Buddhist Leadership Initiative Evaluation 2008-2012, Cambodia (English)

BUDDHIST LEADERSHIP INITIATIVE
EVALUATION 2008-2012
O C T O B E R 2 0 1 2 C A M B O D I A
About this evaluation

This evaluation of the Buddhist Leadership Initiative, Cambodia, took place through a desk review of programme documents, a literature review, and quantitative and qualitative data collection in five provinces: Kampong Thom, Kampot, Siem Reap, Takeo and Prey Veng. Interviews were conducted with key stakeholders and activity implementers including representatives of the Ministry of Cult & Religion, Provincial Departments of Cult & Religion, UNICEF country office & sub-national staff, NGOs, monks & programme participants. A quantitative survey was administered to programme participants in all five provinces over 15 consecutive days in August 2012. Twenty focus group discussions were conducted with programme participants (adults, children and monks) in the same time period. The purpose of the evaluation was to provide relevant, comprehensive and timely data to inform the future direction of the programme and to contribute to national learning.
Acknowledgements
The Evaluation Team extend their sincere thanks to H.E. Dork Narin, Mr Chhoeum Chhad and Mr Ho Silin of the Ministry of Cult and Religion; the Provincial Departments of Cult and Religion Directors and BLI Focal Points: Mr Korm Dampheng, Mr Chum Em, Mr Mom Chandara, Mr Hoeun Yenthy, Mr Vann Bunna, Mr Tan Taychroan; Ven. Oeun Sam Art, Office of the Great Supreme Patriarch of the Kingdom of Cambodia; Mr Hing Yan, Dean of Preah Sihanouk Reach University; UNICEF country & regional office staff: Souad Al Hebshi, Ulrike Gilbert-Nandra, Bunthy Chea, Gabrielle Robens, Usha Mishra and Ada Ocampo; UNICEF zonal child protection staff: Soyorn Choun, Phalla Chem, and Chivith Rottanak; Chanthy Prang, Save the Children Cambodia, Mr San Vandin and colleagues at Partners in Compassion; and the many programme participants, adults, children, volunteers, and the valuable input of the Buddhist monks within communities and at the highest levels in Phnom Penh. The Lead Consultant would like to thank Ulrike Gilbert-Nandra, HIV Specialist at UNICEF, specifically for providing substantial technical support throughout the evaluation and through the process of developing this report. Special thanks also go to Nikki Ward, Mr Savath, Mr Komsath and Mr Phim.
Evaluation team
Jo Kaybryn (Lead Consultant) Hoeun Sopheak (Interpreter) Tong Soprach (Interpreter) Mak Chantanary (Researcher) Hang Phally (Researcher) Prum Viseth (Researcher)
Contents
Acronyms ............................................................................................................................. 9 Executive Summary . ...................................................................................................... 11 Purpose of the evaluation ........................................................................................ 19 Scope and Methodology ............................................................................................. 21 scope .................................................................................................................................... 21 Methodology ..................................................................................................................... 21 Participants profile ..................................................................................................... 23 Limitations .......................................................................................................................... 24 Ethical considerations ................................................................................................. 25 Introduction to the Buddhist Leadership Initiative ...................................... 27 Implementation . ............................................................................................................... 30 Findings .............................................................................................................................. 33 Survey coverage and focus group participants . .............................................. 33
- Participation In Activities ................................................................................................ 36
Relevance ........................................................................................................................... 38
- Relevance to national policies ...................................................................................... 38 - Relevance to UNICEF strategies ..................................................................................... 41 - Relevance to the most vulnerable people . ............................................................... 42
Coverage and Effectiveness ....................................................................................... 44 Efficiency ........................................................................................................................... 47 Impact . ................................................................................................................................. 49

- Spiritual and Practical Support for Vulnerable Children . .................................. 49 - Spiritual and Practical Support for Vulnerable Adults ........................................ 53 - Realised and potential opportunities ......................................................................... 54 - The vulnerability of adults ........................................................................................... 55 - Promoting rights ............................................................................................................. 56 - Stigma & discrimination . ................................................................................................. 58 - The Role of Monks ............................................................................................................ 62
Sustainability . .................................................................................................................. 63
- Management and ownership of the Initiative . ........................................................... 64
Child Protection Issues .............................................................................................. 67 Conclusions ..................................................................................................................... 69 Recommendations .......................................................................................................... 71 Ministry of Cult and Religion ..................................................................................... 71 Buddhist Leadership and Hierarchy . ...................................................................... 72 UNICEF ................................................................................................................................... 74 BIBLIOGRAPHY .................................................................................................................... 75 Survey ................................................................................................................................. 77
List of Figures
Figure 1: Survey participants by province and as a proportion ........................................ 23 of programme participants Figure 2: Detailed information on all evaluation participants by province ...................... 24 Number of Districts, Communes and Pagodas participating ........................... 28 Figure 3: in the Buddhist Leadership by year Figure 4: Numbers of adult and child participants by province (2011) ........................... 28 Figure 5: Annual budgets by province and by year 2008-2012 ....................................... 29 Figure 6: Age distribution of survey respondents by sex .................................................. 33 Figure 7: Ages of focus group participants by province and by sex . ................................ 34 Figure 8: Household size by province . ............................................................................... 34 Figure 9: Household income per month by province . ....................................................... 34 Figure 10: Income per capita per month by province in table format . ............................ 35 Figure 11: Income per capita per month by province in graph format ............................ 35 Figure 12: Annual average income per capita by province . ............................................. 36 Women self-help group members who meet regularly ................................... 36 Figure 13: at the pagoda for meditation sessions Figure 14: Length of time as participants in the BLI by province ..................................... 37 Figure 15: Participation in different types of BLI activities . ............................................. 37 Figure 16: Based on monitoring data 2012 (11) .............................................................. 44 Figure 17: The most important activity for participants by province ................................ 45 Figure 18: Children who meet regularly at a pagoda for support sessions . ................... 49 Figure 19: Children who meet regularly at the pagoda for support sessions ................. 51 Figure 20: A self-help group member with her child ......................................................... 53 Figure 21: The activities considered most important by BLI participants ....................... 53 Figure 22: Expenditure of cash support by sex ................................................................. 58 Figure 23: Proportion of women and men excluded from social activities: . ................... 58 BLI evaluation data 2012 Proportion of women and men excluded from social activities: . ................... 59 Figure 24: Stigma Index data 2010 Proportion of women and men excluded from religious activities: ................ 59 Figure 25: Stigma Index data 2010 Feelings of internal stigma by sex over the last 12 months: .......................... 60 Figure 26: BLI evaluation data 2012 Feelings of internal stigma by sex over the last 12 months: . ......................... 61 Figure 27: Stigma Index data 2010
BUDDHIST LEADERSHIP INITIATIVE EVALUATION
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Executive Summary
Introduction to the Buddhist Leadership Initiative
The Buddhist Leadership Initiative originated in Thailand in 1997 as part of UNICEFs regional strategy for Buddhist engagement in the response to HIV and AIDS in the Mekong Sub-region1. It was launched in Cambodia in 2000 by the Ministry of Cult and Religion, with UNICEF support. An evaluation of Cambodias Buddhist Leadership Initiative was commissioned by UNICEF, in 2007. The programme expanded from seven to 14 provinces over its twelve years and currently 10 provinces participate reaching 2,300 adults living with HIV and 1,500 vulnerable children in 239 communes. These men & women regularly attend self-help group meetings at the pagoda which is preceded by a meditation session led by a monk at the pagoda, usually twice per quarter. The Buddhist Leadership component to reach vulnerable children takes the form of group sessions at the pagoda twice per quarter and children get their transport reimbursed, a small amount of cash support, and materials especially for school. An agreement through Annual Work Plans which have been in place since 2004 have been signed between the Ministry of Cults and Religion, the Provincial Departments of Cult and Religion and UNICEF to provide technical and financial support and capacity building to government staff and monks and the development of training materials. UNICEFs support was targeted to reach adults and children over a longer period of time in order to increase the effectiveness of the response to HIV and AIDS.
Purpose
This evaluation aims to assess the organisational and programme performance between 2008 and 2012, including the Buddhist Leadership Initiatives efficiency & effectiveness. It further sought to review the institutional capacity of the initiative; evaluate the outcome of the programme with regard to the provision of support to individuals and families affected by HIV at the household level; provide recommendations on how to include other areas of child protection; and draw lessons & recommendations for programme adaptation and revision. The evaluation was guided by the OECD DAC Principles for Evaluation of Development Assistance as well as the UNICEF-adapted United Nations Evaluation Group (UNEG) Evaluation Report Standards. It was implemented between July and September 2012 and collected quantitative & qualitative data in five of the ten participating provinces.
Methodology
Field data collection took place over 15 consecutive days in August. The methodology included a comprehensive literature review, key informant interviews with policy makers, implementers and technical support staff, focus group discussions with women, men and children affected by HIV, focus group discussions with monks, surveys of adults affected by HIV, and observations of group interactions and individual behaviours during the data collection. A total of 357 adults and children participated in the assessment: 214 adults in the quantitative survey, 116 women, men, children and monks in focus group discussions, and 27 government, NGO, Buddhist leadership and UNICEF representatives. Preliminary evaluation findings were discussed with representatives from MoCR & Buddhist leadership.
Initiated by UNICEF East Asia and the Pacific Regional Office (EAPRO) and Country Offices, the Buddhist Leadership Initiative was introduced in five countries (Cambodia, China, Lao PDR, Myanmar and Viet Nam) of the Greater Mekong Sub-region between 1998 and 2004 (29).
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Participants profile
The majority of the assessment participants were women aged between 30 and 49, which reflected the wider Buddhist Leadership Initiative demographic profile. In total 154 women and 60 men participated in the quantitative survey, which mirrors that generally more women participate in the initiative than men. Among the 20 focus groups there were 30 women, 30 men and 30 children (18 girls and 12 boys). Among the 214 survey participants there were noticeable demographic differences between provinces. A large proportion (43%) of the surveyed participants had been involved in the programme for five years or longer. Approximately a quarter had been involved for 3-4 years, another quarter had been involved for 1-2 years, and the remaining 9% had been involved for less than 12 months.
Intended audience
Primary users of this evaluation will be Ministry of Cult and Religion, Buddhist leaders and UNICEF. The findings will be also shared with a broader group of relevant stakeholders, including NGOs and development partners, working in the area of HIV and AIDS. The good practices and lessons learned are intended to be used by MoCR, Buddhist leaders and other relevant stakeholders to address the gaps and expand the services to other areas of child protection and inform MoCR on steps to institutionalise and sustain the initiative.
Limitations
Participants for focus group discussions were not selected randomly by the researchers, who relied on Provincial Department of Cult and Religion representatives to select participants. This was also true for the survey participants to some extent as the researchers relied on the Provincial Departments of Cult and Religion to select which pagoda they would visit, but as visits were mostly arranged when regular meditation and self-help group meetings were taking place all members of any self-help group had the opportunity to participate in the survey. There were challenges with the quantitative survey, particularly in relation to interpretation of questions into Khmer. In some cases this was due to emphases altering during the translation from English to Khmer, and in other cases there were differences in understandings of terms or concepts. The majority of these were clarified in the early phase of data collection and in most cases earlier completed surveys could be reviewed and corrected by corroborating responses within each participants responses.
Ethical considerations
All programme participants (adults and children) were provided with written information explaining the purpose of the research and with the researchers contact details. All participants were made aware that their participation was voluntary, that there responses were given in confidence, and all signed an informed consent form. Photographs were taken only of those people who gave their consent, and with the understanding that the images would be used in relation to these research findings and not as part of any widespread publicity material for HIV campaigns or public health messages in Cambodia.
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Findings
Relevance
The objectives of the Buddhist Leadership Initiative were found to be in line with and therefore relevant to national and UNICEF strategies and policy frameworks. At national policy level, the Buddhist Leadership Initiative directly responded to the governments Policy on Religious Response to the HIV/AIDS Epidemic in Cambodia which was the first of its kind in May 2002. Alongside this, other HIV focused policies make specific references to the role of faith leaders including the National Strategic Plan for the Comprehensive and Multi-sectoral Response to HIV/AIDS III (2011-2015) which promotes the role of faith leaders in reducing stigma and discrimination. The governments commitment to the Convention on the Rights of the Child provided the backdrop for introducing the childrens component. This looked at including children affected by AIDS and children vulnerable for other reasons, championing an AIDS sensitive, but not AIDS exclusive approach. Within UNICEF, the programme contributes to strategies and targets in UNICEFs Country Program Action Plan (2011-2015) such as developing national capacity for realisation of child rights, results at greater scale for children, results-based programming, and the support of key interventions for multi-sectoral response in HIV prevention, treatment and care. For the most vulnerable people, the value of the initiative was found to be extremely high and relevant, with almost all of the survey respondents reporting that the spiritual support they had received through the BLI was very important. Noting the rapid decline of HIV prevalence in Cambodia in recent years and the concentrated epidemiological context among key affected populations, the research findings question whether the main objectives are still appropriate given the changing circumstances. Overall, the support provided by the programme remains highly relevant to the most poor and vulnerable community members, but the narrow focus on people affected by HIV means those who are highly vulnerable for reasons other than HIV do not qualify for support.
Coverage and effectiveness

