Prior studies [24, 27] have illuminated the coordination challenges pervasive within the health sector, warranting an in-depth analysis. In this vein, we independently assess the degree of aid fragmentation within the health sector, seeking to bolster the existing evidence with our own empirical analysis. Presented in Table 2, our comprehensive analysis, utilizing data from all OECD DAC donor countries, spans aid contributions to Cambodia from 2010 to 2021. This analysis reveals a stark landscape of fragmentation across multiple sectors, with the health sector markedly standing out as particularly fragmented. The analysis extends to 14 additional sectors, all of which exhibit HHI scores beneath the 0.25 threshold, indicating a high degree of aid dispersion and a lack of dominant donor presence. The inclusion of other sectors in our analysis provides a necessary benchmark, establishing the health sector’s fragmentation in relative terms and highlighting its distinct challenges within the broader context of aid distribution in Cambodia.

Ranking third in ODA funding among sectors, the health sector shows a conspicuously low HHI score of 0.1420. This figure falls well underneath the 0.25 HHI threshold indicative of concentrated aid with few dominant donors. It instead signals the $870 million in health ODA is sharply dispersed across multiple actors and interventions. Specifically, there are 23 donor countries supporting no less than 1,134 separate health projects and initiatives. Over 70% of these efforts are minor in scale, receiving under $1 million in funding each. This paints a picture of health assistance as a wide assortment of small, disjointed schemes sprinkled across a multitude of donors, agents, and recipients. Such findings not only corroborate the challenges faced by the Cambodian government in coordinating a wide array of donor activities but also illustrate the tangible impact of fragmentation, as detailed by [24], including the operational burden of managing numerous parallel project implementation units and the inefficiency brought about by the duplication of efforts among an extensive list of donors. Indeed, the evident dispersion of efforts and resources across the health sector accentuates the pressing need for health sector-specific strategies aimed at enhancing aid coordination.

Analysis presented in Table 3 (left panel) delineates the distribution of health aid to Cambodia by principal OECD-DAC member donors. This segment of the dataset reveals that a quintet of donors—the United States, Australia, Korea, Japan, and Germany—accounts for 82.8% of the cumulative $870.9 million in health aid to Cambodia (as detailed in Table 2), illustrating a pronounced concentration of influence and, by extension, a significant responsibility to foster coordinated intervention efforts. An expanded review incorporating all OECD DAC-reporting entities (Table 3, right panel) indicates these five donors still command a substantial 52% of health aid. The balance, 48%, emanates from an assorted collection of 31 other multilateral and non-OECD DAC contributors.

Delving into specifics, the United States stands out as the principal bilateral donor, contributing over $187 million, which represents 21.5% of the total $870.9 million in health assistance (as detailed in Table 2). This funding supports initiatives such as USAID’s ‘Enhancing Quality of Healthcare (EQH) Activity,’ which is designed to bridge gaps in service delivery and health outcomes. Korea, contributing 15.7% or $137 million, primarily targets health system capacity enhancement, while Japan’s 15.3% ($133 million) share supports infrastructure and medical service advancements. Germany and Australia, allocating 11.2% ($97 million) and 18.8% ($164 million) respectively, focus on expanding service delivery and access, alongside policy, administration, nutrition, and infectious disease control efforts. This detailed breakdown of health aid not only accentuates the pivotal role played by these nations but also signals the critical importance of synchronized efforts. In fact, their disproportionate influence juxtaposed with the extensive fragmentation across a wide array of smaller-scale projects underscores an urgent call for strategic collaboration.

Table 4 elucidates the distribution of health aid across 12 principal thematic areas from 2010 to 2021 by the top five donors. It reveals noticeable differences and commonalities between donor priorities and spending fragmentation. At the aggregate level, health aid is highly fragmented across themes. The overall health portfolio HHI score is just 0.161, falling well short of the 0.25 threshold for concentrated spending. This signals aid proliferation across too many recipients and initiatives, with potential coordination issues.

