Khmernews

NGOs Transforming Health Care in Countryside

Posted by khmernews on June 14, 2007

By Celia Dugger
The Cambodia Daily

REAB VILLAGE, Pea Reang district, Prey Veng province- Sovan Sna had been in labor all night long. By the 16th hour of contractions, she was in trouble. The baby, her first, was not coming out. And she was so exhausted and in such pain she could barely speak.
Her mind churned with fear. In Khmer, this most treacherous passage in a woman’s life-child-birth-is called crossing the river. Her aunt had died giving birth to a first child who perished in the womb. Sovan Sna wondered if she and her baby, too, would drown before reaching the other shore.

Not long ago, Sovan Sna would have had little choice but to give birth at home, like her aunt, and risk both her life and her baby’s. But on this morning, her terrified husband hired a pony cart and was able to take his wife to a small, no-frills public hospital.

if childbirth is a miracle of nature, then the thriving, honestly run network of clinics and hospitals here is a human marvel, man-aged not by the government but by one of the nonprofit groups it has hired to run entire public health districts.

The approach is catching on in a growing number of poor countries around the world, from Bangladesh and Afghanistan to Congo and Rwanda, reaching tens of millions of people; these contracted services have allowed international donors and concerned governments to cut through dysfunctional bureaucracies, or work around them, and to improve health care and efficiency at modest cost.

In Cambodia, the NGOs- all of them international- are instilling discipline and clarity of purpose in a health care system enfeebled by corruption, absenteeism and decades of war. They have introduced incentives to draw Cambodia’s doctors and nurses back into the system. Patients, especially the poorest, have followed in droves.

Today, international donors provide about two-thirds of public spending on health and over the years have financed the construction of hundreds of hospitals and clinics. But money and buildings alone were not enough to overcome a bureaucratic culture afflicted by favoritism and lackadaisical accountability.

The Health Ministry began testing the use of contractions in 1999. Then, the main hospital in the Pea Reang district was a crumbling shell. Six years after it was turned over to Health Net International, based in the Netherlands, Pea Reang’s hospitals and clinics now see thousands of patients a week. In just the first nine months of 2005, more than half the district’s 200,000 people sought care.

The five NGOs running parts of the health system, Health Net and Save the Children Australia among them, are paid based on their performance in improving services. With additional support from the British and the World Bank, the government recently expanded the approach to cover one in 10 Cambodians.

Districts managed by the NGOs have been much more successful in improving health services than districts run by the government, a World Bank study found, though both have made progress.

The changes took time. For years, Dr Fred Griffiths, the 54-year-old Pakistani who runs the Pea Reang district for Health Net, said he saw most of this operating budget from the government skimmed off as it made its way through layers of bureaucracy.

” At least 10 percent of the budget just disappears, ” said Sao Chhorn, who then monitored the contracted districts for the Health Ministry, and now works for a consulting firm. ” and this is the best situation. In the worst situation, almost all of it disappears.”

Dr Griffiths found himself in the worst of situations, and the did not take it quietly. “We screamed at workshop and conferences, wherever there was a forum, ” he said. I as year, to his relief, the government began transferring the funds directly from the national treasury to the contractors.
But his toughest job was motivating the staff. The government paid just $20 a month to a doctor, and $15 to a nurse. The staff pocketed the paltry government salaries and spent almost all their time operating private practices.
Not surprisingly, there were almost no patients at the district hospital in Snay Pol, a three-hour driver from Phnom Penh. Sokong Lim, 34, then a paramedic, said he saw only two patients come for treatment in the two years before Health Net arrived. But he also admitted that he was usually working at this own clinic. “Nobody was willing to work at that time, ” he said. ” Even the chief of the hospital had his own business.”

The hospital itself was like a stolen car stripped of its parts. Dr Griffiths said the equipment had simply disappeared, probably into staff members’ private practices.
Dr Griffiths decided to use part of his contracting budget to supplement his staffs’ pay. Pea Reang also introduced small fees, charging $0.25 to see a doctor and $0.75 for a day’s stay at the hospital.

Health Net used the revenues to bolster staff income, paying incentives for punctuality and reaching child immunization targets, and generally instilling a culture of accountability. Despite grumbling, most staff gave up their side jobs to work full time. Nurses now earn $60 to $200 a month depending on qualifications and performance, while doctors make $200 to $250.

The hospital under Health Net’s management has gradually won people’s trust. Not least, the district’s newfound credibility, as well as the 24-hour availability of qualified midwives and doctors, has transformed childbirth habits.
As far back as anyone can remembers, the women in Reab village have depended only on traditional birth attendants- village women with no formal medical training- to deliver babies. But now more than half the women in the district give birth in a health center, compared with less than 10 percent in Cambodia overall.

“All our parents delivered at home, ” said Sovan Sna’s husband, Veasna Van, ” Now, nobody does. We believe the health care center can save lives if there is a problem.”
Sovan Sna’s birth attendant, Min Heng, 50, agreed. Health Net turned women like Min Heng into some of its best recruiters. It pays the clinic an extra $20 for every woman who gives birth there. The clinic, in turn, pays the attendants a bonus of $1.25 for each woman in labor they bring in.

With Min Heng assisting at the clinic, the midwife began to worry that Sovan Sna’s labor had reached a standstill and decided she should be taken to the hospital in Snay Pol, where surgeons and better equipment were available. A half hour later, they arrived at the hospital.

Dr Sorny Kong hustled into the birthing room. She started Sovan Sna on a sugar drip to give her a bit of a lift, got out the vacuum extractor and attached the suction cup to the crown of the baby’s head. A half hour later, a healthy boy emerged into the world.

-The Cambodia Daily: Monday, January 16, 2006 ” NGOs Transforming Health Care in Countryside”

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