Internal contracting of health services in Cambodia: drivers for change and lessons learned after a decade of external contracting

** From PubMed via Jisc Publications Router. ** History: received 05-05-2017; accepted 30-04-2018.Since the late 1990s, contracting has been employed in Cambodia in an attempt to accelerate rural health system recovery and improve health service delivery. Special Operating Agencies (SOA), a form of 'internal contracting', was introduced into selected districts by the Cambodia Ministry of Health in 2009. This study investigates how the SOA model was implemented and identifies effects on service delivery, challenges in operation and lessons learned. The study was carried out in four districts, using mixed__methods. Key informant interviews were conducted with representatives of donors and the Ministry of Health. In-depth interviews were carried out with managers of SOA and health facilities and health workers from referral hospitals and health centres. Data from the Annual Health Statistic Report 2009-2012 on utilisation of antenatal care, delivery and immunisation were analysed. There are several challenges with implementation: limited capacity and funding for monitoring the SOA, questionable reliability of the monitoring data, and some facilities face challenges in achieving the targets set in their contracts. There are some positive effects on staff behaviour which include improved punctuality, being on call for 24__h service, and perceived better quality of care, promoted through adherence to work regulations stipulated in the contracts and provision of incentives. However, flexibility in enforcing these regulations__in SOA has led to more dual practice, compared to previous contracting schemes. There are reported increases in utilization of services by the general population and the poor although the quantitative findings question the extent to which these increases are attributable to the contracting model. Capacity in planning and monitoring contracts at different levels in the health system is required. Service delivery will be undermined if effective performance management is not established nor continuously applied. Improvements in the implementation of SOA include: better monitoring by the central and provincial levels; developing incentive schemes that tackle the issues of dual practice; and securing trustworthy baseline data for performance indicators.sch_iih18pub5389pub37

Public Private Partnership for Equitable Provision of Quality Health Services

This report presents the findings of an independent Technical Review that focused on the promotion of Public Private Partnership (PPP) for equitable provision of quality health services in Tanzania. The report is meant to contribute to the Annual Joint Health Sector Review 2005. The ToR has been broadly defined, signifying the interest that many stakeholders currently take in PPP. The Review Team (RT), with two international and three national consultants, undertook efforts to consult stakeholders for prioritisation of the issues included in the ToR. The RT had access to a large number of official documents such as laws, by-laws, policy documents, guidelines, etc. and a wide range of studies on PPP set in Tanzania complemented by international literature. The RT undertook efforts to interview relevant persons and committees, associations, organisations, ministries, donors, etc. at the national level as well as in four districts, two rural and two urban. Nevertheless, time constraints did force the RT to limit itself and consequently not all actors that constitute the private health sector could be contacted. It is hoped that the Annual Joint Health Sector Review 2005 will allow a representative participation of all actors in the field of PPP to discuss this review and compensate for any issue or actor that was left out unintended

State Capacity and Non-state Service Provision in Fragile and Conflict-affected States

