Executive summary

WORKING THE SYSTEM:

Cambodian health provider’s response to health sector reform

Authors

Natalie Grove

Pat Naidoo

Margaret Ward

Lauren Weller

A report submitted in partial fulfillment of the award of Masters of Public Health/ Tropical Health at the University of Queensland, in collaboration with the National Institute of Public Health, Cambodia

March 2002

Abstract

Cambodia has been undergoing extensive restructuring and reform of the health service over the last decade, following years of civil war and unrest. The country has made considerable progress since 1996 in implementing a reform process based on structural, organisational and financial strategies in order to improve health services for the population. A national health coverage plan (HCP) was implemented in 1996 which outlined a two-tiered system of health care with the health centre as the first point of contact in the public system and the avenue for referral to hospital services.

This research was conducted in a central province of Cambodia, north of Phnom Penh. The study aimed to provide information about a select group of health centre staff’s perceptions of their roles and responsibilities within the health system and the determinants that influence their performance under the health sector reform. A qualitative research method was employed using an exploratory multiple case study design and the discussion was framed in political economy theory.

The findings of this study indicate that health centre staff constructs roles and responsibilities for themselves that are substantially different to those that have been conceptualised in the HCP. The providers exercise their power to resist reforms by constructing new roles, influenced by public health sector policy, private practice and by the community’s expectations.

Furthermore, the findings revealed a series of ‘manoeuvres’; creative ways in which the staff tolerate, adapt, negotiate and resist new rules and regulations that affect their working practices. Manoeuvring of the health system occurs across a range of areas including outreach, curative care, financial reporting and referral procedures. It is widely acknowledged that health policies cannot simply be transferred from one social, economic and political environment to another. This study examined some of the social and cultural influences that affect providers and revealed complex social relationships that affect providers’ implementation of reform. The desire to maintain smooth social relations, to adhere to embedded hierarchies of respect and obligation and preserve social order were all important factors that influenced manoeuvring. Furthermore the manoeuvring response can be framed in a historical and political context which sees staff action as resistance to imposed regulations. The analysis demonstrates providers are seeking to negotiate and exert some control over their working environment within the constraints of the externally planned health reforms.

One of the conclusions of the study is that there is potential to improve the HCP by incorporating providers’ sense of roles and responsibilities, especially as they relate to the community. Secondly the ‘manoeuvring’ in the health centre is a complex response that is not motivated by economic goals alone. However it is clear that manoeuvring will continue while ever the mismatch between expectations of the staff and the resources available to them continues. In addition there is evidence that manoeuvring is representative of strong and creative leadership in many instances, and that there is substantial capacity at the health centre level to develop management skills. The current environment however is resistant to decentralisation and there is little experience of decision making responsibilities being held at lower levels such as the OD and the health centres. And finally this paper concludes that regardless of the strategies employed by donor agencies and the MoH, health providers will support reform to the extent that reform is congruent with provider’s needs and their professional roles.

Key words: health sector reform, political economy, health care providers, health centres, health policy, Cambodia.

Introduction

Power cannot be concentrated in the hands of a few… by its nature it is dispersed… it is everywhere it comes from everywhere and is exercised from innumerable positions (Foucault, 1981).

Cambodia has been undergoing extensive restructuring and reform of the health services over the last decade, years of civil war have left its infrastructure in ruins and its human resources capacity decimated. The formal health system is shifting from the centralized government operated facilities to a decentralized system involving a wide array of public and private financing and delivery methods. These reforms have been largely influenced by international agendas with input from the World Health Organization (WHO) and facilitated by generous support from the World Bank, Asian Development Bank (ADB), bilateral and multilateral agencies, and non-governmental organizations (NGOs). The pace of change that has been, and continues to be, experienced in the public health sector is rapid. The achievements of the Ministry of Health (MoH) during this brief period are striking. It has successfully reasserted technical and fiscal control, developed a national health policy and strategy that includes major financial reform and a national system of primary health care coverage (MoH, 2001a). Despite the many achievements, Cambodia’s health status is among the poorest in the region and the cycle of poverty and ill health remains for many of its people.

