The HSSP-run government health center in Tram Hok, in Takeo province. Patients are coming back.

A n absence of customers has been a common feature of government health-care centers in rural Cambodia, with poor service from underpaid doctors and nurses driving patients to the private sector.

But since 1999 the government has been working with international donors and NGOs under the Health Sector Support Project (HSSP) to improve government health-care provision, increase utilization of government facilities, and reduce "out of pocket" expenditure on services.

"The NGO's role is providing structural support and to cooperate with high-level Ministry of Health staff to develop models to improve [the] functionality [of government health-care centers]," said Bart Janssens, Medical Coordinator at Medecins Sans Frontières.

According to some health-care experts the improvement has been dramatic.

"It is two different worlds," said Dr Chan Neary, Acting Operational District Director for the state health service in Ang Rokar. "Before [the HSSP program] we didn't provide a good service; now things have dramatically improved and people are increasingly comfortable with coming to the government health-care center."

Likewise Uch Dara, an employee at Ang Dasom Health Center, said, "Right now people [in Takeo] use government facilities more than private practices."

The increase in patient numbers is rooted in improvements in service provision, according to Dr Fred Griffiths, of HealthNet International.

"Government health-care facilities were entirely under-utilized," Griffiths said. But now, "The habit of going to private practices first has changed [because] the quality of service provision has improved dramatically."

Gerry Pais, a Swiss Red Cross technical adviser in Ang Rokar, said, "People come to the Ang Dasom health center from all the surrounding districts because we offer 24-hour services. They are sure that any time they come to the Health Center there will be a light on and someone will be here."

Through introducing standard user fees (which are subsidized for those who cannot afford them) the cost of treatment has been reduced and standardized. Moreover, HSSP facilities provide only basic, essential, healthcare services - meaning that vast financial outlays on a plethora of potential cures are a thing of the past:

"When I come here I do not spend as much money as I would at a private practice," said Phum Horn, a patient at Kus Health Care Center in Takeo.

Service provision has been transformed for the better, Griffiths said. "Both peoples' perceptions, and the actual quality of service provision have improved."

To make government health facilities enticing takes more than just having appropriate drugs, equipment and services on offer, Janssens said.

"It is a question of improving the overall quality of the establishments," he said.

This requires, for example, delivery rooms pleasant enough to lure expectant mothers into the centers, and the capacity to provide a comfortable, secure environment for new mothers, babies, and the family entourage.

But though material trappings have a role to play, it is the "human factor" which is paramount:

"Motivated, friendly staff are very important," Janssens said.

Griffiths said the management support provided by the NGOs has helped transform the work ethic and attitude of HSSP health center staff.

"The major achievement of the contracting approach has been to effect a change in the mentality of government healthcare workers. [It is] this change in mentality which has led to the improved performance at government health care facilities," he said.

The staff at HSSP-run government facilities are civil servants on standard government salaries, ranging from US$20 a month for a nurse, to $45 a month for a doctor.

But Neary said that through the introduction of performance-related bonuses and overtime payments - funded through a combination of NGO inputs and user fee profits - staff at the Ang Dasom Health center in Takeo receive an average salary of $120 a month. This has served to transform the attitudes of health center staff.

"The staff are very happy to work here now they receive a living wage," he said.

Neary said it is difficult to create a motivated, professional, and friendly workforce when wages are insufficient to live on.

"When health center staff do 24-hour duty but don't get paid [a living wage] it is very discouraging for these workers," she said.

Janssens said, "A cultural shift within government healthcare workers in Cambodia has to start with more intelligent financing. If you increase the wage of a nurse from $25 to $125 then you will start to see the beginnings of a cultural shift. Before this, you cannot do anything."

With NGOs as contractors, their cash is available to supplement the health center's budgets - for example, by paying staff performance-related bonuses. And as a major problem faced by the HSSP health centers is delays in the arrival of their allocated funds, contractors have been able to rescue health centers from cash-flow crises.

In Ang Dasom only two-thirds of the allocated funding for 2005 had arrived by February 2006. The shortfall has been rectified by the contractor - the Swiss Red Cross (SRC) - advancing the money to the health center.

However, Pais said that in 2007 the SRC will cease its involvement with the project. "We are contractually bound to reduce our financial supplements to the Health Center before we, the contractor, leave in 2007," he said.

Neary is apprehensive about SRC's departure. "I am concerned for the staff - what will happen after 2007? Who will support us then? I am afraid our budget will not arrive on time," she said.

Griffiths said that ensuring the longevity of the HSSP-driven improvements in service provision necessitates a firm commitment - of money and time - from both international donors and the Cambodian government.

"If our financial disbursement system can stay in place then the chance of sustaining improvements is very high," he said.