Introduction: A decade after health sector reform, public health services in rural Cambodia remain under-utilised for multiple reasons related to financial, structural and personnel factors. Ineffectiveness of rural public health services has led to a significant increase in private providers, often the same people who staff public facilities. Public health clinics are often portrayed as low quality, with long waiting times and unexpected costs; in contrast, private clinics are seen to provide more convenient health care. Several strategies, including contract management and health equity funds, have been introduced to improve public sector performance and encourage utilization; these efforts are ongoing. However, the feasibility of these strategies remains in question, particularly in terms of cost-effectiveness and sustainability.
Methods: In this article the strategies of and barriers met by health workers who remain in rural areas and deliver public health services are elucidated. Ethnographic research conducted in 2008 with health providers involved in treating tuberculosis patients in Kampong Speu Province, Cambodia is drawn on. Participants were recruited from the provincial health department, provincial hospital and four health centres. Data collection involved in-depth interviews, participation in meetings and workshops aimed at health workers, and observation of daily activities at the health facilities. Data were transcribed verbatim, imported into NVivo software (www.qsrinternational.com) for management, and analysed using a grounded theory approach.
Results: Primary healthcare service delivery in rural Cambodia was reliant on the retention of mid-level of health staff, primarily midwives and nurses. Its performance was influenced by institutional characteristics relating to the structure of the health system. Personal factors were impacted on by these structural issues and affected the performance of health staff. Institutional factors worked against the provision of high-quality public health services, and included the fragmentation of service delivery and structure, limited capacity and shortage of high-qualified health staff, competition with the private sector, and shortage of medical supplies. These factors all de-motivated health staff, and undermined their performance in public service positions. Personal factors were paramount for staff retention. These included: optimism and appreciation of work responsibilities and position, the personal ability to cope with financial barriers, and institutional benefits such as opportunities for professional development, job security, financial opportunities (via performance-based allowances), and status in society. Individual financial coping strategies were the dominant factor underlying retention, but alone were often de-motivating: clients were diverted from the public services, which led to distrust, and thus undermined the capacity of public system. There was significant interaction between institutional and personal factors, which impacted on the effectiveness of health staff retention in rural areas. Health workers tended to remain in their government positions for prolonged periods of time because they experienced personal rewards. At the same time, however, their job performance in the public health services were hindered by challenges related to the institutional factors.
Conclusions: The interaction between institutional factors and personal factors was crucial for effectiveness of health staff retention in rural Cambodia. Efforts aimed at ensuring quality of care and encouraging health staff retention should attempt to remove the institutional barriers that discourage the use of rural public health services.