 79 59 25 17 16 117 75 21 3 5 104 20 Stung Treng 0 0 0 0 21 Kratie 2 7 6 2 1 16 12 19 8 3 42 16 5 2 1 24 22 Ratanakiri 1 3 5 0 0 8 2 5 0 2 9 5 6 1 0 12 23 Mondolkiri 1 2 4 0 0 6 6 1 2 2 11 6 1 0 1 8 24 Preah Vihear 1 4 1 0 0 5 4 2 1 3 10 9 1 1 0 11 57 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Total 72 165 239 132 41 577 467 310 276 141 1194 496 177 107 61 841 Percentage per bracket 29% 41% 23% 7% 100% 39% 26% 23% 12% 100% 59% 21% 13% 7% 100% Health Centers - Health Workers by Age Bracket Doctors Nurses Midwives No. of Age Bracket Age Bracket Age Bracket No Provinces Health 20- 30- 40- 50- 20- 30- 40- 50- 20- 30- 40- 50- Centers Total Total Total 30 40 50 60 30 40 50 60 30 40 50 60 1 Battambang 79 5 5 4 2 16 68 92 92 82 334 143 87 80 45 355 2 Banteay Meanchey 66 0 0 0 1 1 59 39 101 54 253 104 61 58 15 238 3 Otdar Meanchey 34 10 0 0 1 11 73 9 32 18 132 80 24 5 7 116 4 Siem Reap 89 2 1 1 0 4 101 63 85 34 283 146 64 37 17 264 5 Pursat 40 0 2 1 0 3 38 19 42 32 131 70 40 32 15 157 6 Kampong Chhnang 41 0 0 3 0 3 72 31 48 42 193 72 19 40 26 157 7 Pailin 6 0 1 1 0 2 26 21 7 5 59 13 8 2 0 23 8 Kampot 59 0 3 6 2 11 96 75 56 54 281 146 62 31 18 257 9 Sihanouk Ville 13 6 2 4 2 14 27 21 18 22 88 35 20 6 6 67 10 Koh Kong 12 2 3 1 0 6 33 13 4 9 59 47 12 3 5 67 11 Kep 4 1 0 0 0 1 15 2 5 1 23 21 6 2 0 29 12 Takeo 79 0 4 8 4 16 68 75 72 53 268 165 122 39 23 349 13 Kampong Speu 54 0 5 6 2 13 58 56 67 55 236 117 47 24 22 210 14 Kampong Cham 87 0 0 2 0 2 64 47 92 33 236 129 61 48 22 260 15 Kampong Thom 52 3 1 5 2 11 77 36 35 48 196 106 28 24 32 190 16 Tboung Khmum 63 0 2 1 3 6 78 45 40 16 179 135 62 16 4 217 17 Prey Veng 103 0 5 5 1 11 125 89 88 68 370 149 53 52 22 276 18 Svay Rieng 43 0 0 0 0 0 56 26 33 73 188 101 35 3 11 150 19 Kandal 99 0 7 8 4 19 94 86 36 29 245 147 60 22 29 258 20 Stung Treng 12 0 0 0 0 0 40 36 20 9 105 45 30 9 5 89 58 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery 21 Kratie 30 2 1 0 0 3 61 64 48 13 186 111 67 18 14 210 22 Ratanakiri 16 0 1 0 0 1 37 46 18 31 132 42 25 8 9 84 23 Mondolkiri 11 0 0 0 0 0 23 27 12 7 69 39 24 1 3 67 24 Preah Vihear 27 1 4 1 0 6 63 70 21 9 163 81 43 8 10 142 Total 1,119 32 47 57 24 160 1452 1088 1072 797 4409 2244 1060 568 360 4232 Percentage per 20% 29% 36% 15% 100% 33% 25% 24% 18% 100% 53% 25% 13% 9% 100% bracket 59 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.4 FGD UHS FGD UNIVERSITY HEALTH SERVICES (UHS) MAIN CAMPUS Doctor Students (3 groups, 6 participants) Combined Teaching Staff (18 participants) FGD Questions 17 Dec. 2019 (04:00-5:00 pm) 17 Dec. 2019 (04:00-5:00 pm) 1. What can be done to  Give priority to women during, equal number of quota given  Government should give opportunity to students promote the gender to women during National Entrance. to work balance in the enrolment  Inform women about group during National Entrance (NEE)  Government to open more places for job for for nursing and midwifery?  Provide accommodation female students medical graduates  Provide access to equal opportunity for woman  Increase salary for medical workers  Provide baby care for female doctor in the work place  Access to information related to medical journey (school to hospital++ through any means 2. What can be done to  Provide document related to ethnicity to  Give priority, support, provision of jobs to IPS promote the enrollment of  Provide scholarship for Ethnic minority (Tuition, Medical Graduate- send them back to their more ethnic minorities as accommodation and food communities nurses and midwives?  Partner with ORG working with IPs in terms of  Priority in work hiring foundational education to enable IPS cope  Financial support competitive in Medical Entrance Exam.  Job guarantee back to serve to their own community  Promote equity and equality 3. What can be done to  Building should be friendly to PWD  To add curriculum responding the needs of PWD, promote the enrollment of  Signs for PWD for CR, stairs responsive to their physical psycho emotional more persons with needs & wellbeing of PWD a  Support equipment for PWD disabilities as nurses/midwives? 4. What can be done to make  Focus on family medicine, include family care in the  Offer more English classes for medical students sure the curricula for curriculum  Medical classes are in French is mainly used for nursing and midwifery  Make doctor more inclusive (behavioral sciences Medicine and Pharmacy education is more +community-based education-student support services  Nursing and midwifery are in English teaching responsive/inclusive to better include vulnerable 60 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery groups (poorest of the poor, disable, mental disorders, street children, SOGI, etc.)? 5. What can be done to make  Government police requiring medical Doctor Graduates will  Government schools to provide more scholarship sure the curricula for be required to work in the countryside for 2 years (support for poor people nursing and midwifery housing, living allowances)  Research on people who suffered for medical education promote  Make doctor more environmental sustainable(equip and waste hazards environmental empower students with knowledge and skills related to  To improve the KSA on environment specifically sustainability (better Environment i.e. infection control, and waste management; of medical health hazards. treatment of medical study tour to communities/facilities related to waste, occupational health  CRC in charge of collecting processing the environmental protection and safety, etc.)? medical wastes, in the provinces medical waste  Short course on how to manage Materials and infection are collect or sent to PHD. (Incinerators) control  Train medical workers staff working in clinic The subject on SOGIE, PWD, Environment etc could be  Improve the implementation/enforcement of embedded in the curriculum or create another media such as PPE and waste disposals exposure visit/trips, fora, workshop, awareness raising activities, etc. in order to concientisize the issues among medical students FGD UNIVERSITY HEALTH SERVICES - TSMC CAMPUS Nursing Students ( participants) Midwifery Students (21 participants) FGD Questions 17 Dec. 2019 (02:30-3:30 pm) 17 Dec. 2019 (02:30-3:30 pm) 1. What can be done to promote the gender  nursing work need men as they have  Open school for male midwifery balance in the enrolment for nursing and more strength and more rational  Encourage men to register as men midwifery?  tell them the advantages of studying  WS for male and the role of nurses  Advertise, give them the value of this job   Encourage men that midwifery can also be good midwives, they are stronger and wiser  Change the Khmer stereotyping. Make video that men can also work as midwife 61 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery 2. What can be done to promote the  Information dissemination of the  Identify traditional midwives and train them in the RTCS enrollment of more ethnic minorities as nursing course among the IP  Inform advertise through social media nurses and midwives? communities  Encourage Ethnic and give equal opportunity  Minimize if not eliminate discrimination in the society  Scholarship for IPS  Full scholarship for IP(Tuition and living allowance  Benefits of taking up nursing  Family-based promotion among IPS to make them aware and to encourage them to send their children to study midwifery 3. What can be done to promote the  Info dissemination among the  Institute should give opportunity to PWD to get a job enrollment of more persons with PWD  Scholarship for PWD disabilities as nurses/midwives?  