Health Center Contest in Kampong Trach Operational District, Kampot Province

Introduction

For two years now, Kampong Trach Operational District has been conducting annual awarding of the best health centers in its district. This was an idea that was developed by the OD Vice-Chief when he realized that he could make good use of the Monthly Health Center Supervision (ICS). The indicators were mostly health service indicators and some aspects on HIS quality, staff discipline and working hours. The awards include bicycles, cash awards from then PHD, bags from OD and felicitation certificate signed by the PHD of Kampot. From the interview conducted with the OD VC it was known that the hospital assisted in financing the ceremony during the time when the income from the hospital health financing scheme was on its peak. The bicycles came from the EPI program (10) and were distributed to top ten health centers. For the awarding in 2001, the GTZ assisted in providing bicycles (5) and assistance to the awarding ceremony.

Process in the Health Center Contest

The indicators that were used are listed in Annex 1 (Checklist for Health Center Evaluation). It includes health services results e.g., ANC2, BS, EPI, OPD among others. Other indicators include HIS quality, staff discipline and working hours. The HC Chief and the OD Supervision Team agreed on these indicators. The scoring system is done by assigning the highest score to the target for the year, e.g., target for ANC2 is 40% which is plotted against the highest score which is 6. For HIS quality, the scores were taken from the Peer Evaluation System/HC Spot Check as discussed in another paper (see Annex 2 – Excerpt of Comprehensive HIS in Kampot). Equal weights are given to all the ten indicators.

There are several steps involved in collecting the data and ensuring reliability:

  1. During OD supervision at the Health Center, the OD team fills up the ICS form, checks HC1 and Health Center Register of the previous month. During this time, the team also sees whether important schedules for outreach activities, staff working hours, among others were pasted on the wall. Supervision is not scheduled hence the HC staff does not know when the team is coming.
  1. During Discocom (meeting of HC Chief at the OD), HC1 were submitted to the OD. It is also during this time that HIS quality is being checked through Peer Evaluation System (see Annex 2). The results of last month's evaluation are presented to the HC Chief. The HC Chief are then informed of their monthly ranking. The OD VC also provides them a copy of the previous month's evaluation result.
  1. The data for twelve months were collated and summarized and the best health centers (number depends on available resources) are given awards.

Perception of Health Center Staff on the HC Contest

Interviews conducted to three health centers (Numbers 1, 5, 11 from 2000 contest) revealed the following:

  1. Knowledge about the Health Center Contest

The Health Center Chief and some of its staff are aware of the contest and link their score with the supervision results conducted by the OD Supervision Team and the Discocom meeting. Most of them know some of the indicators used and how they achieve such ranking. There was no opposition on the part of the Health Center staff interviewed regarding their ranking. Most of the indicators are quantifiable and sources are their own reports (e.g., HC1). All of them agree that the contest is fairly treated.

  1. Motivation

The HC staff would like the contest to continue even without big awards because it gives life to their work. During Discocom meeting there was a lot of discussion because that is the time when they see that what they have accomplished (or not accomplished) at the Health Center are discussed, given attention and summarized. Question on what else motivates staff to be in a competitive mood is still not answered fully.

  1. Ways to improve

The Health Center Contest also allows the HC staff to be more aware of their problems. The staff of the poor performing health center expressed that they need the support of the OD/PHD on promotion of their EPI activities because of its low acceptance by the population.

All the HC staff points to the following in achieving their targets:

-good community participation as the key in achieving the best results (with and without NGO support),

-good planning of outreach activities,

-support from OD/PHD in terms of erring staff, health promotion activities

The best performing health center identified internal supervision and internal conflict resolution as important aspects in achieving their results.

Some observations

The health center contest in Kampong Trach is an innovative initiative by the OD VC. It provides practical use of the supervision checklist and HC1. It also maximizes supervision visits and Discocom meeting as venues to monitor activities and compare one health center achievement with others. In that sense the HC chief sees perspective beyond their health centers. A feeling of pride of being the best and feeling of getting there motivates health center staff to work. It is interesting to note that this initiative did not fall too much on the trap of motivating staff for financial remuneration. It tries to capitalize on a human being's drive to do well and to improve.

Listed below are some observations on what is good and what needs improvement in the Health Center Contest in Kampong Trach District based on three aspects: process, tools (indicators/criteria) and resource mobilization.

