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Implementation Research: Taking Results Based Financing from scheme to system
Factors driving changes in arrangements and scaling up of
health schemes: the case of Performance-Based Financing
in Cambodia 1997-2015
Research report Cambodia
December 2015
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Acknowledgements
Conduct of this study is the product of collaboration and partnership with many
individuals. I would like to express sincere gratitude to the team members of the
study, Prof. Saphonn Vonthanak, Assoc. Prof. Peter Annear, Dr. Sok Kanha and
Mrs. Pen Linda for participating in the conduct of this study.
The study team would like to thank key informants for their contributions, in
terms of time and inputs in the study. This study would not have been possible
without their participation. These include officials at the Central MOH,
Provincial Health Departments, Operational Districts and staff members and
advisors of Development Partner agencies.
Thanks go to the team based at Antwerp Institute of Tropical Medicine in
Belgium who provided technical support. This includes Bruno Meessen,
Matthieu Anthony and Ir Por for providing technical advice and guidance in the
conduct of this study. Finally, we would like to thank Maryam Bigdeli, Maryse
Coutty, Lydia Bendib, Shroff Zubin, the staff members of the Alliance of Health
Systems and Policy Research for their coordination, assistance and most of all
for making grants available for this study.
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Table of Contents Acknowledgements .................................................................................................................... 2
Executive Summary ................................................................................................................... 6
1. Introduction ............................................................................................................................ 9
1.1. Background ..................................................................................................................... 9
1.2. Objectives ...................................................................................................................... 13
2. Methodology ........................................................................................................................ 14
2.1. Research Questions ....................................................................................................... 14
2.2. Research Design ............................................................................................................ 14
2.3. Instruments .................................................................................................................... 14
2.4. Sample ........................................................................................................................... 14
2.5. Data Collection .............................................................................................................. 15
2.6. Data Processing and Analysis ....................................................................................... 15
2.7. Analytical Framework ................................................................................................... 15
2.8. Ethical considerations .................................................................................................... 16
2.9. Limitations ..................................................................................................................... 16
3. Results .................................................................................................................................. 17
3.1. Factors that have driven changes in PBF arrangements ................................................ 17
3.2. The scaling up of the PBF schemes ............................................................................... 34
Integration of PBF into the health system ............................................................................ 38
3.3. Results of the timeline analysis ..................................................................................... 38
4. Discussion ............................................................................................................................ 40
5. Conclusions .......................................................................................................................... 44
List of References ..................................................................................................................... 46
Annexes .................................................................................................................................... 49
Annex 1: Timeline of PBF evolution in Cambodia .............................................................. 49
Annex 2: Question guide ...................................................................................................... 50
Annex 2: List of key informants who were interviewed ...................................................... 51
Annex 3: Informed Consent Form ........................................................................................ 52
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List of Tables
Table 1: Health situations in Cambodia since 1990 ................................................................. 10 Table 2: Evolution of PBF schemes in Cambodia between 1997 – 2015 ................................ 13
Table 3: Factors behind the introduction of PBF between 1999-2002..................................... 18 Table 4: Factors driving changes in PBF arrangements between 2003 and 2009 .................... 23 Table 5: Factors driving changes in PBF arrangements between 2009 and 2015 .................... 30
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Acronyms
ADB Asian Development Bank
AFD French acronym for French Development Agency
AMDA Asian Medical Doctor Association
Ausaid Australia government aid for international development
BTC Belgian Technical Cooperation
DP Development Partners
DFID Department for International Development (UK government agency)
GAVI Global Alliance for Vaccines and Immunisation
GFATM Global Fund to fight AIDS, Tuberculosis and Malaria
HEF Health Equity Fund
HNI Health Net International
HU Health Unlimited
MBPI Merit-based Pay Initiative
MCH Maternal and Child Health
MEF Ministry of Economic and Finance
MOH Ministry of Health
MSF Medecine Sans Frantiere
MWI Midwifery Incentive
NGO Non-governmental Organisation
OD Operational District
PBF Performance-based Financing
PFMAR Public Financial Management Reform
PHD Provincial Health Department
PMAS Performance Management and Accountability System
RACHA Reproductive and Child Health Alliance
RBF Results-based Financing
RGC Royal Government of Cambodia
RHAC Reproductive Health Association of Cambodia
SCA Save the Children (Australia)
SDG Service Delivery Grant
SOA Special Operating Agency
SRC Swiss Red Cross
SWiM Sector Wide Integrated Management
UNFPA United Nations Population Fund
Unicef United Nations Fund for Children
WB World Bank
WHO World Health Organisation
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Executive Summary
Results-based financing (RBF) has been implemented widely as a means to improve the
performance of health systems. RBF methods have also been used with a number of demand-
side initiatives in Cambodia, including Health Equity Funds and vouchers for maternal care.
Cambodia has also implemented a number of supply-side financing arrangements (commonly
known as “Performance-based Financing - PBF”) with different forms of provider payments,
management and autonomy of providers.
Background
Early PBF schemes were introduced by different NGOs and with the support of development
partners. PBF implementation in Cambodia can be seen in three phases – the first phase
between 1997 and 2002, the second phase between 2003 and 2009 and the third phase
between 2009 and 2015. The first PBF pilots in Cambodia began in 1997 with the piloting of
different PBF methods. One was contracting with NGOs to manage government health
services in five health districts. The other was integrating performance-based incentive
schemes (called New Deal) in health district and provincial hospital systems in five other
health districts. In the second phase, the contracting model evolved to hybrid contracting (also
external contracting) which was implemented in 11 health districts with NGOs being
contracted to support the management. In this phase, a new version of New Deal was
proposed and implemented in 10 other health districts and provincial hospitals. During the
third phase, contracting with NGOs model and New Deal approach become a unified system
of “internal contracting” within the framework of the Public Health Sector Reform. In this
reform, health districts and provincial hospitals were designated as Special Operating
Agencies (SOAs) with more management autonomy and special funding. Currently 40 SOAs
have been made and implemented internal contracting. Previous research indicates increased
efficiency in service delivery in areas where PBF was implemented. However, little is known
about why and how changes occurred and what influenced the pace of PBF scaling up. This
research attempted to document factors driving changes in and scaling up of PBF
arrangements in Cambodia between 1997 and 2015.
Methodology
The research analysed data from a review of published and grey literature as well as primary
data from key informant interviews and researcher observations. The grey literature included
operational and policy documents. Researcher observations included the results of an earlier
extensive study of PBF in Cambodia as well as meeting and discussion notes and personal
communications. Key informant interviews were carried out with a wide range of participants,
including national policy makers, provincial and district MOH officials implementing the PBF
scheme, and development partners. A total of 29 key informants were interviewed. Face-to-
face interviews and Skype were also used for key informant interviews. Policy triangles
developed by Walt and Gilson (1994) and timeline of PBF evolution were used to guide the
analysis and structure the results.
Key Findings
Factors that have driven changes in PBF arrangements
The start of PBF in Cambodia was influenced by development policies of major donor
agencies and their changes in domestic health management and financing policies.
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A commitment to PBF arrangements as a means for improving efficiencies and service
delivery outcomes has been one of the driving forces behind the contracting
arrangements.
A concern both about the additional unit costs of contracting and about the sense of
local ownership of the schemes were prominent among Cambodian respondents.
Both financial and administrative sustainability are among the key issues.
Many respondents viewed the introduction and evolution of the various PBF schemes
as the testing of new ideas.
PBF methods have contributed to capacity building for contract management,
institutional development and other methods of administrative reform.
Gaining a greater sense of national ownership of PBF and contracting schemes has
been implicit in the discussions about PBF, nonetheless, at the centre of the evolution
of PBF arrangements.
There may have been a trade-off in some efficiencies and service delivery outcomes,
but the results in increased domestic sustainability may have offset these costs.
The needs for a PBF method to suit and support the architectures of the country’s
major public sector reforms dominated the discussions and formulation of the latter
PBF model in Cambodia.
Overall, the improved management capacity at lower levels, improved financing by
and contributions from the government and the persistent emphasis on sustainability
have steered the discussions about and shaped the design of PBF schemes.
The scaling up of the PBF schemes
Scaling up of PBF has been slow and influenced by the changes in PBF arrangements
which required testing of efficiency, feasibility and suitability to the country systems.
Lack of clear evidence on PBF efficiency in improving service delivery, lack of DPs’
support for financial incentives for providers and providers being rather direct
beneficiaries of PBF schemes than users were factors contributing to less-than optimal
support for PBF.
The scope and comprehensiveness of PBF schemes involving several levels of the
health system were perceived to be large and complex, which contributed to the
complexity in implementation and uncertain results.
PBF scaling up in Cambodia suffered from the lack of strong policy direction, lack of
focus and of PBF champion.
The availability of financial resources to support PBF implementation more broadly
has been a key concern.
The national health budget has increased significantly while the level of development
assistance for health has relatively diminished, placing increased responsibility on the
Ministry of Health and the government to support the PBF approach.
At national and sub-national level, there was high levels of consciousness of the
constraints on national budget funding available to support the wider application of the
PBF model.
Innovation in PBF methods is required to further improve the coverage and the quality
of public health services.
Key Recommendations
Understanding country context is critical in applying PBF concepts and practices.
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To increase sustainability of PBF, its design and arrangement must take into account
and complement other reforms.
Specifically to Cambodia, it is suggested to fully consider the role, function and
scaling up of SOA arrangements in the next Health Strategic Plan 2016-2020.
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1. Introduction
1.1. Background
A lack of improvement in public health services and in accountability to population in the traditional
approaches using line-item budgeting and provision of supplies. This has led to global quests to
identify models or methods for improving efficiencies and quality of public health services, one of
which is linking payment to results, what is called in the World Bank term “Results-Based Financing”.
Results-Based Financing (RBF) for health has been defined as "a cash payment or non-monetary
transfer made to a national or sub-national government, manager, provider, payer or consumer of
health services after predefined results have been attained and verified” (Musgrove, 2010). There are
three basic models of RBF: (1) supply-side RBF with a demand-side component; (2) demand-side
RBF with a supply-side component; and (3) demand-side RBF with no supply-side component.
Differentiation of these forms is in what side of incentives are modified to leverage greater results,
although in practice the boundary between what is defined as demand-side and supply-side is not a
clear cut, depending on the extent to which the ‘purchasing power’ is given to providers or consumers.
Performance-Based Financing (PBF) is also a form of supply-side RBF and a new provider payment
mechanism in which health providers are (at least partially) funded on the basis on their performance,
measured (at least in some extent) against a set of predefined outputs or health outcomes. PBF is
interchangeably used with pay-for-performance (P4P), performance-based incentives, and sometimes
also Performance-Based Contracting (PBC) where contracting with private sector or NGOs is used as
a main mechanism for linking payment to results.
PBF is therefore deployed as a modality to incentivise public and private providers, using different
contract arrangements as informed by lessons learned from global and local context. PBF has been
well documented as a modality under contracting of health service delivery, in Bangladesh for
nutrition services (1998), Cambodia for operational district level contracting of primary and secondary
level health services (2000) and in Haiti for provincial health services delivery (1998-2008) (Toonen et
al., 2009). In this research, PBF includes supply-side financing schemes, whether or not contracting
being the main relationship mechanism, where payment to providers is variably linked to their
performance. In the case of Cambodia this includes contracting with NGOs for management of health
service at different stages of implementation, performance based contracting employed in New Deal
arrangements and internal contracting.
Cambodia has implemented several models of PBF schemes since 1997 to address the low
coverage and quality of public health services and to speed up improvement of population
health. All these schemes could be viewed in three phases: Between 1997 and 2002 when a
number of pilot schemes were started, including a contracting pilot and Performance-based
Incentive schemes called New Deal. Between 2003 and 2009 were implementation of two
major PBF schemes – the hybrid contracting and New Deal version 2. Between 2009 and
2015 was the implementation of uniform PBF model using internal contracting between units
under the MOH to support the health sector reform. Each phase represents changes in purpose
and arrangements, incremental scaling up and deeper integration into the country health
system.
Previous research in Cambodia suggests that PBF has a strong potential to leverage health worker’s
performance and enhanced management entrepreneurship (Soeters and Griffiths, 2003). Most positive
evidence is related to improved maternal and child health services (Bhushan et al., 2002, Keller and
Schwartz, 2001, Keller et al., 2008). PBF impact varies as a function of organizational, demographic
and provider characteristics including volume of activity, local competition, acceptance of salary
supplements and trust in the rationale behind PBF (Blanchet, 2002). Contracting contributed to
improved accountability in providers and increased job commitment (MOH, 2007). Performance
incentives, enhanced performance management system and adequate financing are essential in
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ensuring success of PBF (Jacobs et al., 2010). The implementation of the latest phase of PBF faced
with strong challenges in terms of level of funding, capacity and lack of institutional rules and
procedures and support mechanisms (Khim and Annear, 2013).
International evidence on the effect of PBF schemes on intended health services and outcomes
has been inconsistent. The results were often mixed with positive results on some indicators
and not so positive on others and with greater focus on maternal and child health and less on
other health problems (Witter et al., 2012). A review of 70 RBF studies also indicates mixed
results, but the schemes could be more impactful with careful consideration of such factors as
design features, context and incentive regimes and monitoring unintended behaviours of
providers (Gorter, 2013). In high-income countries, evidence on impact of pay-for-
performance on quality of care is limited and often conflicting (Wilson, 2013). A review
offered limited evidence on the effect of incentives, partly because of varied characteristics of
incentive programs (Latham and Marshall, 2015). Relevant to Canada health system,
Ontario’s P4P program was found to have made a modest improvement in physicians’
performance with respect to Pap smears, mammograms, senior flu shots, and colorectal cancer
screening, and no improvement with respect to toddler immunization (Li et al., 2014). The
small size of incentives, direct payment to individual physician and lack of follow up calls
were among factors limiting the impact. P4P scheme was found to have little or no
improvement in cancer screening rates in Ontario despite substantial financial investments in
the program (Kiran et al., 2014).