Minor disability are able to work as nurse 4. What can be done to make sure the  Nursing service is for all kinds of  Scholarship for the poor curricula for nursing and midwifery people…serve with fairness and  Midwifery should have code of ethics education is more responsive/inclusive to justice  Follow the policies of health better include vulnerable groups (poorest of the poor, disable, mental disorders,  Midwives to have the mindset of inclusiveness to all street children, SOGI, etc.)? people/ sector especially to the disadvantaged groups 5. What can be done to make sure the  Add environment subject in the  Same with others curricula for nursing and midwifery curriculum  Information dissemination, educate people, awareness education promote environmental  Exposure to environment related raising on environments concerns and apply sustainability (better treatment of medical activities waste, occupational health and safety,  Waste sorting, recycle, wastes etc.)? FGD with UHS Decision Makers 4:00-5:00 pm 17 December 2019 -Which are the main ways students and  Orientation meeting at the beginning of every semester for every class and one Students teaching staff can participate/been general meeting at the end of the school year are venues where students could ask clarification consulted in the decision making of the on the school program, policies and regulations, they could also raise feedback and concerns related to the previous semester/year. Faculty?  Each faculty has student association where they elected class representatives. The class 62 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery representatives choose from among themselves the faculty representative who participate in the UHS planning and strategic workshops.  UHS Formulation of Strategic Plan 2019-2023 was with the participation by faculty and students representatives.  Each faculty conducted consultative meeting with the teaching staff and with the student body. The faculty dean brings up the issues and concerns to the management level for deliberation and for action. -Have the students/teaching staff any  Curricula for medical courses are regulated by MoH and the UHS has to stick on it, curricula possibility to evaluate/influence the however was designed 12 years ago in 2007 and there are many new and updated medical contents of the curricula? concepts and technologies that UHS need to be at pace with. UHS has adopted the national program and international program  Monthly staff meeting by department to evaluate and discuss how to improve teaching content and materials. -Is there in place any mechanism to raise 1. UHS has three level complain pathway: feedback and complaints? In case it is:  1st level: aggrieved students raise their complaints to →class representative, if not resolved how is it working? → faculty, if not resolved →Dean  2nd level: if not resolved at the Dean level, the aggrieved party raise the complaints to the Student Affaire Rectorate  3rd level: if not resolved at the SA Rectorate the complainant can raise the complaint to the UHS Rector by dropping a complaint letter at the complaint box. The complaint box is made of glass and is installed in a place where the UHS Rector could see before reaching his office, Only the Rector has the key of the complaint box and when he see any letter in the complaint , he has the responsibility to respond and take action on it. 2. UHS has website and Face Book account, some students raise their feedback and concerns by means of these social media. 3. Evaluation of Teachers by the students (using the evaluation forms) which purpose are:  To improve the teaching methodology and course content  Basis for selection of the “Best Teacher” -Is there in place any specific provision to  All regular staff of the university have Health Card from the National Social Security Fund (NSS) promote safety and health at work? And for free or subsidized medical treatment. Health Care was issued in the Rectangular Strategy easy accessibility for PWD? Phase III of the Royal Government and established by Sub-Decree No. 01 SD.E, dated 06 January 2016, concerning the Establishment of Social Security Scheme on Health Care for Persons Defined by the Provisions of the Labour Law. The implementation of social security schemes on Occupational Risk and Health Care is two consistent mechanisms because health prevention of 63 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery workers shall not only receive disease or injury treatments due to work but also include the prevention of personal health or non-work injury. The implementation of both schemes is a mutual connection and has a comprehensiveness to protect workers.  Both of UHS campuses (main campus and TSMC campus) have dispensary clinics for students and faculty staff. There are also first aid units for each of the faculty building, laboratory and for the campus administrative building.  Each laboratory has safety regulations which are discussed with the students at the start of their laboratory classes/course.  UHS also installed lift for their high story building for easy accessibility for PWDs, pregnant staff and students  There are also fire hydrants at the campuses and fire training drills are conducted with faculty staff and students.  Handicap International provide training workshops for students on road accidents and Red Cross Cambodia conduct first aid training for interested students, UHS encourage all students to attend the first aide training. Is there in place provisions to promote  UHS is open for all qualified students regardless of ethnicity, religion, sexual orientation, fair treatment, nondiscrimination and physical form as long as they pass the National Entrance Examination and have finished Grade equal opportunity of students/teaching 12 education.  Promotion of teaching staff are based on qualification and tenure. staff?  