Bart JacobsLuxembourg Development

Institute Tropical Medicine, AntwerpSwansea University

Using P4P to sustain high service delivery level during transition of

management authority at Cambodia

ObjectiveMicro perspective on contracting in

CambodiaMore specifically on the role of P4P during

transition of management authority from NGO to government authorities

Longitudinal 4-year case studyLessons for scaling up –at Cambodia

Setting Kirivong Operational Health District

4 administrative districts, 31 communes, 290 villages

≈220,000 peopleSubsistence farming, foraging35% (2002) poverty rate20 health centres, 80-bed hospital180 staff members95% Buddhist91 pagodas, 5 mosques

Service delivery level (%)

Variable 1999 2001 2004

ANC2 9 36 83

Qualified delivery

14 25 43

Facility delivery

5 9 31

Full immunisation

40 61 97

Vitamin A 50 63 93

Contraceptives

9 27 34

High level reached by 2004 byContract with 8 administrators (DHTAT) -

$100 each per monthMonthly supplement of $15-20 for other staff

members –mainly to be present at workMonthly outreach (ANC, EPI, contraceptives,

health education) Affordable curative services (user fees since

2001)Free preventive services Community participation

Community participation

Community participation -actors

Initiation P4PStart 2005Disciplinary committeeWorking rules an regulationsMission and objectivesContracts per facilityMonitoring team and formsFresh job descriptionsFocus all building blocks health systemsTraining (team building, communication,

leadership, motivation, community organizing, financial management )

Distribution bonus amongst staff (qualification, position, facility)

Distribution bonus over facilities

Challenges

Responsibilities

Activity 2004 2007

Amount of subsidies NGO Gov

Internal rules and regulations

NGO Gov

Bonus distribution NGO Gov

Management contracts facilities

NGO Gov

Allocating MoH funds NGO NGO + Gov

Monitoring NGO NGO

Indicators and targets NGO NGO

Admin management contract

NGO NGO

Approach to P4PEach facility a teamFlexible, quarterly indicators, weighting

system$60/staff/year; bonus 20% total income

staff member by 2007 Start ≥2006

Admin linkage with facilities

0% 45-75%

Quantitative targets health centres

30% 90%

Quantitative targets hospital

0% 50%

Bonus subjected to P4P 40% 100%

Payment method Possible-to-reach

Fee-for-service

Results -1

Variable%

2004 2005 2006

Fully vaccinated 97 90* 96

Vitamin A 93 86* 92

ANC2 83 81 83

Qualified delivery

43 44 66*

Facility delivery 31 39 59*

Contraceptives 34 36 35

Results -2

Results -3

Results -4

Lessons for CambodiaPossible to build health systems with minor

effect on service delivery level; more durableUser fees can play a role –with social health

protection scheme (Health equity Fund); 18% from bonus by 2007

Need to link management remuneration with facilities’ performance

Utilisation treatment services poorest 50%

1999 2001 2008

2.5% 20% 61%

Lessons for Cambodia -2Payment method is important –fee-for-service Maximum % of bonus subjected to

performance Flexible indicator setting method; no fixed

approach –carrot and stickEnsure continued regular government funding

for health sector Can external funding be phased out? Still 33%

by 2007Community participation creates external

accountability at all levels

Indicator and target setting and monitoring by independent agency (NGO)–objectivity

NGO support for administrative issues

Lessons for Cambodia -3