Despite the long existence of PBF, empirical evidence to date relates mostly to effect of
schemes on outcomes in health services and population health as presented above. In such
cases as in Bangladesh, Cambodia and Afghanistan where PBF has been implemented for a
long period of time, and its arrangements have changed, little is known about how changes in
PBF happened over time, what drove the changes and if and the extent PBF has been
integrated in the country health system. With the long history of PBF implementation,
Cambodia is a good case study to examine questions related to this area.
1.2. Cambodia health system and PBF schemes
Cambodia is a country in Southeast Asia with an estimated population of 14.8 million in
2015. It is considered a post-conflict country, as it experienced almost two decades of wars
and armed conflicts in the 1970s and 1980s. Rebuilding the country started in the early 1990s,
with a UN-sponsored first democratic election in 1993 and full attainment of peace in 1998.
Rebuilding the country’s health system started in the 1990s and was extremely challenging,
with extremely limited resources and lack of infrastructures and human resources. The health
system was very poor and the health situations were dismal as health indicators in Table 1
show.
Table 1: Health situations in Cambodia since 1990
Indicator 1990* 2000 2005 2010
Neonatal mortality (both sexes) (per 1000 live births) 37 37 28 19
Infant mortality (both sexes) (per 1000 live births) 85 95 66 36
Under 5 mortality (both sexes) (per 1000 live births) 117 124 83 43
Maternal mortality ratio (per 100,000 live births) 830 437 472 250
% HIV among general population n/a 2.0 1.2 0.6
Tuberculosis prevalence (per 100,000 population)** n/a 1670 n/a 817
n/a: data not available; all data are from Cambodia Demographic Health Survey except marked otherwise
*World Health Statistics 2013; **WHO Global TB report 2011
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Two major policy developments in the middle of 1990s provided a foundation of the current
health system: the Health Coverage Plan and the Health Financing Charter. In 1996,
Cambodia established a health coverage plan bringing health services closer to people and
community (MOH, 1996a). According to the Plan, the health system is of three tiers. The
central level, including central departments housed at the Ministry of Health, and national
hospitals, centers and institutes. It is where national policies and guidelines are formulated.
The provincial level providing oversight and management support in the province; and the
health districts comprise an administrative office, one or two referral hospitals and primary
health services. The health district is the operational unit of the health system, and thus called
operational health districts (OD). Each OD usually contains one or two referral hospitals and a
number of health centers. A referral hospital provides inpatient services and covers a coverage
population of 100,000 to 150,000. A health center, provides primary health services (i.e.
immunization and outpatient care) and covers a population approximately 10,000 to 15,000.
As of 2013, the country has 8 national hospitals, 81 ODs, 94 referral hospitals and 1088 health
centers and 86 health posts. In 1996 the country established the National Health Financing
Charter which provided a framework for institutionalizing a user fee system in public health
facilities (MOH, 1996b). At primary health care level (health center), the Charter provides
that user fees can be established with consultation of the community in the coverage area and
39% of the revenue from the user fees is used to cover operational costs of the facility, 1% to
send to provincial treasury and 60% to use as incentives for facility staff. Subsequent major
policy documents include Health Strategic Plan (HSP) 2003-2007 and HSP 2008-2015.
Cambodia’s PBF has a long history of PBF implementation which could be viewed in three
phases. The three phases of Cambodia’s PBF are summarized in Table 2. The first phase of
PBF schemes implemented between 1997 and 2002 included a pilot contracting trial in 5
health districts and implementation of New Deal which was a new way of managing staff
performance and financing a provincial hospital, in Takeo starting in 1997 (Barber et al.,
2002). In the pilot contracting, three different models of contracting were compared –
contracting out, contracting in and control. In the contracting out, NGOs had complete and
independent control over all aspects of the management of the health district, whereas in
contracting-in, NGOs used government administration and support for human resources and
drug supply, and control districts followed the routine government procedures (Keller and
Schwartz, 2001). At about the same time (early 2000), the idea of New Deal was replicated in
the district of Sotnikum and Tmor Pouk in Siem Reap province with some modifications, for
instance, involving more stakeholders, higher and more realistic bonuses, being flexible to
changing conditions and targeting the poor (Meessen et al., 2002). A number of studies
indicated that contracting with NGOs for provision of health services had improved efficiency
of service provision albeit with high costs (Leovinsohn and Harding, 2005, Bhushan et al.,
2002). The New Deal in Sotrnikum had demonstrated to produce quantitative increases in
utilisation of public health services, such as consultations, delivery of newborns by trained
personnel and hospital inpatient services (Meessen et al., 2002).
The second phase are schemes implemented between 2003 and 2009 which included
contracting for provision of basic public health services in 11 health districts and schemes
supported by Belgian Technical Cooperation called New Deal 2 in 10 health districts and
provincial hospitals in Kampong Cham and Siem Reap provinces(BTC, 2009a, BTC, 2009b).
Contracting for service provision was an extension of the early contracting trial with a
purpose to build the capacity of local management to take up contracting responsibilities
when the contracted NGOs exit. This latter phase of PBF was in line with the new Health
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Strategic Plan 2003 – 2007 which directed efforts to improving financing, human resources,
institutional development, service delivery, health behaviours and quality of health services
(MOH, 2002b). A review of contracting commissioned by MOH indicated that contracting
with NGOs in the latter phase contributed in a significant way to increased utilization of
public health services and efficient use of resources (MOH, 2007). The end-of-project
assessment of BTC funded assisted internal contracting indicates that when linking incentives
to outputs, providers’ performance increased which in turn resulted in improved maternal and
child health services (Keller et al., 2008).
The third phase is internal contracting employed as a mechanism to provide special funding to
Special Operating Agencies (SOAs) (MOH., 2008b). The SOAs are health districts and
provincial hospitals which had been turned to SOAs provided with increased management
autonomy as part of the public health sector reform launched in the middle of 2009 (RGC,
2008). Starting with 11 health districts as SOAs, currently 40 SOAs are involved (MOH,
2014). The SOA model represents a unified approach of PBF scheme placed under the
management of MOH officials and signifies a major shift from contracting with non-state
actors (NGOs) to internal contracting with state actors from the same entity (MOH) as contracting
parties. Few empirical studies on the reform have been conducted. An examination of implementation
of the reform suggested that both the level and allocation of incentives and management bottlenecks at
various levels continue to impede implementation and major conditions related to clear separation of
contracting functions, management autonomy and the provision of adequate resources to meet contract
demands were less than optimal (Khim and Annear, 2013). Adequate performance incentives and a
strong system for performance management were main ingredients for successful implementation
(Jacobs et al., 2010). A recent study by the World Bank related to RBF and quality of healthcare in
Cambodia indicates that providers in health districts with PBF are more motivated and have a
higher score on correct diagnosis than those in non-PBF districts (WB, 2014).
Along these timelines, there were several other supply-side financing schemes coming into or
established in the country in the 2000s. Global Alliance for Vaccines and Immunisation
(GAVI) has started in the country since 2001 (MOH, 2002a) and its component, GAVI-Health
System Strengthening (HSS), a form of performance-based pay by GAVI focuses on primary
health care services, including immunisation of children and women and up to 2013 was
active in 15 health districts (MOH, 2013). Midwifery Incentive scheme (MWI) established in
late 2006 is the government-funded nation-wide performance-based pay which pay monetary
incentives to public health providers US$15 for a live birth at primary health centers and
US$10 at hospitals. The scheme was scaled up nationwide in late 2007 and was evaluated to
be contributing to significant increase in facility delivery (Ir et al., 2015).
A number of demand-side schemes have also been implemented in Cambodia. These include
Health Equity Fund, Voucher and voluntary community based health insurance schemes
(CBHI). Most of the schemes focus on maternal and child health services. HEF is a scheme
implemented by NGOs to reimburse providers for the costs of health services provided to the
poor and other related costs, including transportation and meals. Having established in 5
health districts in 2000, HEF by early 2015 has attained the national coverage (73 health
districts). HEF schemes have been associated with increased utilization of public health
services and decreased out-of-pocket health expenditure among the poor (Annear, 2010,
Jordanwood et al., 2009, Ir et al., 2010b, VAN DAMME et al., 2008, Biacabe, 2008,
Noirhomme et al., 2007, Flores et al., 2011). Voucher schemes were also found to be
associated with increased delivery of newborns at public health facilities (Van de Poel et al.,
2014)
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Table 2: Evolution of PBF schemes in Cambodia between 1997 – 2015
Time
frame
Scheme Name Units involved
1997 –
2002
New Deal arrangements:
Performance incentives
Performance contracting and management
Creation of new bodies (Steering
Committee)
New Deal: Takeo provincial hospital (by
SRC)
Replicated New Deal: 2 health districts
(Sotrnikum, Thmar Puok), 2 provincial
hospitals (Svay Rieng, Kratie), and 2 district
hospitals (Moung Russey, Stong) (by MSF,
Unicef, HNI, Movinmondo, WHO)
Pilot contracting:
Contracting-out with NGOs to provide
overall management of district health
services.
Contracting-in with NGO to manage
service delivery aspects health districts
Control: all aspects based on public sector
rules and regulations
Supported by ADB/WB
Contracting out: 2 (Angroka and Memut)
Contracting in: 3 (Kirivong, Pearaing,
Cheung Prey)
Control: Bati, Preah Sdach, Kamchaymear,
Krochmar
2003 –
2009
Hybrid contracting with NGOs to provide
assistance in the management of health
districts and capacity building
11 health districts (Memot, Ponheakrek,
Banlung, Tbeng Meanchey, Preah Sdach,
Pearaing, Ang Roka, Kirivong, Senmonorum,
Srae Ambil, Smach Meanchey), financed by
WB, DFID, Ausaid, Unicef, Unfpa, ADB
New Deal 2: Assisted Internal contracting
with PHD in charge of administering
contracts with health facilities supported
with TA of BTC
10 health districts and provincial hospitals
(Chamkaleu, Preychhor, Cheung Prey ODs,
Siem Reap, Kralanh, Angkor Chum,
Samraoung ODs, Kampong Cham, Siem Reap
PRHs) financed by BTC
2009 –
2015
Internal contracting in public health sector
reform, where Health districts and provincial
hospitals made Special Operating Agencies
(SOAs) and operating as semi-autonomous
units and provided with Special funding
called Service Delivery Grant
Initial 11SOAs in the middle of 2009
Later scaled up to 40 health districts and
provincial hospitals
Funded by pool funds from MOH/HSSP &
development partners)
Note: Medicine Sans Frantiere (MSF); HealthNet International (HNI); United Fund for Children: (Unicef); World Health Organisation
(WHO); Swiss Red Cross (SRC); Asian Development Bank (ADB), World Bank (WB); Belgian Technical Cooperation (BTC).
Looking back, the implementation of SOAs can be seen as a limited scaling up of PBF in the
country. Scaling up from health system perspectives may be interpreted in terms of an
increase in population or geographic area coverage, the level of integration into the whole
system, or the extent of scheme being afforded financially by the country. Using these
interpretations, the internal contracting has been seen as a unified standard of operating
procedures and joint management (by donor and MOH) protocol to manage SOAs. The
internal contracting model used in SOA arrangement may be seen as more sustainable
compared to other models as it includes the role of PHD in the arrangement and employs local
human and financial resources. The government contribution to the finance pooled for the
implementation has increased from 10% in 2009 to 40% in 2013. All the SOAs have now
been managed by national and local managers (MOH, 2014).
1.2. Objectives
This research makes a retrospective and prospective policy analysis of PBF implementation in
Cambodia to determine the reasons for and the implications of the change over time between
different forms of design and implementation of the PBF schemes. The research explores the
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factors driving changes in PBF arrangements and its scaling up, including financing capacity
and issues related to human resources capacity and “national ownership”. This research
collected qualitative information on the nature of change between the various Cambodian
supply-side PBF schemes implemented between 1997 and 2015.
2. Methodology
2.1. Research Questions
The research addressed two main questions:
What factors have driven changes in PBF arrangements?
- To what extent was the experience with various RBF schemes incorporated in the
formulation of PBF design (2004-2009; 2009-2013)?
- To what extent were good practices incorporated in new PBF designs?
Why has scaling up of the PBF schemes been slow?
- What factors and who determined the coverage of scaling up?
- To what extent did the size of available financial resources (government and donors)
affect PBF scaling up?
2.2. Research Design
Adapting the policy analysis framework developed by Walt and Gilson (1994), the research
analyses data from a review of published and grey literature and well as primary data from
key informant interviews and researcher observations. The grey literature includes operational
and policy documents. Researcher observations include the results of an earlier extensive
study of PBF in Cambodia as well as meeting and discussion notes and personal
communications.
This is a case study of policy analysis based on documentary analysis and qualitative data
from key informant interviews. A wide range of policy and operational documents were
reviewed.
2.3. Instruments
Tools for the key informant interviews were based on the review of literature and relevant
documents. The instruments were semi-structured and open-ended to allow respondents to
provide information according to their knowledge and experience. Different tools were
prepared for the different categories of respondents, tested and revised where necessary. The
tools were field-tested among local officials.
