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Assessment of the operational capability of Kirivong Operational District's Health Centre Management and Feedback Committees
Evaluation 1
Introduction
Kirivong Operational District's 20 health centres have Health Centre Management and Feedback Committees comprised of volunteers associated with its 91 pagodas and 5 mosques. It was opted to collaborate with pagodas for their extensive community networks and because their associated members and volunteers are highly respected by the rural population. The Cham Mosques were included to assure maximum coverage. These committees were established during September-October 2001. Members of the committees were trained during 1 day at their respective health centre. This training covered: (1) primary health care; (2) health sector reform in Cambodia; (3) operational district; (4) community participation; and (5) roles, activities and limitations of the committees.
The first activities of the committee members concerned mainly information, education and communication campaigns that aim at positively influencing maternal and child health behaviours of caretakers. The messages are those developed by Murray et al[1]. These were arranged by topic and are to be disseminated through peer education on monthly basis. The number of monthly messages is limited to avoid confusion. In November, two pagoda-associated volunteers were recruited at each village to aid during the outreach campaigns. During December real participation was tested when the semi-annual vitamin A supplementation and deworming campaign targeted out-of-school children. Results were mixed: a median of 54% of out-of-school-children were reached (range 15-92%). All communication between the health centres and committees was delegated to the health centre chiefs.
Here we report on the committee members' and chief monks' views on and perceptions of their role and functioning of the committees.
Methods
During the month of December 2001, forty six committee members were visited at their residence and interviewed using an open ended structured questionnaire. A similar approach was used for 26 chief monks of pagoda. Data were manually analysed.
Results
Health Centre management and Feedback Committee members
Profile
A total of 46 committee members were interviewed. Women accounted for 28% and had a median age of 51 years (range 46-63) compared with 60 years for men (range 44-74). Seven women were chas tom without specified tasks; 4 were pagoda committee members; one a cook at the pagoda and one was a pritticaar. Of the male interviewees, 26 (79%) were pagoda committee members; 5 achaar; and one was the Imam of a mosque.
Perceived roles and responsibilities
Perceived roles and responsibilities of the members are displayed below.
Perceived duties / Number (%)1 / Spread information from health centre to population and promotion of health centres services / 30 (65)
2 / Convince pregnant women to attend antenatal care / 19 (41)
3 / Give information from community to the health centre / 15 (33)
4 / Inform people when the staff will visit their village for outreach and/or help during outreach activities / 12 (26)
5 / Persuade people to have their child vaccinated / 14 (20)
6 / Inform about birth spacing / 8 (17)
7 / Persuade people to consult the health centre when they are sick / 7 (15)
8 / Identify the vulnerable for exemption from payment for user fees / 6 (13)
9 / Educate people about sanitation / 2 (4)
10 / Persuade pregnant women to deliver at the health centre / 2 (4)
11 / Disseminate information on cost recovery / 1 (2)
12 / No idea (new member) / 1 (2)
Difficulties encountered to properly executing their roles
Many, 44%, reported not to encounter any difficulty. Other members said that people had difficulty understanding why they had to pay for curative care at the health centre [13%] and that some people refused to pay [7%]. One reported that the people were too poor due to flooding. It was reported that people had no confidence in the health centres whereby they preferred the private providers [13%]. The lack of transport was deemed a major impediment by 17% of interviewees, four percent considered themselves too poor for effectively performing the expected roles. Other impediments mentioned were that some people do not like to be patronised, 4%; and that some say that the centres have insufficient drugs, 4%.
Suggestions to improve their roles
When questioned for suggestions on how to improve their capability to execute the expected tasks, 41% had no idea. A similar proportion reported that they should spread health and health centre related messages to the population on an ongoing basis, 4% proposed to include authorities in the committees as they have considerable influence. Nine percent of interviewees reported that their work would considerably improve with the availability of transport and/or provision of a financial remuneration. Four percent would welcome training on health related issues. Twelve percent reported that their tasks would benefit from more friendly staff at the health centre, for 4% availability of sufficient drugs at the facilities, and for 2% improving the technical quality of the staff would aid. One requested to appoint another volunteer as he was too busy with other activities. One interviewee proposed provision of an incentive for the best performing committee.
How the volunteers spread the messages to the community and perceive their ability to convince people
Most of the committee members [76%] reported to spread the news during pagoda ceremonies. The second most reported way was spreading the information during the Sabbath, 39%; closely followed by conducting home visits, 37%. The former concerns a meeting –conducted 4 times monthly- during which people gather at the pagoda for offering food to the monks and spiritual cleansing. Seventeen percent reported to spread the news during meetings at village level when villagers meet with the village chief. Thirteen percent said to disseminate messages opportunistically when meeting groups of people, 11% during neighbourhood meetings. One person said to spread messages during outreach.