The Buddhist Leadership Initiative financially supported 653 people living with HIV in 2011 to access their medication on a regular basis. Although the programme provides some financial support to child participants, if it also facilitates access to HIV services for children who need them, this aspect was not emphasised in programme documentation or by participants. The cash support that the programme provides to children amounts to approximately $6 USD which is provided twice a quarter, part of which ($2 USD) is to reimburse their travel costs for coming to the session, and the remainder is intended for education and other household needs. Some children of adults in the self-help groups benefit as well from the cash that their parents receive from the Buddhist Leadership, for example, 6% of survey respondents said they used the money to pay for their childrens education (fees and school materials), and 5% of women who received cash said they used some of it for transport costs for education. Overall, according to programme monitoring data, largely output data, nearly all provinces reached or exceeded their quantitative targets. One province reached 78% of its targets, with the main barrier being that trained monks either left the monkhood or moved to another pagoda and were not replaced.
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The initiative provided spiritual care to 2,355 adults living with HIV in 2011 through its activities, and 64% of survey participants said meditation sessions were the most important activity for them. In the same year the programme provided spiritual support to 1,622 orphans and vulnerable children.
Efficiency
Efforts to reduce the administrative costs were discussed at annual review meetings as were comparisons between costs between different provinces implementing the same activities. However, operational costs by the Provincial Departments of Cult and Religion appeared quite high at the time of the evaluation, questioning whether activities were delivered in the most cost efficient way. Further, there were differing views about whether the Buddhist Leadership Initiative activities were formally recognised as part of the Ministry of Cult and Religions workplan which caused some implementers at provincial level to experience their engagement in the programme as an imposition. Related to this, was an overall finding that government civil servants requested financial incentives (allowances in addition to travel costs) which seemed contentious for several reasons and ultimately a disincentive to increase the efficiency of the programme. Cost efficiency varied among the provinces. This was largely due to the way activities were organised, with some provinces organising activities locally at district level requiring less travel from provincial levels. Another reason was that in some provinces selected wats were in faraway districts, necessitating long journeys to transport cash and in kind support to programme participants.
Impact
The Buddhist Leadership Initiative made a decision in 2010 to increase awareness among children of their rights by developing a set of advocacy messages for monks to promote during the group sessions. Monks often used the Five Buddhist Precepts or Virtues to encourage qualities such as loving-kindness and compassion, while discouraging high-risk behaviours. The Dharma (the teaching of the Buddha) was also mentioned as an important vehicle for transfer of information from monks to community members, albeit by only 10% of focus group participants. More members of the focus groups, approximately a quarter, mentioned specific Buddhist teachings, such as aspiring to become self-reliant. On the whole, focus group participants seemed to think that the messages that Buddhist monks give them were appropriate, and a small proportion acknowledged that they would not expect monks to use sexually explicit language to discuss HIV. It seems that the provision of spiritual support by the programme has been highly successful. Spiritual and practical support for adults is provided through the twice quarterly meditation sessions and self-help groups. The practical application of meditating was found effective and mentioned by nearly all of the focus group participants who described how it helps calm them, helps them feel spiritually and emotionally strong, and it helps relieve depression and anxiety. The self-help group activities, whether they focussed on health and hygiene messages or had a more dynamic entrepreneurial emphasis were also valued by the participants. The importance of the dual spiritual and secular approaches of the initiative was mentioned specifically by a small number of participants. The self-help groups seemed to vary in their effectiveness to reduce peoples vulnerabilities. Some had developed overlapping microfinance mechanisms to facilitate loans
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for income generating activities and for emergencies, while others had never heard of a savings and loan club and the nature and content of the quarterly sessions had essentially remained unchanged for many years. There were noticeable differences within self-help groups as well as between them, for example, one-off income generating activities had been implemented prior to 2008 and the members of a self-help group who had been programme participants at the time had benefitted and continued to benefit, while people who had joined the programme later did not get access to the same opportunity. Effects on rights awareness seemed to vary dramatically across the focus group participants with some people citing legislation which should protect people living with HIV from discrimination, despite which they felt that potential employers still managed to sidestep the law. The effects of cash support were considered very important by 83% of the survey respondents and the most frequently cited expenditure was on food. A small number of people used the cash for generating income. Many more said they would like to spend the money on income generation but seemed more compelled to meet their immediate needs of food with the cash rather than make investments which could earn them more income in the future. Almost all the survey participants said that levels of stigma and discrimination had reduced as a result of the activities that involve monks. Meditation sessions and spiritual support from monks seems to have impacted positively on peoples feelings of self-stigma, which overall was reported at lower rates compared to respondents of the Stigma Index survey. Although there were extremely positive effects for most focus group participants of being visited at home by a monk, one participant pointed out that all of the activities inadvertently advertise her HIV status without her consent, particularly the home visits. The visit by the monks is not a quiet private event, it is quite the opposite when a contingent of people descends on a persons home and the monk begins sharing messages about HIV. Whether the Buddhist Leadership Initiative was able to reduce inequalities between the worst-off or most vulnerable and other people was more complex to ascertain. Data was not systematically collected on whether participants financial or social statuses had increased, so any evidence of change was gathered qualitatively in the focus group discussions. Within the same self-help group some individuals discussed increases in economic stability while others had not achieved any improvements. Those that reported improvements cited income generation activities and/or saving and loan schemes as the key factor in changes to their economic situation. At a strategic coordination and partnership level there were Provincial Departments of Cult and Religion that regularly participated in Provincial Department of Health meetings in order to coordinate responses, including with local NGOs, for example in Prey Veng and Kampong Thom. However, close engagement with other government departments and NGO service providers was not consistent across all provinces. Similarly at local level, some of pagodas linked in with existing governance and community structures such as Village Health Support Groups (initiated by the Ministry of Health) while others did not.
Sustainability
Most of the activities as they are currently implemented rely on external donor support. Some one-off or time-limited activities have had profound results and do not need to be repeated consistently, such as the first home visit to a person living with HIV which can significantly reduce stigma and discrimination experienced by the person. The activities seem more likely to be sustainable if they originate from each wat rather than organised by the Ministry of Cult and Religion at provincial level. Monks can distribute donations given to the pagoda to vulnerable people in the local community without incurring the
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administrative costs associated with the provincial level engagement, although the amount of cash support that participants receive is likely to be less than current rates. Sustainability of results could be increased if monks and other implementers more systematically connected participants to other social protection schemes and other existing services. At most levels of organisation of the programme, implementers and participants alike did not seem to claim ownership over the activities, meaning they did not feel in charge. It seemed to them all that someone else was responsible and they did not want to suggest changes or take ownership for fear of stepping on toes. This is potentially most problematic among monks who arguably should be more at the centre of the decision making. A minority of self-help groups seemed to have increased their participation spontaneously by meeting regularly within their communes once a week or more. Recently (in 2011) UNICEF re-iterated that the initiative is only sustainable if integrated into government plans and budgets, but to date most implementers and participants continue to refer to the activities as a UNICEF initiative. However, given the overwhelming value of participants of the spiritual support, the initiative may well be sustained if planned locally, with monks at the centre and even in the absence of external funding support. A challenge may be as to how overall achievements and progress would be monitored and data shared.
Child protection issues

Vulnerable children are supported by the Buddhist Leadership Initiative and opportunities are taken to increase their awareness of their rights such as the right to have a name, to be cared for, to be fed etc. The programmes approach to child protection issues could go further than awareness raising, for example, informing children and parents that children have the right to a name could more be more closely linked to birth registration by monks and implementers providing specific support to register births such as instructions, accompaniment or help completing forms. Currently, the programme promotes messages for a limited number of child protection issues and there is scope for monks at both senior level and at the pagodas to have greater understanding of serious abuse of childrens rights.
Conclusions
The Buddhist Leadership Initiative seems highly relevant to the national HIV policy expectations of religious leaders to engage in the HIV and AIDS response. It has made a significant difference to most of its participants. With the HIV context in Cambodia changing dramatically since its launch, with lower rates of HIV prevalence, increases in access to treatment and an overall reduction in stigma & discrimination, the programme has an opportunity to re-focus its efforts on reaching the most vulnerable and the worst off, which is likely to include many people living with HIV but would also include people who are vulnerable for reasons such as other illnesses and extreme poverty. Monks have a positive influence on both external & internal HIV related stigma experienced by people living with HIV, while the cash support is very important to the poorest participants, at the same time it causes some limitations to the programmes ability to include more people. The more dynamic self-help groups have skills & experience of microfinance mechanisms to share with other groups which create opportunities for learning within the programme. Overall the efficiency of the programme does not compare well with other organisations which are designed to implement similar activities, and its reliance on external donor funding raises challenges to its sustainability. It seems likely that efficiency and sustainability would be increased if ownership of the programme was with the monks implementing the activity at pagoda level, and with senior monks in the Buddhist hierarchy who have the authority and influence to institute its aims and objectives into its networks and education system.
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Recommendations
The subsequent recommendations were developed in consultation with MoCR representatives, Buddhist leaders themselves and UNICEF staff in national and sub-national offices. While the recommendations note the key actors for their implementation, it is important to note that the recommendations are intertwined and related to each other. The full recommendations are articulated in the final section of the report. The following provides a summary of their key emphases.
Ministry of Cult and Religion

To increase relevance the following suggestions are made: 1. Share and discuss the findings of this evaluation with all relevant stakeholders. Initiate a consultative process with all stakeholders that would lead to adjustments to 2. the initiatives approach. To increase effectiveness the following suggestions are made: 3. Continue (and expand) the programme. 4. Encourage the replication of proven methodologies which reduce economic vulnerabilities. 5. Further link its activities with those of others. Redirect resources within the existing geographical areas of programme focus to 6. increase participation. 7. Introduce outcome-based rather than output-based indicators and targets. 8. Share experiences of the successful results of the initiative and learning. To increase efficiency the following suggestions are made: 9. Introduce a strategic coordination role for PDCRs. 10. Further mobilise Buddhist monks and other faith leaders to take on more active implementation roles. To increase sustainability the following suggestions are made: 11. Give the programme a new and fresh identity by re-branding and re-launching it with a wider range of development partners. 12. Place future engagement within Ministry workplans and budgets.
Buddhist Leadership and Hierarchy

To increase relevance the following suggestions are made: 13. Make links between Buddhist teachings and key social issues. 14. Take the lead in helping people realise their rights. To increase efficiency the following suggestions are made: 15. Increase the capacity of monks to absorb implementation responsibilities.
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16. Design and promote cost-effective activities. To increase effectiveness the following suggestions are made: 17. Promote the successful approach of providing spiritual support for vulnerable community members. Facilitate monks increased capacity to identify people and organisations which can 18. support local communities to reduce their economic vulnerability. 19. Identify routes to agreeing and sharing the provision of spiritual support. 20. Increase awareness and training in child protection. To increase sustainability the following suggestions are made: 21. Institute good practices around Buddhist responses to reducing vulnerabilities. 22. Use its leadership networks to explore expanding the role of monks in community engagement.
UNICEF
To increase relevance the following suggestions are made: Noting the rapid decline of HIV prevalence in Cambodia in recent years and the concentrated epidemiological context among key affected populations, the research findings question whether the main objectives are still appropriate given the changing circumstances. Overall, the support provided by the programme remains highly relevant to the most poor and vulnerable community members, but the narrow focus on people affected by HIV means those who are highly vulnerable for reasons other HIV do not qualify for support. Therefore an overall relevance recommendation is for UNICEF to review the objectives and the intent of the programme. 23. Support MoCR in the process of initiating and strengthening dialogue 24. Support MoCR to transition out of the current initiative To increase effectiveness the following suggestions are made: 25. Provide technical support on income generation & reducing economic vulnerabilities 26. Promote the successful spiritual support approaches of the initiative To increase efficiency and sustainability the following suggestions are made: 27. Facilitate capacity building between current implementers. 28. Help identify strategies to institute capacity building within the Buddhist hierarchy. 29. Support the MoCR and PDCRs to transition into a more strategic leadership and coordination role.
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Purpose of the evaluation

