title: Addressing the human resources crisis: a case study of Cambodia's efforts to reduce maternal mortality (1980-2012).
abstract: OBJECTIVE
  To identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in fragile resource-constrained countries.
  
  
  METHODS
  Qualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors ('House Model'; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR).
  
  
  METHODS
  Three rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners.
  
  
  METHODS
  A total of 49 interviewees, who were identified through a snowball sampling technique.
  
  
  METHODS
  Scaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction.
  
  
  RESULTS
  The incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment.
  
  
  CONCLUSIONS
  Lessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and of ongoing capacity enhancement and leadership development to ensure effective planning, implementation and monitoring of HRH policies and strategies.
authors.affiliation: Bureau of International Medical Cooperation, National Center for Global Health and Medicine, Tokyo, Japan.
authors.forename: Noriko
authors.initials: N
authors.lastname: Fujita
authors.forename: Kimiko
authors.initials: K
authors.lastname: Abe
authors.forename: Arie
authors.initials: A
authors.lastname: Rotem
authors.forename: Rathavy
authors.initials: R
authors.lastname: Tung
authors.forename: Phuong
authors.initials: P
authors.lastname: Keat
authors.forename: Ann
authors.initials: A
authors.lastname: Robins
authors.forename: Anthony B
authors.initials: AB
authors.lastname: Zwi
keywords: Public Health