The health sector reform and the process of decentralisation have demanded considerable changes from health providers in the delivery of services in the public health system (JHSR, 2001). The reforms have demanded changes that include organisational and structural changes, financial system changes, human resources training and deployment and development of the Health Coverage Plan (HCP). The HCP is a framework for developing the health system infrastructure based on national coverage and standardised care. The health centre staff is expected to be the first point of contact for the public, delivering a Minimum Package of Activities (MPA) and the avenue for referral to hospital facilities. The role of these basic level health workers is therefore vital in the implementation of the reforms. Their mandate is to operate as an integrated team to serve a population of approximately 10,000 people through clinic based activities and outreach programs (Schmidt-Ehry, 2000).

While it is evident that the health system is undergoing a period of transition this is also true of the country as a whole. Cambodia has been described as a country undergoing rapid change including a restructuring of social organisations and re-shaping of traditional Khmer culture (Van de Put et al., 1997). Comprehending these wider issues of culture and local context is critical to understanding the position of health providers and their capacity to meet the expectations of the HCP. For example it is often stated that Khmer culture is highly individualistic in its focus and that Cambodian society is currently atomic in nature with very low levels of social integration (Ovesen et al., 1995). These issues are potential constraints to the health reform that asks individual health centre staff to work together in a team model.

This research explores these issues in relation to the health care provider and their understanding of the radical change that is taking place both professionally and socially. This study uses political economy theory to frame the discussion concerning the health care provider’s actions within the health centre and the determinants that influence their work behaviour. Political economy theory places the current health sector reforms in historical and political context and encourages the examination of power, control and decision making process (Donoghue and McGuire, 1995). In this study we focus on the health centre workers as a subordinate group responding to national and international directives.

Aim and rationale of study

As a result of the country's recent history of unrest, health research has been difficult. The limited research to date, has been focused in two areas; studies that have examined the public/ users health seeking behaviours and their expectations from a health service (CARE, 1999; Collins, 2000) and policy-level research addressing quality and cost-effectiveness of the public services (Turton 2000; Chuor, 1999). The views of providers, who implement the policies and work to meet the demand of users, have yet to be examined and it is unclear what determinants influence their practice. Currently the health staff does not have a strong voice in the health reform process.

The study was developed in response to this knowledge gap identified by the researchers concerning health care providers' understanding and implementation of current health sector reforms in Cambodia. The research aimed to discover, from a provider's perspective, what has influenced their implementation of these reforms. The objectives of this research are as follows.

1. Identify the role of health centre staff within the Cambodian health system.

2. Analyse health centre staffs' perceptions of their role within the Cambodian health system.

3. Explore the activities of health centre staff

4. Identify the factors that influence the health centre staffs’ implementation of their roles and responsibilities in the health sector reform.

5. Estimate the potential of health centre staff to meet the expectations of health sector reform.

Study design

Qualitative research was conducted to develop understanding and meaning of the health care providers’ perceptions of their role in a rapidly changing society. The project used a multiple case study approach that examined eight health centres for individual characteristics and identified common themes across the cases. The research was conducted in the Operational District (OD) of Tamao in a central province north of Phnom Penh. The study was implemented in three stages; a period of literature-based research in Australia, a twelve week block of field work in Cambodia and a final stage of write up in Brisbane. Tamao OD was an appropriate field site that enabled the researchers to examine a range of issues related to change in the health system and provided insight into how some providers are responding to the difficulties facing public health workers in Cambodia.

Sampling

Sampling of the primary data sources for this study was done in two stages: first the health centres were sampled and then the health care providers in each health centre. Eight health centres were chosen using maximum variation technique to select a diverse range of facilities. The sample consisted of 19 providers, with at least two staff from each of the health centres. The process for this involved purposeful selection of each health centre chief. Health centre chiefs were purposefully selected for their knowledge of the health system and their insight into the workings of the health centre as a unit. Health centre chiefs also enabled the researchers to discuss issues of administration, decision making and communication between the various levels of the public health sector. Opportunistic sampling was employed to select other staff members from each of the eight health centres. Opportunistic sampling is a technique that allows the researcher to make an instant decision about sampling to take advantage of new developments during the data collection (Patton, 1990).