The purpose of this end-of-programme evaluation, commissioned by UNICEF, was to provide relevant, comprehensive and timely information to analyse the strengths & gaps in the Buddhist Leadership Initiative in order to inform decisions about the future direction of the programme. The evaluation report is available in Khmer & English and will contribute to national learning and discourse on faith-based responses to HIV and development. The findings of the evaluation will be discussed with national partners to determine whether the value and cost-effectiveness of the programme warrants its continuation, and in the case of continuation whether changes are required to its strategies and implementation. The evaluation will be used by UNICEF and Ministry of Cults and Religion to identify the lessons learned and map the future programmatic directions with a concise national adaptation by the Ministry and exit strategy for UNICEF. Specifically the evaluation aimed to: Assess the organisational and programme performance for the time period 20082012 (i.e. subsequent activities to the earlier evaluation in 2007 as part of a regional process), including its efficiency and effectiveness; Review the institutional capacity and set-up of the initiative; Evaluate the outcome of the programme with regard to the provision of support to individuals and families affected by HIV at the household level; Provide recommendations on how to include other areas of child protection; and Draw lessons and recommendations for programme adaptation and revision;
The following criteria & evaluation questions were utilised to guide the evaluation following the format of the OECD Development Assistance Committees Principles for Evaluation of Development Assistance: RELEVANCE To what extent are the objectives and activities of the programme suited to contribute to achieving the priorities and policies agreed at the national level as well as the strategies of the Ministry of Cult and Religion (MoCR), Provincial Departments of Cult and Religion (PDCR), Orphans and Vulnerable Children (OVC) Task Force and UNICEF (e.g. National HIV Strategic Plan III, UNICEF Country Program Action Plan 2011-2015) as well as human rights (Right to Health, Rights of the Child)? What is the value of the initiative in relation to the needs of the worst-off groups/most vulnerable people? What is the value of the initiative in reducing inequalities between worst-off groups/ most vulnerable people and others? EFFECTIVENESS To what extent were objectives achieved and what were the major influencing factors?
To what extent did the initiative provide spiritual care for families and children infected with and affected by HIV and AIDS (how appropriate are the messages)? To what extent did the initiative contribute to support referral for most vulnerable adults and children living with HIV to access medical care?
Organisation for Economic Co-operation and Development
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To what extent did the initiative contribute to cash support to vulnerable children and what were the results? To what extent did the initiative contribute to promote family based care for vulnerable children as the best option for child care? EFFICIENCY Were the activities cost-efficient compared to other programs that aim to provide support and to reduce stigma and discrimination against families and children affected by HIV and AIDS? Were the activities cost-effective with respect to operational costs? How does the cost-efficiency vary within the programme and why?
IMPACT What are the intended and unintended results of the Buddhist Leadership Initiative? In particular in respect to: The extent and the way the initiative contributed to increased self and community acceptance and to reduced stigma and discrimination against families and children affected by HIV and AIDS; The extent to which the initiative was able to reach the most vulnerable people; The extent to which the initiative contributed to decreasing inequalities between the worst-off and best-off; The contribution to strengthen the rights of people infected with and affected by HIV; The level of impact with respect to HIV knowledge and attitudes towards families and children affected by HIV among communities, Ministry of Cult and Religion & Provincial Departments of Cult and Religion staff, as well as monks; Management and ownership of the initiative; and Achieved coordination and partnerships. SUSTAINABILITY What are major factors that influence the achievement or non-achievement of sustainability of the programme (inter alia role, ownership and leadership of MoCR)? Are the interventions and impacts on the worst-off/ most vulnerable people likely to continue when external support is withdrawn? What needs to be done to achieve sustainability? How likely is it that the initiative will be replicated or scaled up?
In addition, the evaluation considered: To what extent, and how, can the Buddhist Leadership Initiative structure be used to address broader child protection issues?
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Key informant interviews with concerned NGOs (Save the Children Cambodia and Partners in Compassion); Focus group discussions and in-depth interviews with women, men & children affected by HIV, and implementing monks; Observations of participants.
The lead consultant led the qualitative data collection in English & Khmer which consisted of: 20 focus group discussions with 90 programme participants (30 men, 30 women and 30 children: 18 girls and 12 boys) and 26 junior and senior monks (total 116). Focus group discussions lasted between 45 minutes and 1.5 hours. Groups were asked a selection of similar and unique questions, and participants were encouraged to discuss the issues that were most important to them; Semi-structured interviews with 27 representatives of the Ministry of Cult and Religion (1), Provincial Departments of Cult and Religion (17), UNICEF (5), members of the Buddhist hierarchy (2) and NGO stakeholders (2). Questions were based on a prepared interview framework and participants were encouraged to discuss the issues that were most important to them. A team of three researchers collected quantitative data from 214 programme participants (154 women and 60 men) in the five provinces. The survey was conducted in Khmer and took between 20 and 40 minutes per respondent. The evaluation team relied on requests to the Provincial Departments of Cult and Religion to help identify programme participants to take part in the focus group discussions and survey data collection. Nearly all data collection took place at a pagoda. In most instances the participants were attending a regular support meeting for the meditation and self-help group meetings. Provincial Departments of Cult and Religion selected the focus group discussion participants in order to identify six male, six female and six child participants per focus group, and all of the members of the self-help groups were invited to take part in the survey. The focus group discussions were conducted using an interview framework to facilitate responses to similar questions across all groups as well as unique questions depending on their specific contexts and situations. They were conducted in an informal manner, often sitting in a circle on the floor of the wat or meeting space, or at a table with seats in the grounds of the pagoda. Among the childrens focus groups the children were encouraged to discuss what was important to them. The mix of data sources was designed to obtain a diversity of perspectives. In order to increase the level of data accuracy, the data collectors were trained in the data collection tools, and daily debriefings during the field work provided opportunities to clarify categories of responses from programme participants. The quantitative data was input into Excel during the field work so that anomalies or patterns could be identified and followed up in focus group discussions. Basic analysis was performed in Excel to identify proportional responses to multiple choice questions and averages of data related to income levels. These computed results focussed on identifying similarities and difference between responses given by women and men and responses distributed by province. A stakeholder consultation meeting was held at the completion of the of data collection to share and discuss the preliminary findings of the evaluation. Subsequently the survey data was cleaned for errors, and analysed again in Excel with the results triangulated with the qualitative data to both substantiate findings and identify unique insights.
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Some questions in the survey instrument required some clarifications or revisions as the data collection progressed. For example, one of the response options to a question about what activities people participated in was A monk gave me cash. There were differing beliefs about whether monks can handle money so some respondents answered no but indicated that someone else in the programme had given them cash. The question was rephrased during the interviews so it emphasised the receiving of cash as part of the initiative rather than whether a monk specifically handed cash to the participant. An ambiguity was revealed in the same question with the option A monk (or representative from the District Office of Cult & Religion) referred me to a service because the initial translation into Khmer placed an unintended emphasis on referring participants to this service (i.e. the Buddhist Leadership Initiative activities) rather than another service as the question was originally intended. The incorrect emphasis was not identified until the latter part of the data collection. Responses to similar questions within each survey response were corroborated and errors were corrected where possible. For example, some participants indicated that they were referred to another service as above, but later when asked which service they were referred to answered none. In these cases, the earlier response was changed in the data cleaning process.
Ethical considerations
Participation in the data collection was entirely voluntary and this was made clear to potential participants. All participants (including children in focus groups) were provided with written information in Khmer about the purpose of the data collection and the contact details of the researchers and interviewers, and all signed a consent form. When participants were asked to pose for photographs, the researchers emphasised their prerogative to decline. Most agreed to appear in photographs on the understanding that they will be used in relation to these research findings and not as part of public media campaign materials about HIV in Cambodia. A small number of individuals declined to appear in photographs and they were reassured that their decision was respected by the researchers. Photographs were taken only of those participants that consented. The approach taken to interviewing children in the focus groups was to allow children to lead in raising sensitive issues themselves rather than ask direct questions which may have made them uncomfortable. For example, the researchers assumed that most children were affected by HIV and some may have been living with HIV, and did not assume that all the children in any group knew about each others situation or status. Therefore, no questions were asked which would have caused a child to reveal their HIV status or how they were affected by HIV. The researchers did not mention HIV unless the children raised it as an issue first. In some cases children mentioned they received HIV information as part of the initiatives childrens sessions, in which case, the researcher asked them how useful the information was and whether they talked to their friends and family members about the HIV information they received. The researchers asked children about their relationships with friends at school and whether any other children were unkind to them. In one case, a child responded that other children bullied her by saying that she would give the other children HIV. The researcher made no assumption that she was living with HIV and asked her and all the children present about their own reactions to bullying and what they do about it. At all times the researcher encouraged children to speak about what was important to them. The decision to focus on adults in the quantitative survey was motivated by the fact that the majority of programme participants are adults. Children had the opportunity to share their views as part of the focus group discussions.
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A significant proportion (164 or 77%) of people was visited at home by a monk and other implementer although the frequency and number of visits were not recorded for these respondents. The 2007 evaluation noted that monks in focus groups mentioned that home visits were infrequent at that time and constrained by: a lack of material support; a lack of support from senior monks; and a lack of motivation for monks to spend their time on home visits (12). Since then the BLI has instituted regular home visits as part of its activities. In general, according to programme documentation, home visits are made twice per quarter to persons living with HIV and who are too ill or frail to come to the pagoda. Across Cambodia the number of people who are infirm because of HIV has reduced dramatically as a result of increased access to treatment. In most provinces the number of people visited per quarter is less than 30. There was ambiguity about the fourth option on the list A monk (or representative from the District Office of Cult & Religion) referred me to a service because the initial translation into Khmer placed an unintended emphasis on referring participants to this service (i.e. the Buddhist Leadership Initiative activities) rather than another service as the question was originally intended. The incorrect emphasis was not identified until the latter part of the data collection. Initially 173 participants checked this option, but 148 confirmed that they were referred to another service in a later question. The results in the chart have been updated to reflect the lower number.
Relevance
Relevance to national policies
The objectives of the Buddhist Leadership Initiative were found to be in line with and therefore relevant to national and UNICEF strategies and policy frameworks. At national policy level, the Buddhist Leadership Initiatives aims and impacts contribute to achieving a range of the HIV related priorities and policies. The programmes key priorities, agreed on in late 2011, are (13): To improve care and support for people living with HIV To promote compassion for and support to families affected by HIV, & other vulnerable children To provide care and support to vulnerable children, including children affected by HIV The Buddhist Leadership Initiative component that includes vulnerable children was introduced as part of the governments commitment to the Convention on the Rights of the Child which Cambodia ratified in 1992. Recognising that the state has the responsibility to act in the best interest of the child, the government has introduced a wide range of policies related to the care of orphans and other vulnerable children. Over one third of all HIV affected households are caring for a child orphaned by HIV, and there are more than 85,000 children in Cambodia who have been orphaned or made vulnerable by HIV (1). As such the BLI started to promote family based care for vulnerable children as the best option for child care in 2010 and this was piloted in the four provinces of Prey Veng, Svay Rieng, Kampong Speu and Kampong Thom (14). This was undertaken to explore if and how local religious clergy can play a role in promoting family based care among households who have high child dependency ratio and who are economically impoverished or vulnerable for other reasons. As a result of this pilot, the important role of religious leaders was formally recognized in the new government guideline on alternative care.
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commune councils & religious leaders should be supported to maintain a prominent role & ensure that monks play a key role in mobilising the community and reducing stigma (22). In the above context of national priorities & policies which emphasise the role that Buddhist monks can and should have in the response to HIV, the Buddhist Leadership Initiative upholds its relevance because participating monks are perceived by the target group to play a hugely significant role in reaching out to people living with HIV by visiting them at home and inviting them to the pagoda, and by applying Buddhist messages to the context of HIV.
Relevance to UNICEF strategies