What is good / What needs improvement/ still to be done
Process
-the evaluation of HC is done on a regular (monthly) basis / -need to set clear objectives of the HC contest
-results of the evaluation are known and discussed among the HC Chief / -there is a need to continuously improve HIS validity since this is the most important basis for scoring.
-it makes use of the existing activity (supervision to HC, Discocom Meeting, etc) / -there is a need to follow up and make use of Social Capital as a sustainable motivating factor for HC staff.
-participatory – the contest and indicators used are all agreed by the HC Chief and OD
-effort on integration – tried to put together NP and support programs like drugs, HIS
-capitalizes on advantages of competition and HC staff's drive to be the best
Tools (Indicators/Criteria)
- indicators are verifiable i.e., results from HC1 is the primary source of data / -need to consider putting weight on some inputs e.g., HC with or without qualified staff, HC with or without NGO support, the number of staff in HC, etc.
-Grading or Scaling of scores are objective i.e., target ranges are plotted against the score / -Can gradually start on putting other quantitative indicators on HC management e.g., no of FBC meetings and minutes, % of exempted patients from HFS, income from HFS, etc. Nevertheless, additional indicators will only be useful once the objective for the HC contest has been clearly spelled out.
-Scoring aims toward achievement of target ie., target for the year has the highest score / -Can gradually start also on qualitative indicators phrased quantitatively e.g., on patient interaction, proportion of patient greeted and patient seen/attended
-indicators are mostly on health service results (process indicators – utilization, coverage) / -Can make use of other data collection method, e.g., direct observation, exit interviews, community interviews other than document review (HC1, HC Register) which can be tampered anytime
- / -consider putting different weights on criteria/indicators, more important ones, more weight.
Resource Mobilization
-Resourcefulness and maximizing resources e.g., making use of bicycles given by EPI program as award / -Proper judgment is necessary when making use of resources that deviates from original purpose. The initial purpose of the resources should be addressed first e.g., distribution of bicycle to areas where it is needed then the rest for the contest.
-The financial assistance from the HFS of the Kampong Trach District Hospital when it was functioning well played an important role in assisting OD finance the ceremony. / -There is also a possibility that HFS in the HC can play a role in the sustainability of the Contest.

It is premature to look into the impact of the health center contest to the functioning and overall performance of the health centers in Kampong Trach. Nevertheless, the initiative is quite promising. The fact that the OD VC tried to make use of the supervision results and the health staff agreed to it is a good indicator that there are still aspects in motivation (other than monetary) left untapped. This needs further observation and attention.

Annex 2 Selection from the Paper on Comprehensive Health Information System for Kampot PHD

Health Information System in Kampot

Improvement in Data Documentation

For three years now, PHD-HIS in Kampot with the support of the Reproductive and Health Alliance (Racha) has been improving the quality of Kampot health data. In 1999, the first problem encountered was the irregular documentation of HIS data. Often, these data were just written in small pieces of paper, which would later on disappear. The PHD has not had yet the capacity to print forms for this. In the interim the HC staff were taught to write down data in journal/book. Most health centers did except that the forms were not uniform. The PHD-HIS and Racha then provided a standard tabulation based on the MOH format. Then the PHD also made available print forms for distribution to Health Centers.

After improvement in the documentation of HIS data, the next problem they realized was that in most Health Centers, there were discrepancies between the data in the HC1 and the Health Center Register. They then introduced the so-called Peer Evaluation System. During monthly Discocom meeting at the ODs, the Health Center Chiefs bring their respective HC1 and Health Center Registers. Two Health Centers exchange their documents and check consistency of these two documents (HC1 and HC Register) using the criteria (evolving) in form of a checklist (Annex A). The results are then summarized in percentage and each HC sees their performance (called quality validation) in relation to others in form of a bar graph (see example in Fig. 1).

After the Peer Evaluation, the PHD-HIS, PHD-MCH and OD-HIS conducts HC spot checking, choosing the best or the worst performing Health Center to conduct the spot check monthly. They use the same checklist as the ones used in Peer Evaluation at OD and compare it with the grading it has received at the OD.

Efforts on Data Visualization/Utilization

Racha, through the PHD-MCH, also introduced visualization of health data with emphasis on MCH indicators i.e., ANC, BS, and EPI. Previously, the PHD/OD HIS, EPI, MCH staff on how to make graphs from the health data collected, plot them against the program's yearly target. The graph is then updated monthly. The OD HIS staffs are the ones doing the graphs for HC. Recently, Racha conducted training to Health Center staff on data visualization for them to do their own graphs.

The Malaria Unit of the Technical Bureau also assisted the Operational Districts to make the data on Malaria useful for both the Health Centers and the Operational Districts. The Head of the Unit (Mr. Saroth) provides graphs to the OD and from there, analyses which HC has increasing incidence of the disease. Nevertheless, visualization is done at the PHD level and distributed to the priority ODs (particularly Chum Kiri in Chhouk).

Present HIS in Kampot

The result of regular peer evaluation on HIS limited if not eliminated the inconsistencies between HC1 and HC Register (along with other problems) as can be observed in the evaluation summary from 1999 – 2001 (see examples in Fig 2 and Fig 3). The visualization at PHD/OD also provided the staff clear signal on which program in what OD/health center needs assistance.