Administrative reform and pay‐for‐performance methods of primary health service delivery: A comparison of 3 health districts in Cambodia, 2006‐2012

Abstract

Since 1999, performance-based financing or pay-for-performance (P4P) methods have been piloted in the Cambodian public health sector, first as one part of external contracting approaches with international nongovernment organizations and from 2009 as a part of internal contracting arrangements between units within the Ministry of Health under a wider public sector administrative reform. This study analyses these reforms and compares outcomes in 3 health districts. The study analysed routine quantitative data for primary care service delivery by using the interrupted time series method. Qualitative data were collected from key informant interviews. Both the level and the trend line of key service delivery indicators during earlier contracting/P4P models were at least maintained and in most cases increased with the move to internal contracting. The results of the interrupted time series analysis were mixed, mainly due to contextual issues. Qualitative results indicated an increased sense of local ownership and financial sustainability. Despite the gains, the management of personnel and the implementation and the integrity of contract monitoring were found to be compromised in this case. To be fully effective, contracting and P4P approaches must be accompanied by changes in the structure and culture of government administration.

Factors That Influence Data Use to Improve Health Service Delivery in Low- and Middle-Income Countries

“…The majority of the studies that we identified had a cross-sectional design and were conducted in a range of settings. Our sample included a study based in a subnational area of Nigeria 32 ; a study on a national level in Afghanistan that analyzed changes in health system performance over a 5-year period 33 ; a study based in 3 districts of Cambodia reporting on implementation of an initiative centered around performance-based financing 34 ; a study based in a subnational area of India that evaluated a well-established health management information system 35 ; and an evaluation based in Côte d’Ivoire assessing change in quality, availability, and use of data following an intervention that aimed to improve RHIS performance. 36 In addition, there was 1 randomized controlled trial set in Uganda that examined the effectiveness of a community monitoring intervention by comparing communities that received the intervention with communities that did not.…”

“…Leadership and the role of active engagement from senior management was highlighted across multiple included studies as a feature associated with strengthened M&E capacity and facilitating uptake at the local level. 33 , 34 , 38 , 40 , 41 The concept of leadership is itself nuanced and difficult to measure and is represented slightly differently in each of the studies. In the study by Holvoet and Inberg, 38 which compared Rwandan and Ugandan health systems, there was evidence demonstrating the role of leadership in both countries.…”

“… 38 Similarly, in another study that was also based in Uganda, Kananura et al 41 observed that involvement of management at a local level (health district leaders, health facility managers, and subcountry leadership team) in planning and M&E processes strengthened managers’ capacity to use available data to advocate for change. In Cambodia, Khim et al 34 compared service delivery across 3 districts during the same time period and attributed the success of the highest performing district to strong leadership and management capacity within the district (managers were perceived to objectively undertake performance monitoring). While these 3 studies present insights into leadership and data use, their quality was determined to be low or very low.…”

“…Two of the included studies noted that contextual factors such as local politics and available re-sources affected the local capacity to respond to findings from indicators or M&E activities, both positively and negatively. 34 , 41 These issues are often deeply entrenched in the local culture. While recognizing that these factors can be influential is important, little can be done in practice to promote or mitigate their impact in the short to medium term.…”

“…The studies in our systematic review that discussed the role of leadership referred to engagement of health service managers and senior executives in the planning and evaluation processes at the local level. 33,34,38,40,41 The importance of leadership in the context of effective health services management is widely acknowledged, [50][51][52][53][54] so it is not surprising that strong leadership may be an enabling factor in promoting use of service delivery indicators. However, the challenge lies in understanding the ways in which leadership capability can be strengthened.…”