The health aid portfolio of the United States exhibits a targeted approach, as demonstrated by an HHI score of 0.400, channeling over 58%, or $109 million, of its $187 million in assistance predominantly towards infectious disease control. This focus is not entirely misaligned with Cambodia’s healthcare priorities, given the significant burden of communicable diseases within the country. However, the concentration of resources in this area, arguably influenced by broader global health security concerns such as preventing disease spread to its population—as highlighted by the Covid-19 pandemic—suggests a disproportionate allocation. While addressing communicable diseases is crucial, the substantial emphasis here risks overshadowing other critical health challenges that Cambodia faces, such as heart disease, stroke, maternal mortality, and malnutrition. These areas, essential to the national health agenda, appear to receive less attention and funding, pointing to a need for a more balanced distribution of aid. While these areas require more attention and funding, this does not imply advocating for the current degree of fragmentation because the dispersion of the US’s remaining $78 million across seven other health areas indicates a moderate level of fragmentation. In the end, the goal should be to secure a more balanced distribution of aid that addresses a broader range of health challenges without contributing to the existing fragmentation.

Australia’s approach to health aid in Cambodia, with a concentrated investment of $133 million—representing 81% of its total contribution—towards ‘health policy and administrative management’ and ‘basic healthcare’, closely mirrors the approach taken by the United States in its aid distribution. This targeted allocation reflects a commitment to reinforcing the structural and foundational aspects of healthcare, which are vital for long-term health capacity development. However, similar to the United States, Australia’s allocation strategy exhibits signs of fragmentation, with the residual aid dispersed among various ancillary themes, including basic nutrition.

Germany exhibits lower dispersion with a higher 0.41 HHI score and over 60% of its funding targeting just three categories – ‘health policy and administrative management’, ‘basic nutrition’, and ‘medical training & personal development’. Although the focus areas differ, this strategic concentration is analogous to the U.S. approach, which allocates a significant portion of its funding to ‘infectious disease control’ and ‘basic nutrition’. However, unlike the U.S., which tends to heavily favor one category over others, Germany maintains a more balanced allocation among its prioritized categories, ensuring a more evenly distributed aid strategy within its focus areas.

In contrast, Japan and Korea face significant fragmentation issues in their health aid contributions, as evidenced by their low HHI scores among the five major donors—Japan at 0.22 and Korea at 0.21. Despite having some relatively dominant themes—Japan in ‘basic health infrastructure’ and ‘COVID-19 control’, and Korea in ‘COVID-19 control’ and ‘medical services’—this approach does not adequately address the fragmentation. After excluding their respective dominant focus areas, Japan allocates smaller portions of its funding across eight varied categories, while Korea distributes its investments across nine diverse health themes. While these diversified investment strategies of Japan and Korea may offer broader coverage, they fall short of effectively bridging the significant healthcare gaps in Cambodia, which necessitate focused, intensified financing.

The analysis of the five major donors reveals a pivotal limitation that transcends the political will and ethical motivations of individual donors: the inherent inability to address the entire spectrum of health challenges in Cambodia. The health sector in Cambodia presents a diverse array of issues, from infectious diseases to non-communicable conditions such as heart disease and malnutrition, underscoring the intricate landscape of health needs. Despite the political and moral inclination of donors to provide extensive coverage across all health areas, the reality of financial and strategic limitations renders such comprehensive support unfeasible. This situation underscores the necessity for heightened collaboration and strategic alliances within the global donor community. By pooling resources and aligning strategies, donors have the potential to create a more cohesive and comprehensive support network that addresses the multifaceted health challenges in Cambodia.

Table 5 provides an invaluable complementary lens alongside Table 4 aid amounts. It categorizes the project volume and specific objectives within each major focus area. Cross-referencing the number of projects per domain with the financing data exposes where fragmentation hides beneath superficial top-level priorities. For instance, the United States directs $109 million towards infectious disease control, suggesting this is a key focal point. However, further analysis through Table 5 would reveal whether this finances a few large-scale programs or a proliferation of disconnected small projects. In other words, the tandem insights unlocked across Tables 4 and 5 (categorical project volumes and sector financing data) spotlight critical areas where otherwise significant donor attention descends into detachment and diffusion when analyzed in aggregate.