The Buddhist Leadership Initiative commenced in the previous UNICEF Country Programme of Collaboration (2005-2010), and has been modified and adapted over the years. It remains relevant to a number of UNICEF strategies and targets as articulated in the Country Program Action Plan (CPAP) (2011-2015), namely: Developing national capacity for realisation of child rights: The programme has contributed to this strategy by promoting child rights across the participating provinces through the Provincial Departments of Cult and Religion & monks engaged in the Buddhist Leadership Initiative. The emphasis on child rights was introduced in 2010, and as a result has raised awareness of child rights among all the implementers and the participating children and their families. The CPAP additionally identifies the strategy of simultaneously developing the capacity of local groups at village level to effectively interact with village leaders, demand quality service provision, and identify local solutions to issues. In this regard, the Buddhist Leadership Initiative has significant potential to contribute to this secondary strategy because of its implementation location at pagodas. However, to date, management and coordination has remained at provincial level with limited engagement of local communities in implementation. Results at scale for children: UNICEFs engagement in Cambodia, prior to the current CPAP timeframe, was concentrated in six of the 24 provinces. The Buddhist Leadership Initiative has contributed to the strategy of more comprehensive coverage by UNICEF by expanding its reach. It currently operates in ten provinces, and over its twelve years has been operational in fourteen. Results-based programming: Systematic data collection has become instituted in the Buddhist Leadership Initiative activities and all provinces provide detailed records of the numbers of adults & children participating in the range of activities every quarter. Learning and knowledge sharing takes place at annual meetings of all provincial level implementers. The quantitative data collection allows the programme to monitor its progress and achievement of targets easily. This is significant in the context of the limited capacity in monitoring evaluation of the Provincial Departments of Cult and Religion, however, it should be noted that currently the targets are all output-based rather than outcome-based This means that the programme records the numbers of pagodas, villages, districts and provinces involved, and the numbers of children and adults in receipt of activities. Support key interventions for multi-sectoral response in HIV prevention, treatment and care: The Buddhist Leadership Initiative has engaged the Ministry of Cult and Religion at national & provincial level in the response to HIV, including through cross-ministry working groups and the development of the first national policy on faith-based responses to HIV. The Buddhist Leadership Initiative is relevant to the following Programme Components and corresponding Key Progress Indicators
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Two focus group participants mentioned that the first precept conflicts with income generating activities that involve livestock. They explained that the monks promote the message that they should not take life, not even from the smallest bird, while at the same time the participants are or have been encouraged by Buddhist Leadership Initiative representatives or NGOs to breed chickens and other animals. Given that vegetarianism is not a deliberate practice by Buddhists (some participants said they could afford to eat meat only rarely) or Buddhist monks to any significant degree in Cambodia, these participants did not seem highly conflicted by the opposing messages but they acknowledged the dissonance. The Five Buddhist Precepts or Virtues to encourage qualities such as loving-kindness and compassion, while discouraging high-risk behaviours that were mentioned by both monks and participants in focus groups were: 1. 2. 3. 4. 5. Abstain from taking life. Abstain from taking what is not given. Abstain from sexual misconduct. Abstain from false speech. Abstain from fermented drink that causes heedlessness.
The extent to which the Initiative supported referrals

In the fourth quarter of 2011, the BLI provided financial support to 653 people living with HIV to access treatment. Among the 214 survey participants, 133 said they were referred to HIV services and 60 said they were referred to health services for non-HIV related matters. The programme provides some financial support to child participants ($6 USD which is for their transport to the sessions and to spend on education or other household needs) but it does not explicitly provide financial support for children living with HIV to access treatment. One monk and a handful of participants mentioned that monks discuss PMTCT services but no data was collected which could indicate whether messages around PMTCT create referrals in practice. In the context of the Buddhist Leadership Initiative referral support means helping a person living with HIV with financial resources to collect their antiretroviral therapy from a hospital or clinic on an on-going basis. This is a different definition from the more widely used understanding in that a referral is the process of directing someone to medical care, and once that person has been connected to the medical service that they require the referral is complete.
The extent to which the Initiative contributed to cash support to vulnerable children
As mentioned the children participating in the BLI activities received a small cash benefit of $6 USD for their transport costs to attend the sessions at the pagoda, and the remainder is intended for education and other household needs. Children did not participate in the quantitative survey so detailed information is not available on the expenditure and results of the cash support. However, anecdotally, in the focus groups with children, most said they give the money to their parents who do the household purchasing and manage household budgets. One boy who lives with his grandmother spends the money himself by buying food and he explained that he likes to be able to use the money this way and feels proud to be able to bring food to his career.
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Some of the children of adults participating in the self-help groups also benefit directly from the cash that the adults receive. Five per cent of women who received cash said they used some of it for transport costs for education; 13 people (6%) said they used the money to pay for their childrens education (fees and school materials); and two people said they bought medicine for their children.
The extent to which the Initiative promoted family based care for vulnerable children
Monks in focus groups reported promoting messages about good parenting skills among adults with children, particularly by giving encouragement to children. In this way the initiative promoted more caring family environments. This must be understood against the background of a pilot where in 2010, UNICEF supported PDCRs in five provinces to pilot in selected communes the support to testing a new government guideline (Prakas) on implementing the Alternative Care Policy. This test saw monks assisting families in crisis situations and thereby linking the BLI to the evolving child welfare system under the Prakas. This process included the training of all five PDCR, MoCR focal points and monks from the 10 communes on the Prakas new procedures. During this time, monks conducted home visits to 340 families which were believed to be at risk of separating from their children and provided moral, spiritual and small cash allowances (one to three times per family per quarter). Monks worked closely with commune council focal points for women and children and district social workers. Small, regular cash transfers of $10 USD per family were used to support vulnerable childrens basic needs and education. A review of programme documents found that field visits demonstrated that the support from monks was well appreciated by government, commune workers and, importantly, vulnerable families, many of whom were affected by HIV. The decentralized approach greatly assisted in the forging of a high degree of involvement and ownership by PDCRs. Moreover, visits by UNICEF staff to Tep Vong, the Great Supreme Patriarch of Cambodia, also supported this collaboration and revitalized high-level support within the Buddhist fraternity for this initiative. As a result of this pilot, the important role religious leaders play in protecting children at the community level was formally recognized in the Prakas
Efficiency
Support to orphans and vulnerable children was noted to have significant variances in spending between provinces in 2010. Participants were asked to review the operational costs and reduce them where possible and a target limit was set of 25% for operational costs in 2009 (24) and reiterated in 2011 (14). There are potential inaccuracies in the monitoring of participants and therefore the calculations of the costs of activity per person. An effort was agreed in 2009 that Provincial Departments of Cult and Religion would reduce the likelihood of double counting of orphans and vulnerable children by preparing a master plan which would include all children who are enrolled for support (25). Other issues of efficiency were not clarified in the evaluation, for example, there are costs associated with providing cash for transport (referral support) to people living with HIV to access treatment. The costs are for travel and allowances for a Provincial Department of Cult and Religion representative to make a visit to each of eight districts once per quarter to distribute the cash to 80 participants receiving this support. It is not clear why there are separate costs for a person to deliver this support when presumably the cash could be given to participants at the meditation sessions/self-help group meetings or during home visits.
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The cash payments to programme participants are potentially divisive between those who get a cash benefit and those who do not, and are one of the reasons why the monks and Provincial Departments of Cult and Religion find it difficult to include more people in the activities that take place at the pagoda. They find it awkward to try and explain why most of the participants receive cash for coming to the activity and some do not. Another challenge related to the cash benefit is that it is given to all self-help group members and vulnerable children participants regardless of whether income is one of their priority vulnerability factors. In identifying children to participate in the programme, income is among the selection criteria, however, among both adults and children it is hard for the Provincial Departments of Cult and Religion to differentiate which participants are poorer than others. From the focus group discussions and the survey data it seems that some of the participants are living in severe poverty and that the cash helps them significantly. However without facilitating any routes to increase their income on their own, the practice of giving cash seems likely to be needed indefinitely for some of the participants. Although in earlier joint reviews of the programme, Ministry of Cult and Religion & UNICEF agreed that the Buddhist Leadership Initiative would be integrated into the ministrys workplans, there seemed to be mixed views within Provincial Departments of Cult and Religion as to whether this had happened. One Provincial Department of Cult & Religion director was confident that the programme had been integrated into its work plan, while others were adamant that it had not. Regardless of whether the activities are integrated into workplans, a senior representative from the Ministry of Cult & Religion highlighted the fact that the ministrys structures are not designed to implement a programme of this nature. This accounts in large part for why the activities are implemented with higher costs compared to other initiatives of a similar nature: the Buddhist Leadership Initiative activities are not part of the ministrys core business, and every activity that a provincial or district representative participates in incurs allowance and travel costs for each person per activity. A comprehensive cost comparison with a range of other implementing organisations was not possible within the time constraints of this evaluation; however the costs of the home visits within the BLI were compared to home visits of an NGO. Essentially the NGO could make 10 times the number of home visits per quarter as one of the Provincial Departments of Cult and Religion. In 2009 the costs of home visits in the programme were reviewed and found that on average, home visits cost $35 USD to deliver $20 USD (24). A maximum target of 25% for administrative costs was set for home visits in 2009 (24). Some cost-comparison tables/ charts were included in an annual meeting report which highlighted the variances in expenditure between provinces for the second quarter of 2011 (26). Some of the differences seem to be caused by the differences in distance that monks had to travel to visit people, and the suggestion was made that more pagodas should be involved, particularly those more local to where people live. Overall it seemed that there was some tension between UNICEFs expectations about how the provinces spend and monitor their budgets (14) (26) and the provinces capacity to increase their efficiency. The 2010 annual review meeting discussed the difference between the costs to provide meditation sessions between two provinces when they reached the same number of people. The suggestion was made that provinces that spent more should review the situation with the staff that manage the activities to find ways to achieve the same results with less money (14). The efficiency of the programme is hampered by the distribution of incentives both to the implementers and the programme participants. Incentives are requested by the government to perform tasks and providing them is common practice in Cambodia, similar to sitting fees or meeting fees given to government officials who participate in external meetings in other countries. Therefore, implementers (i.e. representatives of Provincial Departments of Cult and Religion and District Offices of Cult and Religion, volunteers and monks) receive an incentive and their travel costs for each activity, as do the programme participants. The payment per person for carrying out activities creates a disincentive among implementers to increase the efficiency of the programme and reduce implementing costs.
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Group sessions for orphans and vulnerable children are usually held at pagodas twice a quarter for up to 30 children at each pagoda. The format consists of a monk leading the children in meditation for five to ten minutes and then providing advice on appropriate behaviours, such as paying attention in school and to teachers, and respecting older people. A representative from the Provincial Department of Cult and Religion or District Office of Cult and Religion gives the children advice about hygiene, health and nutrition. A decision was made in 2010 to increase childrens awareness of their rights as part of the programme. Advocacy messages for monks to share during the support sessions with vulnerable children, including children affected by HIV, were agreed at the 2010 annual review meeting (27). In one pagoda, children were informed of their rights through a written letter which was sent to their home so they could discuss it with their parents or guardians.
Advocacy messages for monks to share during support sessions for vulnerable children 1. Children and adults who have HIV or another chronic illness have the same rights than all other people and deserve respect and compassion. 2. All children have four fundamental rights: You should not suffer discrimination. Your best interests should be at the top of the agenda when decisions affecting you are being made. You have the right to survive and develop. This includes the right to mental and physical well-being. You should be free to express your views. And these views should be taken into account in all matters that affect you. You have the right to have a name. The birth of any child should be registered with 3. the commune council within 30 days after the child is born. You have the right to be protected from physical and mental injury and abuse, and 4. from neglect, whether youre living with your parents or other approved caregivers; no one should hurt you. HIV is not transmitted by everyday contact. HIV is not transmitted by: hugging, 5. shaking hands, everyday contact, sharing bed or food, mosquito and other insect bites. Education gives you choices & the confidence to take advantage of those choices. 6. 7. Education is not just good for you as an individual. If you are educated, you can share what you have learned with your family and friends. Washing hands with water alone is not enough! Proper hand washing requires 8. soap and only a small amount of water. Hand washing with soap can prevent diseases. You have to wash your hands at two critical moments: before touching food and after using the toilet, and always with soap! You should wash your hand while signing Sa-at cheanich.
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negotiated with the head teacher for her granddaughter to register at the school at no cost. But having successfully achieved this, she did not dare to try and negotiate any other discounts (i.e. for fees for the private afternoon schooling). The girl has one notebook for her school work which she writes in for all her subjects. She grows some vegetables and can sometimes sell them for 500-1000 riel ($0.12-0.25 USD). In contrast another girl in the same group lives with her mother who owns a food stall selling noodles and earning approximately $5 USD a day. Her mother has successfully negotiated all of her daughters afternoon private schooling for free with the teachers. The girl also earns money herself with her friends when she is not at school by carrying bricks from the factory to the truck; they earn $2.50 USD per day which they share between them. The isolation of the girl living with her elderly grandmother with zero income except the occasional sale of some vegetables and living off the goodwill of her neighbour made her seem exceptionally vulnerable in comparison to her peers in the same group. But the activities at the pagoda did not seem to meet her specific needs. She seemed to be in a precarious position and in need of food and safe adult supervision. The sessions at the pagoda provide her with peer support, friendships and good advice, and she receives $6 USD (twice per quarter) and some in kind support such as school materials. However, this support does not address the underlying causes of her vulnerability. All of the facilitators and monks who supported the childrens sessions seemed committed and enthusiastic about the activity. But there were instances which raised questions about the level of training in and understanding of inclusive practices among some of the group facilitators. During a session for children in which a monk provided advice, there were children loitering at the doorway and some sitting inside the wat that were ushered outside by a facilitator because they were not OVC before the monks blessing took place. It is understandable that children that are not officially part of the programme would not receive the resource-constrained aspects such as the money for transport but it seemed unnecessary to reject them from the activity. In another instance, a number of children among a large group were instructed to stand up and the facilitator explained that these were taking daily medication, presumably identifying them as living with HIV. None of the children standing or remaining sitting had any noticeable reaction to this announcement, but nevertheless it seemed to be a breach of the privacy of the children if they were living with HIV. Even if everyone in the group already knew that they were living with HIV, identifying them to a group of visiting strangers (i.e. the researchers) showed a lack of judgment and understanding regarding the childrens right to confidentiality. Overall, the outcomes of the childrens sessions were dependent on the skills and abilities of the facilitating monk and Provincial Department of Cult and Religion or District Office of Cult and Religion representative. Where a monk engaged with the children outside of the six-weekly activities of the Buddhist Leadership Initiative, children were lively and talkative about their participation and experiences. Where childrens participation was limited to the six-weekly sessions there were varying responses. One group of children was visibly supportive of each other, as they chatted and planned who would ride on which bicycle on their journey home after the focus group discussion. In other cases, children respectfully expressed their appreciation for the sessions but their near-identical responses could be interpreted to reflect socially desirable bias (the tendency of respondents to answer questions in a manner that they think will be viewed favourably by others). Stigma and discrimination remains an issue for some children, whether they experience victimisation at school or whether they prefer to keep their visits to the pagoda a secret.
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citing meditation sessions as the activity that was most important to them. There is some ambiguity about the data because the meditation sessions by default also include the self-help group meetings which was not articulated as a specific activity in the programme documentation and was therefore not included as an option that participants could choose in the survey.
Two strings intertwined make a stronger rope

