Bart Jacobs

1
Using P4P to sustain high service delivery level
during transition of management authority at
Cambodia

• Bart Jacobs
• Luxembourg Development
• Institute Tropical Medicine, Antwerp
• Swansea University

2
Objective

• Micro perspective on contracting in Cambodia
• More specifically on the role of P4P during
  transition of management authority from NGO to
  government authorities
• Longitudinal 4-year case study
• Lessons for scaling up at Cambodia

3
Setting

• Kirivong Operational Health District
• 4 administrative districts, 31 communes, 290
  villages
• 220,000 people
• Subsistence farming, foraging
• 35 (2002) poverty rate
• 20 health centres, 80-bed hospital
• 180 staff members
• 95 Buddhist
• 91 pagodas, 5 mosques

4
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
5
High level reached by 2004 by

• Contract with 8 administrators (DHTAT) -100 each
  per month
• Monthly supplement of 15-20 for other staff
  members mainly to be present at work
• Monthly outreach (ANC, EPI, contraceptives,
  health education)
• Affordable curative services (user fees since
  2001)
• Free preventive services
• Community participation

6
Community participation
7
Community participation -actors
8
Initiation P4P

• Start 2005
• Disciplinary committee
• Working rules an regulations
• Mission and objectives
• Contracts per facility
• Monitoring team and forms
• Fresh job descriptions
• Focus all building blocks health systems
• Training (team building, communication,
  leadership, motivation, community organizing,
  financial management )
• Distribution bonus amongst staff (qualification,
  position, facility)
• Distribution bonus over facilities

9
Challenges
10
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
11
Approach to P4P

• Each facility a team
• Flexible, 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
12
Results -1
Variable
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
13
Results -2
14
Results -3
15
Results -4
16
Lessons for Cambodia

• Possible to build health systems with minor
  effect on service delivery level more durable
• User 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 Utilisation treatment services poorest 50 Utilisation treatment services poorest 50
1999 2001 2008
2.5 20 61
17
Lessons for Cambodia -2

• Payment method is important fee-for-service
• Maximum of bonus subjected to performance
• Flexible indicator setting method no fixed
  approach carrot and stick
• Ensure continued regular government funding for
  health sector
• Can external funding be phased out? Still 33 by
  2007
• Community participation creates external
  accountability at all levels

18
Lessons for Cambodia -3

• Indicator and target setting and monitoring by
  independent agency (NGO)objectivity
• NGO support for administrative issues