UHS also provide prayer room for the Muslim Cham students and employees -Is there in place provisions to prevent  Harassment, intimidation and bullying are not tolerated and are against the UHS code of ethics. and address harassment, intimidation  Any cases of harassment and intimidation are to be reported to the school authorities through and/or bulling of students/teaching staff? the faculty dean, the Student Affairs office and if needed to the UHS Rector. -What you consider can be done to UHS believes in inclusiveness and non-discriminatory to any qualified students and teaching  promote inclusion as students and facultystaff, in fact there students with physical deformities that are enrolled at the university. IPs, member (e.g. more ethnic minorities as Cham, LGBT and PWD are welcome to study and work at UHS as long as they pass the national entrance test. students/teachers or more women at  Scholarship for poor students (8-11 slots) supported by charity foundation management level)  There are two women in the management level of UHS. RGC promote women in leadership and management but at this point, the number of women in the leadership is still low, UHS would welcome more women on top position. Others; How to improve the curriculum 1. UHS follow the National Curriculum by MoH which was since 2007, however faculty staff modify that is responsive to the implementation to make the course updated and responsive to current need and technological advancement. 64 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery 2. There is a need to revise the current curricula and upgrade them into “competency-based curricula” but need the external Medical Curriculum Expert/s who could give practical inputs and who would facilitate discussions and workshops with UHS and other Medical schools and with MoH in designing the international best practice - competency-based curricula that is tailored fit for Cambodia context. 3. The medium of instruction at UHS are French English and Khmer. H.5 FGD Stung Treng RTC FGD with Students and Teachers Nursing Students (22 participants- 5 Midwifery Students (10 participants- 2 Combined teachers for Midwifery and FGD Questions groups) groups) Nursing 9 Dec. 2019 (10:00-11:00 am) 9 Dec. 2019 (10:00-11:00 am) 9 Dec. 2019 (11:00-12:00 am) 6. What can be done  There are a number of male nursing  Men midwives are better in managing  Nursing students have both men and to promote the students at STR_RTC emergency cases, stronger in carrying the women students, only midwifery gender balance in  Advertise the nursing course, women during birth delivery, men are not students are all women. the enrolment for opportunity for work, benefits scared, can be more rational and quick in  Cambodian Law does not prohibit men to nursing and making decisions during emergency become midwives, however, it had not  Men is strong and make nursing care midwifery?  Special scholarship for male midwifery been encouraged for men to train for improved students midwifery.  3 years only short to get a profession  Men can be encouraged to take up midwifery  Culturally, women and also husbands  Proactive promotion of nursing as there are also male doctors conducting would not be comfortable to have male enrollment among male year 12 birth delivery. midwives to assist during birth delivery students  Breaking cultural barrier of “shame” and the unless it is emergency no other choice  MoH increase the number to absorb mindset that “midwifery is the women’s  Men could be good midwives because nurses in the public health institutions work” there are also many male doctors in (HC, RH, PH)- mention by all 5 groups  Motivate men, “I’m a man, I am strong, I can Cambodia who do birth delivery of  Increase salary of nursing staff do it” babies. (current $300/mo) to be attractive to  Sports activities/competition at school to  It needs to be promoted and accepted men attract men to study at RTC for male midwives but maybe it will take 65 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery  Men as midwives can help their own family time and their community 7. What can be done  Information dissemination among  Proactive promotion among the IP  There are around 10 IP students to promote the high schools at the provinces with communities about the opportunity to study currently enrolled at Stung Treng RTC enrollment of many ethnic minorities about Stung nursing at RTC and they assimilate with the Khmer more ethnic Treng RTC program and medical  Graduates to be assisted to get the job as students minorities as courses offered and to encouraging nurse, make it easy for the IPs to get work to  The constraints for IPs to study nursing is nurses and the IP students to enroll help family and also the community passing the national entrance exam and midwives?  Poor high school training in remote national exit exam,  Partner with organizations/NGOs working areas make it difficult for IP students among the IP communities, in encouraging  National exit exam (NEE)s are taken at to pass the national entrance exam and promoting enrollment among the IP’s Phnom Penh, students from RTC Stung for medical course high school graduates to study nursing at Treng are at disadvantaged as they have  Discrimination at school, makes the Stung Treng RTC to travel far, spend more money, adjust IPS students ashamed to be identified  Advocate and promote the IPs, educate to environment of the city. as IP, fear of being looked down or them, strengthen  Suggests for NEE to be conducted at discriminated. Stung Treng RTC or at Kampong Cham  Health post at the IP community to promote  Working with government need to awareness and interest among them to send RTC to be nearer to the examinees take the civil service exam their children to midwifery school  Intentional promotion of enrolment to  Special scholarship for IP students,  Fundraising to support the poor, orphan and midwifery among the IP students at the ensure non-discrimination for the IP IPs for medical education high school campuses students  Acceptance and tolerance for the IPs  Free to study at RTC, make billboards  RTC has dormitory free for IPs, have full with message such as “minority can scholarship for IPs study nurse at RTC”  IP medical graduates to be assured of work  For not so smart IPs but are interested and be assigned back in their communities. to study nursing, to provide extra or remedial tutorial to cope with the nursing course. 66 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery 8. What can be done  There are some nursing students with  PWD can study at RTC like normal students,  The school is open to accept the PWD to promote the physical disability enrolled at RTC motivate and give priority to PWDs students as long as they pass the enrollment of  Promote medical courses among the  Give work opportunity for PWDs when they qualification requirements more persons PWD groups and offer scholarship and finished their nursing course  There has been a decrease in the number with disabilities as support for them of students enrolled at RTC Stung Treng.  