Transcript Contracting in Cambodia - Performance Based Financing

Contracting in Cambodia
Maryam Bigdeli
WHO Cambodia
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Cambodia at a glance
 Population – 14 million (2008) – 80% rural
 Administration
 24 provinces; 77 operational health districts
 District hospitals and health centers, national generalist and specialized
hospitals in Phnom Penh
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GDP/capita
Poverty rate
MMR
U5MR
IMR
THE per capita
 OOP
 Government
 External assistance
US$635 (2008)
31% (2008)
472 (CDHS 2005)
66 (CDHS 2005)
83 (CDHS 2005)
US$40 (2008)
US$24 (CDHS 2005)
US$8 (2008)
USD$8 (2008)
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Historical view of contracting
 Phase 1 – Pilot: 1999-2003
- “New Deal”
 Phase 2 – Contracting with NGOs: 2004-2007
(2008)
- BTC supported PB Incentives: 2004-2008
 Phase 3 – Contracting within the Public
Administration: Special Operating Agencies
2009-
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Contracting Phase 1 – 1999-2003
 Context
 Decades of conflict resulting in a destruction of the health system
 Reconstruction: design of a health coverage plan, funding through an ADB
loan
 Contracting experience
 Opportunity to test feasibility and effectiveness of contracting with NGOs
 Pilot experiment (8 ODs)
 Results
 Both models of NGO contracting proven effective
 CO more effective but also more expensive and estimated less sustainable
 Ref: Loevinsohn 2005, Bhushan 2002 and 2007, Bloom 2003
OD
Mgt Resp
Staff
Contracting –out
(CO)
3
NGO
Contracted
Contracting-in (CI)
2
NGO within
MOH system
Civil
servants
Controls
3
DHMT
Civil
servants
(note: input same level
of donor funds)
Performance
Incentive
Salaries
HSD indicators
Basic staff
performance
Salary supplements
Revenue from UF
Salary supplements
Revenue from UF 4
Contracting Phase 2 – 2004-2007 (2008)
 Context
Health Sector Support Project 1: WB-UNFPA-DFID-ADB
 Design
11 ODs were contracted to 7 NGOs through competitive
bids
No standardized implementation arrangements:
 Each contractor free to design and operate scheme as
suited their local context
 Performance could be either staff based or facility based
 Remuneration and incentive left at the discretion of
contractor
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MOH
MOEF
MG
HSSP1
Donors
PMU
Contract
PHD
Accelerated
Disbursement of
Government
budget
Quarterly disbursements
Monitoring
NGO
Contract
OD
Health service delivery through health centers
And district referral hospitals
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User Fees
Contracting Phase 2 – 2004-2007 (2008)
Performance monitoring (1)
 Central and provincial level
monitoring
 Assessing performance of
the contractor
 Site visits
 HH visits in 2 villages per
quarter
 Authorizing quarterly
release
 Contractor monitoring
 Monthly visits to facilities
 Verification of staff
performance
Central level monitoring stopped 2005
Only contractor monitoring
Performance indicators
(district specific targets)
ANC 2 coverage
Delivery by trained staff
Delivery at facility
Full immunization
Vitamine A
Use of modern birth spacing method
Utilization of curative services
BF within 2 hours after birth / collostrum
feeding
 Exclusive breastfeeding
 Number of contacts per year
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9/11 ODs increased access for the poor
7/11 ODs reached all their targets
-1 OD did not reach ANC target
-1 OD did not reach BS target
-1 OD missed 3 targets (BS, EPI, contact)
-1 OD missed 4 targets (idem+VitA)
Ref.1) Cambodia health services contracting review, 2007 – 2) Final evaluation of contractors’ performance, 2009
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Contracting Phase 2 – 2004-2007 (2008)
Performance monitoring (2)
 Each contractor had their own staff
performance, incentive and penalty
system
 Contract termination in case of dual
private practice:
 Ban on private practice has been
loosely interpreted and in many cases
completely ignored
 Sanctions according to MOH/civil
service disciplinary measures:
 Lack of appropriate follow-up by PHD
 Promotion of poor performers to other
positions outside contracting
arrangements
 No provision for contractor-PHD
relationship
 No Monitoring of PHD oversight
 OD management capacity developed
to various degrees
 Eg. Staff performance assessment
 AR- Peer evaluation, average scores,
feedback
 K- Supervisor evaluation and scoring, no
feedback
 Eg. HC visits
 AR- OK
 K- too many HC for 1 Vice-director, other
V-D post vacant, group meetings for
problem solving not conducted
Ref. Keller, Thome, Dekestier
Contracting of Health Services AR & K OD, Takeo
Province- Final Evaluation Report Apr2008
 No thorough documentation from all NGOs
 Only 1 OD developed a comprehensive exit
strategy
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Contracting Phase 2 – 2004-2007 (2008)
Staff remuneration and incentive
 Government budget: salaries and
allowances
 Project budget (ADB financed loan):
performance incentives
 NGO counterpart funds
 User fees: 50% and later 60% of
revenues from UF redistributed as
incentives to staff
Sources of funding for 2 ODs in Takeo
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48 % government budget
29% Project budget
