Mind the Gap! An investigation into the optimisation of public health skills, knowledge and practices of health workers in Cambodia

Universal health coverage (UHC) has been identified as a priority in the sustainable development goals (SDG3), but it is argued here that this is only possible if the health workforce is educated in, and values a public health approach at the primary health care (PHC) level. Encouraging community participation by developing a critical awareness of the social determinants of health and supporting communities to take action is needed. Community health workers (CHWs) have the potential to act as agents for social change to improve the health of rural communities if trained and supported appropriately. This study investigates the optimization of public health skills, knowledge and practices of health workers at the PHC level in rural Cambodia. It is anticipated that this study will afford new insights to inform stakeholders of the factors impacting on the development of public health workforce capacity. The research engaged twenty CHWs over two studies using a participatory action research approach. Over eight participatory workshops and a two-day training session CHWs identified (using photovoice), implemented and reflected on solutions to community health problems. In addition, ten semi-structured interviews were undertaken with key stakeholders from government and non-government organisations (NGOs) to gain an understanding of current methods used to develop the public health capacity of health workers in Cambodia. The public health skills gaps identified at provincial and community levels included planning, communication, community engagement techniques and using initiative to identify and implement solutions. These gaps are intrinsically linked to Cambodian social and political structures, and cultural values which promote a hierarchical working environment. In addition, aid dependency and a lack of ownership has created a new patronage which encourages further disempowerment and an apathetic approach to independently tackling community health issues. Fragmented public health training mainly directed by international agents and a lack of financial support to develop sustainable training, supervision and monitoring negatively impacts public health skill development. Health promotion and prevention training is provided to health facility workers, but there is a ‘know-do’ gap. They view their role as purely curative and removed from the community public health agenda, thus devaluing the application of new public health skills. The implementation of community participation policies in Cambodia is hindered by a reliance on external agencies and cultural norms of respect, obedience and fear of challenging the elite. The capacity for CHWs to act as agents of social change is unlikely given the current policy structure and implementing environment. The health workforce in Cambodia has the potential to contribute significantly to the goal of UHC, however factors affecting their desire and ability to implement a public health approach need addressing. Although many health systems are hierarchical in nature, the degree to which people can innovate, openly analyse processes and procedures and suggest solutions needs to be considered. Identifying ways of supporting CHWs to mobilise and enable communities to be empowered within the contextual environment is required, as is a better understanding of how to close the know-do gap in health facility workers