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 31
Full immunisation 40 61 97
Vitamin A 50 63 93
Contraceptives 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
Bonus distribution
Management contracts facilities
Allocating MoH funds
NGO + Gov
Monitoring
Indicators and targets
Admin management contract

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
50%
Bonus subjected to P4P
40%
100%
Payment method
Possible-to-reach
Fee-for-service

12. Results -1 Qualified delivery Facility delivery Variable % 2004 2005
2006
Fully vaccinated 97
90* 96
Vitamin A 93
86* 92
ANC2 83 81
Qualified delivery 43 44
66*
Facility delivery 31 39
59*
Contraceptives 34 36 35

13. Results -2

14. Results -3

15. Results -4

16. Utilisation treatment services poorest 50%
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%
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