2009 Cambodia: Assessment of the HIV/Reproductive Health Programme - Health for Future Work
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In October 2008, three years after the commencement of the HIV/ reproductive health programme „Health for Future Work“, UNICEF commissioned an evaluation to assess progress towards attaining its objectives and to provide guidance for future implementation and programme sustainability. The survey aimed particularly at assessing the level of HIV knowledge, attitudes, skills and behaviour of female garment workers, the capacity of factory health service providers related to HIV, VCCT and PMTCT and whether referral mechanisms are in place and being used.
The five-year programme “Health for Future Work” is a Public-Private Partnership between UNICEF and H&M and is carried out by the Cambodian NGO Women Development Association (WDA). Launched in September 2005, it aims to increase access to reproductive health, HIV and sexually transmitted infections prevention as well as nutrition information and services for female garment workers in twelve garment factories in Cambodia.
The programme builds on a model designed by CARE “Sewing a Healthy Future” and encompasses activities such as peer education, small and big health promotions, libraries, social marketing of contraceptives, training of infirmary personnel and other stakeholders, consultations with key persons and line leaders as well as supervision of peer educators.
Rapid assessments have been conducted in six out of twelve garment factories involved in the programme and in one garment factory, which does not run a health programme. A total of 458 standardized quantitative interviews with female workers have been carried out to assess HIV knowledge and attitudes as well as health seeking behaviour. Focus group discussions with 61 female workers of the six factories participating in the health programme were held to discuss issues concerning knowledge, attitudes, skills and behaviour in relation to HIV and sexuality. An additional 76 peer educators and eleven nurses and doctors of the factory infirmaries have been interviewed to assess knowledge, attitudes and referral systems. Key informant interviews have been conducted with the six programme key persons of the factories and four general managers of the factories in order to gain a better understanding of the programme structures and procedures, its impact as well as strengths and weaknesses. All findings and recommendations presented in this report represent the opinion of the consultant and do not necessarily represent, reflect and accord with UNICEF’s opinion and the opinion of other partners.
The findings of this survey clearly demonstrate that factories are concerned about the health of their workers, appreciate the efforts of WDA, UNICEF and H&M and are interested in implementing the health programme in their enterprises.
The programme is well accepted among female garment workers, as 90% of interviewed female workers participated in health activities. The assessment provides evidence of an increased level of comprehensive correct HIV/AIDS knowledge among factory workers participating in the programme. While 59% of the garment workers, whose factories implement the health programme are able to identify modes of prevention and reject major misconceptions, only 32% of the garment factory workers in the reference factory without a health programme were able to answer all five questions correctly. Furthermore, findings of the survey indicate that some respondents (49%) acquired life skills such as the ability to assess and to solve risks while others (41%) still feel unconfident to handle possible risk situations. In general, focus group discussions provide evidence of a social change within the society as relationships before marriage become more common and accepted. Thus the programme plays an important role in equipping female garment workers with appropriate HIV and reproductive health information and empowering young workers to make informed, healthy choices about their behaviour.
Peer educators and infirmaries are well informed about suitable service providers for HIV and reproductive health issues. However, the survey indicates that the referral component of the programme is not yet as advanced as other parts of the programme since the majority of female factory workers interviewed was not able to name health service providers they would consult related to HIV, sexually transmitted infections, birth spacing, antenatal and postnatal care or nutrition counselling. There are particular uncertainties regarding the health services offered by the infirmaries, whose technical capacity has been build up by the programme.
Over the past three years, the programme has invested a lot in establishing capacities, structures and infrastructure within the factories that contribute to smooth programme implementation and sustainability. Factories can rely on a pool of qualified, influential key persons, skilled infirmary staff, trained peer educators and informed line leaders. While the established communication and supervisory system with each stakeholder group is very comprehensive no formal communication has been established in the factories between the key person, the infirmary personnel, line leaders and peer educators. Thus, awareness of the role and activities as well as internal cooperation and coordination among the various groups involved in the programme exists only to a low extent within the factories. The programme design did not make arrangements for the development of workplans or budgets in the factories that facilitates institutionalisation of the programme and only limited experience and expertise exists in factories in this regard.