The practical application of meditating was expressed by nearly all the focus group discussion participants it helps calm them, it helps them feel spiritually and emotionally strong, and it relieves depression and anxiety. Depending on the skills & experience of the monk, some participants have learned a great deal of Buddhist philosophy & meditation skills. Some reported applying the meditation practices and chanting at home, and described its impact on reducing domestic violence. One man said that he no longer lashes out at his wife if he gets frustrated with her. Not all the participants showed the same depth of understanding of Buddhist practices and messages but all highly appreciated the opportunity to come to the pagoda. Self-help group is the term that all the participants used to describe the gathering that takes place immediately after the meditation session, usually where the messages about health and hygiene are shared by a representative of the Provincial Department of Cult and Religion or District Office of Cult & Religion and other activities may take place, depending on the group. The contents of these sessions varied greatly, again depending on the skills and activities of the facilitator as well as the expectations of the participants. The importance of the dual approach of the activity the spiritual support provided by the monks and the health and other information provided by the Provincial Department of Cult and Religion or District Office of Cult and Religion representative was summed up by one of the male participants who said that the combination of both inputs was akin to two strings intertwined to make a stronger rope. Programme participants repeatedly stressed the importance of the meditation sessions. The invitation to come to the pagoda and learn the Dharma from a monk has significant meaning to many. It is a privilege to be invited, and that act of inclusion for people living with HIV who were experiencing isolation and rejection is extremely important.
Realised and potential opportunities

The differences of impacts of the self-help groups were also noticeable within groups as well as between groups. There had been an income generating initiative prior to 2008 in which self-help group members in some pagodas were given a $50 USD loan to invest. One woman described buying five or six chickens with the money and could now count nearly 40 chickens. She and three fellow focus group participants reported that they thought that the emphasis on the money being a loan was to ensure that they invested it wisely. However, they said they had never been asked to pay it back, even though they calculated that they could now afford repayments of $10 USD per month. Another woman in the same focus group said she had not had been a member at the time the income generating money was given out and that she would welcome the opportunity to get a loan. An opportunity presents itself at this self-help group for a revolving fund that has not been capitalised on. The earlier comparisons of average per capita income show that all the participants are likely to be in the second lowest quintile in terms of poverty levels. Nevertheless, the improved financial situation of some members who can afford to make loan repayments raises the question of whether all participants really need the travel reimbursements for visiting the pagoda and collecting their medications. The fact that some people have improved their circumstances should be recognised as a success, and if financial support is withdrawn appropriately from them, new members can be brought into the programme. The programme should be aiming to move people from a position of most vulnerable as a matter of policy.
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There was a difference noted between the current activities of the Buddhist Leadership Initiative and the practices reported by people living with HIV in the 2007 evaluation. Most of the people living with HIV in the focus groups in the earlier evaluation said they belonged to a self-help group that met regularly at a pagoda. The focus seemed similar to the current programmes self-help group content: advice and discussions about health care, hygiene and taking antiretroviral therapy. The people living with HIV surveyed in 2007 said they were encouraged by monks to contribute money to the group to help individual members in the case of emergency. Among the monks surveyed at the same time, 49% said they met with the groups once a month, and 19% reported weekly meetings (12). The 2007 evaluation reported that the rationale for introducing the self-help groups was linked to the economic impact that people living with HIV experienced as result of their status. When asked, in 2007, who assisted them most with their economic problems, 32% of people living with HIV said family members, 28% said NGOs, and 10% said wats and monks, although 59% of self-help group members also said that monks provided income generating support for their group. At one end of the spectrum, the self-help groups showed a high level of autonomy and organisation by sub-dividing into smaller groups according to the members village/commune, and with elected leaders. These smaller local groups met regularly outside of the programmes activities, and the members demonstrated high levels of financial literacy with multiple types of savings and loan schemes. In response to questioning about the high levels of activity in the active self-help groups with savings and loan facilities, the facilitating monk said that the people in the area were particularly entrepreneurial and self-organised. They lived close to a major tourist destination which offered opportunities for employment and income earning. At the other end of the scale, the activities did not seem to reflect any definition of selfhelp group: they were one-way information streams from facilitator to participant, and the information given did not change over time. Male participants of one focus group described coming to the pagoda twice per quarter for eight years and receiving the exact same messages on health, hygiene and reminders to collect their medication. These and other participants said they were too shy to make suggestions in the group, and in most cases there was no opportunity for discussions or to make suggestions. They said they were too afraid to go off-topic and talk about anything other than their health. Among the male focus group participants mentioned, none had ever heard of a savings club. When asked about what they might do if they could have some help increasing their income, two responded they had no idea; that they had never thought about; and that no-one had ever asked them before. The self-help groups should provide a support network for the members and facilitators to help each other solve their challenges, whatever they might be.
The vulnerability of adults

The question of whether the initiative has reduced inequalities between the worst-off or most vulnerable people and others has a more varied response. Although the activities increased peoples feelings of inner strength as reported by approximately half of focus group participants, it seemed to reduce inequalities for some but not all of the worst-off and most vulnerable people. An obvious measure of inequality is income disparity, which, as already mentioned, had become a key factor for many people living with HIV. At one pagoda, four out of six participants in the focus group reported increases in their financial situations as a result of self-help group activities, while the other two members had not achieved the same improvements. The range of activities that take place within the self-help group meetings, which happen immediately after the meditation sessions, was highly variable. Where self-help groups facilitated savings & loan facilities, or participants benefited from income generating grants in an earlier iteration of the programme (pre2008) there were examples of women and men who had turned around their situations of financial instability and poverty. However, this success was achieved inconsistently both between provinces and also within individual self-help groups. So while for some of the participants the initiative has reduced inequalities it does not seem to have a deliberate or comprehensive strategy for doing so.
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Similarly to the disparity in circumstances among members of the childrens groups, there were notable differences in the economic and health stability of adults within some of the self-help groups. Statistically significant data was not collected in regard to improvements in economic situations, but during focus group discussions and quantitative surveys where the lead researcher had the opportunity to ask more in-depth questions, very different situations were reported by participants. The four women who had received a loan in 2008 reported significant improvements in their health and financial situations, enough that they said they would easily repay their original loans within five months. At the same time, one woman in the same self-help group who was interviewed for the quantitative survey described her precarious circumstances in which she had no regular income and she could not afford enough food or medicine for her child who was frequently sick with malnutrition.
Some participants are extremely impoverished One woman described her financial instability which was mired in some confusion about the support that she was getting. With no regular income and poor health, she reported that the Buddhist Leadership Initiative referred her to another NGO which provides her with 25kg of rice per month. She has to find the money for travel costs to go and collect the rice. But the organisation gives her $2.50 USD for travel costs to collect her antiretroviral therapy, so she does not get travel costs for clinic visits from the Buddhist Leadership Initiative. She knows she is likely to spend the money she is given on her childs health because he is consistently malnourished and frequently sick. Five of her six chickens have died because of some unknown disease, and if she does not find the money in time to pay for her travel to collect her medication she will have to sell her last chicken. When asked if she had told anyone in the self-help group about her predicament she said that she dare not speak up. It is more complex cases like this where people have heightened vulnerability and lack confidence to ask for help that the self-help groups can play a greater role in identifying and supporting individuals in need.
Another issue was raised by approximately one third of focus group participants about the divisiveness that the programmes focus on HIV can cause. The perceived favouritism by NGOs and programmes like the Buddhist Leadership Initiative towards people living with HIV causes jealousy and sometimes conflict between them and other poor members of their communities, and people with other illnesses such as diabetes. When a disaster such as flooding takes place, the Cambodian Red Cross will often deliver resources to the village chief. Whether because of the chiefs own prejudices or as a result of pressure from community members, people living with HIV in receipt of other services are often overlooked when the resources are distributed. This raises the issue of whether living with HIV should be the sole or even main criteria of vulnerability for the Buddhist Leadership Initiative. A deeper analysis of vulnerability could see the programme activities reach the most vulnerable among the community members. Although there are defined criteria for childrens vulnerability (within which being affected by HIV is one aspect) there are no written criteria for identifying adults vulnerability. If low income and health needs are part of the criteria, undoubtedly many people living with HIV would qualify for Buddhist Leadership Initiative support, particularly those that have sold all their assets or cannot work frequently because of poor health. However, the programme would be able to broaden its scope to help more people who are most in need.
Promoting rights
Among focus groups, adult participants showed varying levels of understanding about their rights. Six men in one focus group discussed the fact that they are required to undertake a number of health tests (which include a HIV test) for some employment positions. They feel that they are discriminated against by employers when they know they are living with HIV. They said that they knew about Cambodia laws which prohibit discrimination based on
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HIV status; however potential employers never cited HIV as the reason for declining employment so they could not see a way that they could use the law to help themselves. While this illustrates the frustration of people living with HIV and the subtle discrimination that they may face, the fact that this group of men were aware of the laws was in sharp contrast to all of the focus group discussion participants in other parts of the country. Rights are hard to realise when you do not know you have any One woman described a situation where she was owed $200 USD by a company that she worked for over a number of months harvesting rubber. The foreign owner of the company claimed that the local man responsible for distributing the salaries had been given her wages, while the local man claimed that the owner had not given her wages to him. When asked who she had asked for help she responded that she had never asked anybody to help her with this situation. She had not told the self-help group members, nor had she sought help from any other organisation or authority. She believed that she could not ask local governance structures for help because she had not sought permission from them to go to the other area to do the work. She gave up on trying to claim the money that she was owed, even though this would have made a significant difference to her financial circumstances. Her experience, and her lack of courage and resourcefulness to resolve the issue, reflects timidity in the face of perceived authority that was noticeable from comments made about other circumstances by a number of participants of the focus group discussions.
Cash support
The cash support is desperately needed by many participants, but not all, particularly those who have access to savings and loans clubs, have more adults in their households earning incomes, and those who have gainful employment. The cash support creates a number of challenges for the programme. Being limited to usually 30 participants per pagoda, it means that it is difficult for the Buddhist Leadership Initiative facilitators and monks to draw in more people to the meditation sessions and self-help group meetings because they find it difficult to explain to new members why most of the people present will get cash, and the newcomers will not. It also causes divisiveness among other community members. One person described a situation in a village where the chief expects to receive money at programme events because everyone who comes to the meeting at the pagoda in his village gets cash support. If one of the group members does not come to the meeting, the facilitator feels obliged to give the chief that persons allocation. This raises another issue that is not explicitly stated in programme documentation: that of whether or not the cash support is a conditional cash transfer meaning that it is provided on the condition that the person attends the session at the pagoda. In the example above, if someone does not attend the session at the pagoda then they do not receive the cash support. However, in another district, the fact that someone does not attend the session does not exclude them from receiving the cash support. The coordinators take the view that not attending a session could be an indicator that the person is facing some difficultly, for example, they may have become unwell. In these instances they ask another member of the self-help group to take the cash to the absent person and check on them to see how they are doing. Cash support was checked as the most important activity by only 15% of survey respondents, when the component was singled out and participants were asked to rate its importance, the majority (83%) said it was very important and 13% said it was somewhat important (none said it was not important). The most frequently cited expenditure of the cash support was on food, followed by donations to the pagoda. Buddhist tradition includes the regular giving of small donations to pagodas, either money or in-kind gifts, which monks
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Stigma indirectly related to HIV