The question guide for government officials and donors focused on issues related to the
motive for proposing PBF schemes, why such PBF arrangement were adopted, what factors
were considered in the arrangement, who had the final say in the arrangement, the reasons for
changing the arrangement, evidence used to support the changes, and whether or not these
changes considered contextual factors.
2.4. Sample
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The sample of respondents was selected purposively with a view to including a wide range of
participants, past and present, who had played a direct role in the design, implementation and
evolution of the PBF arrangements. The sample of respondent was expanded up to the point
of saturation where no new information was provided by adding respondents. Sample
respondents were selected from the central, provincial and district levels. Three SOAs
(Memut, Chamkeleu and Kirivong) in two provinces (Kampong Cham and Takeo) were
included in the study. The rationale for selecting the districts and provinces was that they were
involved in different stages of PBF evolution, please refer to Table 2.
2.5. Data Collection
The review of the published and grey literature has been completed. Data collection was
carried out in April and September 2015. Key informant interviews were conducted with 29
participants, including national policy makers, provincial and district MOH officials
implementing the PBF scheme, and officials of DPs. Most of the interviews were face-to-face,
and a number through Skype. The interviews ranged between 30 and 45 minutes in duration.
They were conducted in Khmer and English by the Principal Investigator and the two Co-
Investigators. The interviews were recorded and transcribed in Khmer. Major statements were
extracted from the transcripts and translated into English. Data analysis was carried out by
theme and tabulated according to the research questions.
2.6. Data Processing and Analysis
The methodology of this study comprised both a review and analysis of literature and relevant
documents and policies, collection and analysis of primary qualitative data and observations
of prospective developments in the health sector. Some of the materials for review were
already in the investigators’ own collection. Search for additional materials, both grey and
published literature was conducted. Some of the materials were obtained through contacts
with officials and donors who used to be or have been involved in the discussions,
formulation or implementation of PBF schemes in the country. The materials were ensured to
be relevant to all PBF schemes. The available materials were reviewed and quotations from
the materials matching the research questions were compiled. Review and analysis of
monitoring reports and service delivery statistics were conducted to assess the extent of
scaling up and document issues therein.
Interviews were transcribed and transcripts translated from Khmer to English. The principal
investigator is bilingual and analysed the results of the completed key informant interviews
written in Khmer. We adapted Walt and Gilson policy analysis framework to guide analysis.
Responses were recorded and coded according to time periods and policy elements based on
the framework and research questions. A simple tabulation of quotations extracted from the
transcripts was prepared by theme related to PBF scheme in question, to provide an
understanding of similarities and differences between groups of participants. No identifying
information will be included in the tabulation.
2.7. Analytical Framework
We adapted and used the policy analysis framework by Walt and Gilson (1994). The
framework comprises four components –policy process, content, context and actors – is
particularly relevant to this case study. This framework is highly simplified showing the four
components separately and may not entirely reflect the complex set of inter-relationships in
reality. Moreover, the aspect of knowledge translation throughout the RBF scaling up may not
16
be easily captured with this framework. Taking these limitations into account, we employed
this framework with slight adaptation to document and analyze RBF scaling up process and
identify enablers and barriers to the scale up process. Among the four components, we put the
scale up process at the heart of our descriptive work. There is a strong reason to embrace a
multidimensional definition of scale up for this research. The object of the scale up of an RBF
scheme is not ‘just’ a health service intervention or a technological solution (e.g. a new
treatment against a disease) but a revision of the institutional arrangements shaping behaviors
of various actors already involved in the delivery of general health services to the population.
This is reflected by the definition of Performance-Based Financing proposed by Fritsche et al.
(2014) (Fritsche G, 2014) and by Bertone & Meessen (Bertone and Meessen, 2013). As
argued by several experts, RBF not only requires several structural reconfiguration of the
institutional system (such as involvement of new actors, distribution of new roles and
reconfiguration of respective functions), but can also, through spill-over, trigger some
systemic changes (Meessen et al., 2011). For this research, we therefore endorsed a broad
definition of scale up. We recognized scale up as a policy process, which had a number of
implicit and explicit policy dimensions to be addressed when planning or assessing it (Hardee,
2012).
On a timeline, we reported the multi-dimensional evolution of the content, which also
included knowledge management processes, the related actions taken by the actors and the
phenomena at context level which affected the process.
The framework takes into account the two major research questions related to underlying
reasons for changes in the arrangements of PBF schemes between 1997 and 2015 and reasons
for the pace of scaling up of PBF schemes observed during this period. For question related to
changes in PBF arrangement, we traced factors related to changes by time period and by
elements of policy analysis. The development of PBF in Cambodia has been in phases as
showed in Table 2 above. For question related to scaling up of PBF, time period alone was
used to guide analysis of factors driving scaling up.
2.8. Ethical considerations
This study was based on documentary analysis and verbal information obtained from
participants through interviews and observations of policy dialogues and discussions. No body
specimen (i.e. blood, urine, tissue) were collected. There was little chance participants of this
study may be harmed, in terms of loss of face, impact on their image, credential, reputation,
status, position, or on their relationships with other people. All identity information was kept
confidential and codes were used to replace individual’s name or position.
The study was approved by the National Ethics Committee of the MOH in Cambodia and by
WHO Ethics Committee.
2.9. Limitations
The most significant limitations are related to the availability of key informants, many of
whom are situated in different countries. Many senior officials faced the pressure of limited
time to join an interview. In general, respondents were willing to provide their views on the
evolution of the PBF schemes. While many of the respondents at provincial level and below
had good information on the implementation of PBF in their area, they were less well
informed about the national policy debate.
17
While several documents on assessments, policies and strategies were available, they tended
to reflect the end-products of discussions, debates and meetings, with little mention about
dynamics of the process, the documentation of which appeared to be lacking. This means a
great loss of information in this respect.
3. Results
Results come from interviews with key informants and document review. They cut across two
dimensions – a chronological account of PBF implementation in Cambodia and the policy
triangle elements. The time progression are the period between 1997 and 2002, between 2003
and early 2009 and between 2009 and 2015. The policy triangle elements are context, content,
process and actors. For practicality in presenting the findings, it may be necessary to combine
elements, for example, content and actors together.
3.1. Factors that have driven changes in PBF arrangements
3.1.1. Start of PBF in Cambodia (1997 – 2002): why was PBF introduced in Cambodia?
This is the start-up phase of PBF in Cambodia so the most relevant question to answer here is
why PBF was introduced in the country and who was involved in the introduction. Table 3 in
the next page summarises factors driving the PBF introduction structured by the key element
of policy analysis.
Context
The major contextual factors in the country influenced the initiation of PBF were the need for
improved service coverage and provision and for increased efficiency, receptiveness by
Cambodia to external assistance in technical matters, available financing and the global aids
agenda in favour of private sector model.
Documentary analysis suggests that other contextual factors also played a role and these
factors are related to the implementation of Health Coverage Plan and the National Health
Financing Charter (Barber et al., 2002). While the Health Coverage Plan launched in 1996
paved the way for creating health districts and their subsidiary health facilities – referral
hospitals, health centers and health posts, the National Health Financing Charter endorsed in
the same year allowed levies of public health services and health facilities retained a high
proportion of revenues for operation and staff incentives (MOH, 1996a, MOH, 1996b). The
introduction of levy and staff incentives brought with them several possibilities and paved the
way for PBF initiatives.
Information from documentary review and most respondents, both local and foreign, pointed
to the similar argument that dismal population health in the 1990s and the need for speedy
improvement in public health services were major reasons for initiating contracting and
performance contract. High mortality and morbidity among women and children were the
situations described by respondents which demanded improvement. This also reflects the
recognition by the government that the current pace of health system development was not
good enough in the recovery effort.
In the 1990s, MMR, IMR and under-5 MR were high, and that prompted the government to
find ways to speed up improvement (KII 17, central MOH official)
18
Table 3: Factors behind the introduction of PBF between 1999-2002
Policy triangle 1997 – 2002
Context Poor population health status (MMR, IMR, prevalence of HIV, TB and malaria)
Poor health service coverage and quality
Opportunity to test new ideas
Cambodia receptive to international cooperation and external assistance
Global aid agenda leaning for Public-Private Partnership and adoption of private-sector
management models
Health reform 1996 -2002
Health policies as platform: Health Coverage Plan, the National Health Financing
Charter leading to establishment of health districts, health facility based on population
coverage and implementation of user fees and community participation
Content and
actors Contracting pilot supported and financed by ADB (USD 18.3 million) (ADB, 2004,
Bhushan et al., 2002)
Contracting out: Contracted NGOs had complete autonomy over overall management,
including financial and human resources (hiring and firing), incentives, procurement of
medical supplies and drugs; established performance monitoring groups; contracted
NGOs were SCA and AMDA.
Contracting in: varied by NGO, but principally Contracted NGOs provided expertise in
managing health districts, followed public sector rules and regulations (financial and
human resources) and procurement, allowed some flexibility in managing incentives for
staff; established performance monitoring groups; contracted NGOs were HNI, Enfant
pour development.
Control: all aspects based on public sector rules and regulations
Boosted health districts (New Deal 1) and principles of implementation (va Damme et
al., 2001, Meessen et al., 2002):
Performance contracting and incentives
Performance management and monitoring
Creation of new bodies (Steering Committee)
Principles:
Accountability of providers
Reliable financial management
Assisted financing
Autonomy and flexibility for providers
Process Contracting pilot:
Proposal by ADB to pilot contracting to the MOH, involved WB
Implementation of contracting pilot by different International NGOs
Deviation from design in the implementation of contracting
New Deal:
Initiation of New Deal in Takeo provincial hospital by SRC
Replication of New Deal in 5 other health districts by different DPs (MSF, SRC, WHO,
Unicef, Monvimondo)
Creation of health financing steering committee
Source: Authors
Many of NGOs and donor agencies also saw the challenges in public health situation as
opportunity to test the PBF approach as a vehicle for achieving these changes. Provider
incentive payment along with restructuring of the hospital management, considered as a form
of PBF, was first introduced at Takeo provincial hospital in 1997. However, this case does not
seem to be well known among local MOH officials at PHD and OD levels apart from those
respondents in Takeo province. Many respondents saidthat the introduction of the various
19
PBF schemes as the testing of new ideas to determine what might work and what would not,
and how new policies might be refined and adapted to local needs and conditions.
The health situations in the 1990s presented big challenges as well as new scope to try things
out, to experiment new ideas to make changes (KII 26, an expat advisor to an NGO)
The views about PBF and contracting often differed between local officials and national
policy makers and between national officials and development partner advisors and even
among DP advisors. Local respondents tended to think about the PBF from the operational
perspectives with little link to the health system architect, for example, the issues of lack of
discipline and management system, poor remunerations for staff, and little information
management. Respondents at the central viewed PBF from the perspective of health system
policy, but this perspective may only come with a hindsight, whereas a number of expatriate
advisor viewed it as a unilateral proposition by DPs with big money and resources.
The decade of 1990s was the start of reconstruction of Cambodia health system. The lack of
resources and expertise on the part of Cambodia presented an opportunity for development
partners to engage and assist in provision of finances and technical expertise. Cambodia then
was poor and receptive to ideas for change, such as that related to contracting.
In the early days [1990s] Cambodia was poor and resources for the health sector as well as
for the contracting pilot came mostly from DPs and NGOs (KII10)
Among certain of the development partner respondents, a prior commitment to the
introduction of PBF and contracting arrangements as a means for improving efficiencies and
service delivery outcomes was one of the driving forces behind the contracting arrangements
in Cambodia. The idea of contracting in/out pilot of the 1990s was the most prominent
example of PBF and was cited by many local respondents. It was proposed by Benjamin
Loevinsonh, who then worked for Asia Development Bank and afterwards moved to the
World Bank. The World Bank and ADB proposed to MOH the idea of piloting contracting
in/out and led in the design of the 1997 pilot.
Other NGO partners were also involved partly as they saw opportunity to increase the profile
of assistance to Cambodia. These included Save the Children Fund, HealthNet International,
Enfant et Developpment (a French NGO), AMDA. They were engaged in pilot contracting
project which were implemented in 5 ODs (Keller and Schwartz, 2001). Healthnet
International was engaged in contracting in in Pearaing, Enfants et Developpment in Kirivong
and Save the Children in Cheung Prey. AMDA were engaged in contracting out in Angroka
and Save the Children Australia in Memot.
Document review indicates that at about the same time, other ODs were involved in what was
called New Deal. The New Deal was a model for boosting the performance of health districts
by directly engaging local district officials in the management of health staff and services by
linking their performance to additional payment on top of their regular salaries (va Damme et
al., 2001). The model was adapted from what was implemented in Takeo provincial hospital
and was applied in Sotrnikum and Tmar Pork and a number of provincial hospitals (Barber et
al., 2002).
20
Aside from the development at the country level, movement in Global Aid agenda also played
a role in driving the spread of PBF in developing countries. This movement was influenced by
policy change in developed countries, such as UK and the US. The National Health Services
(NHS) in the UK underwent a reform which embraced practices, such as contracting and pay
for performance. The change in NHS influenced the arrangement of international aid around
the world as DFID was an influential player in the global aid sector.
According to respondents, early results from Takeo and Kampong Cham provinces indicated
that PBF arrangements were the most satisfactory means for increasing efficiencies in service
delivery. Even so, it is understood that contracting is more expensive per capita.
Content and Actor
The content of PBF arrangements differed by scheme and was influenced by actors who were
involved in the design and implementation. Two major schemes – contracting pilot and New
Deal which were implemented during this phase can be compared and contrasted. There are
similarities in both schemes in the sense that they focused on improving the management of
health services, making variable payment of incentives by linking them to performance, and
increasing flexibility of providers. Differences in these schemes were related to the level of
autonomy given to the management of health districts, in case of contracting pilot the
contracted NGOs, and the creation of health financing steering committee in New Deal
districts as a mechanism to build consensus and support for the initiative.
