Operational Research on Improving Health Center Outreach Activity

Operational Research on Improving Health Center Outreach Activity

Improving Health Centers’ Outreach Activities in Kampot Province

Applied Health Research by the Provincial Health Department


The Provincial Health Department in Kampot Province with the support of the German Technical Cooperation Health Project (GTZ HP) has started a process of improving capacity of health managers in the province. Regular discussions in issues relating to performance of health centers, planning process at different levels, NGO coordination are included. Such practical aspects are used to compliment the continuing education being undertaken by both senior managers and operational district staff. As a complementary aspect of this process of capacity building a new component has been introduced in collaboration with the National Institute of Public Health i.e., to initiate health managers to conduct applied health research.

The research component aims to improve the quality of health service delivery in Kampot Province by identifying problems and constraints, providing feedback and corrective measures to improve the quality of health services offered to the population. It is also the intention to create a pool of researchers within the Provincial Health Department who will undertake applied health research when specific needs arise. As a hands-on exercise responding to a priority identified by the management team a research topic has been selected: to look into the performance of the outreach activities provided by the health centers.

Problem Statement

Since the reform of the health system in 1997 the Ministry of Health (MOH) of the Kingdom of Cambodia has put a great emphasis in the establishment and functioning of health centers as the most appropriate channel to deliver health services to the population, particularly to reach those people living in remote areas[1]. A minimum package of activities (MPA) was defined as the main activities to be conducted by health centers to guarantee access to basic services to the majority of the population. This has been reiterated in the Health Sector Strategic Plan 2003 – 2007 as one of the eight essential core strategies.[2]

More than a year ago, the Ministry of Health extended the activities of the health centers from being facility-based to community-oriented. The staff of the health centers were instructed to conduct outreach activities in every village within their coverage area. According to the Outreach Services Guideline of the Ministry of Health, a main operational objective of outreach services is to reach each village at least six times and on the average twelve times per year. By doing this, it is expected that outreach services be able to decrease morbidity and mortality by achieving greater coverage of effective interventions and reaching larger populations with services and health education.[3]

In return for performing outreach services, per diems to cover for food costs and transport allowances are given to the staff. However, per diems are only received when funds became available i.e., usually arrives after several months (4 to 6 months later) except when there are organizations (NGOs) directly supporting the Health Centers in outreach activities. This implies that HC staff should incur their own expenses at the time of the actual outreach activity. Taken into account their low salaries their options are to be challenged and conduct the outreach activity or entirely missing them out, but reporting just the same.

The above problem has been observed by most of the leadership of the Provincial Health Department in Kampot Province as well as other health support organizations working in the province.

Since the Provincial Health Department has limited capacity to make this financial proposal feasible, it was considered whether organizations could assist financially. The health support organization (NGO) provides an initial fund ranging from 75% - 100% for outreach activity for the next six months (extending to one year)and that Provincial Health Department will provide the remaining 25% of the total budget for that same time frame. When the budget from the MOH finally arrives, (on the average four to six months after the outreach activity has been conducted), replenishment of the depleting 75% (health support organization contribution) will then be made by the PHD. This is to ensure that per diems for outreach activities in the succeeding months would also be given on time. This kind of arrangement could facilitate earmarking of the forthcoming budget for outreach activities since there is no budget line specification for every given step. The idea of health support organizations providing initial fund to pay the per diem on time to the staff was proposed by RACHA in Angkorchey OD (starting May 2003) and to be complemented by GTZ Health Project in the remaining three districts (Chhouk, Kampot and Kampong Trach Operational Districts).

In addition to per diem not given on time, other factors affecting the quantity and quality of the delivery of outreach activities have been identified. Some of them are provider-related factors and others are more specific to the characteristics and dynamics of the community including the link between the outreach services providers and community based organisations or key players. These factors were raised during a brainstorming session with the PHD senior management team and are summarized in the figure below.


Kampot Provincial Health Department - Operational Research on Outreach Activities

29 May 2003

Note: / Thicker arrows reveal higher priority in the research
* No standard (transportation): a) transportation allowance be per person or per OA session; b) fixed per trip or per kilometre travelled.


Kampot Provincial Health Department - Operational Research on Outreach Activities

29 May 2003

However within the framework of this operational research it is intended to test the hypothesis that making available timely per diem to health workers conducting outreach activities would improve target group and population coverage and the quality of services provided, in terms of time spent, areas covered in the village, rapport to the community. Finally, it also tries to observe whether or not all relevant components of the outreach activity are carried out during the intervention. Nevertheless other contextual factors and constraints that affect staff performance in outreach activities will be also identified and analysed.

Objectives and Research Questions

General Objectives

▫To assess the performance of the outreach activities in selected health centers

▫To identify constraints and other contextual factors affecting the performance of outreach activities

▫To provide feedback and recommendations to the Provincial Health Department and Operational Districts to improve the quality of the outreach services and performance of the health centers

▫To build the capacity of the Provincial Health Department senior management team in conducting qualitative research. To train and set up a research pool within the PHD

▫To establish and promote links between the NIPH and the provinces

Research Questions

▫What are the HC staff knowledge about outreach activities? How do the HC staff perceive outreach activities? How does a properly performed outreach activity look like?

