Association for Public Policy Analysis & Management

Authors*: Karishma D’Souza and Sebastian Bauhoff

Local health districts are a fundamental unit in most decentralized national health systems, having long been recognized as carrying tremendous potential for improved service quality and coverage (Mills et al. 1990). On one hand, such districts have direct influence over policy implementation; while on the other, through direct engagement with front line workers they are uniquely placed to ameliorate problems of performance and quality.

Understanding the District Health Management Teams (DHMTs) perceptions and thoughts on quality can:

1. provide insights into real and perceived constraints to facilitating improvements in healthcare delivery, with the potential to suggest possible levers for policies;
2. enable the participation of an influential, but often overlooked, cadre of agents, in providing the right responses to health care needs; and
3. supplement existing literature that is highly focused on the challenges faced in direct service delivery.

In this paper, we study the perceptions of healthcare quality held by district-level health managers in Cambodia. While Cambodia has made significant gains in building its health system, the public system is under-used because of the poor quality of the services it provides.  In 2010, only 29% of the country’s unwell or injured patients sought care first in the public system. To asses this problem, we conducted exploratory qualitative interviews with six Operational District Directors (Cambodia’s highest-ranking health district officials). The interview instrument covered four topics: perceptions regarding quality, especially existing quality metrics and perceived opportunities for improvements in quality; perceptions on safety; perceptions on monitoring and evaluation of quality; and perceptions on the effects of incentives to improve quality. We analyzed the results using Atlas.ti software [version 8] and NVivo [version 11] qualitative data management software. The data were categorized and analyzed according to the four abovementioned topics.

Our findings suggest that the top three parameters used to define quality of health care should be whether the care: is patient-centric; has proven clinical effectiveness; and is safe – i.e., minimizes risk and harm to service users. Respondents attributed the shortage of professionals in Cambodia’s public health system to budgetary constraints, and saw this shortage as a deterrent to improving the quality of services. They also called for increased effort to improve staff capacity and skills through refresher training, and viewed monitoring and supervision in favorable terms as tools to build in feedback mechanisms that lead to effective course corrections. Finally, they acknowledged that financial incentives are positive motivators, but discussed that existing incentives are inadequate to this end.

*Author Affiliations:

Karishma D’Souza – Master’s Candidate for International Development Policy, Georgetown University, and Short Term Temporary Consultant at The World Bank

Sebastian Bauhoff - Research Fellow, Center for Global Development