Some local respondents referred to the early period of PBF as addressing the need for
improving management of health worker performance. There was also a perception that staff
job performance was viewed by development partner advisors as not meeting professional
expectations. However, there were mixed feelings about the initiative at the beginning,
according to a number of respondents. The mixed feelings originated from the fear of failure
in institutionalising new roles and procedures. This was because staff members were so
accustomed to the old way of working. At the same, many adopted a “wait and see” approach.
The new rules and procedures under PBF were perceived as strict (i.e. timeliness, presence at
facility, completion of tasks) and may not produce a positive outcome if not supported fully
by the staff, especially in the short term. There was a fear that staff could not change their
work practices quickly and dissatisfaction may arise. However, their feelings changed after a
couple of years of implementation when they saw that health services had increased,
performance of health workers had improved and revenue of health facility had increased.
They [DP agencies] came in to accustom [discipline] us to a new way of management and
delivery of services … (KII9 speaking in reference to the start of financing Takeo provincial
hospital)
While in both schemes flexibility and autonomy for providers were seen as important, it is not
clear that they were able to empower local health workers and managers in every case. The
New Deal approach did attempt to address this issue. However, in contracting pilot, the
contracting-out model was seen as providing contracted NGOs excessive power in the
management, whereas contracted NGOs in contracting-in districts had to cope with
bureaucratic hurdles in many management matters.
During the early implementation of PBF arrangements, the sentiments of local officials were
conveyed to central MOH officials, which helped to inform MOH policy making for
subsequent phases of PBF and contracting implementation. These sentiments include
21
complaints that NGOs involved in contracting were strict and rigid, there was a lack of
sharing and cooperation by NGOs, and that local officials were not sufficiently consulted.
22
3.1.2. PBF between 2003 and early 2009
Between 2003 and early 2009, two distinct PBF schemes were implemented – one was the
hybrid form of contracting and the other the updated version of former New Deal
arrangement. Table 4 in the next page summarizes factors driving changes in PBF
arrangement in this phase.
Whereas context was the main driving force for the introduction of PBF in the early period, in
this phase, it was overshadowed by the contents of new findings from the evaluation of pilot
contracting and experience and operational assessments from early New Deal implementation
and political considerations drawn from them. Actors in PBF remained largely unchanged in
terms of agency, and the process of PBF formulation was much influenced by the new
information and increased involvement of local actors, such as officials of MOH and PHD. In
this phase, there were two major PBF schemes: contracting for provision of basic health
services supported and financed by ADB, WB and DFID and Ausaid, Unicef and UNFPA;
and a scheme supported and financed by BTC based on an updated version of former New
Deal arrangements.
Content
Related to contracting for provision of basic health services, a hybrid form of contracting
combining most features of contracting-in and some features of contracting-out was
formulated and employed. There were contracts between the MOH and NGOs and contracts
between heads of facilities and NGOs and individual performance contract. Service delivery
performance contract with NGO contained service delivery indicators and varied by health
district. Contracted NGOs operated within the government bureaucracies and procedures and
were allowed more flexibility in management of staff and resources, including hiring of
contract staff, setting performance incentives, and creation of necessary units, i.e.
performance monitoring groups, to ensure effective contract management. Health districts
engaged in hybrid contracting were going on two different approaches – one was direct
funding support for contracting for service delivery at district level by ADB and DFID, the
other supported by the WB was based on Annual Operational Plan (AOP) of the health
districts. Eleven health districts were involved in this hybrid form. International NGOs were
contracted to provide management expertise to health districts.
During this phase, contracted NGOs were mandated with capacity building of local
management and to create an exit plan. However, all this part was never realised. However, in
retrospect, according to an official familiar with implementation of hybrid contracting, NGOs
failed in their role to build capacity of local officials and prepare an exit plan. Of all health
districts involved in hybrid contracting (11 in total), by the end of this phase only two of them
were perceived to have some capacity in contract management. But none of them had drawn
an exit strategy.
Related to the latter version of New Deal, internal contracting was employed, with assistance
of BTC. A more realistic term therefore could be Assisted Internal Contracting as BTC as
technical assistance agency often had to be in “a driving seat” in order to push for progress,
according to one respondent familiar with the scheme. In this model, Health Districts and
health facilities entered a contract with PHD which was in charge of managing the contract;
all contracted health facilities would receive a funding package which would pay for
operational costs and staff incentives. The facility manager had the discretion in managing
this funding package. BTC’s role was to provide technical assistance to PHD and coordinated
23
capacity building activities and procurement of resources, including human resources. The
model was implemented in 7 health districts in Kampong Cham, Siem Reap and
Odormeanchey. BTC viewed this scheme as the continuation of New Deal 1 with more robust
involvement of PHD and a higher number of health districts and health facilities. A group
formed at PHD was designated to monitor and support performance of subsidiary
units/facilities.
Similarities of the above two schemes are related to their focus on improving staff
performance by linking it to variable payment of incentives, enhancing the management of
health districts through technical support and performance contracting.
Differences in the two schemes are that the BTC supported Assisted Internal Contracting had
established Health Financing Steering Committee as a mechanism to mobilise support and
build consensus for implementation, provided capacity building to health staff on clinical and
managerial skills and contributed institutional capacity building and health policy
strengthening at provincial and central levels.
Table 4: Factors driving changes in PBF arrangements between 2003 and 2009
Policy Element 2003 – 2009
Content and
actors
Hybrid contracting supported and financed by WB, ADB, DFID and Unicef (MOH,
2007)
International NGOs contracted by MOH to provide expertise in managing district
health services (11 health districts supported by NGOs: CARE, SCA, HNI, Enfant pour
Développement, AMDA, Health Unlimited).
Contract management and monitoring groups and performance incentive system
established
Development of capacity of local officials and exit plan (for transfer to the
government)
Equity issue reflected in having remote health districts involved in contracting
Assisted internal contracting (New Deal 2) supported and financed by BTC with
contribution from the government (Euro 13.5 million) (Horemans, 2010)
PHDs were contracted to provide management support to health districts and facilities
in 7 health districts and 3 provincial hospitals.
Performance management system and performance contracting with incentive system
established with dedicated monitoring groups
Increased focus on capacity building in management and clinical quality
Context Population health remained poor and need improvement; Health services coverage and
quality needed improvement
Results from contracting pilot: High costs of contracting-out; giving government core
resources to NGOs (in contracting-out) seen as politically unfit; systemic suitability of
contracting-in; improved efficiency shown in contracting-inn; compromise between
donors and the government needed
SWiM (Cambodia version of SWAP) approach established
Formulation of HSP 2003 -2007
Arrival of Global Aid agencies (GAVI, GFATM)
On-going government reforms: Decentralisation, Public Financial Management
Reform and Administrative reform
Country economic growth contributing to increased contribution from the government
in the health sector
Process Tough negotiations between the government (MOH) and donors over the model for
contracting implementation resulted in hybrid contracting form and its implementation
Pressure on the government to contribute more to contracting
Consultations and formulations of New Deal 2
Failure of NGOs to establish and implement exit plan
Source: Authors
24
While the New Deal arrangement supported both the PHD and ODs, local respondents
believed that the project (especially in Phase 2) gave more attention to the PHD but may have
neglected, to some extent, the OD role. There was a feeling that officials at OD level may not
have received as much support for management functions, for procurement and for other tasks
as was actually needed. Often, this meant a lack of opportunity to learn by doing, that is, by
implementing new tasks, as the responsibility was taken by the implementing NGO.
We were just receiving. We were not involved in procurement. Most was done by BTC, for
example, in training they coordinated and sent staff to training workshop. They coordinated
and had facilities built, and we received them in the end. …this meant we did not have real
experience of doing it to learn from. (KII6, a local district official)
Process
What led to the formulation of contents of PBF arrangements in this phase was an intense
process of negotiation with consideration of political implications, available evidence and a
long-term vision for building ownership and sustaining improvement in the sector. Both
financial and administrative sustainability are among the key issues. The process played a
major role in explaining the reason for going for the hybrid form of contracting and that
eliminated contracting-out.
At this phase, the MOH was under pressure to contribute financially to contracting project and
if the model was contracting-out, it would be deemed incorrect that the resources from
government would be used to pay NGOs. In the view of a number of respondents who were
closely associated with the MOH, there were two contesting directions: one was continuation
with contracting but with a different form which was to be more appropriate to the country
system. The idea was favourable to the project director (of the contracting pilot). The other
was to expand the initiative of Performance-based incentives piloted in Takeo provincial
hospital and the idea was supported by then the Minister of Health. It was decided that
contracting for health services should continue based on three arguments. First, it would be
difficult to implement PBI in the government system because of high fiduciary risks as the
government financial system was very weak, with no capacity and adequate rules and
guidelines. Secondly, continuation with contracting was an opportunity to learn from
International NGOs and this would make expansion in the future possible. This phase would
serve as capacity building period for local officials. Thirdly, the idea of continuation had the
support of major DP agencies such as ADB and WB.
After contracting pilot finished two schools of thought emerged over what to do next. The idea
of continuation with contracting was supported by DPs because it would allow flexibility to
NGOs to manage government services and staffing and build capacity of local officials
making expansion possible. (KII18)
Many respondents indicated that the decision to go for the hybrid form of contracting was
largely based on the evidence from the contracting pilot which suggested that contracting-in
was most preferable, in terms of efficiency at a lower cost and suitability of this form to the
country political system. That eliminated the choice of contracting-out, partly due to its high
costs and the lack of support among key Cambodian policy makers. Among Cambodian
respondents, there was a concern both about the additional unit costs of contracting above the
usual costs of government health service delivery and about the sense of local ownership of
25
schemes that began as purely donor-funded projects. Also, this created room and an interest to
test out the new form of contracting. This argument was also applied to internal contracting
where internal contracting was introduced.
In designing the next phase of contracting, two main parties among the DPs took the lead in
negotiating and formulating the arrangement – the World Bank and the ADB. The Bank
argued that contracting out was most efficient and should be promoted. The results from
contracting pilot indicated that contracting out was most efficient, but with a higher price tag
of about US$5 per capita while contracting in showed higher efficiency in service provision
albeit operational constraints associated with the government procedures. Contracting-in
achieved still positive results with a lower cost not only attracted the interest of MOH, but
also was viewed by MOH as a model suitable and applicable to Cambodian context. Many
local respondents believed that contracting in also had many positive aspects that were
attractive to MOH decision makers. These included: increased service coverage with lower
costs than contracting out; staff remaining under the government payroll but receiving
additional incentives from contracting in; opportunities to learn from the management of
contracting-in; and the ability of contracting-in to operate within government institutional
rules. The MOH recognised the value of contracting and believed that contracting in had lots
of potential to offer. Besides, the capacity of local officials in contract management was
inadequate and it was necessary to further develop the capacity. Contracting with NGOs was
seen as an opportunity to fill the gap, build local capacity and draw an exit plan for NGOs.
There was a common view among local respondents that the piloting, restructuring and
evaluation of the PBF methods had contributed significantly to capacity building for
contracting and other methods of administrative reform.
Respondents felt that the cost of contracting out was so high the government would not be
able to afford to continue the model and if it was affordable then, it would not be possible to
scale up to other health districts so creating equity issues. This challenge was added to other
aspects of contracting-out perceived to be too demanding by many MOH officials at all levels.
It was too demanding for three reasons. First, many local government officials had to suspend
their posts (leave without pay) in order to join contracting-out project and they had to return to
their government posts after a maximum of four years. If the continuation would mean the
government would lose staff creating disorder in health workforces. Secondly, contracting out
was viewed as complete outsourcing of the government health service unit to NGOs which
was seen as incorrect from an administrative perspective. Thirdly, this model created two
divides – NGO and the government sides and led to the lack of cooperation between NGOs
and the government officials at provincial and health district levels due to various reasons,
including overlooking of PHD roles, huge pay differences, sidelining of some district health
personnel.
The high-level MOH viewed contracting out as too much concession by the government; the
government staff at district level had to ask for leave without pay for the duration of
contracting out in order to work in the districts with contracting out. (KII 3, a local official)
The hybrid contracting in fact happened during a transition period intended for NGOs to
prepare an exit plan, build capacity of local staff, and transfer contracting roles to the
government. (KII 15, a central MOH official)
26
Nevertheless, there were local officials who argued that the results from contracting pilot did
not necessarily reflect the true performance of contracting in/out designs. According to a
number of local officials familiar with the implementation of contracting pilot, the results of
the pilot did not show a clear cut performance for decision making. There were deviations
from the original design of contracting in/ out. One of the three districts which implemented
contracting in showed high performance similar to contracting out because performance
incentives and strict performance measures were employed, and one of contracting out
districts which implemented contracting out had placed Medical Assistants stationed at
primary health centers to improve services and increase clienteles.
One of contracting in districts was performing even better than contracting out districts in
some indicators, but the results of contracting pilot which averaged performance of different
contracting-in districts deemed contracting-in districts inferior in performance to contracting
out because two of the three contracting in districts had lots of problems. (KII 30, a local
MOH official)
Context
Contextual factors remained as a driving force in PBF. These factors include the need for
sustained improvement in provision of public health services, increased experience and
capacity among local management at the central and in the field, increased focus on reducing
inequity in health and poverty, direction for health development provided by Health Strategic
Plan 2003-2007, and arrival of a number of global health agencies, such as GAVI and
GFATM.