How can governments effectively engage with non-state providers (NSPs) of basic services where capacity is weak? This paper examines whether and how fragile and conflict affected states can co-ordinate, finance, and set and apply standards for the provision of basic services by NSPs. It explores ways of incrementally engaging the state, beginning with activities that are least likely to do harm to non-state provision. Through the ‘indirect’ roles of setting the policy environment and engaging in policy dialogue, regulating and facilitating, contracting, and entering into mutual and informal agreements with NSPs, the state can in principle assume responsibility for the provision of basic services without necessarily being involved in direct provision. But government capacity to perform these roles is constrained by the state’s weak legitimacy, coverage and competence, lack of basic information about the non-state sector, and lack of basic organisational capacity to form and maintain relationships with NSPs. The experience of the exercise of the indirect roles in fragile settings suggests: * Governments may be more willing to engage with NSPs where there is recognition that government cannot alone deliver all services, where public and private services are not in competition, and where there is evidence that successful collaboration is possible (demonstrated through small-scale pilots). * The extent to which engagements are ‘pro-service’may be influenced by government motives for engagement and the extent to which the providers that are most important to poor people are engaged. * Formal policy dialogue between government and NSPs may be imperfect, unrepresentative and at times unhelpful in fragile settings. Informal dialogue - at the operational level - could more likely be where synergies can be found. * Regulation is more likely to be ‘pro-service’ where it offers incentives for compliance, and where it focuses on standards in terms of outputs and outcomes rather than inputs and entry controls. * Wide scale, performance-based contracting has been successful in delivering services in some cases, but the sustainability of this approach is often questioned. Some successful contractual agreements have a strong informal, relational element and grow out of earlier informal connections. * Informal and mutual agreements can avoid the capacity problems and tensions implicit in formal contracting but may present problems of non-transparency and exclusion of competition. Paradoxically, the need for large-scale approaches and quick co-ordination of services in fragile and conflict-affected settings may require ‘prematurely high’ levels of state-NSP engagement, before the development of the underlying institutional structures that would support them. When considering strategies to support the capacity of government to engagement with NSPs, donors should: * Recognise non-state service provision and adopt the ‘do no harm’ principle: It would be wrong to set the ambition of 'managing ‘ non-state provision in its entirety, and it can be very harmful for low-capacity states to seek to regulate all NSP or to draw it into clumsy contracts. * Beware of generalisation: Non-state provision takes many forms in response to different histories and to political and economic change. The possibilities and case for state engagement have to be assessed not assumed. The particular identities of NGOs and enterprises should be considered. * Recognise that state building can occur through any of the types of engagement with NSPs: Types of engagement should therefore be selected on the basis of their likely effectiveness in improving service delivery. * Begin with less risky/small scale forms of engagement where possible: State interventions that imply a direct controlling role for the state and which impose obligations on NSPs (i.e. contracting and regulation) require greater capacity (on both sides) and present greater risk of harm if performed badly than the roles of policy dialogue and entering into mutual agreements. * Adopt mixed approaches: The choice between forms of engagement does not have to be absolute. Rather than adopting a uniform plan of engagement in a particular country, it may be better to try different approaches in different regions or sectors

Measuring Performance: The State Management Report Card for 2008

Grades each state's management performance, based on five criteria in each of the categories of money, people, infrastructure, and information. Includes an overview of each category with average grades and grade distribution maps

A cost and technical efficiency analysis of two alternative models for implementing the basic package of health services in Afghanistan.

Since 2003, the Afghan Ministry of Public Health (MoPH) and international partners have directed a contracting-out model through which non-governmental organisations (NGOs) deliver the Basic Package of Health Services (BPHS) in 31 of the 34 Afghan provinces. The MoPH also managed health service delivery in three provinces under an alternative initiative entitled Strengthening Mechanisms (SM). In 2011, under the authority of the MoPH and Delegation of the European Union to Afghanistan, EPOS Health Management conducted a cost and technical efficiency study of the contracting-out and SM mechanisms in six provinces to examine economic trade-offs in the provision of the BPHS. The study provides analyses of all resource inputs and primary outputs of the BPHS in the six provinces during 2008 and 2009. The authors examined technical efficiency using Data Envelopment Analysis (DEA) at the BPHS facility level. Cost analysis results indicate that the weighted average cost per BPHS outpatient visit totalled $3.41 in the SM provinces and$5.39 in the NGO-led provinces in 2009. Furthermore, the data envelopment analyses (DEAs) indicate that facilities in the three NGO-led provinces scored 0.168 points higher on the DEA scale (0-1) than SM facilities. The authors conclude that an approximate 60% increase in costs yielded a 16.8% increase in technical efficiency in the delivery of the BPHS during 2009 in the six provinces

Performance-Based Financing: Report on Feasibility and Implementation Options Final September 2007