▫What are the environmental factors affecting the provision of outreach activities in the village? What experiences do they have in conducting outreach activities? What are the constraints/barriers faced by the HC staff providing outreach activities? What facilitates ease of conducting outreach activities? Does payment of per diem on time lead to better quality or more outreach activities?

▫What are the existing facility and community-based mechanisms supporting outreach activities? In what ways do they provide support to outreach activities? What other mechanisms should be in place for outreach activities to be performed properly? What measures or remedies should be undertaken to improve the quality and quantity of outreach activities?

▫How does the community perceive the provision of health services in the village? What services reach them? What services do they think should be provided? To what extent are the poor reached by these services (outreach activities)?

▫What are the health seeking patterns of the members in the community?

▫What should be the role of the community in health service provision particularly during outreach activities?

▫What communication channels (formal/informal) exist between public health providers and community? among health providers? among community? How do they function? What facilitates/hinders communication?

Research Methodology

Study Design and Data Collection Techniques

The research proposed here encompasses two types of study designs: descriptive and comparative (before-after study). The study intends to provide a clear picture of the functioning of the outreach activities in representative health centers and their selected catchments areas. After taking the baseline information (baseline phase – see below), timely per diem will be given to HC staff doing outreach activities. An after-study will be done (evaluation phase) after eight months (or one year) comparing baseline from the data to be gathered during evaluation phase. In between these two phases is the intervention phase where spot-checking and process evaluation will be conducted.

As briefly mentioned above, this research will be undertaken in three clearly defined phases combining qualitative and quantitative approaches. The phases are as follows:

Baseline Phase

This phase searches to capture and assess what is the present situation regarding outreach activities both from the perspective of the providers as well as the beneficiaries and other community members. This phase will also explore existing communication channels for both, facility and community-based mechanisms for outreach and health seeking patterns in the community.

Different data collection techniques will be used such as document reviews from the health centers, OD/PHD HIS regarding the coverage of key indicators. Survey will be conducted to the selected villages focussing on the services provided during outreach activities and the segment of the population benefiting from the services. In-depth interviews will be conducted to health center staff, health support groups, local authorities and community key informants. There will also be focus group discussions to be conducted to the communities concerning health issues experienced, perceptions regarding the services and how to improve them.

Intervention Phase

In the intervention phase, $2.50 will be paid (for transportation and food allowances), either before or immediately after the outreach, to the staff of the health centers doing outreach.

During this phase, random visits will be conducted in the communities where the outreach is being conducted. A continuing monitoring of the intervention being performed will be developed and applied during the experimental period (process evaluation) and a community member will be identified to check staff behaviour in identified research sites. Unstructured interviews will be performed with selected informants. As this is an operational research, feedback and information gathered during this phase will be used to improve outreach activities when the research is finalised. If possible, repeated measurements of key outcomes to estimate trends (increase in coverage of services, staff behaviour, community, local authorities and support group responses, etc) will also be conducted.

Evaluation Phase

This phase will assess the outcome of the intervention and will measure whether changes in the quantity and quality of the outreach activities have been identified; whether those are attributable to the payment of per diem on time or to changes from other contextual factors.

During the evaluation phase interviews will be conducted with the health staff, support groups, local authorities and community members (as in the baseline phase).

Sampling and Study Population

There are two study units in outreach research: the health centers and the villages. The following paragraphs explain the selection criteria for each study units.

The Provincial Health Department in Kampot Province is composed of 4 operational districts (OD) encompassing 47 health centers. The operational research proposed here will be conducted in nine (9) health centers and in selected villages in their catchment areas. These represent health centers in three out of four operational districts. Such arrangement was made after discussion with Racha who will do a parallel study on Outreach in Angkorchey OD. Another reason is that there is a significant difference between the interventions to be provided by this research and those by Racha. Nevertheless, there will be constant communication between the PHD and Racha as regard the progress and findings from their study and vice versa. This means that the ten health centers in Angkorchey will be excluded in the study. Another group of health centers (except one) will also be excluded in the study, as there was already assistance on outreach provided by another organization (GTZ-RDP). The said health center was included in the study based on the result of the HC categorization criteria the research used in selecting representative health centers.

As mentioned, the selection criteria took first the OD distribution of the health centers. Thus, three health centers will represent each Operational District. The next step is to consider representation of these health centers based on the categorization used in the Reward and Sanction Mechanism of Kampot PHD in which health centers were classified in terms of the input provided to them[4].

Figure 2. Health Center Grouping.

From the above criteria and grouping, draw lots were done to select health centers, which will represent each category in that OD. Finally, all health centers were allocated as in Table 1.

The selection of villages follows catchment areas of the chosen health centers. Initially, it was thought to have three villages for each health centers. The unequal distribution of villages covered by each health center prevents this distribution. Instead more villages were chosen in those health centers with larger catchment areas (more villages). This also fulfils the 30-cluster sampling to be used in the survey (Table 1).

As mentioned, 30-cluster sampling will be used in the quantitative component of the research where each village (30 all) will have seven-seven representation of women with children less than one and aged 12 to 23 months, respectively. All in all, there will be a total of 420 respondents in the survey.