Interview respondents cited a number of factors and agendas of different partner agencies
which culminated in the two PBF schemes. Two major contextual factors were that population
health and coverage and quality of health services remained poor despite some improvement
in health status; and a more coherent approach to donor coordination and management called
Sector Wide Integrated Management (SWiM).
By early 2000s population health in Cambodia remained dismal and needs major
improvement, with the release of Cambodia Demographic and Health Survey 2000 which
showed high maternal and under-five mortality, and the HIV prevalence rate was around 2%
despite a decline from 3% in late 1990s. The situations required speedy improvement in
improving access to public health services and in expanding service provision.
This phase was marked by a concerted effort by MOH to streamline and coordinate donor
support. More donors came into the country, with global players such as GFATM and GAVI.
With more partners there was a push to streamline and coordinate partners so to maximise the
benefits of their support. A Health Strategic Plan 2003-2007 was formulated with support of
DFID to provide guidance on strategies and platforms for coordination. TWGH was then
started as a forum for consulting and exchanging ideas for health sector development. Health
Sector Support Project 1 was established and operated with a SWiM approach whereby
partner’s supports were managed under a single framework of HSSP but each entity held on
to their funding and mandatory activities.
… one of DFID aims was to bring together the ADB and WB, DFID and WHO into a more
coherent set of support for the sector and we supported the writing and development of first
HSP 2003-2007 so we put lots of efforts/TA to support the government to do the analysis
27
which led to the writing of SP and we as DFID worked with ADB and WB and WHO to make
sure our resources into that period supported the direction of the SP for the sector. (KII 29,
expat advisor)
During this period, the New Deal arrangements, which were implemented in five districts
variously by MSF, WHO, UNICEF, evolved to stage 2 of implementation. New Deal 1 aimed
to change the OD institutional set up, bringing more autonomy to health facilities, setting up
performance linked payment mechanism, and empowering local officials to take the lead.
New Deal 2, implemented in close cooperation with the PHD, was based on lessons learned
from New Deal 1 and attempted to empower local officials and further build capacity, both in
clinical and management skills.
The BTC design was aimed at building the health system wanting to make sure the system is
sustained by learning lessons and designs from contracting in/out but changing contracting
parties. In contracting with NGOs there were many problems affecting work relationships.
(KII 23, former expat advisor).
The New Deal 2 design was based on the view that there was still a lot of room for
improvement in the Cambodia health system, and evidence and experience elsewhere were
ample for devising a design that would work. This included lower costs achieved through
contracting among local units, performance-based incentive, giving more management
autonomy and providing additional needed funding and leveraging support from district and
provincial governments.
The BTC project was designed based on an understanding that population health was still
poor, and health staff were not performing at their best because they were not adequately
paid, and lacking autonomy was hindering initiatives to achieve results. (KII 19)
However, observations from many respondents indicated that weak provision of public health
services remained a huge problem. This is despite provision of performance incentives,
improved management system and practices. A PBF expert familiar with Cambodia pointed to
the coincidence of PBF evolution and fast-expanding private healthcare sector as a huge factor
in undercutting the impact of PBF. Income made by health staff from private practices was
much bigger than the incentives received from the public sector job. This was compounded by
the lack of management and regulation of private practices. The problem affected all levels in
the system, including provincial and central. A number of key informants indicated that
despite greater involvement of PHD in the management and oversight of contracted facilities,
the performance of the PHD team was perceived to be slow and the supporting external
agency had to take the lead in many activities.
By design, PHD was supposed to handle everything, but in reality BTC had to take a driving
seat [to move things forward]. (KII 23, a local official).
Pay differences between NGO staff and the government staff were huge so cooperation
between them was a big challenge. (KII 8, a local official)
A respondent with international knowledge and experience about PBF felt that in hindsight
the introduction of PBF in Cambodia coincided with the rapid private healthcare growth in the
country during 2000s in which period there were many opportunities for private practices and
that raised a strong challenge to PBF. PBF at the time was seen as a method of salvation of
28
public healthcare and diverting and mobilising resources from the private sector to the public
sector healthcare. Nonetheless, a respondent with global health sector experience argued that
the issue of dual practice and competing interests and interference with public sector jobs by
economic pressure and private sector practices was a global problem and there seems to be no
strategy in contracting to counter the problem yet. The problem is particularly persistent in the
context of the public sector where politics has greater influence on managers and staff.
29
3.1.3. PBF between 2009 and 2015
By 2009, Cambodia had over 10 years of experience in contracting implementation. In the
middle of 2009, thirty health districts and provincial hospitals were designated as Special
Operating Agencies (SOAs) by a sub-decree issued by the Council of Administrative Reform
(CAR). The SOAs are semi-autonomous in its operation.
To support the initiative and strengthen the performance of the SOAs, support mechanisms
were devised. These entailed special funding package called Service Delivery Grant (SDG),
internal contracting arrangement in SOAs, short-term capacity building to SOA management
team, and PHD and central teams specifically formed to support SOA implementation.
Internal contracting was employed as mechanism to support SOAs and SDG used to provide
partial financing to SOAs. Internal contracting represents a major shift in the MOH policy to
disengage NGOs in contracting after over 10 years of engaging NGOs in this area. These
arrangements were consistent with the policy stated in the Health Strategic Plan 2008 -2015,
and formed a part of Health Sector Support Project 2 which served as an implementing
platform.
Context
Contextual factors were the higher-level government reforms requiring conformity in public
sector institutions, the availability of domestic resources for health, Health Strategic Plan
2008-2015 with strategic focuses on accountability, equity and quality and sustainability and
improved harmonisation of DPs’ support. These factors are interconnected and influenced the
direction of PBF arrangements, change in policy, with considerations of existing evidence
related to contracting. There was a pronounced need to identify an arrangement which could
accommodate the government higher reform initiative and further improve sustainability and
ownership, with focus on developing institutions, uniformity and improved functions of
public sector service delivery. All of these had to be consistent with the directions of other
reforms and ownership of the system.
Contextually, Cambodia was at the stage of trying to stand on own feet, in terms of technical
expertise, and to some extent, financially. With over 10 years of PBF implementation it was
understood that the country has the expertise and capacity to carry on PBF. However, an
assessment of the management capacity in health districts and PHDs indicated some
shortcomings which required assistance to address. Financially, Cambodia had done well
economically with an average increase in GDP term of 7% annually, health spending by the
government increased from approximately USD 150 million in 2010 to USD 250 million in
2014 (Low, 2014).
There was advancement in financing PBF in this period, in terms of contributions from the
government and of funding arrangement. The government was willing to contribute and
increase the contribution by 10% annually and replace the fund withdrawn by DPs. Funding
of PBF came from a pooled fund by various DPs, including UNFPA, Unicef, WB, Ausaid,
BTC and AFD, with contribution from the government. This represented a more harmonised
approach (MOH, 2009).
In development terms, the SOA arrangement would assist the long-term sustainability of the
system and national ownership of the system. The government believed that the idea of SOA
supports to and be consistent with the advanced development in other areas of reforms,
including PFMR and decentralisation which promoted accountability and autonomy at service
30
delivery levels (MOH., 2008a). This was echoed in interviews with a number of respondents
based at the MOH who said the SOA arrangement fit in and supported the larger government
reform schemes.
Table 5: Factors driving changes in PBF arrangements between 2009 and 2015
Policy
triangle
2009 – 2015
Context Country economic growth and health budget increased
Population health was improving but improvement remained necessary
CAR made health districts and provincial hospitals Special Operating Agencies (SOAs)
(RGC, 2008)
PFMR and decentralisation support more autonomy to service delivery units and
accountability of decentralised units
Health Strategic Plan 2008 -2015 focussing on equity, quality, accountability and
sustainability
Capacity for contract management was assessed to be inadequate
Content and
Actors Internal contracting was the strategy to support SOAs currently 40
Cascade contracting across hierarchies of health system: MOH with PHD, PHD with SOAs
and SOAs with individual staff members and managers
SOAs as uniform service delivery management model
A short-term capacity support provided by NGOs (RHAC, CARE, SCA, SRC, BTC)
SOAs supported by a number of systems and tools: Service Delivery Grant (SDG), Merit-
based payment initiative (MBPI); Performance Management and Accountability System
(PMAS)
SDGs from pooled fund contributed by WB, AFD, Unicef, Unfpa, BTC, DFID and Ausaid
(WB trust fund) and the government
Performance contracting, performance management and incentives
Monitoring of SOAs by SOA teams, PHD teams, Central teams
An external agency contracted to audit program and financial management
Process Before implementation
Oxford Policy Management (consulting firm) prepared and assisted in design and implement
SOAs and contracting and established support mechanisms (PMAS) and MBPI.
Protracted negotiations within the group of donor agencies over model of management of
pooled fund
Assessment of PHD and health district management capacity
In the implementation
Main architects of SOAs established
Challenges in implementation and monitoring of results: slow fund flows, lack of objective
management of performance, inadequate clear rules and procedures and lack of autonomy
(Khim and Annear, 2013)
Source: Authors
Content
There were changes in the content of PBF in this phase. These include a switch to internal
contracting, making health service delivery units SOAs, funding of PBF through Service
Delivery Grants (SDGs), cascade contracting across the hierarchies of the health system and
various mechanisms to support SOA implementation.
Respondents involved in the broader government reform policies indicated a wider
understanding the rationale for the establishment of SOAs. The idea of SOAs was a top-down
decision by CAR and reflected thinking in the government office that a uniform service
31
delivery unit with a robust system of management can improve service delivery. This idea is
not only applicable to the health sector, but other sectors as well.
The government was trying to find way to do things a little different where contracting can be
used not only in the health sector, but other sectors. …. it was a valid effort to modify the
structure of it that fits and support the government other reforms, like to get government
agencies with a semi-autonomous status. (KII28, an expatriate official)
The establishment of SOAs and adoption of internal contracting were consistent with the view
of CAR, expressed in the health service contracting review in 2007. The report indicated that
CAR preferred internal contracting model (then of BTC) because it involved and built
capacity of PHD to provide oversight and employed contracting as mechanism to leverage
higher performance (MOH, 2007).
The SOA arrangement cuts across the hierarchies of the health system using internal
contracting
Building institutional capacity with consideration of financial sustainability was a major drive
toward SOAs and internal contracting. Such model would give more autonomy but at the
same improve their accountability. This requires less control from external partners and more
control in the internal system.
“…in developing institutions, we have to build capacity of local managers, involving them in
implementation and having them gain practical experience. To achieve more accountability of
local officials, internal control [in reference to monitoring and oversight] should be elevated
and external control [in reference to control by Development Partners] decreased. ” (KII 11,
an MOH official)
SOA is the idea of CAR who told MOH to implement it. MOH was accommodating this and
with a view that this would also let go off expatriates CAR. (KII 24)
The SOA model was considered because it provided hand-on management opportunities to
local managers. This came from most of local respondents at provincial and district level.
They believed that after more than 10 years of contracting trials and implementation, it was
time to hand over to local people, not only to provide them opportunities to have hands-on
management experience and build the capacity, but also this is the right thing to do to improve
sustainability and save costs.
The lack of NGOs for contracting was also considered a factor driving toward internal
contracting. It was argued that there would be too few NGOs available for contracting with
NGOs to go on if NGO contracting were to scale up to more health districts. NGOs would not
have the capacity to manage a vast number of health districts, let alone the consideration that
engaging with NGOs may undercut the sense of ownership of local managers. The latest
reason was reminiscent of contracting-out when relationship between NGO contractor and
health staff at times soured. The view was shared by some respondents who thought that the
idea of internal contracting had double wins – promote ownership, disengage the expatriates
and accommodate CAR initiative.
Related to the current PBF arrangements in SOA model, a number of respondents
knowledgeable about PBF suggested that there needed to be more innovation in PBF
32
arrangements in order to further improve service delivery performance. They also indicated
that the current PBF based on the methods used since early 2000s seemed to lose
effectiveness. For example, there was hardly any change to the performance indicators such as
child immunization or ANC while many of these indicators have reached high levels and
suffered from the ceiling effect. They argued innovation was needed in contracting
mechanisms to encourage system improvement with the involvement of all relevant parties:
for example, improved performance of a health center or a group of facilities is linked to
incentive payment of facility manager and to OD management, and variations in contract
indicators from year to year to target and improve particular services or their quality.
Process
The process toward SOA arrangement is of two stages: preparation and implementation. Even
before the preparation, the idea was conceived outside the health sector at CAR, and it was
long in coming. How CAR arrived at the decision to establish SOAs was based on experience
and lessons from contracting. CAR believed that with autonomy officials are more likely to
take initiative to improve their institutions. CAR was informed of the progress with
contracting and the different features of contracting models through meetings and
presentations by MOH officials.
I made presentation to CAR and kept them informed about contracting implementation. They
learned from us about strengths and weaknesses in contracting models, and that helped them
make decisions about SOAs. (KII 16, an MOH decision maker)
The government allowed contracting to carry on because they saw results, at the same time
they wanted to sustain contracting and build capacity. The switch to internal contracting
serves the interest in health system strengthening and country development. (KII 20, an
expatriate official).
The preparation stage was a lengthy process of discussions and negotiations between the
donors, MOH and the CAR, with a consulting firm serving as an intermediary. A series of
preparations and negotiations took place in 2007 for the formulation of HSP 2008-2015 and in
the middle of 2008 for the design of HSSP 2. Stakeholders involved included officials of the
MOH, Development Partners and a consultant team of Oxford Policy Management (OPM).
