1. Bart Jacobs Luxembourg Development Institute Tropical Medicine, Antwerp Swansea University Using P4P to sustain high service delivery level during transition of management authority at Cambodia

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 (%) Variable199920012004 ANC293683 Qualified delivery142543 Facility delivery5931 Full immunisation406197 Vitamin A506393 Contraceptives92734

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

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 Activity20042007 Amount of subsidiesNGOGov Internal rules and regulationsNGOGov Bonus distributionNGOGov Management contracts facilitiesNGOGov Allocating MoH fundsNGONGO + Gov MonitoringNGO Indicators and targetsNGO Admin management contractNGO

11. Approach to P4P Each facility a team Flexible, quarterly indicators, weighting system $60/staff/year; bonus 20% total income staff member by 2007 Start2006 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-reachFee-for-service

12. Results - 1 Variable % 200420052006 Fully vaccinated 9790*96 Vitamin A 9386*92 ANC2 838183 Qualified delivery 434466* Facility delivery 313959* Contraceptives 343635

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% 199920012008 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. Indicator and target setting and monitoring by independent agency (NGO)–objectivity NGO support for administrative issues Lessons for Cambodia -3