No discrimination, give priority for PWD, nurses/midwives? Students feel it is difficult as there are  Make classroom and facilities motivate PWD to study conducive for the PWD (PWD friendly many exams and it is not easy for them  Motivate the PWD to study as midwife, school facilities) to pass the national exit exam make the atmosphere conducive for  Assurance of work for PWD medical learning, update quality of teaching  Currently RTC offers free tuition, free graduates housing (1 dormitory for boys and 1  Acceptance and tolerance dormitory for girls, however the space is  Atmosphere of tolerance for PWD, in  Exposure trips to PWD Centers. not enough to accommodate all students, the school  Encourage participation in by these some students stay in the boarding  Full scholarship for the poor and vulnerable groups houses near the school campus. deserving students, PWD  9. What can be done  Medical outreach of students to the  Soft skills course (behavioral science course)  The curricula used at RTC are prescribed to make sure the areas with vulnerable groups for medical students to have the right from MoH which is not updated since curricula for  Include in the curriculum, how to attitude in dealing and treatment of the 2007. The curricula are time-based are nursing and deal, manage, treat and care for the vulnerable people group. and adopted from other countries, they midwifery persons from vulnerable groups  Evaluate the curriculum if respond to Q4 and need to be upgraded into competency education is more (mental disorders, PWD, SOGI) upgrade if needed based curriculum (CBC) responsive/inclusi  Need to revise the curriculum using best  Request for MoH to prepare  Provide nursing care for the vulnerable ve to better international practice but responding to fundraising to support the vulnerable groups in the same manner with the normal include vulnerable the local context. groups (similar to that of like Kontha people and even extra care for them to groups (poorest of Bopha) boost their morale the poor, disable, mental disorders,  Advertise nursing is free for top 30 of  Provide free medical treatment for street children, the year 12 graduates vulnerable people SOGI, etc.)?  No discrimination, extra care for the  Open information to the community to all vulnerable people for acceptance of vulnerable people  Fair treatment, boost the morale of and discourage discrimination PWD enrolled in nursing  Cut down mortality rate of mother and child during birth delivery 67 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery  Free schooling for the vulnerable group 10. What can be done  Greening of the school campus,  Social outreach for students to clean the  Personal Protection Equipment (PPE) not to make sure the planting of more trees as part of public places enough, lack of material support at curricula for students social activities  Environment awareness raising activities school. nursing and  At school wastes or garbage are environment  Curriculum not clear on PPE, midwifery normal, only at hospital practice that  Promote the practice of daily hygiene, sign  Waste disposal system at school use, education have medical wastes which are sorted for dust bin of proper waste disposal, incinerator for burning, burry and promote as contaminated and non- segregation of wastes recycling environmental contaminated. Contaminated wastes sustainability  Minimize, cut down of using plastic, join or are burned in the incinerator, non- (better treatment promote tree planting activities, the contaminated wastes are sorted out of medical waste, importance of maintaining the forest to be recycled or to be buried or occupational decomposed  Stricter the rule and implementation of health and safety, environment ,  Implement and apply what have been etc.)?  Start from self in the environment learned in the school on medical waste management and PPE rule of protection conservation the curriculum garbage bin for general  Sorting of wastes and clinical waste, practice the proper  Explain to medical staff and patients about waste disposal, health and hygiene in each department  Maintain Clean the room regularly, sign board to promote clean and sustainable environment Interview with RTC Director: Tek Leng Soeu Dec 9 2019 (11:00-12:00 nn) -Which are the main ways students and - During the orientation meeting at the beginning of every semester, there is venue where the teaching staff can participate/been consulted teachers and the students express their concerns regarding the school policies. in the decision making of the Faculty? - There is the student council elected by the students and every class elect their representative, these student representatives and leaders bring the concerns of the students to the school management. The student leaders also join the meetings of the RTC management whenever there participation are needed or when there are concerns affecting the students. 68 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery - For teachers they have periodic meeting with the faculty dean and whatever issues plans they discuss, the dean brings up to the upper management of the RTC. In the same manner, whatever are discuss in the management level, the dean would inform to the teachers. -Have the students/teaching staff any The school has just follow the curricula provided by MoH, but in the implementation, the possibility to evaluate/influence the contents teachers supplement the teaching materials with updated teaching content and materials. The of the curricula? RTC Director had also translated the teaching materials from English to Khmer. The RTC had joined the workshop for curriculum assessment conducted by MoH. -Is there in place any mechanism to raise Feed backing and complaints are done in several ways: feedback and complaints? In case it is: how is 1st level- students/teacher could bring their concerns/complain to their class level then to the it working? faculty dean level 2nd level- students/teachers bring up the concern to the RTC Director - Complain box is provided for those who want to give feedback and complain but don’t want to be identified, this medium is not used much. - Complaints and feed back via Face Book Messenger and or Telegram. Complaints are resolved by level it is raised to, those which are not resolve at the lower level are resolve at the Directors level. The use of social media has given opportunity for students and teachers to bring up their feedback to concerned person, office. Is there in place any specific provision to All regular RTC staff have the National Social Security Fund card, which they can use for health promote safety and health at work? care (hospitalization). Safety rules and guidelines are implemented such as having fire extinguishers in the classrooms and offices Personal Protection Equipment for students and teachers during Clinical Practice at hospital (this however is limited) Safety rules, health and hygiene, health hazards are discussed during the orientation at the beginning of the semester -Is there in place provisions to promote fair The RTC provides equal treatment for all students and teaching staff. treatment, nondiscrimination and equal Follow the guidelines of the RGC labour law for the RTC work force. opportunity of students/teaching staff? IP students are given priority in the dormitory accommodation. 