Key departments of the MOH involved in the preparations were Department of Personnel, of
Hospital Services, of Planning and Health Information and of Finance and Budget. During the
process, officials at provincial and district levels were involved in series of workshops to
brainstorm and discuss formats of business plans and structures of contracts. In the health
sector, the formulation of SOAs and related support mechanisms, including Merit-based Pay
Initiative (MBPI), Performance Management Accountability System (PMAS), were led by
Personnel Department under the direction of Director General for Administration and
Finance, with involvement of officials from other departments. In the process of formulating
HSSP 2 and guidelines for implementing SOAs and internal contracting, OPM consulted the
Director General of Administration and Finance of the MOH and CAR in clarifying the status
of SOAs, what they entail and the implications of their establishment in the next phase,
including how SOAs would function, be funded and what mechanisms and support needed.
The process was smooth and we didn’t have major issues. We involved officials from DPHI
and Hospital Services when there were matters under their scope. There was no conflict or
contestation. (KII16, an MOH official)
33
On the donor side, however, there was a marked contrast, with different donors struggling to
find a common ground for working together. Development Partners involved were Unicef,
UNFPA, the World Bank, AfD, BTC, Ausaid and DFID. Ausaid and DFID contributed to the
WB trust fund and were considered influential in shaping discussions and negotiations about
the modality for joint management of HSSP 2. Initially, the WB in Cambodia, with direction
of the WB in Bangkok office, hoped to lead the Development Partners in the management of
the health sector project. This idea was contested, and there was some tension in getting all
partners to find a common agreement. Other development partners argued that if they were to
contribute to pooled fund in a SWAP model, there should be rotation of chair, division of
labour on technical issues and participation of all in decision making. Finally, the WB agreed
to take charge in managing the WB trust fund part of the pooled fund and joint management
of the pooled fund.
We were fighting among ourselves to sort out the arrangement and have fair representative
structure. After many months of negotiations we reached a conclusion to have a joint
partnership agreement, division of labour, rotating chair and the WB leads the trust fund
(contributed by Ausaid and DFID). (KII 28, an expatriate official)
Even after the main architecture of PBF was identified and formulated, much more work was
needed to spell out the details for the implementation of the PBF. This included, at the central
level, the design and formulation of SOA manual, the formulation of Service Delivery Grant
for SOA institutions, the establishment of joint monitoring group, and the writing of
guidelines and rules for procurement, budgeting and reporting of programmatic activities and
financial expenses, and the recruitment and establishment of PHD MBPI teams. Adding to
these was the recruitment of an external agency to be responsible for conducting audits of
programme implementation and financial management. At the provincial and district levels
were the preparations of contract and AOP of SOA institutions and tools for contract
management and incentive distribution.
Aside from these tasks were the recruitment of NGOs to implement a short-term capacity
building (for 6 months to one year) in SOA districts. These NGOs were RHAC, RACHA,
CARE, BTC, SCA, and SRC. The areas of capacity building were related to contract
management, contract monitoring, financial management and compliance with procurement
guidelines.
34
3.2. The scaling up of the PBF schemes
Scaling up of PBF can be defined in terms of coverage areas, types of health services and
population involved and level of integration of PBF in the country health system.
Document review indicates that in terms of number of health districts involve in PBF, starting
with about 10 in late 1990s, it grew to about 20 in the middle of 2000s and by 2015 to 40
health service delivery units (ODs and provincial hospitals). This corresponds to growth in
population coverage. Along this line, range of health services and number of health service
indicators included in PBF also grew. During the first phase, number of contract indicators
was around 10 and all of them pertained to maternal and child health, including antenatal care,
child immunisation, immunisation of pregnant women, facility delivery, delivery by trained
personnel, Vitamin A supplement, and outpatient consultation (Bhushan et al., 2002). The
primary reason for this was that PBF was employed to attack the high maternal and child
mortality and morbidity in the country. The nature of contract indicators changed little during
the second phase, and the number of service indicators grew little. The number of service
indicators included in the contract almost doubled in the last phase of PBF (SOA
arrangement) to capture a wider range of health service delivery including dengue fever
prevention, HIV/AIDS care, malaria, diabetic care and hypertension (MOH, 2011).
Information from the interviews with key informants pointed to a number of factors behind
the pace of scaling up of PBF in Cambodia. These were financial availability for financing,
local capacity for contract management, the need to improve equitable health services, the
need for incremental change to allow testing and learning from experience, the lack of
philosophical advancement and complexity of the arrangement.
The availability of financial resources to support PBF has been the key concern affecting
scaling up of PBF. While the service delivery outcomes with PBF arrangements appear to be
sustainably improved over time compared to the traditional form of public health
administration, the PBF schemes incur higher unit costs and have relied for many years on
donor funding. This is because more funds were needed to pay staff incentives and improve
infrastructures and management practices. At national and sub-national level, respondents
were very conscious of the constraints on national budget funding available to support the
wider application of the PBF model.
Contracting then involved paying incentives to staff and building infrastructures like health
facilities, we didn’t have the resources in terms of finance and human so we relied heavily on
donor communities. (KII 7).
Consideration of equitable health services started quite early in PBF evolution. By year 2000,
the idea of health equity fund took shape in the areas supported by New Deal arrangements
(Barber et al., 2002, va Damme et al., 2001). Health Equity Fund was then considered as a
solution to improve financial access to hospital care for the poor through third-party
management and eligibility assessment. The consideration of equity issue was integrated in
the formulation of hybrid contracting and remote health districts were included in contracting
in the hope that it would help make public health services more available and accessible to
remote populations, such in the West and Northeast of the country.
During the hybrid contracting more remote health districts, like those in Preah Vihear,
Ratanakiry and Mondulkiry were involved because of equity consideration. It was thought
35
that implementation contracting in those districts would help improve inequity problems.(KII
29)
A PBF expert indicated that in hindsight Cambodia may have missed a chance for scaling up
PBF in early 2000s due to a lack of policy focus and weak agenda setting in health system
strengthening, and the lack of policy entrepreneurship. It was reasoned that during the early
2000s, Cambodia seemed to be overwhelmed by the influence of and influx of monies
brought in by major Development Partners who came with different ideas and focuses, these
Partners include GFATM and GAVI. These coincided with growth of more health schemes,
including a number of voucher and community-based health insurance. There were studies
and research which produced necessary evidence, but nobody was paying adequate attention
to the large architect and direction of the health system, nobody was championing PBF at the
policy level.
In terms of financing, increasingly the government has been accepting responsibility for
funding through its health budget, which also brings constraints on the rate of expansion of
PBF coverage. In recent years, the national health budget has increased significantly while the
level of development assistance for health has relatively diminished, placing increased
responsibility on the Ministry of Health and the government to support the PBF approach.
These financial constraints are a key factor in accounting for the slow scaling up of the PBF in
the latter phase – the SOA arrangements. Despite the government sub-decree which states 30
health service units to be made SOAs, only 11 health districts were actually made SOAs in the
middle of 2009, and number of SOAs reached 40 only in late 2014.
During the period of implementing hybrid contracting, that was the many health districts
involved because that was how much donors could afford to support. The government had
little funding to contribute then. Now the government could contribute more. (KII 07, a
district official)
Increasing number of SOAs requires more financial investment by the government and
donor’s contributions, and this needs to be consulted and negotiated. The MEF also needs to
see evidence of improvement.
Aside from financial availability, the pace of scaling up was explained by the limited capacity
for contract management and the growing complexity of contract management when
involving a high number of health institutions and the need to gain more experience in this
respect. During the contracting trial in the late 1990s, only few government officials were
familiar with contracting practices and much of assistance in contract management came from
donor-provided technical assistance. In the latter phases, the MOH had accumulated
experience in contract management but the capacity and human resources were not
commensurate with the increased number of health districts. Besides, the MOH officials
involved in contract management were officials who had core responsibilities in their
respective central departments, thus contract management was seen as additional tasks.
Respondents indicated that it was intentional that PBF was scaled up in such a pace.
According to a number of informants, gradual scaling up was seen as necessary to allow time
for local officials to gain and learn through experience and because there were changes in
contracting modality since the start. At all the stages of PBF evolution, it was necessary to test
and evaluate the new schemes and new forms of PBF. For example, the hybrid contracting
was seen as a new form of contracting after the early contracting trial with a focus on building
36
capacity and establishing an exit for contracted NGOs, and nobody knew if it would work.
The change to internal contracting in the SOA arrangement was also a new form of
contracting where most of contract management tasks, if not all, were implemented by local
and national officials. It remained in a pilot form and change in its arrangement is subject to
evidence from an evaluation although so far no impact has ever been carried out.
Every phase a new form of contracting emerged, and we needed to test if this form works. The
SOA arrangement with internal contracting is an example. We don’t know how it would work
and I think currently it is still a pilot. (KII16, an MOH official)
Even if with a smaller number of health districts engaged in contracting, support from the
central was insufficient, imagine when many more health districts implement contracting. (KII
09, a provincial official)
Supply-side contracting is more complex than health equity fund because it involves
management of the whole health district, including hospital services and health centers,
whereas health equity fund focuses mainly on compensating providers and checking services
provided to the poor who is small in number. (KII02, a provincial official)
However, a PBF expert (KII 26) familiar with Cambodia health sector believed that the pace
of PBF scale up was slow because the lack of policy entrepreneurship in the country in the
early time, and this was compounded by the problematic feature of contracting-out which
antagonised the government, and that may have been the cause of loss of support to PBF.
Lack of evidence about the impact of PBF also explains the current pace of PBF scaling up. A
number of respondents felt that PBF scaling up was at least partly linked to the lack of strong,
convincing evidence of the impact of PBF on service delivery. They pointed out that there has
been no rigorous impact study of the PBF schemes implemented to date. Even the evaluation
of pilot contracting in the late 1990s suffered from design-deviated implementation which
made conclusions questionable. A respondent familiar with the project indicated many
deviations from its initial design, for example, a contracting-in district injected more funding
for staff incentive, whereas in another district (Cheungprey) compliance with the study design
resulted in no or very little improvement in service delivery.
There was no hard evidence from contracting implementation which convinced people that it
is the way to go. Available evidence is weak and riddled with problems. Even the results from
the contracting trial which was considered the most robust was challenged. (KII 12, an MOH
official familiar with RBF)
Respondents from provincial and central MOH had a convergent view that evidence on
efficiency of contracting influenced the consideration of scaling up and is linked to contract
monitoring and management. They pointed to the lack of adequate monitoring at individual
and institutional level as a major shortage of current contracting, and that needs improvement.
However, local and central MOH respondents were split in their view about whether or not
the lack of provider-purchaser split in the current internal contracting was responsible for
ineffective monitoring. Local respondents said monitoring by district team was carried out
regularly but were not sure how effectively this monitoring could enforce the sense of job
commitment among staff. They also said that some providers were willing to accept a cut in
the incentives or completely forego the incentives (because they were small) in exchange for
the freedom to make extra income from private practice. However, respondents from the
37
Central MOH were steadfast in the view that despite loopholes in monitoring, the current
model contributes to improved ‘internal’ accountability which should be increased as part of
efforts to strengthening institutional capacity.
Scaling up of PBF was considered slow when comparing to Health Equity Fund. HEF was
often mentioned when discussing PBF scaling up. A number of respondents familiar with both
schemes pointed out that the lack of evidence was one of the main explanations for pace of
expansion of PBF when compared to scaling up of HEF. HEF scheme scaled up from a few
health districts in 2000 to nationwide coverage in 2015 while PBF has not reached half of the
total number of health districts yet. According to the respondents, there are three major
reasons. HEF was partly seen as a politically attractive scheme as it targets the poor and
vulnerable populations – any government would want to be seen as assisting the poor and
vulnerable populations. The second reason, partly it came timely during the time when
poverty reduction was the gaol of the government’s and donors’ social and health policy. And
the third was that many previous studies had produced enough evidence to convince policy
makers and donors alike that the scheme was effective in assisting the poor to access and
utilise public health services and contributing to reducing poverty and healthcare-related
debts.
HEF was a solution to channel funding to target population, the poor. And research has
found that it reached its equity objectives by increasing access to and utilization of health
services by the poor. (KII 27)
HEF was a political lift when the country needed it so much and there was buy-in from both
donors and the government to support HEF to contribute to poverty reduction. (KII 26)
A number of respondents cited source of funding and ownership of scheme as important
factors to scaling up of health scheme. They raised midwifery incentive scheme as an example
when discussing this issue. According to them, the scheme succeeded because it is funded by
the government budget, is a government program and is owned by the government, the
government very much wants it to continue. Other than that, the scheme arrangement was said
to be simple and feasible for implementation.
Trust in the government financial management and corruption therein were also mentioned by
a number of respondents as barriers to donor’s commitment to invest in PBF. Documentation
by the WB and the WB assessment of high fiduciary risk associated with the government
financial management were raised. One respondent indicated that while the country needed
DPs’ support, this was compounded by the fear of financial mismanagement.
Nevertheless, respondents from the central MOH and provincial levels indicated that the
current PBF scheme (internal contracting) has a strong prospect of continuation for two
reasons: The ODs and hospitals involved in PBF are designated as SOAs by sub-decree and
their status will continue regardless of the availability of additional resources (either domestic
or external); secondly, the current model promotes national ownership and is likely to sustain
although modality of support to SOAs may have to change to whatever forms considered
suitable by the government.
This is the government reform and it has to continue with or without financial support from
donors. And we may not have the same SDG [to support SOAs]. (KII11, an MOH official)
38
Integration of PBF into the health system Integration of PBF in the country health system refers to the level of adoption of PBF
elements in setting policy and guidelines. Common PBF elements include linking payment of
financial incentives to health staff to performance, providing flexibility and/or autonomy to
providers, institutionalising performance management using contracting. Integration of PBF
in the country system has inherent advantages and benefits in sustaining capacity and building
familiarity with and trust in PBF.