Participants

This study drew its primary participants from the eight sampled health centres as well as additional providers from other health centres who were involved in some of the focus groups. The sample included unqualified staff, primary and secondary midwives, primary and secondary nurses, medical assistants and doctors. A range of secondary participants were selected to provide background knowledge to the study. These informants included MoH officials working at national, provincial and local level as well as staff from international donor agencies. A further five participants were selected for their knowledge of local health services during different periods of change.

Methods

Multiple methods of data collection were employed during this study, these included: interviews, observations and documentary analysis

Qualitative research involves an iterative process of data collection and analysis. There were two stages of data collection; the initial stage involved key informant interviews, unstructured in-depth interviews, focus groups discussions including community mapping and elite interviews. This identified important themes that required further inquiry. The second stage of data collection was more focused using semi-structured interviews, observations and life history interviews. Field notes and documentary analysis were ongoing during the research period and prior to leaving the field site, exit key informant interviews and exit focus group discussions using vignettes were conducted.

Analysis

A thematic analysis was conducted in four stages using an explanatory building process which began with open coding to develop initial concepts, then major and minor codes were collapsed to develop inferential codes and discover relationships between emerging themes. Following this initial statement of argument was produced using matrix and other data displays to examine our findings. The final stage was the interpretative write up which lent shape and gave meaning to our analysis from the raw data. Throughout this process the team looked for alternative explanations, identified outliers and tested our theories asking, what are other ways to explain what we are seeing?

Ethical considerations

Ethical clearance was obtained from the Ethics Committee of the University of Queensland prior to leaving the country. There was no formal system of ethics approval in Cambodia; however, ethical considerations were discussed with the National Institute of Public Health in Phnom Penh, and locally at the Provincial Health District (PHD) prior to entering the field. The key ethical issue faced by the team was the sensitive nature of the research created potential for exposure and exploitation of the participants and the researchers were vigilant in their attempts to maintain confidentiality. To conceal the participant’s identity the data was de-identified at time of collection and pseudonyms have been used for places and participants related to this study.

Current health sector reform

The process of health sector reform has been implemented in three phases with the aim to strengthen the health system. The problems facing the reform process included poor quality service, inadequate funding, under utilization of public health facilities, burgeoning and unregulated private health sector and excessive use of un-prescribed drugs (Chuor, 1999). In the earliest days of reconstruction, external assistance was in the form of service delivery with agencies setting up and operating clinics, hospitals and outreach services, delivering health needs as vertical programs (Lanjouw et al., 1999). The health sector reform is now addressing nation-wide issues of physical infrastructure, human resources for health, training and service coverage for the whole community. The health reforms have concentrated on strengthening management processes and procedures through policy formulation, planning and service delivery. The public health sector has been restructured by adopting a district-based approach to health services. Capacity development has been promoted through management development and technical skills training.

The health system is currently in the third phase, the immediate objectives of the reform process were to increase people's access to and utilization of quality essential health services whether they were subsidized by government or paid for through a public-private mix (Grose et al., 2001). The operational district is the most peripheral sub-unit within the health system. Its main roles are interpreting, disseminating and implementing national policies and provincial health strategies, maintaining effective, efficient and comprehensive services according to the needs of the community, ensuring equitable distribution and effective utilization of available resources and mobilizing additional resources for district health services (MoH/WHO, 1997).

Health coverage plan

In 1996 the HCP was implemented by the MoH. This plan is based on fundamental principles of equity through improved access to heath care for all of the population (MoH, 1999). The HCP sees the division of Cambodia’s 22 provinces into 69 operational districts each containing between 100 000 and 200 000 inhabitants. The fundamental unit of the HCP is the operational district. Each operational district contains one referral hospital and a network of health centres (10-15) that each serves catchment areas of approximately 10,000 people. The HCP describes the structure of heath care at the operational district level and outlines the process of service delivery. It has included a MPA provided by the health centres and a Complementary Package of Activities (CPA) provided by the district referral hospital (MoH/WHO, 1997).