69 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery How to improve the quality of Pre-Service 1. Quality of teachers – need capacity development Training for Health Workers? Trainer teacher (preceptors) paid 2,000 Riels per hour (same since 1996) Policy to encourage to increase compensation rate of preceptors The compensation is low affecting the quality of teaching 2. Materials and equipment - Books are of mix language - All teaching documents are English or French, either to translate books into Khmer or the students’ language proficiency need to be improved - Create a committee to translate the teaching materials and documents into Khmer - Standardize teaching materials and translate to Khmer. - Include English subject in the curriculum but the constraints at Stung Treng is the availability of good English teachers and the salary for those teachers 3. Students’ problem - after finishing nursing or midwifery course, no work available for them - decrease in the number of students studying at RTC because no job after they graduate, there is limited recruitment of government, low salary, competition among nurses and midwives is high - Hiring of nursing and midwifery graduates is limited and salary with private clinic is lower - Needs Policy on minimum wage standard - Increase recruitment for private clinics – but no standardized policy on minimum standard policy - $120/month salary for private clinics (20 hour work/day) - $250/month salary for government but limited hiring -What you consider can be done to promote Partner with organizations assisting the IPs in information dissemination and in promoting the inclusion as students and faculty member health course and introduce to them the opportunity to study at RTC. (e.g. more ethnic minorities as Provide information about RTC to secondary schools in the provinces of Ratanakiri, Mondolkiri, students/teachers or more women at Kratie, Preah Vihear, so that students especially the graduating once would know about Stung management level) Treng RTC. The Dean for Midwifery and Nursing are women. Other issues: To enter the medical profession, the students need to take several qualifying exams: - National Entrance Exam - National Exit Exam 70 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery - Exam to enter work with government These exams are theoretical and are of multiple choice questions (MCQ), the quality and type of exam need to be reviewed and improved and with practical exam - Professional Councils to oversee (prepare and conduct) the National Exit Exam (NEE) for their line of profession, i.e. NEE for Nursing to be taken cared by the National Council of Nurses, the same with Medical Doctors and Midwifery. Examinations, Evaluation and Accreditation should be by the respective professional Councils After passing the NEE. MoH issue the certificate but where to register? How to guarantee the quality/qualification of the medical professional? RTC suggests but not being listened to by the upper level 71 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.6 FGD Khmer-Soviet Friendship Hospital FGD Khmer Soviet Friendship Hospital, 16 December 2019 (2:30-4:30) Questions Nurses (20 Participants) Midwives (20 Participants) 1. Existing practices - Medical waste - Hospital provide PPE (masks, of Clinical Sharp wastes-safety box (burn), gloves, apron) but midwives don’t Hazardous waste tissues-yellow plastic (burn) like to use them management chemical waste(burry), - Infection control, always give system, radioactive waste (burry) training but when check/ monitor, Occupational - General waste (black plastic/ bin) to the midwives do not apply health safety Cintri truck (garbage collection truck) - Not enough garbage bin (only 2 (yellow, green) so difficult to sort out wastes, request to upper level but no response 1.b occupational - Follow the RGC law - health and safety - PPE (old, goggles not clear, not enough), PPE are limited, nurses have to provide for their own to keep them safe while performing the duty. 2. Labor - Hospital must have training course for - Russian hospital is higher standard Management nursing staff to upgrade clinical skills 2nd to Calamet Hospital, strict in - Frequency should be often 2 local recruiting the staff, qualified. training, 1 international exposure - Advertizee, interview, exam training. select, hire - CPD is ongoing as required for Nursing - New heard, orientation on License with the National Council for hospital policy, JD, Nurses)l - For regular staff CPD 2 times a year in the hospital and international training for the selected staff - -promotion- discussed at management level, interview, observe, performance, give project assignment - retirement (70% of monthly salary+ NSSF card and send off party) 3. Stakeholders - Hospital Partners (PSE, INP, CCF, NSSF, - Small group discussion at lower engagement H.EQIP, EDC, Operation Smile, Friends level, to upper level if not resolve International) up to the board level (related to the budget) 4. Grievance - More security guards during night - Complain to file, service Mechanism shift department head to the board - Hospital to motivate good performing - Complain box staff with rewards and incentives - Complains include: - Complains are channeled through - Work overload chief of department - Hard work, no rest so many - Want to train abroad patient, asks - Complain box but seldom used as - No complain about sexual channel to complain. harassment 71 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery 5. Recommendation - Increase hourly rate for Preceptors - Not all students are serious in to improve the (clinical teachers) as it is very low. clinical practice, National Exit pre-service - Medical students are more advance in Exam to include practical exam on training for information technology, they search clinical work ex. filling up of Health Workers information on internet than learning patients form, getting of vital clinical practice at hospital. Clinical signs of patients, prenatal check, Teachers need to be updated with and other necessary clinical advance medical practice through practice. training workshop Con’t. FGD Khmer Soviet Friendship Hospital, 16 DECEMBER 2019, 2:30-4:30 Questions Doctors (10 Participants) Decision Makers (10 Participants) 1. Existing practices of Medical Waste: - The hospital follow the Australian Clinical Hazardous -contaminated waste (with blood protocol and guidelines on waste waste management stains and fluid stains) burned in management and disposal and system, Occupational the incinerator. pollution control- the staff in-charge health safety -non-contaminated wastes are are trained on environmental sorted out at workplace then to protection, pollution control and waste management facility waste management and disposal Non-medical waste are disposed - On waste disposal → garbage bins to Cintri garbage truck are labeled for clinical waste and for non-clinical waste. For clinical waste bins there sub-label for contaminated waste and non- contaminated waste. Hospital employees and patients are guided how and where to throw their wastes. The hospital cleaners collect wastes, sort them out. Non-clinical waste are disposed to garbage collection truck. Clinical wastes ate brought to the waste management facility. 