During the first phase of PBF, there was some integration of PBF in the system at the central
and district levels. Project Coordination Unit was established with involvement of leadership
of the MOH and staff drawn from relevant units of the MOH. At district level, integration in
contracting-in districts was high as contracted NGO staff worked with and involved district
staff to formulate and implement rules and procedures.
The level of integration increased significantly during the subsequent period when PBF was
implemented in 20 ODs during 2003-2009. At the central level, the PCU was later known as
HSSP in this phase and was involved in a SWiM approach, with participation of relevant DPs.
PBF elements were adopted in management practices, including performance contracting,
flexibility for hiring contract staff, shuffling of under-performing staff, transparency in
procurement practices. In provinces supported by BTC, integration was particilarly high as
PHD was given a role in management and oversight and performance contracting was
institutionalised in the provinces.
Integration of PBF during the period between 2009 and 2015 may be seen as the strongest as
PBF in the form of internal contracting was employed as the main mechanism to support
SOAs and they were provided with more management autonomy, by a government sub-
decree. This is the first time PBF was formally adopted as part of the government initiative.
As such the financial contribution from the government for SOAs increased, as well as
involvement of high-ranking government officials in monitoring SOAs.
3.3. Results of the timeline analysis
The timeline for Cambodia PBF has three major phases: 1997 – 2003, 2004 – 2009, 2009 –
2015. The diagram of the timeline is annex 1. Five indicators are used in monitoring PBF
evolution: population coverage, health system policies, country ownership, service coverage
and society, knowledge and ideas. Explicit is the increase in population coverage as more
health districts and provincial hospitals were involved. Starting from 10 health districts in
1999, by 2015 PBF was implemented in 40 health districts and provincial hospitals. Along
with this, service coverage also occurred with inclusion of more indicators and services, such
as diabetes, hypertension and communicable diseases in contract. In terms of health system
policies, the past experience with implementation of PBF had fed into and improved health
policies, with supplements from research and studies. For example, evaluation of contracting
pilot in 2002 provided the basis for formulation of hybrid contracting in the subsequent phase
and management practices therein. Formulation of SOAs using internal contracting was based
on review of contracting approaches. These reviews, studies and evaluations were the bases
for publications which is essential for disseminating and improving knowledge about PBF in
Cambodia and internationally and contributes to advancing ideas about PBF. This is linked to
the fifth indictors.
PBF evolution in Cambodia is a good case which reflects increasing country ownership over
time. Starting from complete outsourcing of district management to NGOs in contracting-out,
39
ownership of PBF had gradually transferred to Cambodians, with integration of contextual
considerations to make it locally feasible and appropriate.
Over time, PBF was gradually integrated into the health system though it remains to be seen if
it will sustain. Likewise, the trend of changes reflects the importance of improving local
capacity and resources as sustainability moves more to the forefront.
40
4. Discussion
This research seeks to document and explain factors influencing changes in PBF design and
arrangements from the start in 1997 to 2015 and the factors explaining scaling up of PBF in
Cambodia. The development of PBF in Cambodia over this period has shown a clear pattern.
The pattern is characterised by moving of national ownership and sustainability to the
forefront and switching the role of management from the external party to the internal actor.
The pattern started with an almost total dependence on donor assistance in both financing and
technical assistance and through NGOs in the management and delivery of public health
services. This was the time when population health in Cambodia was in a dire state and needs
rapid improvement. It was also the time when Cambodia started the reconstruction of the
health system and the capacity and expertise in health system management were very weak.
The start of PBF occurred as Cambodia was opening up to the world and was receptive to
external ideas. The MOH endorsed the contracting pilot and New Deal as part of a wider
health sector reform project, this was greatly mediated with the formulation of the Health
Coverage Plan and the National Health Financing Charter (Barber et al., 2002). The
government was willing to consider and evaluate its benefits based on practice. The start of
PBF in Cambodia coincided with the global movement spearheaded by the WB in their 1993
report encouraging structural change in financing and management of public health sector
services, namely the adoption of market rules to healthcare management (World Bank, 1993).
The status quo changed after the completion of contracting trial in late 2002. The experience
from contracting implementation provided many lessons to Cambodia MOH officials. These
lessons and experience were critical in the negotiation for the subsequent phase of PBF. The
shift to hybrid contracting in 2003-2009 marked a successful bid by Cambodia to have a form
of contracting which benefits from contracting advantages and expertise of NGOs while
retaining the features of public institutions, with a level of coordination. The bid not only was
supported by field stories of bitter-sweet relationships between the local officials and
contracted NGOs in contracting implementation, but also by the arguments for strengthening
capacity of public institutions through NGO and donor involvement.
The PBF phase in 2009-2015 represented a major change in the management structure of the
government controlled public health service. This was seen as a signal that the MOH was
ready to take increased direct responsibility for the management of public health institutions.
This was required of MOH to meet the requirements of top-down policy initiative by the
higher government office and to benefit from contracting arrangements and partners’ interests
in co-financing. The result is a uniform design of service delivery units and co-financed
jointly by the government and partners and operating within the bounds of Cambodia public
administrations. Although the model has not been scaled up nationwide, early implementation
suggested that it was able to maintain the high level of service delivery, according to results of
monitoring by HSSP and a previous study (Khim, 2014, MOH, 2014). This is despite inherent
challenges with internal contracting and a number of shortcomings in the design of SOA
arrangements (Khim and Annear, 2013). With improved capacity of local management and
increased financial support from the government, this model is likely to sustain after partners’
supports phase out.
Despite absence of rigorous evaluation of PBF schemes, results from Cambodia
implementation of PBF to date suggests that PBF has the potential to improve service delivery
outcomes, and that this potential was not impaired by the move to a scheme that relied more
heavily on national resources, local management and a sense of national ownership.
41
The sustainability of financing, outcomes and administrative capacity are key issues in the
evaluation of PBF arrangements. The move towards funding contracting methods in
Cambodia through the national budget supports the further sustainability of PBF arrangements
generally, though it may come at the cost of a slower pace of expansion and scaling up of
these arrangements to national coverage.
There has been on-going debate about what PBF model works best in the Cambodian context.
Some see the earlier models of contracting-in and contracting-out as the most efficient and the
most productive. However, the unit costs of service delivery mean that more cost-effective
methods – using local personnel, administrative systems and resources – have been developed
and implemented. The shift from provider-purchaser split to a contracting form with merged
roles of purchaser and provider in SOA implementation has brought scepticism about
purchaser’s ability to carry out objective contract monitoring. This is further compounded by
a lack of will to enforce the contract and the political implications involved in contract
management (between principal and agent), which compromises the ability to hold
contracting parties accountable and strengthen service delivery. The Cambodia case offers a
caution about the possible trade-off between efficiency in the coverage and quality of health
service delivery and long-term sustainability and ownership of the system. It will be
interesting to see how PBF evolves in the next phase of development and whether or not PBF
will achieve an efficiency gain.
Different understanding of ownership by different actors, local or foreign, has far-reaching
implications and is seen as influencing the development of PBF. Whether ownership is rather
defined in terms of who has a broader oversight in health system management and less in
terms of who is involved in the actual daily operation is important to clarify as it has
implications in the involvement of local or international NGOs in purchasing arrangements in
the management of various health schemes, such as HEF and PBF.
One outcome of the longer-term process of PBF implementation – through both supply-side
contracting schemes and the demand-side financing schemes – has been to rely on an
evidence-based policy process that draws on the piloting and evaluation of different
approaches. This has not meant, however, that those schemes with apparently the best
performance outcomes have been automatically selected. Rather, a wider process of
consideration of national needs and resources, and a need to accept national ownership for
future sustainability, has unfolded.
A contextual factor – economic opportunity for private practices – may have influenced and
made the implementation of PBF challenging. Private sector in health care grew exponentially
since Cambodia adopted an open market approach in the 1980s, but especially after 1993
national elections. That created more opportunities for healthcare businesses for providers
working in the public sector. At the same time, it also created conflict with the public sector
objective. As reported by respondents, income from private (dual) practices may have
outweighed performance incentives from PBF so they were willing to forego the incentives
and have freedom to run own practices. For this reason, some NGOs involved in early
contracting made it a requirement in the contract with providers that they had to completely
refrain from private practices while performance contract was in effect (Soeters and Griffiths,
2003).
42
The interlinkage of the health system and the national development contexts must be
underscored. These contexts include economic growth, other country reforms, such as public
financial management reform, civil servant and compensation reform, Decentralization and
Deconcentration, and other national reforms. These reforms were often overlooked when
analysing trends and changes in PBF evolution while in fact they were instrumental in
explaining the MOH choice of design and arrangement.
Based on the rate of expansion of PBF and information from the interviews, it is clear that
scaling up of PBF has been slow, even without comparisons to the scaling up of HEF or
Midwifery incentive scheme. There were many factors contributing to this pace of
development, but three factors appear to be the most influential. First, the nature of PBF itself
being provider-focussed and directly benefitting providers put it in a disadvantage position.
This is partly because PBF growth was in competition against HEF whose focus on the poor
and vulnerable as its beneficiary appeared to be the most appealing to the government and
donor community when their focus converged on poverty reduction. Secondly, Cambodia
health sector lacked clear policy direction in the early 2000s and there was no one in the
country to champion PBF and advance its agenda at the policy level. The arrival of global
health agencies, such as GAVI and GFATM, put pressure on the country human resources and
pulled Cambodia to diverse directions. Championing PBF required evidence and information,
and there was little literature about PBF at the time. The lack of evidence on its efficiency did
play a role in this regard. This development was in contrast with that of HEF whose
development was supported with evidence from research and studies which was related to
policy makers (Ir et al., 2010a, Annear, 2010, Bigdeli and Annear, 2009). Thirdly, resources
have been the main factor all along PBF development. The resources were limited and the
lack of policy directions means they were spent on piloting other schemes, such as
community-based health insurance which to date have shown little impact on health or health
service outcomes (Ozawa and Walker, 2009).
The scaling up of the PBF contracting arrangements to national coverage through the SOA
model is currently under serious consideration in the national health strategy and planning
process being currently undertaken for the next phase of development up to 2020. There is an
urgent need for evidence on impact of the SOA approach to feed into the design and
formulation of the next phase. A particular issue is related to financing. Currently, SOAs are
supported by an SDG, which is funding in addition to routine budget and which provides
funding for performance incentives. Whether the SDG is sustainable in the longer term and
for all ODs and provincial hospitals is still open to question. Even so, the PBF approach in
SOA implementation remains a sought-after goal and may continue to be implemented in
some form. The SDG is a supply-side supplement; there is now discussion about the
advisability, at least for the short term while the new Strategic Plan being developed, of
transferring a major portion of this supplement to the demand side in the form of a subsidy for
services provided to patients. This may take the form of an additional payment made through
the existing health equity funds (for all patients and not just the poor), with conditions related
to improved quality of care.
Looking back on the Cambodia PBF evolution, it appears that PBF has been employed as ad
hoc interventions, temporary solutions to weak health system and service delivery. This partly
is because of limited availability of funding, lack of effective coordination mechanisms and
capacity and competing ideas for interventions and acceptance by the MOH of these ideas.
For PBF to be sustained long into the future and integrated into a country health system, its
arrangements must be linked to and congruent with the directions and policies of country
43
public sector reforms. This does not mean in anyway the end of PBF in Cambodia; there is
more opportunity for PBF to be involved and make a greater impact at a country level. This
means at least conceptually there is a need to get a comprehensive understanding of the
reforms and the directions and vision of the country and study to formulate PBF strategies to
be congruent with and complement those reforms. A pertinent question is how to best
introduce and integrate provider payment methods in the government civil pay reform to have
payment linked to performance, for instance. The country direction toward creating public
semi-autonomous institutions also provide opportunity to introduce the idea of provider
autonomy and mechanisms for improved accountability in line with the direction of
Decentralisation and Deconcentration.
44
5. Conclusions
RBF arrangements have been tested in Cambodia both in supply-side contracting schemes and
in demand-side financing schemes. PBF is the supply-side focused RBF which aims to
leverage performance of providers by linking it to variable payment of incentives and other
support tools, for example, giving more flexibility to providers. It has been implemented in
Cambodia since 1997 in three consecutive periods with distinct characteristics – between
1997 and 2002, between 2003 and 2009 and between 2009 and 2015. Results from PBF
implementation at different stages appear to have been efficient and effective in improving
service delivery.
Two major PBF schemes between 1999 and 2002 were pilot contracting and performance-
based incentive scheme implemented in 10 health districts and provincial hospitals. Financial
incentives to providers, restructuring of the management of health facilities and units, and
allowing more autonomy to local managers, with a view of long-term sustainability (at least
associated with New Deal) were the common principles of these schemes. Conceived largely
by DPs, the schemes were based on a number of considerations of country contexts. Dominant
contextual factors were the felt need for a rapid improvement in coverage and provision of
public health services to respond to dire population health, country opening up to the world,
adopting liberal market economy and policy makers being receptive to external assistance in
technical and financial terms which allowed room for testing different ideas. Global
movement influencing this development was the global aid agenda in favour of private sector
model being applied in healthcare sector.
During the period of 2003 and 2009, two major PBF schemes – the hybrid contracting and the
new version of New Deal arrangement – implemented in 21 health districts and provincial
hospitals. This represented a double increase in coverage. Hybrid contracting was a form of
contracting between MOH and NGOs for the NGOs to provide expertise in managing health
district health services and build capacity of local management. This model adopted most
features of contracting-in implemented earlier. Change to the hybrid contracting was driven
largely by evidence from the evaluation of earlier contracting pilot, considerations of political
feasibility and equity in public health services. The new version of New Deal arrangement
employed internal contracting where PHD contracted with and provided support to health
districts and facilities. This new version represented a step further from previous New Deal in
which PHD was involved in management and support, with support of intense capacity
building in management and clinical quality. This came with a purpose to build a sustainable
and strong provincial health system.