Although 98% of survey respondents agreed that HIV related stigma and discrimination has dramatically reduced, focus group participants discussed animosity towards them within their communities which they attributed to the perception that people living with HIV receive more help than other vulnerable people. In some cases they described the reaction of other community members as a form of jealousy, and in other cases they recounted the complaints of people living with other serious or debilitating health concerns such as diabetes who do not receive help from the programme.
The Role of Monks

Approximately a quarter of focus group participants reported that they greatly appreciate the inputs of the monks who speak to them about HIV in the context of the five Buddhist precepts. Some of them were able to recite the precepts and explain how they related to HIV messages. They see this as relevant to messages about HIV prevention and providing care and support to people living with HIV. Additionally, as already mentioned, the meditation practices help some participants apply calming techniques when they are frustrated or depressed outside of the meditation sessions. The women of one focus group explained that they still experience ups and downs in their moods between the meditation sessions but that these feelings are much less exaggerated than previously.
Opposing perceptions of Buddhist practices

All of the survey participants except for one said that they thought the Buddhist monks were knowledgeable about HIV. Some of the monks explained that they are constrained by Buddhist etiquette in discussing HIV related issues using sexually explicit language, including the use of the word condom. A senior member of the Buddhist hierarchy during an interview for this evaluation explained that this is a misconception among both monks and Buddhist practitioners; and that a monk may use language that could be described as sexually explicit if there is a valid purpose such as explaining HIV prevention issues. When this idea was put to the monks who had said there were language constraints, they replied that that was not their understanding. A similar difference in perception existed about whether monks are allowed to physically hold money. Some monks said that they can use cash as long as it does not change their attitudes towards money. While some monks and many community members said they believe a monk cannot hold money under any circumstances. There are smaller numbers of Dhammayut monks whose order forbids them from handling money, although this sect is in the minority. This has implications for the activities which include giving cash to participants, and the number of people that need to be involved, i.e. in some pagodas there was an expectation that monks could not implement any activities on their own because they would always have to have a volunteer or representative from the Provincial Department of Cult and Religion or District Office of Cult and Religion with them. Consequently the cost of delivery is increased because of the travel and other costs associated with each person involved in the activity. One of the messages that the Buddhist monks promote to community members is the first Buddhist Precept of not killing and doing no to harm any animal no matter how small, which participants said is in direct opposition to the promotion of keeping small livestock for income generating: something that they might want to do themselves or have had promoted to them by Provincial Department of Cult and Religion or District Office of Cult and Religion representatives or other NGOs.
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Sustainability
The initiative has already demonstrated that it can be replicated as it has been introduced into new provinces over the course of its implementation, and in theory it can be scaled up. To date none of the provinces have scaled up their responses to 100% coverage of their geographic area, mainly because of funding limitations and the current arrangements for implementation. The sustainability of the effects for some participants are likely to be long lasting and the self-help groups in some districts seem as if they could easily continue without external donor support. However where self-help group activities have not evolved to facilitate participants ability to move out of poverty and reduce their vulnerability, the activities of the programme are likely to continue needing external donor support. In one of the provinces, an NGO partner took part in the Buddhist Leadership Initiative for a number of years until 2010. Since the external funding support came to an end, it estimated that the activities (home visits and meditation sessions at the pagoda) continue at a level of approximately 75% compared to the previous scale of operation with external donor support. Although cash support is not given to participants as regularly or at the same level as before, the monks distribute donations to the pagoda in cash or in-kind. The NGO attributes the 25% reduction to the fact that monks trained as part of the programme have left the monkhood or moved to another pagoda and the concept of monks finding their own replacement for the activities has not been instituted systematically. The NGO reported that it intends to facilitate a training session in the near future to bring more monks into the activities. Despite the reduction, the continuation in activities at the level of 75% is a significant result in the absence of major external funding. The NGO did not indicate exactly how much time and financial resources it continues to invest in supporting the monks but it would seem minor in comparison to the earlier levels of funding. This example highlights the difference in both the implementing costs and the likelihood of sustainability of activities in the absence of external donor support when the activities become part of the core business of pagodas. Similarly, minimal oversight can be absorbed into the activities of the implementing partner when community-based development work is part of its core business, which is not the remit of Provincial Departments of Cult & Religion. The initiative has the potential to continue supporting the worst-off/most vulnerable people beyond the external donor support if its aims are institutionalised at the level of the pagoda and within the teaching mechanisms of the Buddhist hierarchy so that more monks engage in vulnerability issues. However, most of the activities have specific costs associated with them and unless they can be combined with other interventions or implemented at lower or no cost, it is likely to be challenging for pagodas to implement activities at the same scale as they are currently doing. One-off or time-limited interventions which provide support to people affected by HIV and AIDS can have long term impacts. The reduction in stigmatising attitudes, for example, through monks visiting people living with HIV and sharing accurate information about the transmission of HIV, can have long lasting impacts on community responses and attitudes and on the quality of life of people living with HIV. To increase the sustainability of the initiative it would be important to link the activities and therefore programme participants to existing social protection mechanisms such as the health equity funds or scholarship programmes to enhance sustainability. For example, the Identification of Poor Households Programme (IDPoor) led by the Ministry of Planning has been introduced into a number of districts & provinces. Essentially it is a categorisation initiative which identifies poor households as either Poor Level 1 (very poor) or Poor Level 2 (poor). The aim of the scheme is to identify poor households, in order to reduce the overall administrative costs of selecting target groups and to allow more efficient distribution of scarce development resources to those most in need (28). It would seem logical to ensure that Buddhist Leadership Initiative participants are linked into this scheme in those districts where IDPoor is operational. However, in focus group discussions there was
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conflicting understandings among participants about the scheme. Some said they did not have the yellow card (the IDPoor card) because they get help from UNICEF through the Buddhist Leadership Initiative, while others said they did have the yellow card but that it did not give them access to resources at village level because they already get support from UNICEF through the Buddhist Leadership Initiative. By not integrating with existing schemes the programme risks becoming an unsustainable parallel structure. Similarly, by linking participants to microfinance institutions and income generating schemes the programme would be able to facilitate strategies that increase peoples incomes rather than provide cash support which will remain an indefinite need. Links with existing governance and organisation structures were found to be inconsistent across the pagodas visited as part of the evaluation. For example, some Buddhist Leadership Initiative volunteers, who accompany monks and help with activity coordination, were also members of Village Health Support Groups. These volunteer groups are an initiative of the Ministry of Health as part of an effort to mobilise people at village level and increase access to health services. They are present in many but not all villages. The village and commune level governance structures were mentioned by some Provincial Departments of Cult and Religion and monks, particularly as etiquette dictates that implementers inform them of their activities within their geographical jurisdiction. In some cases, the commune and village leaders join the activities such as home visits. However, there seemed to be little in the way of significant levels of coordination with commune and village leaders in terms of programme management and planning. Additionally, provincial and district level Women and Child Consultative Committees and Commune Committees for Women and Children were mentioned by a minority of Provincial Department of Cult and Religion representatives or monks, systematic coordination with them does not seem instituted in the Buddhist Leadership Initiative activities.
Management and ownership of the Initiative

