Health Center Contest in Kampong Trach Operational District, Kampot

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					   Health Center Contest in Kampong Trach Operational District,
                        Kampot Province

         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:

   a. 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.

   b. 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.

   c. 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:

   a. 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.

   b. 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.

   c. 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

      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
- the evaluation of HC is done on a            - need to set clear objectives of the HC
  regular (monthly) basis                        contest
- results of the evaluation are known and      - there is a need to continuously
  discussed among the HC Chief                   improve HIS validity since this is the
                                                 most important basis for scoring.
- it makes use of the existing activity        - there is a need to follow up and make
  (supervision to HC, Discocom Meeting,          use of Social Capital as a sustainable
  etc)                                           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      - need to consider putting weight on
  from HC1 is the primary source of data         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             - Can gradually start on putting other
  objective i.e., target ranges are plotted      quantitative indicators on HC
  against the score                              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           - Can gradually start also on qualitative
  target ie., target for the year has the        indicators phrased quantitatively e.g.,
  highest score                                  on patient interaction, proportion of
                                                 patient greeted and patient
- indicators are mostly on health service      - Can make use of other data collection
  results (process indicators – utilization,     method, e.g., direct observation, exit
  coverage)                                      interviews, community interviews other
                                                 than document review (HC1, HC
                                                 Register) which can be tampered
-                                              - consider putting different weights on
                                                 criteria/indicators, more important ones,
                                                 more weight.
Resource Mobilization
- Resourcefulness and maximizing             - Proper judgment is necessary when
  resources e.g., making use of bicycles       making use of resources that deviates
  given by EPI program as award                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      - There is also a possibility that HFS in
  of the Kampong Trach District Hospital       the HC can play a role in the
  when it was functioning well played an       sustainability of the Contest.
  important role in assisting OD finance
  the ceremony.

       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).

                                                Fig. 1
                            Evaluation on HIS Quality in Kampong Trach HCs
                                             January 2001


































                                       Health Centers
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.

                                        Fig. 2 Evaluation of HIS Quality in Kampong Trach (1999 - 2001)









                     Svay Tong   Tnot    Boeng Sala   Russey Srok   Sre Chea   Touk Meas    Banteay Meas   Damnak Kantourt   Prek Kroes   Sdach Kong   Kanthor   Kampong Trach

                                                                                   Health Centers
                    Fig. 3 Evaluation on HIS Quality in Kampot Province
                                        (1999 - 2001)

              60                                                          2000
              40                                                          2001

                    Angkorchey      Chhouk       Kampong Trach   Kampot
             1999     87.85         69.62                84.02   71.53
             2000     97.62         90.99                91.62   96.26
             2001     99.14          95.5                96.25   99.02

                                 Operational Districts

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