1.b occupational health - The hospital follow the Health Occupational Health safety: and safety guidelines on Personal Protection - radiation protection at Equipment (PPE). The hospital operating theater (OT) not provide the PPE to health workers meeting the radiation but some health workers do not use protection standard, need to them all the time. improve wall with radiation protection - need to upgrade clinical protection, supplement the 72 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery lacking clinical supply and to upgrade the OT 2. Labor Management - Competency upgrading ex. - The hospital follow the Cambodian Implementation of safety Labor Law, all regular staff are have procedure. the National Social Security Fund - Continuing Professional (NSSF) card which entitle them for Development (CPD) done by medical care/medical insurance. medical Professional Councils - Staff on probation period are not 2-3 times/year on rotation per provided with NSSF Card but the province. hospital provide them free medical - Teach, present, listen attend care and treatment when they are workshops local and abroad) sick - Nurses training are general- - All staff regular and contractual) sign recommend to specialize contract with the hospital. nursing training. - Regular staff renew contract on a - Most staff are happy, hospital yearly basis, the hospital submit the pay higher that labor law (5 names of staff to MoH for approval times higher) as per recommendation of the - hospital operate as semi- hospital management based the staff private performance evaluation. 3. Stakeholders - Hospital Annual Meeting, - The relationship between and MoH Engagement Hospital management (regulatory) → Medical School (train attended by Department medical workforce → Hospital heads and Board of Directors (absorb Health workforce) is already (BoD) working but need to be strengthened and improved in terms of information sharing - Constraints → everybody are busy with their own activities and targets - This “Pre-Service Training for Health Workers” could be a venue for this key stakeholders to meet together and do the “SWOT” analysis of the for Cambodia’s Health Workers 4. Grievance - Complaint Box - There is a grievance mechanism in Mechanism - There is a grievance place at the hospital but rarely do mechanism but seldom that people made a complaint. there is a complainant - Most staff prefer to keep silent but share the issues with co-workers 73 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery 5. Recommendation to - Teaching and evaluation of - Medical Schools and hospital to talk improve the pre- medical students must be and discuss on how to make the service training for serious-those who does not hospital internship of students Health Workers qualify (theory, practice and effective and useful. behavior) should not be - Medical schools should get feedback allowed to go up to the next on students internship performance year level. (absenteeism, lack of interest) - Medical student needs - The time frame of internship is seriousness, discipline and sometimes shorter than the planned hard work because we deal time frame. Internship is delayed due with people’s lives). to official letter. - There are cases of nurses who - Time is short for clinical practice, are not qualified yet to work- practicum is low quality. very low knowledge, skill and - Students undertaking internship are not good attitude but able to preoccupied with OSCE as they are graduate. Difficult for doctors concerned with passing the National to work with them Exit Exam. The practical experience - More practical experience or or clinical practice are left behind. exposure to clinical practice in - Recommend for Theory and Practice hospital. for National Exit Exam, i.e. to add H.7 FGD PPCIL (PWD) FGD- PPCIL (PWD), 13 December 2019 (2:30-4:00) Phnom Penh Center for UNICEF support for PWD healthcare and rehabilitation, project and Independent Living (PPCIL) is services in areas of: founded by Cambodians with - Information disabilities led by Mr. Mey - Personal assistance from home to HC Samit and promotes rights - ID Poor for easy access to health services - PPCIL has 15 staff, 10 of them have disability, all 15 staff have based approach to disabilities National Social Security Fund (NSSF) by RGC and Ministry of Labor and development aimed at (MoL) to cover work accident and health insurance, premium paid empowering disabled persons by PPCIL for group insurance for 15 staff ($80-$90/month) 10 through the independent living - ID Poor identification card for PPCIL communities in 15 Sangkat from movement. PPCIL Believes that 5 district in Phnom Penh and Kandal province. 2 Sangkat are the most effective way to bring supporting the PPCIL with $75/person/month from the about lasting social change is Commune/Sangkat Fund, 2 PWD per Commune/Sangkat with severe disability are recipient of the C/S Fund support to promote equal Direct beneficiaries 90 PWDs of which 35% are female, medical care opportunities for disable with Health Centers (HC) persons through independent For common sickness → support on medicine is $5/month Living movement. For serious cases → ask dona on from donors (Japan, UK) - Rehab: PPCIL staff help to bring PWD Beneficiary to HC or clinic with PWD easy accessibility Tuktuk (motorcycle trailer) - Personal assistance service: 2 days/week to wash hair, assist in shower, change clothes @ least 2-3 times per week 74 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery - Going out for exposure and live better - PWD have chance to work with PPCIL for advocacy work, negotiate with government specifically with the Ministry of Social Affairs (MoSA) PWDs challenges for going to Inability to take care of self and limited mobility: get medical treatment - Problem of accessibility - Use of inappropriate words by health providers at HC and public hospitals, so that most PWD go to private clinic - Lack of PWD signs at hospitals to guide them what to do and where to go PWDs” expectations from the - Understanding of people with disability, Medical schools to orient health service providers medical students on PWD - Theory and visit program to PWD homes/communities, medical outreaches, interact and hear from PWDs, see their situation Experiences with HC and public - Queuing, waiting time, PWDs are not given assistance to get the hospitals priority number but has to queue in the same way as the normal people, request to give priority to PWD in terms of medical treatment, PWDs have disadvantages in terms of mobility to go ahead of the queue line - Medical secretary (welcoming the patients) to treat PWDs with fairness and no discrimination, not let PWD feel small, please help boost the morale of PWD patients - Even if there is the law for free medical services for identified poor PWDs, still the government hospitals collect service fees from them. - PWD should be treated free but have to wait long, PWD will have to inform the medical staff that they will pay so that they will not wait very long, - Some hospital have very high counter