The majority of the interviewees, 91%, reported that their means of disseminating was excellent. Two were of the opinion that spreading the messages would benefit from inclusion of the authorities, one thought that posters would aid, one that more messages should be given, and one had no idea.
Most interviewees, 70%, reported no problems to convince people. The fact that some children develop fever following vaccination impeded attempts to persuade parents having their children vaccinated, 11%; adherence to traditional beliefs at the expense of allopathic medicine was deemed an hindrance by 7%. Other impediments were preference of injections over tablets 2%; poor people being unable to pay for transport, 2%. One interviewee had no idea because she just started; one failed to grasp the subjects himself; and one female of 52 years reported that some people do not listen to her.
Suggestions to improve their role
The majority, 54%, were of the opinion that the current way of operating did not require improvement. Eleven percent valued receiving more information or training on health related topics; 2% would appreciate to receive the outreach schedule; 2% suggested that the committee members should focus more on people with problems in daily life; 2% proposed that the centres would have sufficient drugs; 7% would like transportation; 2% would welcome training in problem solving; 2% were of the opinion that the staff should more interact at village level; 2% that the staff should be more present at the facility; and 2% would value more respect by the staff on committee members' opinion. Surprisingly, 9% would welcome monthly meetings and 7% proposed a financial remuneration for the best performing committees.
Suggestions to have people consulting the health centre when sick
Sixty seven percent of interviewees did not hear any complain and reported, therefore, being unable to formulate suggestions. They were of the opinion that ongoing provision of information about services provided by the health centre constituted a good means to have more people consulting the facilities. Nine percent reported that it would considerable aid to have staff present at the facility when required; 7% suggested to give injections instead of tablets; 7% to have sufficient drugs available; 4% to improve communication between midwives and the community to facilitate deliveries to be attended by them; 4% for staff to considerably enhance rapport building with the population; 2% to improve the technical quality of the staff; and 2% to have free services for the poor.
Twenty two percent of interviewees, however, were of the opinion that health centre services were cheaper than those of the private providers and lauded the quality of the drugs.
Pagoda Chief Monks
Opinion about Health Centre Management and Feedback Committee
All monks but one lauded the fact that the committees are comprised of pagoda volunteers. It was deemed a good initiative because pagoda volunteers are highly esteemed by society members and considerably interact with the population. One monk was of the opinion that the implementation of initiatives warrants improvement. The volunteers who were committee members updated all but three monks. Two of them reported that their respective committee members did not inform other pagoda volunteers.
How the health centres can employ the pagodas to ensure effectively reaching the population, especially the poorest.
Nineteen monks (73%) were of the opinion that the population was targeted and reached by use of the current approach, 4 were definitely sure that the pagoda volunteers were reached but uncertain that messages got spread to the wider population, and 3 had no idea.
Suggestions for reinforcement of the current approach were: (1) the health centre staff to build good rapport with pagoda committee members, 42%; (2) to use pagoda ceremonies for dissemination of information, 38%; (3) always assure that the respective chief monks are informed, 8%; (4) provide training to the Health Centre Management and Feedback Committee members, 4%; (5) assure follow up of activities, 4%; and (6) no idea, 8%.
To effectively reach the poorest, reinforcement of ongoing dissemination of messages –informative and educative- was recommended by 19 interviewees. Five monks were of the opinion that the exercises would benefit from more proactive involvement of health centre staff at community level and 2 had no idea.
Suggestions for assuring all poor people to attend outreach sessions
Forty six percent of interviewees were of the opinion that the poor already attended the outreach sessions; 31% suggested reinforced dissemination of information employing the current approach; 12% recommended using the Health Centre Management and Feedback Committee members for collecting these people during the sessions; 8% had no idea; and 4% were of the opinion that the exercise would benefit from improved interpersonal skills of the staff.
Assuring Health Centre Management and Feedback Committee members' devotion without financial remuneration
Responses were mixed and included: (1) health centre staff to discuss the matter with the respective chief monks when encountering difficulties, 35%; (2) no idea, 27%; (3) they can not claim remuneration because it is their Buddhist duty to help free of charge, 15%; (4) the pagoda committee can provide financial remuneration to their representatives, 12%; (5) reimbursement of transport costs is justified for people living far from the health centre because they are often poor individuals, 8%; (6) provide free treatment at the health centre for committee members, 4%; (7) the health centre chief to better explain to committee members, 4%; (8) provision of more training for members to better grasp intention and meanings of activities.