13% SRC counterpart funds
10% User fees
20%
 Other incentives unrelated to
contracting arrangements:
 GFATM
 GAVI
 Midwifery
40%
Staff income
Ref. Keller, Thome, Dekestier
Contracting of Health Services AR & K OD, Takeo Province- Final
Evaluation Report Apr2008
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Contracting Phase 3 – 2009 Context
 Health Sector support Project 2: pooled funds from 7 donors
WB-DFID-AUSAID-UNFPA-UNICEF-AFB-BTC
 Willingness of MOH to regain ownership on contracting
arrangements
 Special Operating Agencies:
 A general reform of the public service delivery: Royal Decree
NS/RKT/0308/346 on “The common principles of establishing and
functioning Special Operating Agency”-2008
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Improve quality and delivery of public services
Change attitude and behaviour of civil servants
Enhance management through results
Develop capacity for service delivery
 MOH requested to adapt the SOA concept to the Health Sector
• MOH SOA Manual 2009
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Contracting Phase 3 – 2009 Design
 SOAs: Health SOAs nominated by decree
 Provincial Referral Hospitals, Operational Districts
 Eligibility
• Capacity assessment
• Readiness criteria
Provincial Health Departments become Commissioners
of contracts
Funding for SOAs can come from various sources:
Service Delivery Grants (HSSP2), government budget,
user fees, other
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MOEF
MOH
MG
PMU
Performance agreement
Government
Budget – no
Preferential
Disbursement mechanism
HSSP2
Donors
Contracts for
capacity
building
PHD
Service delivery
management
contracts
NGO
Service
Delivery
Grants
Monitoring
OD
Health service delivery through health centers
And district referral hospitals
Other
External
Funds?
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Contracting Phase 3 – 2009-
Capacity assessment / readiness criteria
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Capacity assessment tool for
PHDs and ODs
I.
II.
III.
Planning
Monitoring and supervision
HR allocation and
management
IV. Technical support
V.
ED management
VI. Financial management
VII. Coordination
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Readiness criteria: 75%
60% score would need a phased
capacity building
NGOs contracted for 1 year for
capacity development
 In practice
 The 11 contracted districts under Phase 2
were always meant to become SOAs
regardless of their capacity assessment
scores
 PHDs in these areas only remotely
involved
 Example PHDs
 Domain II: average score 34%
 Domain I: average score 59%
 Example ODs
 Domain I: average score 37%
 None reach 75%
 Only 3 reach 60%
 Domain II: average score 44%
 None reach 75%
 Only 3 reach 60%
Ref. OPM Summary report and analysis, PHD and OD Capacity
Development Assessment, 2008
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Contracting Phase 3 – 2009-
Performance monitoring
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Service delivery targets
included in service delivery
contracts
I.
II.
III.
IV.
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Service outputs
Quality of care
Organization
Community participation
and networking
Supervision by PHD
Monitoring by central
monitoring group
Community monitoring
through a scorecard
 Complex monitoring tool – need to be
amended?
 Monitoring Group not performing
since 2006
 They have to use public transports
to go in the field
 How will they manage the
transition?
 Community scorecard left out of the
monitoring tool in 2009
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Contracting Phase 3 – 2009-
Staff performance and remuneration
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Staff Performance
assessment
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No agreement yet
Staff remuneration
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Government budget for
salaries and overtime
Service Delivery Grants
Revenue from user fees
All other incentive
schemes in place,
including midwifery
incentive
 Government budget
 Not linked to performance
 SDG
 80% paid on quarterly basis
 15% system performance bonus
 5% kept for special circumstances
 Staff incentive
 SDG can serve to pay staff
incentives but cannot account for
more than 80% of staff income
from all sources
 Decided by head of SOA
 No link to staff performance
described
 UF
 60% for staff incentive
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Concluding remarks
 NGO contracting has always been seen by Cambodian policy
makers as a transitional arrangement for accelerated district
development
 Bottlenecks for regaining ownership and scaling-up still needs to
be addressed:
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Role / capacity of PMU vs MOH departments
Role of central Monitoring Group
Comprehensive civil service reform
Control over government budget allocation and disbursement
Role / capacity of PHDs
Dialogue with NGOs / oversight on their work (and their remaining
role)
 Other influences?
 All incentive schemes: Midwifery, GAVI PHC block grants, GFATM, NGO
initiatives (eg RACHA safe motherhood), PMG and many more
 Dual practice
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Thank you!
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