Health systems strengthening offers a prime example, which emerges as the top focus by project volume with the US dedicating 45 projects, Australia 27, and Germany 18. However, in financial terms, the US directs just 12% or $22 million of its health ODA towards policy/management and basic healthcare representing common health systems strengthening priorities. This signals vast fragmentation as funding is dispersed across many small initiatives rather than larger strategic programs. The sheer project volume (90 combined) likely creates substantial coordination needs and high overhead costs as well. Greater collaboration between the US, Australia and Germany such as on national capacity building programs could start addressing this fragmentation.

Maternal and child health which funding derives from a mix of basic healthcare, medical services and basic nutrition represents another prime area for enhanced partnership – given alignment on project volumes (US-41, Japan-25, Korea-18, Australia-12, Germany-8 projects) but dispersion across 126 isolated efforts. The United States ($54 million towards conduits encompassing MCH priorities) and Australia ($45 million) emerge as natural lead partners based on focused resourcing coupled with their wealth of implementation experience to provide consolidated platforms then integrating specialized technical skills from Japan, Korea and Germany operating with subscale, fragmented funding despite project interests. Effectively transitioning atomization to impact lies in gradual partnerships rooted in divisions of labor - US and Australia resource mobilization and systems integration proficiencies first merge before tailoring evidence-based localized innovations from experienced donors into national public health programming. This secures sustainability and local ownership now lacking under duplication and misalignment prevalent across $173 million in MCH aid endangering efficacy absent collaboration.

Malaria control stands out as an area of clear project volume convergence alongside strategic financing priority visibility. The United States dedicates 22 projects and over 58% of its health ODA funding to infectious disease control. Meanwhile, Australia directs 8 projects and 3.9% of its health aid towards infectious disease control, displaying consistent secondary level interest. Forming an aligned partnership around malaria prevention, diagnosis and treatment programs has potential to take advantage of specialized US technical competencies to enhance Australia’s project capacities grounded in national health priorities. This could manifest through consolidated research, surveillance and case management efforts reducing duplication across the existing 30 discrete initiatives. Similarly, there is pronounced potential for an impact-enhancing partnership between the United States and Germany on tuberculosis control. Despite dedicating just $0.2 million across 3 projects, Germany displays consistent priority through initiatives like the STOP Tuberculosis program. Conversely, the United States directs large amount on 15 tuberculosis projects representing one of its top health focus areas. This asymmetry signals strategic opportunity. By consolidating Germany’s specialized TB efforts into aligned and larger-scale US programming, substantial efficiency gains become available.

Japan and Korea with the lowest HHI scores in Table 4 indicates a high degree of aid fragmentation and dispersion across numerous small-scale health interventions. Fortunately, Table 5 highlights potential strategies to mitigate this fragmentation through enhanced partnerships. Areas of common ground emerge in infrastructure development (34 projects in Japan and 20 in Korea) and medical equipment provision (17 projects in Japan and 6 in Korea). Given this volume, pooling resources into joint infrastructure planning and consolidated medical equipment procurement programs presents a coordination opportunity. Rather than separate facilities or technology investments under fragmented master plans, collaborative alignment on Cambodia’s highest infrastructure needs and rationalized appeals for cost-efficient health technologies offer impact enhancement paths.

Lastly, there is alignment on disability priorities between Australia, Germany and Japan based on 13 cumulative projects. However, aid funding is dispersed across small-scale efforts. The United States and Korea do not showcase disability inclusion as a stand-alone priority area though likely encompasses social inclusion aspects within its health systems strengthening activities. Blending Australian implementation experience, German technical assets, and Japanese technologies under a locally reinforced umbrella ultimately provides pathways to address entrenched fragmentation through scaled consolidation that secures accessibility and inclusion nationally with localized sustainability. In addition, incorporating the United States’ and South Korea’s localized social equity advancements and systems strengthening orientations would allow for the elevation of unified priorities through national platforms. In sum, the tandem insights unlocked across Tables 4 and 5 spotlight critical areas where otherwise significant donor attention descends into detachment and diffusion when analyzed in aggregate.