for pharmacy and cashier, difficult for PWD in wheelchair to reach to the personnel Recommendation for Health - Build health facilities that are PWD friendly, with wheelchair ramp facilities and rails - Building design to be accessible with ramp and guard rails - Toilet and bath that are PWD Friendly, spacious to accommodate wheel chair - Signs and guide arrows for PWD - National Accessibility Guidelines (NAG), parking area for PWD should be bigger and L shape (900) for opening the car door, for easy unloading of wheel chair - Most hospitals have good service now, but no signs for PWD to follow where to go, maybe they forgot to consider about the needs of PWDs. PWDs are treated like normal people in terms of queuing for lines. - Provide special places and facilities for PWD including parking space and PWD signs 75 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.8 FGD MRI (LGBT) FGD- MRI (LGBT), 19 December 2019 (4:30-6:00) Micro Rainbow MRI’s vision is to contribute to a world where lesbian, gay, bi-sexual, trans International (MRI) and intersex (LGBTI) people can achieve their full potential in life and have Foundation equal access to employment, training, education, financial services, healthcare, housing, places of faith, and public places and services. - Although homosexuality is not criminalized, LGBT people in Cambodia are regularly abused and subjected to socio-economic exclusion by their families, communities, employers, local authorities, health care providers and the police. As a result, LGBTI people in Cambodia are more at risk of becoming vulnerable and remain poor. SOGIE(Sexual Orientation - Gender based violence (GBV) on Gender Identity and - Social Norms (male and female) Expression)-sexual - Gender norms (male, female and others) Harassment, stigma, bullying and discrimination characteristics LGBT (Lesbian, Gay, Bisexual, Transgender) LGBT Issues in accessing to - Gay community are most vulnerable to HIV, but most of them do not get health services medical treatment. - Fear/shame to go to health service providers because of social stigma, i.e. getting negative treatment from guard, receptionist, nurses, doctors, other patients Fear and shame of being exposed to many people as LGBT person with sexually transmitted disease. - Feeling of discrimination and of being a social outcast - Gay, bisexual, and other men who have sex with men (MSM) represent an incredibly diverse community. However, these men are disproportionately impacted by syphilis, HIV, and other sexually transmitted diseases (STDs). MRI activities for Ministry of Education, Youth and Sports (MOEYS): SOGIE/LGBT inclusion - Included teachers orientation on SOGIE - SOGIE and their Human Rights - SOGIE sexual characteristics - Gender based violence (GBV), LGBT persons are most vulnerable to GBV from family in particular and society.in general UNESCO supported the LGBT initiative on SOGIE orientation &ToT of teachers among government schools Clinics in Cambodia that - Chhuk Sor (White Lotus) Clinic in Battambang –treat LGBT with HIV cater to LGBT (blood testing, provide medicine for HIV patients). PREP pills → HIV prevention medicine; PEP → cura ve medicine - RACHA (Reproductive and Child Health Alliance) – Provide advice and consultation on the use of sexual hormones, but still limited in terms the holistic and comprehensive professional service/advice. There are clinics that prescribed sexual hormones for LGBT people 76 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery but are not registered, there are already some cases of death due to use of these un-regulated hormones/ drugs. Need regulations and guidelines on dispensation, selling and use of dangerous and non- certified sexual hormones in Cambodia - KHANA supported by (UNAIDS) work for HIV prevention, care & support services at the community level in Cambodia, as well as integrated sexual and reproductive health, family planning, maternal child health. Recommendations - Sexual education at schools and should be inclusive to include, LGBT/SOGIE - Orientation on SOGIE at Medical Schools, so that future health workers won’t discriminate LGBT patients - LGBT community would appreciate if their concerns are heard/included and consulted in any health project or socio-economic project. - Social acceptance particularly by health workers - Sexual Right → Right express sexual preference ( Medical Forms on Gender (Male, Female, Others) 77 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.9 Environmental and Social Codes of Practices (ESCOP)8 Environmental Issues Measures Dust, Noise and Vibration Comply with relevant national legislation with respect to ambient air quality, noise and vibration Ensure that the generation of dust is minimized and implement a dust control plan to maintain a safe working environment and minimize disturbances for patients, staff and surrounding community Implement dust suppression measures (e.g. water paths, covering of material stockpiles, etc.) as required. Materials used shall be covered and secured properly during transportation to prevent scattering of soil, sand, materials, or generating dust. Exposed soil and material stockpiles shall be protected against wind erosion; Ensure onsite latrine be properly operated and maintained to collect and dispose waste water from those who do the works; Should not carry out construction activities generating high level of noise during HCF activities, especially when services are being delivered to the clients. Asbestos Containing Materials No Asbestos Containing Materials (ACM) will be used If ACM at a given HF is to be removed or repaired, the HF will stipulate required removal and repair procedures in the contractor's contract. Adherence to best practices regarding asbestos that meet the Good Practice Note provided in the WBG Environmental, Health and Safety Guidelines F to ensure construction worker protection during renovation and demolition activities. Occupational exposure can be avoided by controlling dust emissions, and through use of effective respiratory protective equipment. Contractors will remove or repair ACM strictly in accordance with their contract. Removal personnel will have proper training prior to removal or repair of ACM. All asbestos waste is to be buried at an appropriate landfill. 8 The ECOPs is to be followed by those who are doing the renovation works in HFs e.g. contractor or HF staff. 