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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. Bart Jacobs Luxembourg Development Institute Tropical Medicine, Antwerp Swansea University. Objective. Micro perspective on contracting in Cambodia

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Bart Jacobs Luxembourg Development Institute Tropical Medicine, Antwerp Swansea University

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  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 (%)

  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

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

  12. Results -1

  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

  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

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