Community Assessment

23 11 2011

As newly-inducted Peace Corps volunteers, we are encouraged to spend some time in our communities conducting assessments before jumping into any projects at site. An assessment allows volunteers to learn more about the strengths and weaknesses of our sites while we start to form initial bonds with community members. An assessment also introduces us to the ideas and resources found within a community or organization so that we can try to leverage them to facilitate a positive change.

After six weeks at site, I can say that I have completed the first stage of my assessment, although I will undoubtedly continue to gather information throughout my time here.  I planned the assessment formally, but knew that many aspects of the plan were bound to change as I went. To be clear, it certainly was not as organized or official as one would guess based on the previous paragraph.

As a health volunteer, my assessment focused on health issues and health service provision. For me, the idea was to collect information from as many sources and methods as possible—keeping in mind, of course, that it was all filtered through my limited Khmer. Another motive for me was to gauge how different groups of people responded to me and to different ways of data collection.

The health center: Where most of the assessment action took place

Briefly, let me outline the different components of the assessment. First and foremost is observation. My most focused observation was at the health center and on outreach runs, but I also picked up additional information during daily activities—in the market, at home, while exercising, etc.  I observed over 500 patients seeking health care; however, the observation also extended to things like the physical facilities, patient-staff relations and hygiene.

The rest of my information was gathered in more direct forms. I gave the professional staff members of the health center a 5-question written survey to fill out, conducted short semi-structured interviews with many of the village health volunteers, and met with the health center director. I talked with NGO staff about community health and had my advanced English students do a ranking activity that revealed their priorities for improving the community and its health challenges. Finally, I interacted with the patients each and every day, gathering basic information about their family size and health, their mode of transportation, their house and their opinions of the health center.

What did I learn from all this work? I learned that Kampong Kdey is, generally speaking, facing the same health issues as most of the country:

  • A lack of clean water sources and latrines
  • High levels of respiratory  infections
  • Fevers, fevers and more fevers—caused by everything from mosquito-borne illnesses to dehydration
  • Prevalent domestic violence
  • A wide range of maternal health issues
  • Childhood malnutrition
  • Poor dental health

The health center seems to need more medications, an ambulance and more outreach. Many people living in the village still don’t know about the health center’s services or what to expect if they go. There seems to be a general undertone of distrust when it comes to the health center. The staff is not welcoming, the center lacks basic resources, and the doctors are under-trained and generally unavailable, the community members I spoke with said.

Apparently, the health center pharmacy is understocked

Most of this information is not unique to Kampong Kdey. In fact, these are the very problems we were told during training to expect. The more interesting element was how people reacted to the process. Not a single patient or health center staff member I spoke with—with the exception of the director and deputy director—saw themselves as a legitimate source of knowledge. They would consistently defer to an authority figure, saying that their own personal opinion did not matter. It was baffling for someone like me who grew up in a culture where you have to answer a survey just to check out at the grocery store or to get a coupon for your dinner. We’re used to seeing our experiences and our opinions as important to researchers, to marketers, to companies. This sentiment is clearly not felt here.

The last thing that I noticed was people’s uncontrollable urge to have the “right” answer. I passed out the written survey to health center staff, and they could not resist getting together to fill it out. I told them time and time again that there were no right answers and that I wanted to hear everyone’s opinions, but in the end, they still huddled together looking at one another’s papers. The patients were the same way. I tried a written opinion-based survey for a few days with the patients—and quickly withdrew it based on the overwhelmingly negative reactions I got—and the patients would all work as a group to fill out the survey, making sure the answer they wrote down was “correct.”

I’m glad to be done with the bulk of my assessment, but there are other pieces of information I’d like to gather too. For example, I’d like to learn a lot more about the physical and social resources in the community, and it would be great to talk to health care providers outside of the public system. These things will come with time though, I’m sure. The learning never ends.

Now that I’m finished and feeling like I’m starting to build a good understanding of Kampong Kdey’s situation, I will start implementing some small projects. I’ve got three or four ideas that I’ve been working on that I’m hoping to get underway in the next few weeks. I’d like to tell you more, but with how volatile things are, I’ll wait until some of them get underway to give any details. Either way, my schedule is definitely filling up, and I’m enjoying the transition into more project-based work.

Katie

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2 responses

23 11 2011
Chris & Jenni

This post is illuminating, Katie. Thank you for sharing your experiences.

I was asked to lead a task force six months ago which is examining the efficacy of traditional community emergency notification models, specifically aimed at public notification of pandemic situations. Each of the participants in our group returned to our second meeting with impressive reports about how to integrate social media into the government’s overall public notification strategy, citing the fact that “…American connections to ‘the Grid’ and to one another are at all all-time peaks as a result of all the mass-adoption of emerging technologies…”

Bar charts and line graphs that tell me how connected we are as Americans are impressive and all, but the pragmatic emergency manager who lives inside of me remembers how effective the mass-adoption of “simplicity” was when I was working away from the USA.