Regarding the relevance of the programme, the survey confirmed that the overall UNICEF programme indicator is aligned with the indicator of the National Strategic Plan II (2006-2010) as well as the Millennium Development Goals and refers to the “Percentage of garment factory workers who demonstrate comprehensive HIV knowledge”. WDA operates with annual logframes and in general, WDA activities and outputs of the programme are relevant and consistent with the overall goal and the attainment of objectives. Some shortcomings of the monitoring system have been detected as no overarching programme document exists and indicators to measure life skills, behaviour change, building networks and capacity/structures within companies are not in all cases defined, clear or relevant.
Overall the outcome of the survey demonstrates progress towards attaining programme goals. However, based on the findings effectiveness, efficiency as well as sustainability could be increased by removing some ambiguities and by adjusting some activities and approaches.
In general, the programme should maintain the integrated HIV and reproductive health approach as this is in line with the international debate recognising the strong linkages between these topics and as this conforms to the workers’ needs. However, programme partners may consider setting specific priorities, limiting the topics and content to ensure that employees acquire the intended knowledge. Thus a revision of the monitoring system and a well defined overall target setting may guide future activities and support the effective attainment of programme goals.
Since different activities are being applied by the programme to transfer knowledge to workers the programme should revisit its approach in order to ensure that the majority of workers acquire essential, indicator-related knowledge. While specific health campaigns in combination with small health promotions could provide the workforce with essential knowledge also an adjusted peer education approach would be an adequate approach to reach out to the majority of workers. As the high staff turnover causes a problem in terms of retention rates of trained peer educators, the programme still needs to determine the most efficient approach for factories based on the provided cost analysis.
In the future, special emphasis should be given to highlight possible health services within and outside the garment factories. The programme may consider developing specific information material that outlines existing health services. The programme should improve participation of infirmary staff in small health promotions, strengthen collaboration between peer educators and infirmary staff and invite external service providers to serve as resource persons and to present their services. Partnerships between WDA, the companies and external service providers need to be increased to improve the referral system and the related monitoring system.
Programme implementation and monitoring should be further institutionalised in order to facilitate sustainability. Linkages between key person, infirmary staff and peer educators within the factories need to be strengthened and formalised. Step by step responsibilities for programme planning, monitoring and evaluation should be passed on to factories, which would include the development of workplans and budgets for each garment factory.
The implementation of the Prakas on the creation of the HIV/AIDS Committee in enterprises and establishments and managing HIV/AIDS in the workplace, No. 86 (Ministry of Labour and Vocational Training, 2006) could serve as an entry point to promote sustainability of the health activities beyond the programme period. Substantial technical capacity already exists in the companies that factories could easily utilise to form HIV committees. In close collaboration with the Department of Occupational Health of the Ministry of Labour, WDA should develop an advocacy strategy to inform factories about the content of the Prakas and to facilitate decision making processes within the companies and their respective head offices. The strategy should outline a roadmap for implementing the Prakas including recommended activities, resources required as well as monitoring activities.
Recommendations regarding a minimum package could guide the committees in complying with minimum standards. A minimum HIV health package would include the development, endorsement and dissemination of an HIV policy that outlines the responsibilities and rights of employers and employees and that protects persons living with HIV from stigma and discrimination. In addition, factories should conduct HIV prevention activities -at least for new employees- by infirmary staff, peer educators or external service providers. Contact persons or ombudspersons should be appointed among the workers. Subsequently, factories should ensure functioning referral systems for additional HIV advisory services, voluntary counselling and testing, treatment as well as prevention of mother to child transmission.
The programme aims at utilising existing resources within the factories and complementing and interlinking it with existing resources and services outside the factories in order to achieve its goal. Thus, strategies and indicators need to be reworked, to clarify the purpose of the various partnerships between WDA and the factories with technical service providers as well as stakeholders that are relevant for coordination, advocacy, policy decisions and development assistance.
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