78 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Protection of Water Resources Location of toilets/septic tanks installation should be at least 30 m away from groundwater sources such as shallow well/deep well; All existing stream courses and drains within, and adjacent to, the Site will be kept safe and free from any debris and any excavated materials arising from the Works. Chemicals, sanitary wastewater, spoil, waste oil and concrete agitator washings will not be deposited in the watercourses. In the event of any spoil or debris from construction works being deposited on adjacent land or any silt washed down to any area, then all such spoil, debris or material and silt shall be immediately removed and the affected land and areas restored to their natural state by the Contractor to the satisfaction of the Health Facilities person in charge. Waste Management Use litter bins, containers and waste collection facilities at all places during works. Dispose of waste at designated place identified and approved by HF management or local authority. It is prohibited to dispose of any debris or construction material/paint in environmentally sensitive areas (including watercourse) Recyclable materials such as wooden plates for trench works, steel, scaffolding material, site holding, packaging material, etc shall be segregated and collected on-site from other waste sources for reuse or recycle (sale). Procurement of asbestos-containing building materials shall be prohibited. Safety Risks During Works The HF/contractor shall provide safety measures as appropriate during works such as installation of fences, use of restricted access zones, warning signs, lighting system to protect hospital/HCF staff and patients against falling debris and other risks. Follow national and good practice regulations regarding workers’ safety. Use of appropriate personal protective equipment. Site Clearing: Cleaning the site The contractor will clean the site carefully and remove all construction waste materials and dispose at designated dumping site. Burning of waste should not be encouraged. 79 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Social Issues Measures Displacement of physical or No construction works will be eligible in case the project activities will economic displacement directly or indirectly cause physical or economic displacement Labor and Working conditions Follow national legislation and the project’s Labor Management Procedures Prevention of Gender- Based Violence Code of Conduct of workers will be signed in line with the project’s Labor Management Procedures Community health and safety The contractor will minimize labor influx of workers through promoting hiring local workers 80 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H.10 Environmental and Social risk screening checklist Proposed Activity: …………………….…………………………………………………………….…………………………… Brief Description: ………………………………………………………………………..……….……………………………… …………………….………………………………………………………………………….……………… Location: ……………………………………………………………………………………………………………… Filled out by: ……………………………………………………………………………………………………………… Organization: …………………………………………..…………………………………………………………………… Date: ……………………………………………………………………………………………………………… Attachments: ……………………………………………………………………………………………………..………… I. Subproject Screening: Has the subproject been screened against the list of ineligible activities? If yes, proceed. If no, screen the sub-project using question 1-3 in the below table. Will the Sub-project: Yes No 1 has potential to cause any significant loss or degradation of critical natural habitats whether directly or indirectly? 2 could affect forest and forest health? 3 could affect sites with archeological, paleontological, historical, religious, or unique natural values? 4 have potential establishment of new buildings or extension of new infrastructures? 5 has the potential to cause full or partial physical or economic displacement whether directly or indirectly? If the answer to any question from 1-5 is “Yes”, the sub-project is ineligible to be financed. II. Areas for Potential Environmental and Social Risks 81 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Will the subproject or any of its associated activities: Yes No Explanation 1 Resource Use Require a large amount of energy, water or other natural resources during project construction or operation? 2 Water Use Extract or use of ground or surface water resources, leading to reduction in the volume and the quality of water available for the public water supply? 3 Water Quality Occur pollution of ground or surface water, via direct or indirect discharges or seepages, or through interception of an aquifer by drilling, cuts or excavation? 4 Soil Quality Create a risk of increased soil degradation, soil erosion or increase in soil salinity? 5 Sensitive Receptors Be located adjacent to the sensitive community area (e.g. school, hospital or medical facility)? 6 Air Quality Have any chance to increase the levels of harmful air emissions including dust? 7 Noise Increase significantly in existing noise levels that will adversely affect nearby community area? 8 Waste Generation Generate solid or liquid waste that could adversely impact on soils, vegetation, rivers, streams or groundwater? 9 Labor and Working Conditions Is going to cause significant labor influx of workers? Will the project use forced labor or child labor? 82 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery 10 Community Health and Safety Would elements of Project construction, operation, or decommissioning pose potential safety risks to local communities? If the subproject includes laboratory related activities, the Yes No Explanation following screening process shall be undergone. 1 Biosafety Level Has the targeted laboratory been assessed for biosafety risks and assigned a biosafety level? 2 Hazardous Waste Management Is there any chance for the generation of hazardous waste during the operation period? 3 Wastewater Management Is there any chance for the generation of toxic wastewater from the operation of laboratory? 4 Hazardous Materials Management Is there any chance for using hazardous materials / chemicals in the operation of laboratory? 5 Identification of risk of existing laboratory Does the existing laboratory have high risk of chemical or biological or physical? If the answer to any of questions is “Yes”, Please prepare relevant subproject specific instruments or subproject’s ESMP together with subproject application. 83 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery H. 11 Outline of Sample ESMP The following are the essential contents that must be considered in the ESMP but not limited to those. It shall refer to the structure of this “Table of Contents” in preparing ESMP of relevant subprojects. Table of Contents 1 Introduction 1.1 Sub Project Description 1.2 ESMP Scope and Development 1.3 Integration of ESMP 2 Potential Environmental and Social Impact Identification 2.1 Environmental Impacts 2.1.1 Air Pollution 2.1.2 Water and Wastewater Pollution 2.1.3 Solid Waste 2.1.4 Noise 2.1.5 Odor 2.1.6 etc. 2.2 Social Impacts 2.2.1 Occupational Health and Safety (OHS) 2.2.2 Community Health and Safety (CHS) 2.2.3 Conflicts 2.2.4 Gender Based Violence 2.2.5 Labor Influx 3 Environmental and Social Management Plan 3.1 Proposed Mitigation Measures Tables 3.2 Monitoring Plan 4 ESMP Implementation 4.1 Institutional Arrangement 4.2 ESMP Monitoring and Reporting 4.3 Schedule and Implementation Budget 4.4 Stakeholder Engagement Plan 84 Human Resource Development Readiness Assessment and Plan for Inclusive Delivery Table of Contents 4.5 Disclosure and Consultation 4.6 Grievance Redress Mechanism 85