The comment you made about vector-bourne fevers, (and what I assume to be a high incidence of them) struck a chord with me. I’m really curious about the process flow. How do the residents of a place like Kampong Kdey communicate emergent health risks to the larger community quickly? How are thresholds which trigger the need to initiate pandemic epidemiological processes communicated to the authority/agency/body responsible for doing the detective work? On the back end of that cycle, how are after-action reports collated from individual communities into a comprehensive incident narrative? In your opinion, are the assorted pandemic numbers and situation updates which we study from the WHO and other NGO’s relatively accurate?

Hope that this finds you both doing well. We follow your posts with great interest. Please keep them coming.

Best,
CWR

24 11 2011
timkatstravels

Hi, Chris. Thanks for posting. Glad to know you’ve been keeping up with the blog. Despite the fact that we haven’t been in great contact, please know that Tim and I think of you often and wish you two the best. Your Facebook posts lead me to believe there might be a move in your near future. Perhaps to the country’s favorite mitten? Would love to hear about your plans. Feel free to shoot us an email when you get a chance.

Anyway, let me try my best to address your questions.

First, it all starts with meticulous recordkeeping—or at the very least a deep dedication to recording information. I suppose the recordkeeping can’t truly be meticulous since many of the people tasked with recording data on the community-level (health center staff, and village health volunteers especially) have little, if any, formal education as a result of growing up during the Khmer Rouge. But there is a concerted effort to record any and all health-related information.

Under normal, non-emergency situations, that information is then slowly sent up the chain of command. It travels from the health center to the operational district level, up to the Provincial Health Department until it finally (hopefully!) reaches the Ministry of Health in Phnom Penh. I can say that I’ve seen very regular communication (formal and informal) between the health center level and the district- and provincial-levels, but I cannot speak to how things work at the highest tiers.

I also can’t speak to the capacity of higher level officials to compile and process information from the entire country in a meaningful way. I’m hopeful that this is happening. At the very least, the information exists, which is a critical first step in my opinion.

As for triggering action, that’s a whole different story. My impression is that the government is not agile enough to respond to health-related issues in any reasonable timeframe. In 2010, the government’s expenditures only hit $2.2 billion. Not health-related expenditures, total expenditures. (For the sake of comparison, the Chicago Public School system’s budget for the same year was nearly three times that amount.) With such restricted funding and social capital, I’m not convinced there’s much chance of “detective work” really being carried out by the government. They can’t afford to keep their health centers stocked with an adequate amount of medication (or, often, a single thermometer or blood pressure cuff), so their response to any pandemic epidemiological crises would be limited, to say the least.

The response—and almost all of the health education and prevention work—is led by NGOs as far as I can tell. Cambodia receives nearly one billion dollars in aid (you haven’t forgotten that government expenditures are only $2.2 billion yet, have you?) so foreign aid plays a large role in the health, resources and national psyche of the country. While much of this is bilateral aid going straight to the government, a significant portion is also being controlled by international NGOs, which seem to have all but taken over Cambodia. When you combine these resources with those of domestic NGOs, you’ve got quite a force (within the Cambodian context at least).

The presence of NGOs in Cambodia is unparalleled in my experience. All of the training for village health volunteers seems to be done by NGOs. NGOs take the lead on TB treatment and play an important role in HIV/AIDS counseling. They are the ones who facilitate a great deal of the record keeping. Plus, they conduct regular research and gather data themselves too. NGOs, along with agencies such as USAID, truly play an invaluable role in improving health indicators here.

(A quick side note: the flooding this year saw an influx of external assistance, but also a reshuffling of government funds to help support those affected. I don’t know much about how this process played out, but it could be an interesting counterpoint to some of the arguments above. On the other hand, “sexy” situations like natural disasters may not be an accurate representation of the government’s efforts.)

Finally, as to whether the well-known statistics about Cambodian health issues are accurate: Yes and no. Tuberculosis and maternal mortality are huge problems. Childhood malnutrition and a lack of clean water sources plague most of the country. I don’t think that the severity of these issues is being exaggerated in any way. However, one day I accompanied a large, well-known international NGO while they collected their data (for program evaluation purposes only), and the methods used were questionable at best. The workers were in no way acting immorally, they were simply undertrained for the work they were carrying out. This, when compounded with some cultural differences, must inevitably lead to some error when collecting data. However, like I said, these are real issues that truly do permeate everyday life here, even in my relatively well-off site.

So the Cambodian health system has a lot of work to do, but the country has had to rebuild (and “build back better”) an entire institution—and they are not even two full decades into the process. If NGO resources can be closely linked with public employee capacity building and if the government can create and enforce further accountability measures to ensure that funds are in fact being used properly (Cambodia ranks #154 of 178 on the Corruption Perception Index), it seems as though the health care system can take a leap in the right direction. Hopefully soon the government will be better poised to address some of the important issues you’ve brought up.

As always, realize this is all based on a mere four months in a country with a long and complex history. I am not an authority on any of this, but this is the best I can do for now…

Thanks for always providing thought-provoking questions that force me to analyze my experiences in ways I might not normally (and for reading to the end of this very long response). Take care!

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