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Plotting an NGO 'exit plan'

Philippe Berneau, the last Cambodian country director of Medecins sans Frontieres Belgium.

AT the end of the month, Med-ecins sans Frontieres (MSF) Belgium will close its Cambodian office after more than two dec-ades in the country. Outgoing MSF Belgium country director Philippe Berneau spoke with the Post about his four years in the country and what the future might hold for health NGOs working in Cambodia.

Could you elaborate on why MSF has decided to withdraw from Cambodia?
The main reason is that our mandate at MSF focuses on unstable contexts, where people are victims of either natural catastrophes or conflicts. And today Cambodia does not fit much with this. We have embarked upon some projects that we could not leave after six months - like HIV/AIDS projects - and at the time we started them it was really an emergency, and the problem was amongst the greatest in Asia. So we had to finish it, and hand it over properly to the Ministry of Health. Otherwise, I think we would have left earlier.

What challenges do you think still exist in Cambodia, and does the government have the capacity to deal with them?
Definitely. Cambodia today is not a country where you have a gap in terms of the health labour force, compared with countries like Malawi and Mozambique, where the prevalence of HIV/AIDS has affected the health labour force. There are not enough nurses [and] doctors in those places. We have enough doctors [in Cambodia]; it's not like 20 years ago. What we hope the government has is a willingness now to deal with remaining health challenges, and for us one of the biggest ones is mother and child health. If you look at the health indicators for the past 10 years, it is one of the few that has not improved. It's even a bit worse compared with 10 years ago, which is unacceptable when you see that Cambodia today has the capital to deal with diseases like HIV/AIDS.

In addition to your HIV/AIDS programmes, what else was MSF Belgium involved in?
The first 10 years was the rehabilitation of the system: training the staff, providing drugs in 10 to 20 hospitals. We built more than 200 structures in 20 years, which is quite impressive. This was until the end of the '90s, [when] there was a basis to start more elaborate projects. We focused on three main issues. The first was malaria in [Pailin, Oddar Meanchey and Siem Reap] where we launched the idea of early diagnosis and treatment of plasmodium falciparum in very remote places. From 2003 to 2006, the prevalence went from 7.8 percent to something like 1.6, so the strategy was very successful.

Then we started HIV/AIDS [programmes] in 2002. And like in many places, there was a reluctance from the Ministry of Health to start providing anti-retroviral therapy to the patients, because it is a treatment for life and at that time was very expensive. The second [objective] was to address new public-health challenges, and diabetes is really a big one at the moment in Cambodia: You have a 10 percent prevalence in urban areas, and in the countryside you have a prevalence of 5 or 6 percent, which is much bigger than HIV/AIDS, which is 0.9 percent.

How do you see the role of health NGOs in Cambodia?
We were able to start the anti-drug-resistant tuberculosis programme very easily here, but we've been trying for three years in China, where it's really an emergency and thousands of people are going to die, and we weren't able to manage it.

There is also a tendency now in many countries ... to have a more structured approach regarding the humanitarian needs in a country. I have to confess that sometimes we come in and say "we want to do this", and we don't even bother asking if this is what [Cambodians] want. It is true that we are very arrogant - sometimes too much. To streamline the action of the NGOs and really try and tackle the challenges of the Ministry of Health is very positive. What is not positive for me is that we need to keep some space for creativity, for initiative. The problem with the NGOs today is that they are funded by donors, so what they do, and I cannot blame them, is follow where the money is going. It's very tricky.

Do you think Cambodia is in danger of aid dependency?
It's a danger, sure. I don't know if it's so much a danger for the government itself, but rather for the people. Our diabetes patients would often say "I wish I had AIDS", because then they would get money for rice and transport to the hospital. It sounds crazy, but this is the reality, and I understand them.

I could see it especially in projects where we stayed 15 years, because after 15 years people think that you are here for life. In a few places where we had to build the capacity for HIV/AIDS, we said we'd do it only for one year. We evaluated those projects after one or two years, and they were functioning. For me it has been very interesting to compare this experience to the experience of [the] hospital where we stayed 15 years - I don't think that the quality of care is what we achieved after one year [in the HIV/AIDS project].

Do you think it makes sense for health NGOs to have an exit plan?
Ideally, yes. But I think that it creates a constructive dynamic to say that you will stay one or two years, then withdraw. Maybe you will come back after that, but at least you are making people responsible, and this is something that we don't do ourselves very often. At the same time, I think that there are some countries where you just can't have a strategy, and HIV/AIDS is a good example. Anywhere where we started HIV/AIDS projects around the world, at the beginning we didn't have an exit plan because there was nobody else. So the exit strategy was built along the road, as the price of the drugs decreased, and it became possible to say we could handle all those patients.




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