Discussion
There was general confusion of their roles and responsibilities by the HCM-FBC members, as reflected by the limited coherent response. All but one interviewee had been trained in these aspects. Tasks such as co-managing the health centre, establishment of transparent accountability systems for efficient use of health centre resources, and planning outreach activities were not mentioned. Instead, the roles and responsibilities mentioned did not constitute more than those of passive recipients[2]. This implies that the health centre develops a plan whereby the community is convened for information purposes only and compliance is expected. Ideally this should develop into a situation whereby HCM-FBC members achieve at least control: i.e. the health centre staff ask community members to identify the problems and to make key decisions on goals and means. Pagoda committee members are in charge of keeping accurate and transparent accounts of all donations to the pagoda[3]. The majority of male HCM-FBC members being part of the pagoda committee allows, therefore, for effective co-management and establishment of transparent accounting systems.
The lack of transport for some of the HCM-FBC members poses a challenge, especially if their understanding of respective roles is limited to that of spreading news and persuading people to attend health services. Provision of transport to all members, however, is financially impossible. Instead, it is worthwhile to explore the suggestion of one interviewee to provide incentives for the best performing HCM-FBC. One in eight interviewees lamented the poor interpersonal skills of the health centre staff. This is cause for concern and suggests the absence of a platform for casting complaints.
Interviewees, however, indicated a considerable zeal for their perceived roles and the majority –91%- deemed their approach appropriate. Numerous means for dissemination of information were mentioned, amongst them: the monthly Sabbath, pagoda ceremonies, monthly meetings at the village, neighbourhood meetings and opportunistically when encountering groups of people. Such happenings should be more exploited. This can be considerably aided by development of standard operating procedures in tandem with targeted trainings, especially regarding peer education. Sabbath days, and neighbourhood and village meetings especially, constitute methods to enable such education. Although pagoda ceremonies allow for a considerable proportion of the population to be reached, the most vulnerable may be missed since their lack of money constitutes a major obstacle for attending these[4].
The support by the majority of the chief monks is laudable, but their opinions contentious to interpret due to the highly diplomatic nature of replies. Few reported to be unaware of the HCM-FBC activities. The chief monks' support is indispensable for the initiatives. As suggested by many, the health centre staff should build considerable rapport with them. This enables also problems -such as HCM-FBC members claiming remuneration- to be discussed, as suggested. Additionally it should be assured that their pagoda volunteers inform all chief monks. Providing them with a copy of the report of the monthly HCM-FBC meeting, for example, can contribute to this.
Recommendations
I. To address the limited understanding of the HCM-FBC members' roles and responsibilities and making health centres more effective and efficient
- Clarify again roles and responsibilities
- Have HCM-FBC members, especially those of pagoda committees, actively involved in accounting, planning and co-managing the centre
- Commence separate monthly meetings with HCM-FBC chiefs in tandem with dissemination of respective minutes to health centre staff and pagoda chief monks
II.To stimulate HCM-FBC members
- Elaborate monitoring tools for assessment of performance by the HCM-FBC
- Develop incentive system for best performing HCM-FBC
- Have prices awarded on monthly or bi-monthly intervals during separate meetings with HCM-FBC chiefs
III.To allow community members anonymously cast their grieves on health centre performance –including interpersonal skills and adherence to opening hours
- Installation of locked boxes at all pagodas where community members can anonymously cast complains and provide suggestions for improvement
- Disseminate information on opening hours of health centres
IV.To allow all information to be effectively disseminated
- Development of standard operating procedures for disseminating information through peer education
- Commence regular and targeted trainings with HCM-FBC members on peer education
- Assure employment of existing platforms such as Sabbath days, and village and neighbourhood meetings
V.To assure ongoing support by the pagoda chief monks
- Have outreach team members conducting courtesy calls at pagodas when conducting outreach activities at the respective village
- Have HCM-FBC members provide a copy of minutes of the HCM-FBC meetings to their respective pagoda chief monk
Bart Jacobs Save the Children January 2002
France
[1] Marray J, Adeyi GN, Graeff J, et al (1997) Emphasis behaviours in maternal and child health: focusing on caretaker behaviours to develop maternal and child health programs in communities. Basic Support for Institutionalising Child Survival Project. Arlington
[2]Tarimo E and Webster EG (1994) Primary health care concepts in a challenging world: Alma-Ata revised. World Health Organisation, Geneva. WHO/SHS/CC/94.2
[3] Collins W (1998) Grassroots civil society in Cambodia. Centre for Advanced Study. Phnom Penh
[4] Watts EM (1999) The meaning of community: English literature review. Working Group on Social Organisation in Cambodia. Phnom Penh