LOCALIZING DEVELOPMENT: DOES PARTICIPATION WORK?
the community care arm. Furthermore, each community health worker in this trial was responsible for 4,000 people, a ratio similar to the primary health care worker-to-population ratio in Bangladesh’s health care system, suggesting an easy route for scaling up existing health infrastructure. Two studies look at the impact of devolving primary health care provision to NGOs. Kremer and others (2006) evaluate the effects of a pilot program under which the Cambodian Ministry of Health contracted with NGOs to run public health facilities in 12 districts. The project, which ran from 1999 to 2003, covered 1.26 million people, about 11 percent of Cambodia’s population. In some districts (“contracting in” districts), contracted NGOs were expected to work within the existing government system to procure drugs, equipment, and supplies and to use Ministry of Health personnel. They could request transfers of personnel but not hire or fire staff; their operating expenses were financed through the government budget. In others districts (“contracting out” districts), NGOs had full management authority. They could hire and fire staff; bring in health workers from other parts of the country; and procure drugs, supplies, and equipment from any source. 47 Staff members from the Ministry of Health were allowed to join the NGO by taking a leave of absence from the civil service. If fired by the NGO, they were allowed to return to government service in another district.48 The study finds that both contracting out and contracting in had significant positive effects on most measures of health center management, including the health center’s hours of service, staff presence during unannounced visits, and availability of equipment, supplies, and vaccines.49 The authors also look at the impact on the specific health outcomes targeted by the program. They find that both contracting in and contracting out had positive and significant effects on the use of public health facilities for curative care consultations, as well as on antenatal care, vitamin A distribution to children, and child immunization. In contrast, there was less systematic improvement in nontargeted outcomes, such as the treatment of diarrhea and knowledge about HIV risk factors. Yoong (2007) studies the Rogi Kalyan Samiti (Patient Welfare Committee [RKS]) program, in the Indian state of Madhya Pradesh, which transferred control over some aspects of hospital management to a local NGO.50 The study used the phased implementation of this transfer of authority to identify its impact on child immunization rates. 212