Contracting in Cambodia

1. Contracting in Cambodia Maryam Bigdeli WHO Cambodia

2. 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 • GDP/capita US$635 (2008) • Poverty rate 31% (2008) • MMR 472 (CDHS 2005) • U5MR 66 (CDHS 2005) • IMR 83 (CDHS 2005) • THE per capita US$40 (2008) • OOP US$24 (CDHS 2005) • Government US$8 (2008) • External assistance USD$8 (2008)

3. 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-

4. 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

5. 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

6. MOH HSSP1 Donors MOEF MG PMU Contract PHD Accelerated Disbursement of Government budget Quarterly disbursements Monitoring NGO Contract OD Health service delivery through health centers And district referral hospitals User Fees

7. 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 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 Contracting Phase 2 – 2004-2007 (2008) Performance monitoring (1) • 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) Central level monitoring stopped 2005 Only contractor monitoring Ref.1) Cambodia health services contracting review, 2007 – 2) Final evaluation of contractors’ performance, 2009

8. 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 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 Contracting Phase 2 – 2004-2007 (2008) Performance monitoring (2)

9. Sources of funding for 2 ODs in Takeo 48 % government budget 29% Project budget 13% SRC counterpart funds 10% User fees 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 Other incentives unrelated to contracting arrangements: GFATM GAVI Midwifery Contracting Phase 2 – 2004-2007 (2008) Staff remuneration and incentive 20% 40% Staff income • Ref. Keller, Thome, Dekestier • Contracting of Health Services AR & K OD, Takeo Province- Final Evaluation Report Apr2008

10. 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 • 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

11. 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

12. MOEF MOH HSSP2 Donors MG PMU Performance agreement Contracts for capacity building Service Delivery Grants PHD NGO Government Budget – no Preferential Disbursement mechanism Service delivery management contracts Monitoring Other External Funds? OD Health service delivery through health centers And district referral hospitals

13. Capacity assessment tool for PHDs and ODs Planning Monitoring and supervision HR allocation and management Technical support ED management Financial management Coordination 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 Contracting Phase 3 – 2009-Capacity assessment / readiness criteria

14. Service delivery targets included in service delivery contracts 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 Contracting Phase 3 – 2009-Performance monitoring

15. Staff Performance assessment No agreement yet Staff remuneration 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 Contracting Phase 3 – 2009-Staff performance and remuneration

16. 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: • 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

17. Thank you!