Representatives of Provincial Departments of Cult & Religion demonstrated varying levels of enthusiasm for the initiative. At one end of the scale provincial directors and focal points were highly committed to the activities and outcomes and showed that they engaged significantly in the implementation of the programme. At the other end of the spectrum provincial directors explained that the initiative is outside of their regular work plan and at best it is an inconvenience for them and at worst an imposition on them. For those that were committed they struggled to see how they could adapt to improve the programme, for example to meet the specific needs of individual participants, without the decision making authority to make changes to the budget. At the same time they did not expect to have decision making power in regard to the budget, nor did they feel they had any skills to manage a budget effectively. In their experience they were tasked with spending the budget as they were told and had never had any training in doing anything else. Among those who saw the programme as an imposition, one was clear that he felt no obligation to implement it. Over a long period of time the activities of the Buddhist Leadership Initiative have not changed significantly. Components and ideas have been introduced such as promoting the rights of children and promoting family based care, but overall the structure and the implementation have been consistent. Consequently without major strategic or activity changes there seem to have been few opportunities to engage the key actors in programme design and evaluation processes. This has resulted in a perception by nearly all levels of implementers (i.e. Provincial Departments of Cult and Religion, District Offices of Cult and Religion, monks, volunteers, self-help group facilitators and self-help group members) that they are not in charge of decision making within the programme.
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If the Provincial Departments of Cult and Religion believed the decision-making power was outside of their control, this was directly translated to all other levels of programme implementers. In some provinces there seemed to be collaborative teams at district level consisting of district officers, monks and volunteers. At best however they were making decisions about times and dates of events, and not the content or strategic direction of the activities. In some provinces the perceived directive nature of the programme translated into limited or no engagement with the monks or district officers in the planning of activities. Some monks described their three or more years of involvement in the programme consisting of receiving a phone call the day before a home visit or pagoda event and being instructed to attend. They felt that they could not follow-up with any of the self-help group members nor plan a progressing curriculum for the meditation and Buddhist advice sessions because they were sent to different pagodas and were never sure they would see the same people twice. The district officers were in a similar position, and also felt that they could not follow-up with people or engage meaningfully in the activities. Some self-help groups were very active and self-directive about their activities. The twicequarterly meetings were a catalyst for them to develop their support networks and they met locally outside of the programme activities very regularly in their villages or communes. Other self-help groups were passive and either never questioned or raised issues with the self-help group facilitators, or if they did they felt like their suggestions were arbitrarily declined. At all levels and among all stakeholders everyone seemed to think that someone else was in charge, and no one wanted to step on toes. Self-help group members were too shy or did not dare to raise issues of concerns with each other, with a facilitator, the Provincial Department of Cult and Religion or District Office of Cult and Religion representatives, or monks, even if they thought they had good ideas to help themselves. Monks expressed keenness to be much more involved in the decision making, and the more confident and educated monks indicated that they have the capacity to take a greater role in programme design and budget management. However they did not want to intrude upon the perceived responsibilities of the Provincial Department of Cult and Religion. A number of provincial directors and focal points expressed minor changes they would like to make or different activities they would like to implement, but none seem to have the capacity or the negotiation skills to make their case to the donor UNICEF. UNICEF staff explained their efforts to help Provincial Department of Cult and Religion representatives take a more participatory approach with other stakeholders (i.e. District Offices of Cult and Religion, monks and volunteers) in the programme, and collaborate more with other organisations. However without a member of UNICEF present to facilitate provincial or district level meetings and actively promote participation and collaboration, such approaches were unlikely to happen in practice. Similarly, reports of the annual
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review meetings record efforts to enhance capacity and sustainability of the programme. These include discussions on cost-effectiveness, and targets on overhead spending of 25%. Ideas were suggested to increase the participatory nature of the childrens sessions and child protection initiatives introduced such as a Commitment Form for people working in the Buddhist Leadership Initiative to promote child protection issues and protect children (27). By 2011, UNICEF put more emphasis into transferring ownership of the programme to the government, rather than continuing the perception that it is a UNICEF project (26). Although this evaluation took place within less than a year of the agreement that was made at the meeting, there was little sign that participants and implementers thought of the initiative as anything other than a UNICEF programme. The activities that include Buddhist monks in home visits and their role in facilitating meditation sessions is highly valued by the participants, but the organisation of the programme (i.e. its planning and management) has not yielded the strengthening of the Buddhist hierarchy to deliver these activities as the initiative intended. In order to achieve sustainability of the activities, the decision-making and capacity building needs to take place among the monks at pagoda. There are opportunities to give more responsibility to monks already involved in the programme, and opportunities to engage many more monks through harnessing the commitment of the senior Buddhist hierarchy who have the ability to mobilise monks through the Buddhist University and its other networks. For the initiative to be replicated in many more provinces, districts and pagodas, its aims need to be instituted through Buddhist education mechanisms, such as the Buddhist Institute, and implemented at the pagoda level. Many of the monks explained that they distribute donations of money & material goods given to the pagoda among the vulnerable people they visit in their homes. Often Self-help Group members and monks pointed out that collection boxes placed in pagodas that are specifically labelled for people living with HIV received little in the way of donations, and in some cases no donations, from visitors to the wat. They believed that there is a perception among community members that people living with HIV are already well catered for by programmes such as the Buddhist Leadership Initiative, and other NGO and government responses. However some monks had made the decision not to have a separate donation box for people living with HIV, and used the donations for the poor in general to give to vulnerable people who are affected by HIV. If the programme redefines its focus on the most vulnerable, of which HIV may well be a factor as discussed, this division of poor people versus people living with HIV would be less likely to be an issue.
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Child Protection Issues

The Buddhist Leadership Initiative has already shown that it can take a specific & targeted approach to child protection issues such as childrens rights. Currently, it promotes the protection of children through supporting vulnerable children in regular sessions. Within these meetings, children are given key messages about their rights and advice on what they should prioritize, e.g. their education. At the same time a number of monks also mentioned issues of relevance to child protection which could be capitalised on and replicated throughout the initiative. In particular, some monks mentioned a form of psychosocial support to children which focussed on promoting better parenting skills among adults. This included simple messages about giving encouragement to children to motivate them, and listening to them. This seemed to happen on an informal basis when the monk visited families at home. These and similar messages could easily be transmitted by monks at all the pagodas if they are not doing so already. There are also opportunities for monks to increase their knowledge of existing child protection issues to provide more practical information. For example, the information distributed to childrens parents about childrens rights included the statement that children have a right to a name. But it is not clear whether the process of registering a childs birth and name is fully comprehended by the monks, and whether they are able to provide practical information about how and when to register a birth.
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Conclusions
The Buddhist Leadership Initiatives aims and activities showed a high degree of relevance to the national policy context in terms of both the HIV response and the role of faith leaders within it. The activities themselves provide an important recognition of and place to meet for people living with HIV who were previously vulnerable because of isolation and high levels of stigma. Since the programmes inception the HIV context in Cambodia has changed significantly. Mass media campaigns and targeted information approaches by NGOs and initiatives such as the BLI have contributed to much more in-depth understanding of HIV and its transmission among the general population. This in turn has alleviated much of the fear among people who stigmatised and discriminated against people living with HIV who had misconceptions about how HIV is transmitted. Although stigmatising & discriminatory attitudes prevail, particularly in more rural and remote areas where information is less accessible, overall participants in this evaluation confirmed that they face little prejudice because they are affected by HIV. In this context the Buddhist Leadership still has a role to play in ensuring that people living with HIV are accepted within their communities, but an opportunity presents itself for the programme to become more relevant to those communities members who are most vulnerable for a range of reasons, and not with HIV being the sole criteria for inclusion in activities. This would also help stem the ill-feelings that some other community members have towards people living with HIV who are perceived to get favourable treatment from NGOs and other responses regardless of the fact that there are people with different illnesses or who are poorer among the community. The BLI activities target people with extremely low incomes which are often both an impact of HIV and a cause of vulnerability in general, which means that the most vulnerable people living with and affected by HIV would continue to be included in the programme even if more measures of vulnerability are incorporated into selection criteria. The effects of the initiative on some of the most vulnerable people living with HIV appear to have been profound. The acceptance shown by monks towards people has transformed their self-confidence. Self-stigma remains an issue among many but the spiritual support in the form of meditation sessions offers some participants a practical way to feel stronger both during the sessions and in between them. The meditation techniques and Buddhist philosophy also help community members reduce harmful behaviour such as domestic violence and social vices such as gambling. The cash support is invaluable to the poorest of the self-help group members and the most vulnerable children. It is most often spent on much needed food and other household items, and a small proportion of people have invested in income generating projects. Overall however, the cash support presents some challenges, especially as financial status is not the most pressing vulnerability of some of the self-help group members while it is for others. Another problem with it is that the distribution of cash to a limited number of participants deters organisers from inviting larger numbers of people to the meditation sessions and self-help group meetings to avoid being placed in a situation where they give some people cash and not others. There are further opportunities for learning within the initiative. The quality of the activities & therefore their outcomes vary greatly and are dependent on the skills of the implementers and the expectations of the participants. Among the participants that took part in this evaluation there were numerous examples of individuals and groups who had improved their economic & vulnerability statuses significantly, often through small income generating schemes such as raising livestock, and in one case a substantial loan to buy a [motorbike] taxi. Among the groups where financial literacy was very low, implementers can make better use of local resources such as microfinance organisations and the skills & expertise of other NGOs. Within the Buddhist Leadership Initiative there are opportunities for the more successful self-help groups to share their experiences and skills with other groups.
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The efficiency of the initiative presents an area where there are a number of opportunities to change the decision making and implementation practices to increase the sustainability of the activities and their impacts. The cost of the activities seems expensive compared to other similar programmes because the programme places the Provincial Departments of Cult and Religion at the centre of the implementation, and they are not set up to deliver such activities. Even among the most committed Provincial Departments of Cult & Religion there is limited scope to reduce implementation costs because of this. With limited capacity, the Provincial Departments of Cult and Religion do their best to deliver the programme, but expecting them to additionally institute the activities within the pagodas by building the capacity of monks seems even further outside their remit. The ownership of the initiative needs to rest with the monks implementing the activity for it to become more efficient. At the same time to increase the sustainability of the activities and outcomes, institutional capacity needs to focus on the Buddhist hierarchy which has the leadership capabilities to transmit the priorities of the programme within its networks and through its education system. Overall the Buddhist Leadership Initiative has made an enormous difference to its participants. The main challenge to its continued sustainability is its current reliance on external donor funding and too few of the practices being instituted within the pagodas because of the lack of decision making and ownership among monks. It has the potential to become instituted at national Buddhist policy level (through the Buddhist University) and at pagoda level. It would be able to benefit a much greater number of people by aiming to help people reduce their vulnerability so that participants can graduate through stages towards self-reliance, and so that other community members in need of support can be included over time. At the same time the investment by the external donor needs to focus on instituting the practices and mobilisation of monks at pagoda level so that external funding can be withdrawn. The NGO that was part of the programme but has since departed from it estimates that activities have continued within the pagodas in its district at the rate of 75% of the capacity that was achieved under external donor funding. They attribute the 25% reduction to the monks who move or leave the pagoda and are not replaced. This shows that it is possible to continue the activities in some form without the external funding if the monks have the coordination and decision making role.
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Recommendations
The subsequent recommendations were developed in consultation with MoCR representatives, Buddhist leaders themselves and UNICEF staff in national and sub-national offices. While the recommendation note the key actors for their implementation, it is important to note that the recommendations are intertwined and related to each other.
Ministry of Cult and Religion

To increase relevance
The Ministry of Cult and Religion has the opportunity to revisit and renew this initiative to increase its relevance, and deliver impacts for vulnerable communities in cost-effective ways. To initiate this process the following suggestions are made: 1. MOCR should share & discuss the findings of the evaluation that will provide opportunities to consider and design a new direction for the programme so that it addresses a range of vulnerabilities including but not limited to HIV. 2. To make major changes to the programme, the MOCR can use such a consultative process to introduce a transitional period through consultative partnerships with all key stakeholders, particularly the Buddhist hierarchy, technical support providers such as UNICEF, other faith leaders and other development partners.
To increase effectiveness
A number of the initiatives elements were shown to be highly effective at delivering results for vulnerable community members and the Ministry of Cult and Religion can focus on and prioritise these aspects to increase its overall response to communities. To capitalise on the most effective programme components the following suggestions are made: 3. The MOCR can consider focusing on the mobilisation of Buddhist monks to continue (and expand) the provision of spiritual support which was shown to be highly effective in addressing the psychosocial status of community members and reducing HIV and AIDS related stigma. 4. The MOCR can encourage the replication of proven methodologies which reduce economic vulnerabilities, such as those demonstrated by the active self-help groups in relation to self-organisation and self-reliance, throughout the existing participants and feature strongly in new iterations of the programme. 5. By making use of strategic partnerships with other development and faith partners, the initiative has the potential to further link its activities with those of others, and create further greater for communities. 6. By adopting a new approach to implementing the initiative with increased efficiency (Recommendations 6 and 7), the Ministry can redirect resources within the existing geographical areas of programme focus to increase participation of implementers and community members. 7. A way of monitoring results of the initiative in greater depth would be to introduce outcome-based rather than output-based indicators and targets, which would allow MOCR to further record and promote the successful impacts of the initiative. 8. Through engagement with other development partners and faith leaders, the Ministry can share experiences of the successful impacts of the initiative and learning from the programme to encourage others to implement effective approaches to spiritual support.
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To increase efficiency
The relatively high implementation costs were highlighted by the MOCR as a consequence of the need for human resources to deliver the current model of the initiative which additionally adds considerable strain to PDCR workloads. The Ministry has the opportunity to reconfigure the initiative through the consultative process suggested above (Recommendations 1 and 2) to reduce the implementation encumbrance and simultaneously draw on PDCRs innate strengths by re-establishing them in a coordination role. To increase the efficiency of the initiative the following suggestions are made: 9. By introducing a strategic coordination role for PDCRs, the Ministry can scale back and eliminate their implementation role which both frees up their time & reduces significant administration and management costs. By engaging the Buddhist hierarchy & Buddhist leaders at provincial level the Ministry 10. can identify effective partnerships to further mobilise Buddhist monks and other faith leaders to take on more active implementation roles, and potentially reach many more communities through cost-effective components such as providing spiritual support, facilitating self-help groups, and linking communities to complementary programmes and responses.
To increase sustainability
The reliance of the initiative on external donor funding is detrimental to the initiatives sustainability and there are a number of lessons learned from the programmes experience which can help identify approaches to increase its sustainability. One of the most notable lessons was the need for greater ownership by the Ministry of Cult and Religion, and all the implementing partners, and the initiatives reliance on external donor funding. To increase the sustainability of the programmes objective and impacts, the following suggestions are made: 11. The Ministry of Cult and Religion has the opportunity to give the programme a new and fresh identity. By re-branding and re-launching it, the Ministry can initiate a new initiative with a wider range of development partners who similarly can have enhanced ownership, particularly among Buddhist leaders. 12. In considering the long term implementation of the initiative, the MOCR can place future engagement within Ministry workplans and budgets, and create its independence from external donor funding.
Buddhist Leadership & Hierarchy