This study examines the feasibility of introducing a performance-related bonus scheme in the health sector. After describing the Tanzania health context, we define “Performance-Based Financing”, examine its rationale and review the evidence on its effectiveness. The following sections systematically assess the potential for applying the scheme in Tanzania. On the basis of risks and concerns identified, detailed design options and recommendations are set out. The report concludes with a (preliminary) indication of the costs of such a scheme and recommends a way forward for implementation. We prefer the name “Payment for Performance” or “P4P”. This is because what is envisaged is a bonus payment that is earned by meeting performance targets1. The dominant financing for health care delivery would remain grant-based as at present. There is a strong case for introducing P4P. Its main purpose will be to motivate front-line health workers to improve service delivery performance. In recent years, funding for council health services has increased dramatically, without a commensurate increase in health service output. The need to tighten focus on results is widely acknowledged. So too is the need to hold health providers more accountable for performance at all levels, form the local to the national. P4P is expected to encourage CHMTs and health facilities to “manage by results”; to identify and address local constraints, and to find innovative ways to raise productivity and reach under-served groups. As well as leveraging more effective use of all resources, P4P will provide a powerful incentive at all levels to make sure that HMIS information is complete, accurate and timely. It is expected to enhance accountability between health facilities and their managers / governing committees as well as between the Council Health Department and the Local Government Authority. Better performance-monitoring will enable the national level to track aggregate progress against goals and will assist in identifying under-performers requiring remedial action. We recommend a P4P scheme that provides a monetary team bonus, dependent on a whole facility reaching facility-specific service delivery targets. The bonus would be paid quarterly and shared equally among health staff. It should target all government health facilities at the council level, and should also reward the CHMT for “whole council” performance. All participating facilities/councils are therefore rewarded for improvement rather than absolute levels of performance. Performance indicators should not number more than 10, should represent a “balanced score card” of basic health service delivery, should present no risk of “perverse incentive” and should be readily measurable. The same set of indicators should be used by all. CHMTs would assist facilities in setting targets and monitoring performance. RHMTs would play a similar role with respect to CHMTs. The Council Health Administration would provide a “check and balance” to avoid target manipulation and verify bonus payments due. The major constraint on feasibility is the poor state of health information. Our study confirmed the findings of previous ones, observing substantial omission and error in reports from facilities to CHMTs. We endorse the conclusion of previous reviewers that the main problem lies not with HMIS design, but with its functioning. We advocate a particular focus on empowering and enabling the use of information for management by facilities and CHMTs. We anticipate that P4P, combined with a major effort in HMIS capacity building – at the facility and council level – will deliver dramatic improvements in data quality and completeness. We recommend that the first wave of participating councils are selected on the basis that they can first demonstrate robust and accurate data. We anticipate that P4P for facilities will not deliver the desired benefits unless they have a greater degree of control to solve their own problems. We therefore propose - as a prior and essential condition – the introduction of petty cash imprests for all health facilities. We believe that such a measure would bring major benefits even to facilities that have not yet started P4P. It should also empower Health Facility Committees to play a more meaningful role in health service governance at the local level. We recommend to Government that P4P bonuses, as described here, are implemented across Mainland Tanzania on a phased basis. The main constraint on the pace of roll-out is the time required to bring information systems up to standard. Councils that are not yet ready to institute P4P should get an equivalent amount of money – to be used as general revenue to finance their comprehensive council health plans. We also recommend that up-to-date reporting on performance against service delivery indicators is made a mandatory requirement for all councils and is also agreed as a standard requirement for the Joint Annual Health Sector Review. P4P can also be applied on the “demand-side” – for example to encourage women to present in case of obstetric emergencies. There is a strong empirical evidence base from other countries to demonstrate that such incentives can work. We recommend a separate policy decision on whether or not to introduce demand-side incentives. In our view, they are sufficiently promising to be tried out on an experimental basis. When taken to national scale (all councils, excepting higher level hospitals), the scheme would require annual budgetary provision of about 6 billion shillings for bonus payments. This is equivalent to 1% of the national health budget, or about 3% of budgetary resources for health at the council level. We anticipate that design and implementation costs would amount to about 5 billion shillings over 5 years – the majority of this being devoted to HMIS strengthening at the facility level across the whole country

Innovative Financing in Early Recovery: The Liberia Health Sector Pool Fund - Working Paper 288

In post-conflict Liberia, the National Health Plan set out a process for transitioning from emergency to sustainability under government leadership. The Liberia Health Sector Pool Fund, which consists of DfID, Irish Aid, UNICEF, and UNHCR, was established to fund this plan and mitigate this transition by increasing institutional capacity, reducing the transaction costs associated with managing multiple donor projects, and fostering the leadership of the Liberian Health Ministry by allocating funds to national priorities. In this paper, we discuss the design of the health pool fund mechanism, assess its functioning, compare the pooled fund to other aid mechanisms used in Liberia, and look into the enabling conditions, opportunities, and challenges of the pool fundLiberia, national health plan, aid effectivenes