HC Category / Operational District
Kampong Trach / No. of Villages / Kampot / No. of Villages / Chhouk / No. of Villages
A / 1 / 4 / 1 / 2 / 1 / 4
B1 / 1 / 3 / 1 / 4
B2 / 1 / 4 / 1 / 3
C / 1 / 3 / 1 / 3
Total Number / 3 / 11 / 3 / 8 / 3 / 11

Table 1. Study sites and number of health centers and villages included in the research.

Work Plan for Data Collection, Processing and Analysis

Data Collection

Prior to conducting the data collection, request to proceed will be forwarded to the Provincial Governor of Kampot Province whose written approval will be provided to all researchers as they start the baseline phase. The PHD also informed all OD Directors and Health Centers involved in the research. After clearing out permissions, the OD Directors will coordinate to the Village Chief of villages in the study for the listing of eligible population i.e., women with children less than one year old and children 12 – 23 months old.

The data collection for the baseline phase will start first with the survey in the villages followed by qualitative component, which involves interviews and focus group discussions with the community and the health staff (see Table 2). The data will be centralized at the PHA Office in Kampot under the supervision of the Principal Investigators. The information from each technique will be numbered and coded.

Data processing of the survey will be done using Epi Info 5 with the assistance of NIPH consultant for Quantitative Methods and the HIS in-charge at the Kampot PHD. Data processing in the qualitative part will utilize codes based on the responses to the questions used in the interview and focus group guidelines.

Analysis will be done when both quantitative and qualitative data are ready.

Activities / Start / Duration (in days) / Who / Resources
Baseline Phase
Training of Researchers / 20/05/03 / 5 / Dr. Kannarath, Ms. Sofi Ospina, Ms. Oeun, Ollie / curriculum, questionnaires,
Permission to Proceed / 26/05/03 / 1 / Dr. Vanna / letter of request
Listing of names of eligible population / 04/06/03 / 2 / Dr. Vanna, Mr. Tann Chheng, OD Directors / Chapter 13 for ODs, gifts for VC
Field Testing
- survey / 06/06/03 / 1 / Dr. Kannarath/ Dr. Supheap, PIs and all researchers / questionnaires, transportation, PHD training hall
- interviews/FGDs / 22/06/03 / 1 / Ollie, Ms. Sofi, PIs and all researchers one Khmer Anthropologist / interview/FGD guidelines, transportation, PHD training Hall
Data Collection
- document review / 04/06/03 / 5 / Dr. Vanna, Ollie, Mr. Tann Chheng, Dr. Chhiay / HIS data at PHD/OD, HC1, HC Register, etc
- survey / 07/06/03 / 10 / Supervisors and researchers / see budget
- interviews/FGDs / 23/06/03 / 12 / Researchers
Data Handling / 07/06/03 / 35 / Dr. Vanna, Ollie / space at PHA office
Data Processing
- survey / 17/06/03 / 8 / Dr. Vanna, Dr. Kannarth, Ollie, Dr. Chhiay, Mr. Heng Chantha / computer, Epi Info program
- interviews/FGD / 04/07/03 / 8 / Ollie, Ms. Sofi, Dr. Chhiay, Dr. Supheap, / computer, interview/FGD guidelines
Analysis / 15/07/03 / 15 / NIPH/GTZ advisor/ consultants and researchers, SC on Research
Reporting/ Documentation (Khmer/English) / 30/07/03 / 20 / Dr. Vanna, Ollie, Mr. Tann Chheng, Dr. Chhiay, Dr. Supheap / computer, results of analysis
Intervention Phase
Spot-checking of Outreach Activities / Aug / monthly / Researchers / transportation
Process evaluation / Aug / monthly / Researchers, all PIs / transportation
Document review / Aug / monthly / Researchers, Dr. Vanna, Ollie / HIS documents, HC1, HC Registers, etc.
Evaluation Phase / 8 months to one year after baseline
Data Collection
- document review / 5 / Dr. Vanna, Ollie, Mr. Tann Chheng, Dr. Chhiay / HIS data at PHD/OD, HC1, HC Register, etc
- survey / 10 / Supervisors and researchers / see budget
- interviews/FGDs / 12 / Researchers
Data Handling / 35 / Dr. Vanna, Ollie / space at PHA office
Data Processing
- survey / 8 / Dr. Vanna, Dr. Kannarth, Ollie, Dr. Chhiay, Mr. Heng Chantha / computer, Epi Info program
- interviews/FGD / 8 / Ollie, Ms. Sofi, Dr. Chhiay, Dr. Supheap, / computer, interview/FGD guidelines
Analysis / NIPH/GTZ advisor/ consultants and researchers, SC on Research / computer, survey results, interview/FGD documents
General Analysis (before-after) / NIPH/GTZ advisor/ consultants and researchers, SC on Research / data from baseline, intervention and evaluation phases
Reporting/ Documentation / Dr. Vanna, Ollie, Mr. Tann Chheng, Dr. Chhiay, Supheap / computer, results of analysis

Table 3. Workplan for Data collection, processing and analysis.