Tries Nonprofit Path
to Health Care
By CELIA W. DUGGER
- 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
mind churned with fear. In the Khmer language, this most treacherous
passage in a woman's life - childbirth - is called crossing the
river. Her aunt had died giving birth to a first child who perished
in the womb. Mrs. Sna wondered if she and her baby, too, would drown
before reaching the other shore.
long ago, Mrs. 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, Mrs. Sna's terrified husband hired a pony cart
and was able to take his wife over a deeply rutted dirt road to
a small, no-frills public hospital.
childbirth is a miracle of nature, then the thriving, honestly run
network of clinics and hospitals here is a human marvel, managed
not by the government but by one of the nonprofit groups it has
hired to run entire public health districts.
approach is catching on in a growing number of poor countries around
the world, from Bangladesh
to Congo and Rwanda
, to Bolivia
and Guatemala ,
reaching tens of millions of people.
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
in Cambodia , the nonprofit groups
- all of them international - are instilling discipline and clarity
of purpose in a health care system enfeebled by corruption, absenteeism
and decades of war and upheaval. They have introduced incentives
to draw Cambodia 's own doctors and nurses
back into the system. Patients, especially the poorest ones, have
followed in droves.
the evidence is that this worked very well in a situation where
nothing much else worked very well," said Shyam Bajpai, the
representative here for the Asian Development Bank, which financed
the original contracts.
health care system is still recovering from the traumas of the murderous
reign of the Khmer Rouge, which in the 1970's singled out the educated
for slaughter, decimating the ranks of medical professionals. Decades
of war that completely drew to a close only in 1998 destroyed hospitals
and deepened poverty.
international donors provide about two-thirds of the 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.
Health Ministry began testing the use of contractors in 1999. Then,
the main hospital in the Pearaing district was a crumbling shell.
It had fallen so far into disuse that termite mounds rose on the
broken tile floors and farm animals rooted in the yard, chewing
on mangy bits of grass.
saw more cows than patients," said Sopha Sum, a nurse then
assigned to the hospital.
years after the main hospital was turned over to Health Net International,
based in the Netherlands
, Pearaing'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 government and donors are spending only $4 a year per person
on health care in the district - what a couple of aspirin tablets
would cost in many American hospitals.
five nongovernmental organizations running parts of the health system,
Health Net and Save the Children Australia, among them, are paid
based on their performance in improving services, like childhood
and the proportion of women getting prenatal care and delivering
babies in a health center. With additional support from the British
and the World Bank, the government recently expanded the approach
to cover one in 10 Cambodians.
managed by the nongovernmental organizations 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 study randomly assigned districts to be managed by nonprofits,
or by the government, then measured results through household surveys
conducted in 1997 and 2003.
were fantastic improvements," said Michael Kremer, a Harvard
changes did not happen overnight. For years, Dr. Fred Griffiths,
the 54-year old Pakistani who runs the Pearaing district for Health
Net, said he saw most of his operating budget from the Cambodian
government skimmed off as it made its way through layers of bureaucracy.
Chhorn, who then monitored the contracted districts for the Health
Ministry, said officials simply took the money through various corrupt
practices. "At least 40 percent of the budget just disappears,"
said Mr. Chhorn, who now works for a management consulting firm.
"And this is the best situation. In the worst situation, almost
all of it disappears."
Griffiths found himself in the worst of situations. A trim man with
a neatly clipped mustache and a no-nonsense style, he did not take
it quietly. "We screamed at workshops and conferences, wherever
there was a forum," he said.
year, to his relief, the government began transferring the funds
directly from the national treasury to the contractors, bypassing
potential layers of graft.
his toughest job was motivating the staff. Dr. Griffiths realized
he would never get the system functioning unless he could improve
the health workers' earnings.
government paid poverty wages: $20 a month to a doctor, $15 for
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 bone-rattling three-hour drive from the capital,
Phnom Penh .
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 his own clinic near a ferry
crossing on the
was willing to work at that time," he said. "Even the
chief of the hospital had his own business. Nobody blamed anybody."
hospital itself was like a stolen car stripped of its parts. Dr.
Griffiths said the equipment had simply disappeared, probably into
the staff members' private practices. Thermometers, stethoscopes,
speculums, obstetrical instruments - all were missing.
Griffiths decided to use part of his contracting budget to supplement
his staff's pay. Pearaing also introduced small fees, charging 25
cents to see a doctor and 75 cents for a day's stay at the hospital.
Net used the revenues to bolster the staff's incomes, paying for
incentives for punctuality and reaching targets to immunize children,
and generally instilling a culture of accountability. Despite grumbling,
most of the staff gave up their side jobs to work full-time and
provide 24-hour coverage.
now earn $60 to $200 a month depending on their qualifications and
performance, while doctors make $200 to $250.
the district's fees are much lower than those charged by the drug
sellers, quacks and government doctors who used to operate private
practices, peasants have flocked to the public clinics and hospitals.
Health Net covers the hospital costs of the poor, about 40 percent
of the patients, out of its contracting budget.
recent afternoon, the beds at the hospital in Snay Pol were filled
with people suffering from the kinds of easily treated illnesses
that kill millions in developing countries each year.
Ros, a 45-year-old mother of eight, had gotten her 10-month-old
twins, Boramey and Bon, to the hospital on an arduous, five-hour
journey that began on a boat slipping through a rice field at dawn,
continued on a bumpy horse cart and finished on a motorbike.
babies, coughing and listless, had two potentially mortal ailments:
diarrhea and acute respiratory infections. The mother watched anxiously
as intravenous drips replaced their lost fluids, preventing their
deaths from dehydration.
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 across this rural landscape.
far back as anyone can remember, the women here in the
Reap have depended only on traditional
birth attendants - village women with no formal medical training
- to bring babies into the world. But now more than half the women
in the district give birth in a health center, compared with less
than 10 percent in
our parents delivered at home," said Mrs. Sna's husband, Veasna
Van. "Now, nobody does. We believe the health care center can
save lives if there is a problem."
Sna's birth attendant, Min Heng, 50, agreed. "I have only my
empty hands," she explained.
Net turned women like Mrs. 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, more than the 75 cents a
family typically pays the attendant for delivering the baby by herself.
Mrs. Heng assisting at the clinic, the midwife began to worry that
Mrs. 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.
Yim, a pony cart driver who has built a good business getting women
to the hospital, pulled in at the clinic. He filled his wooden cart
with straw and lay a mat on top of it. Mr. Van gently picked up
his wife and placed her in the cart. Her face crumpled when yet
another contraction seized her belly.
the cart jounced through the emerald green paddy fields along a
road cratered by the monsoons, Mrs. Sna moaned, her husband rubbed
her lower back and Mrs. Heng rested her hand on Mrs. Sna's hip.
half hour later, they trotted up to the maternity ward at the hospital.
Dr. Sorny Kong hustled into the birthing room. She started Mrs.
Sna on a sugar drip to give her a bit of a lift, got out the vacuum
extractor - operated with a foot pedal - and attached the suction
cup to the crown of the baby's head. A half hour later, a healthy
boy emerged into the world.
later, Mrs. Sna lay on a bed in a row of new mothers, her baby swaddled
beside her, a luminous smile on her face.