Bart Jacobs Luxembourg Development Institute Tropical Medicine, Antwerp Swansea University Using P4P...
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![Page 1: Bart Jacobs Luxembourg Development Institute Tropical Medicine, Antwerp Swansea University Using P4P to sustain high service delivery level during transition.](https://reader036.fdocuments.us/reader036/viewer/2022062511/5518cbd7550346a61f8b5a68/html5/thumbnails/1.jpg)
Bart JacobsLuxembourg Development
Institute Tropical Medicine, AntwerpSwansea University
Using P4P to sustain high service delivery level during transition of
management authority at Cambodia
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ObjectiveMicro perspective on contracting in
CambodiaMore specifically on the role of P4P during
transition of management authority from NGO to government authorities
Longitudinal 4-year case studyLessons for scaling up –at Cambodia
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Setting Kirivong Operational Health District
4 administrative districts, 31 communes, 290 villages
≈220,000 peopleSubsistence farming, foraging35% (2002) poverty rate20 health centres, 80-bed hospital180 staff members95% Buddhist91 pagodas, 5 mosques
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Service delivery level (%)
Variable 1999 2001 2004
ANC2 9 36 83
Qualified delivery
14 25 43
Facility delivery
5 9 31
Full immunisation
40 61 97
Vitamin A 50 63 93
Contraceptives
9 27 34
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High level reached by 2004 byContract with 8 administrators (DHTAT) -
$100 each per monthMonthly supplement of $15-20 for other staff
members –mainly to be present at workMonthly outreach (ANC, EPI, contraceptives,
health education) Affordable curative services (user fees since
2001)Free preventive services Community participation
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Community participation
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Community participation -actors
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Initiation P4PStart 2005Disciplinary committeeWorking rules an regulationsMission and objectivesContracts per facilityMonitoring team and formsFresh job descriptionsFocus all building blocks health systemsTraining (team building, communication,
leadership, motivation, community organizing, financial management )
Distribution bonus amongst staff (qualification, position, facility)
Distribution bonus over facilities
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Challenges
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Responsibilities
Activity 2004 2007
Amount of subsidies NGO Gov
Internal rules and regulations
NGO Gov
Bonus distribution NGO Gov
Management contracts facilities
NGO Gov
Allocating MoH funds NGO NGO + Gov
Monitoring NGO NGO
Indicators and targets NGO NGO
Admin management contract
NGO NGO
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Approach to P4PEach facility a teamFlexible, quarterly indicators, weighting
system$60/staff/year; bonus 20% total income
staff member by 2007 Start ≥2006
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-reach
Fee-for-service
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Results -1
Variable%
2004 2005 2006
Fully vaccinated 97 90* 96
Vitamin A 93 86* 92
ANC2 83 81 83
Qualified delivery
43 44 66*
Facility delivery 31 39 59*
Contraceptives 34 36 35
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Results -2
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Results -3
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Results -4
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Lessons for CambodiaPossible to build health systems with minor
effect on service delivery level; more durableUser 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%
1999 2001 2008
2.5% 20% 61%
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Lessons for Cambodia -2Payment method is important –fee-for-service Maximum % of bonus subjected to
performance Flexible indicator setting method; no fixed
approach –carrot and stickEnsure continued regular government funding
for health sector Can external funding be phased out? Still 33%
by 2007Community participation creates external
accountability at all levels
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Indicator and target setting and monitoring by independent agency (NGO)–objectivity
NGO support for administrative issues
Lessons for Cambodia -3