To increase relevance
Buddhist leaders have the potential to address the overlapping and multiple layers of vulnerabilities faced by children and adults, including but not limited to HIV, through its theological discourse and practical and far reaching network of monks at community level. In order to increase the relevance of the initiative, the following suggestions are made: 13. The Buddhist hierarchy can further make links between Buddhist teachings and key social issues such as child protection, stigma and discrimination, self-reliance, financial literacy and disseminate this through the Buddhist education system to reach its network of thousands of monks who work directly with communities. 14. Buddhist monks may be able to take the lead in helping people realise their rights by promoting rights-based messages in line with Buddhist principles, and linking community members to essential local governance, justice mechanisms, relevant organisations.
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To increase efficiency
Given the need to increase the efficiency of the initiative, the Buddhist hierarchy has the opportunity to contribute to lowering the implementation costs significantly by mobilising its extensive networks of Buddhist monks & partners to deliver impacts in a cost-effective way. 15. The Buddhist hierarchy can collaborate with MOCR & UNICEF to increase the capacity of monks to absorb implementation responsibilities of the initiative at pagoda, district and provincial levels. By consulting with monks with existing experience, the Buddhist hierarchy can further 16. design & promote cost-effective activities that can be implemented and be replicated by monks.
To increase effectiveness
The elements of the initiative with the seemingly greatest effectiveness (i.e. spiritual support and self-help groups) can be replicated at low cost across more pagodas with the support of the Buddhist hierarchy. In addition the lessons learned about the effectiveness of the spiritual support to both children and adults provided by monks in the initiative can be shared more widely by the Buddhist hierarchy within and beyond its networks. To increase the involvement of monks and widen the impact of the initiative, the following suggestions are made: 17. The Buddhist hierarchy can promote the successful approach of providing spiritual support for vulnerable community members throughout its networks and encourage wider and far reaching implementation of the methodology. 18. By emphasising the importance of self-help and income generation, the Buddhist hierarchy can facilitate monks increased capacity to identify people and organisations which can support local communities to reduce their economic vulnerability. In this way, Buddhist monks need not become technical experts but provide important linking and referral systems. 19. The Buddhist hierarchy could identify routes to agreeing and sharing the provision of spiritual support, Buddhist messages and monks outreach practices. For example, there are opportunities such as the annual meeting of Provincial Chief Monks and the komnankhet could become avenues for regularly sharing of learning in delivering spiritual support to vulnerable community members. 20. It could also be appropriate for the Buddhist hierarchy to increase awareness & training in child protection to increase the ability of monks to identify vulnerabilities & introduce ideas to communities to reduce harmful social norms.
To increase sustainability
With the need to increase wider ownership of the initiative among development partners, and to reduce its reliance on external donor funding, the Buddhist hierarchy can contribute to the initiatives increased sustainability in the following suggested ways: 21. By drawing on the Buddhist education & training infrastructure the Buddhist hierarchy can institute good practices around Buddhist responses to reducing vulnerabilities that will endure beyond the timeframe of external donor funding. The Buddhist hierarchy can use its leadership networks to explore expanding the role 22. of monks in community engagement to sustain support for objectives and impacts of the initiative and reduce its reliance on external donor funding.
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1. UNAIDS : Bridging the Gap: Addressing the Impact of HIV/AIDS in Cambodia. 2010. 2. UNDP : The Socioeconomic Impact of HIV at the Household Level in Cambodia 2010. Phnom Penh : National AIDS Authority and The United Nations, 2011. 3. Edstrm, J and Khan, N : Protection and Care for Children face with HIV and AIDS in East Asia and the Pacfic: Issues, priorities and responses in the region. Bangkok : IDS and UNICEF EAPRO, 2009. 4. UNICEF : Report: East Asia and Pacific Region Interfaith Consultation: Children, HIV & AIDS. Bangkok : UNICEF, 2008. 5. WFDD : Faith-Inspired Organizations and Development in Cambodia. s.l. : World Faiths Development Dialogue, 2010. 6. Berkely : Faith-Inspired Organizations and Global Development Policy. Washington DC : Berkely Center for Religion, Peace and World Affairs, 2010. 7. UNICEF : Data of BLI in 2011. Phnom Penh : UNICEF, 2012. 8. . 2010 Provincial BLI Budgets and Q1 2011 Estimates. Phnom Penh : UNICEF, 2010. 9. WFDD : Buddhism and Development: Communities in Cambodia Working as Partners. Washington DC : World Faiths Development Dialogue, 2012. UNICEF : Chronological Overview BLI in CBD. Phnom Penh : UNICEF, 2009. 10. 11. . BLI planned and actual results 2011. Phnom Penh : UNICEF, 2012. Indochina Research : The Buddhist Leadership Initiative: An Evaluation. Phnom 12. Penh : UNICEF, 2007. UNICEF : Evaluation of the Buddhist Leadership Initiative: Terms of Reference for con13. sultants and contractors. Phnom Penh : UNICEF, 2011. 14. . BLI ARPM 2010 Report. Phnom Penh : UNICEF, 2010. 15. NAA : Summary of the National HIV/AIDS Inventory. s.l. : National AIDS Authority, 2007. CAS : The Scope for a UNV Project to Support and Facilitate Ongoing Processes of 16. Greater Involvement & Effectiveness of Buddhist Insitutions in the Response Towards HIV/AIDS in Cambodia: A pre-feasibility study. s.l. : Centre for Advanced Studies, 2002. MoSVY : National Standards and Guidelines for the Care, Support and Protection of 17. Orphans and Vulnerable Children. s.l. : Ministry of Social Affairs, Veterans and Youth, December 2010. MoH : National Guideline for the Prevention of Mother-to-Child Transmission of HIV, 3rd 18. Edition. s.l. : Ministry of Health, November 2010. NAA : National Strategic Plan for the Comprehensive & Multisectoral Response to HIV 19. III (2011-2015). s.l. : National AIDS Authority, 2010. . Cambodia HIV/AIDS Policy Assessment and Audit. s.l.:National AIDS Authority, 2007. 20.
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21. Cambodia Government : Plus 5 Review of the 2002 Special Session on Children and World Fit for Children Plan of Action. Phnom Penh :Royal Government of Cambodia, 2006. 22. OVC Task Force : Orphans, Children affected by HIV and other Vulnerable Children in Cambodia: A situation and response assessment. Phnom Penh : The National MultiSectoral Orphans and Vulnerable Children Task Force, 2007. 23. World Bank : Poverty profile and trend in Cambodia: findings from the 2007 Cambodia Socio-Economic Survey (CSES). s.l. : World Bank, 2009. 24. UNICEF : BLI Annual Review and 2010 Planning Meeting Siem Reap. Phnom Penh : UNICEF, 2009. 25. . BLI Summary Workshop Report Dec 2009. Phnom Penh : UNICEF, 2009. 26. . BLI MYR Report 2011. Phnom Penh : UNICEF, 2011. 27. . BLI Annual Review Meeting - December 2010 SHV - Draft Report. Phnom Penh : UNICEF, 2010. 28. Ministry of Planning : The National Identification of Poor Households Programme. Phnom Penh : Ministry of Planning, no date. 29. UNICEF EAPRO : Regional Review: Buddhist Leadership Initiative. Bangkok : UNICEF East Asia and Pacific Regional Office, 2009.
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Survey
Introduction
This quick survey is for people (aged 18 and over) who have been involved in some way in the Buddhist Leadership Initiative or BLI. This is the programme in which monks provide support for people living with and affected by HIV. We do not need to know your HIV status. We do not need to know your name. All your responses will be treated as confidential. Participation is voluntary, and you can ask to skip a question if you do not want to answer it.
Has the respondent had the research explained to them, and have they signed the consent form?
Province Takeo Interview Location Wat Sex Male Age 18-24 Are you a Buddhist? Yes How long have you lived here? Less than 1 year 1-2 years 3-4 years 5+ years No 25-29 30-39 40-49 50+ Female Transgender Commune/home Other Prey Veng Kampot Kg.Thom Siem Reap
How long have you participated in the monks HIV work and activities? Less than 1 year How many in your household? 1-2 years 3-4 years 5+ years
Adults (18+) Children (under 18)
Male Male
Female Female
What is your household monthly income (on average)? Riel Do you feel monks are knowledgable about HIV? Yes No
10
11
Which activities by monks have you participated in the last 12 months? (tick all that apply) Meditation sessions at the wat Visited at home by a monk Visited in hospital by a monk A monk gave me cash
A monk (or rep from district Department of Cult & Religion) referred me to a service A monk gave me food or other materials Other (pls explain)
My child(ren) attended a group session run by monks
77
12
How important to you is the spiritual support from monks? (prayers, meditation etc) Very Somewhat Not
13
Which activity is the MOST important? (tick one only) Meditation sessions at the wat Spiritual support Visit at home by a monk Visit in hospital by a monk A referral to another service Food or other material support Cash support Group session for children
14
Who offered you/your family most assistance to cope emotionally? Family members Pagodas and monks NGOs Community members Doctors/ health staff Self-help group members Others
15
Has anyone from the wat referred you to other services? Yes If yes, which services? clinic or hospital for HIV services employment opportunities NGO services Other (pls explain) education opportunities clinic or hospital for other health services No
16
17
Did you go to the services that were recommended to you? Yes If not, why not? I did not want to go to the service Travel too expensive Other reason (pls explain) Not enough time because working or child care Service fees too expensive Not enough information about how to access it I felt too shy or worried to go on my own No
18
19
Did the monk (or rep from district Department of Cult & Religion) check back with you to see if you had taken up the referral? Yes No
20
How often have you received cash support from monks in the last 12 months? Never How much did you receive each time? Riel
If Never skip to Q24
Once
2-4 times
5 times/more
21
22
What things did you use the cash for? (tick all that apply) Food Travel (to pagoda for activities Travel (health) How important to you is the cash support from monks? Very Somewhat Not Travel (education) Travel (employment) Household items Donation to monks or pagoda I gave it someone else Other
23
24
Has the monks support to you changed stigmatising or discriminating attitudes of your neighbours and community? People discriminate less People discriminate the same People discriminate more
78
25
How often have you been excluded from these activities in the last 12 months because of HIV stigma? Never Social gatherings or activities (e.g. Weddings, funerals, parties, clubs) Family activities (e.g. Cooking, eating together, sleeping in the same room) Religious activities or places of worship (including at times of bereavement) Once A few times Often
26
Have you experienced any of the following feelings in the last 12 months? (tick all that apply) I feel ashamed I feel guilty I blame myself I blame others I have low self-esteem I feel I should be punished I feel suicidal None of the above
27
Did someone tell any of the following people that you are affected by HIV WITHOUT YOUR PERMISSION? Your husband/wife/ partner Your friends/neighbours Your co-workers Health care workers Teachers Other people living with/affected by HIV Your employer(s)/boss(es) Your clients/patrons Social workers/counsellors Journalist or someone else in the media Injecting drug partners Monks (or other religious leaders) Community leaders (including Commune Council) Government officials (including PDCR/DDCR)
28
How often have you been involved in planning BLI, monk, wat activities in the last 12 months? Never Once 2-4 times 5 times/more
79

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BUDDHIST LEADERSHIP INITIATIVE

About this evaluation

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Coverage and effectiveness

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Child protection issues

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Ministry of Cult and Religion

Buddhist Leadership and Hierarchy

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Purpose of the evaluation

Organisation for Economic Co-operation and Development

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Relevance to UNICEF strategies

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

The extent to which the Initiative supported referrals

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Two strings intertwined make a stronger rope

Realised and potential opportunities

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

The vulnerability of adults

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Stigma indirectly related to HIV

The Role of Monks

Opposing perceptions of Buddhist practices

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Management and ownership of the Initiative

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Child Protection Issues

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Ministry of Cult and Religion

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Buddhist Leadership & Hierarchy

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

Adults (18+) Children (under 18)

My child(ren) attended a group session run by monks

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

BUDDHIST LEADERSHIP INITIATIVE EVALUATION

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