Internal contracting during the period of 2009 – 2015 represented a step further to have a
uniform PBF arrangement under the MOH and in recognition and integration of PBF deeper
in the health system. It was employed as a mechanism to support health districts and
provincial hospitals made to SOAs, currently with 40 of them, under the Public Health Sector
Reform. The change signified a return to government-run health services and increased focus
on building institutional capacity, with a view of long-term sustainability.
The evolution of Cambodia PBF over the periods is the incremental scaling up of and
integration of PBF in the health system. The pace is slow, especially when comparing to other
financing schemes, such as HEF and midwifery incentive scheme. Available financial
resources, management capacity, lack of strong evidence about PBF efficiency, lack of PBF
champion in the country, mismatch in DPs’ policy on incentive payment (at least in the early
45
time) and time needed to test new models and learn from experience and the level of
ownership promoted by the scheme were the factors influencing the scaling up.
In Cambodia, the government and national health planners have been conscious of the need
for national ownership and sustainability, the additional costs of the PBF model and the
limitations on national resource availability. The suitability of PBF models to the country’s
health system and other public sector reforms and the political implications of the models
have shaped the debates and discussions about PBF and its integration in the health system.
For these reasons, new models of PBF have evolved in accordance with national needs, based
on piloting and evaluation.
While it is too early to make firm recommendations in this report, the further scaling up of
PBF and SOA arrangements appears to be warranted from the evidence to date, including the
evidence of an increased level of understanding and capacity among local health
administrators who have gained from their involvement in earlier models of contracting.
The next Health Strategic Plan 2016-2020 is being prepared. It is an opportunity to rethink
PBF strategy and fully consider the role, function and scaling up of SOA arrangements. This
should be based on evidence related to efficiency in service delivery and management
capacity in the SOA implementation. While SOA arrangement will continue and probably
further expand, the remaining question is what design and formulation are required to support
it and improve its contributions to delivery of public health services and population health.
Based on the experience of PBF implementation, three specific recommendations could be
drawn for the future PBF formulation. First, all service delivery units have a mechanism as an
integral part of the administration whereby the incentive is large enough and its payment is
truly linked to provider’s performance. Secondly, improve accountability of providers and
managers by changing contract indicators based on needs and making contract monitoring
more objective. Thirdly, advocate for higher government contributions to PBF to
accommodate improvements in the two above recommendations.
46
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49
Annexes
Annex 1: Timeline of PBF evolution in Cambodia
5 districts (population 810,000) engaged in contracting in/out pilot
Hospital financing scheme operated at Takeo PRH covering 720,000 population in Takeo
province
New Deal implemented in Sotnikum started (population 210,000)
11 districts engaged in hybrid contracting (population 1,405,300)
7 districts and 3PRHs implemented BTC (New Deal 2)
Prakas XX to implement Midwifery Incentive schemes in all public health facilities
11 districts and 8 PRH made SOAs using internal contracting
8 former BTC districts made SOAs using internal contracting
3 districts in Takeo made SOAs using internal contracting
6 more districts made SOAs implementing internal contracting
PHC and hospital care in 11 districts engaged in hybrid contracting
Hospital outpatient and inpatient care at Takeo PRH
PHC and hospital care in 5 districts in contracting in/out pilot
PHC and hospital care in Sotnikum OD
PHC and hospital care in 7 ODs districts and 3PRHs in 3 provinces (New Deal2)
-30 Midwifery Incentive schemes for facility
delivery
PHC plus diabetic care and hospital care in 19SOAs
PHC and hospital care in 8 new SOAs
PHC and hospital care in 3 new SOAs
PHC and hospital care in 6 new SOAs
Launching of the National Health Financing Charter
Health coverage plan approved establishing PHD, OD, RH and HCs and HPs
Applying contracting system in 5 ODs as part of Basic health services project
10 10
Health Strategic Plan 2003-2007 endorsed
10
Continued applying contracting system at OD and provincial levels (18ODs, 8 provinces)
Launching of Health strategic plan 2008-2015
10
Sub-decree designating 30 health institutions SOAs issued
Internal contracting applied in SOAs
Formulation of new strategic plan and health sector project
MOH supported contracting in/out pilot
New Deal empowered local officials MOH supported, coordinated and oversaw
implementation of hybrid contracting
PHD took lead in BTC supported contracting MOH jointly managed, coordinated and
oversaw SOA implementation Ownership gained through internal
contracting
30 30
Documentation of New Deal 1
Published paper on contracting in/out
Contracting in/out pilot published in Lancet
Impact assessment of BTC-supported contracting in Kampong Cham
International conference on improving health sector performance
30
31/01/1993 28/10/1995 24/07/1998 19/04/2001 14/01/2004 10/10/2006 06/07/2009 01/04/2012 27/12/2014 22/09/2017
Population coverage
Societ, knowledge and ideas
Health System Policies
Country Ownership
Service Coverage
50
Annex 2: Question guide Project Title: Factors driving changes in arrangements and scaling up of health
schemes: the case of Performance-Based Financing in Cambodia 1997-2015
Several forms of PBF schemes have been implemented since 1997 as showed in the table
below
PBF
formulation
and
implementation
Takeo
provincial
hospital
1997
New Deal 1999-
2004
Contracting
out/in 1999-
2002
GAVI/HSS
Hybrid contracting
2004-2009
Internal contracting
(BTC-supported New
Deal 2) 2005-2009
GAVI/HSS
Midwifery incentive
Internal
contracting in
SOAs 2009 to
date
GAVI/HSS
Midwifery
incentive
1. In what capacity were you involved in one or several of these projects? What was your
role?
2. What were the major reasons for this project? What major reasons which explain the need
for the schemes and its design?
3. In what way was experience of previous PBF implementation (PBF in Takeo provincial
hospital and HEF and/or contracting in/out, hybrid contracting) incorporated in the
design?
4. What motivated changes from contracting in/out to hybrid contracting or BTC-supported
internal contracting and to the SOA model (using internal contracting)?
5. How was the experience of early contracting models incorporated in the current design
and arrangement of internal contracting (2009 – present)?
6. Since the pilot contracting in 1999, contracting has scaled up in a limited manner.
Currently there are 36 ODs and provincial hospitals implementing SOAs/internal
contracting, why did scaling up of contracting on supply side go slowly while
contracting on demand side for HEF has spread almost nationwide? 7. In what ways do you see PBF schemes (current and previous) are the methods to improve
efficiency, country ownership and sustainability?
8. To what extent are PbF schemes reasons for mobilizing external resources for health?
Why is it so?
9. What factors prevented PBF arrangements from working effectively (as was designed)?
10. How strongly is the conviction of the leaders of MOH and MEF in contracting/PBF to
improve efficiency and quality of public health services? Why or Why not?
11. In what ways does the size of government budget matter in the implementation of the
current PBF schemes (internal contracting)? Why or Why not?
12. In the past contracting has included only local and INGOs. Under what conditions would
it be possible for the MOH to include also private health providers as contractors? Has this
ever been proposed?
51
Annex 2: List of key informants who were interviewed
1. Interviewee 1, MOH field manager at provincial level (interview date: April 7, 2015)
2. Interviewee 2,MOH field manager at provincial level (interview date: April 7, 2015)
3. Interviewee 3, MOH field manager at district level (interview date: April 7, 2015)
4. Interviewee 4, MOH field implementer at district level (interview date: April 7, 2015)
5. Interviewee 5, MOH field manager at district level (interview date: April 8, 2015)
6. Interviewee 6, MOH field implementer at district level (interview date: April 9, 2015)
7. Interviewee 7, MOH field manager at district level (interview date: April 29, 2015)
8. Interviewee 8, MOH field implementer at district level (interview date: April 29, 2015)
9. Interviewee 9, MOH field manager at provincial level (interview date: April 30, 2015)
10. Interviewee 10, MOH field manager at provincial level (interview date: April 30, 2015)
11. Interviewee 11, MOH technical person (interview date: May 15, 2015)
12. Interviewee 12, MOH technical person (interview date: May 12th
, 2015)
13. Interviewee 13, MOH technical person (interview date: June 8th
, 2015)
14. Interviewee 14, MOH technical person (interview date: April 27th
, 2015)
15. Interviewee 15, MOH technical person (interview date: June 8th
, 2015)
16. Interviewee 16, MOH policy maker (interview date: July 7th
, 2015)
17. Interviewee 17, former MOH technical person (interview date: April 23rd
, 2015)
18. Interviewee 18, donor technical person (interview date: July 2nd
, 2015)
19. Interviewee 19, donor official (interview date: May 5th
, 2015)
20. Interviewee 20, donor official (interview date: April 23rd
, 2015)
21. Interviewee 21, donor technical person (interview date: May 14th
, 2015)
22. Interviewee 22, donor technical person (interview date: May 12th
, 2015)
23. Interviewee 23, donor technical person (interview date: April 23rd
, 2015)
24. Interviewee 24, donor technical person (interview date: May 12th
, 2015)
25. Interviewee 25, donor technical person (interview date: July 2nd
, 2015)
26. Interviewee 26, donor technical person (interview date: May 22nd
, 2015)
27. Interviewee 27, donor technical person (interview date: June 9th
, 2015)
28. Interviewee 28, donor technical person (interview date: August 21st, 2015)
29. Interviewee 29, donor technical person (interview date: September, 3rd
, 2015)
52
Annex 3: Informed Consent Form
University of Health Sciences
Informed Consent Form for respondents as staff of bi- and multi-lateral agencies and INGOs and NGOs. This informed consent form is for staff of bi- and multi-lateral agencies and INGOs and NGOs who have been invited to participate in the project with brief information below. Name of Principle Investigator: Keovathanak Khim Name of Organization: University of Health Sciences Name of Sponsor: The Alliance for Health Systems and Policy Research Project title: Factors driving changes in arrangements and scaling up of health schemes: the case of Performance-Based Financing in Cambodia 1997-2015; Version dated March 3, 2015 You will be given a copy of the full Informed Consent Form Part I: Information Sheet
Introduction
I am Khim Keovathanak, the principle investigator. I would like to invite you to participate in
the project above. I am going to give you information and invite you to be part of this
research. You do not have to decide today whether or not you will participate in the research.
Before you decide, you can talk to anyone you feel comfortable with about the research.
This consent form may contain words which you may require clarifications. Please ask me to
stop as we go through the information and I will take time to explain. If you have questions
later, you can ask them of me or of another researcher.
Purpose of the research
The project aims to provide an understanding of the change in the forms of PBF schemes in
the country over the past 15 years. PBF is a term given to health schemes which focuses on
supply side (the providers) with an aim to improve the performance of providers and delivery
of health services. Cambodia has implemented a number of PBF schemes over time, however,
it has scaled up the scheme in a limited manner. We would like to find out reasons and factors
behind these changes and limited scaling up.
Type of Research Intervention
This research will involve communication via email (for those outside Cambodia) and
interviews of staff of multi- and bi-lateral agencies and INGOs who were or have been
involved in the formulation and/or implementation of PBF schemes. The interview will be
about 45 minutes to one hour each.
Participant Selection
53
You are being invited to take part in this research because we feel that you, as staff or former
staff of bi- and mult-lateral agencies or INGO, have the experience and knowledge about PBF
schemes and their implementation, and these can contribute much to our understanding and
knowledge about PBF schemes.
Voluntary Participation
Your participation in this research is entirely voluntary. It is your choice whether to
participate or not. If you choose not to participate, nothing will change and you or your job
will not be affected in any way by the research implementation. By agreeing to participate you
will be interviewed and the information you provide will be recorded. You however can still
ask to have the information withdrawn and deleted in case you feel uncomfortable with the
interview later on. However, you can still participate without your voice recorded, in which
case notes of interview will be taken.
Procedures
If you accept to participate in the interview, you are asked to sign the consent form.
Interview can take place over Skype. You can choose a setting where you feel comfortable,
have a good Internet access and can speak comfortably. If you do not wish to answer any of
the questions during the interview, you may say so and the interviewer will move on to the
next question. No one else but the interviewer will be present unless you would like someone
else to be there. The information recorded is confidential, and no one else except the
investigators will access to the information documented during your interview. The entire
interview will be voice-recorded and transcribed. The data files will be kept safely in the
investigator’s laptop protected by security password. The information recorded is confidential,
and no one else except the investigator will have access to the sound file. The sound files will
be destroyed one year after the final report of the research is accepted.
Duration The research takes place over 12 months in total. During that time, we will contact you for
interview two times. First interview may last for about 45 minutes to one hour and in case we
need clarifications and additional information, we will visit you the second time which lasts
between 20 to 30 minutes. If you like, you may choose to provide answers in writing and send
by email.
Risks
As an official involved in PBF formulation or implementation, your experience and perceptions about PBF are valuable to us. However, there is a risk that you may share some personal or confidential information by chance, or that you may feel uncomfortable talking about some of the topics. However, we do not wish for this to happen. You do not have to answer any question or take part in the discussion/interview/survey if you feel the question(s) are too personal or if talking about them makes you uncomfortable. Benefits
There will be no direct benefit to you, but your participation is likely to help us understand
better about PBF schemes when they were formulated and implemented.
Reimbursements You will not receive any payment for participating in this research. Confidentiality
We will not be sharing information about you to anyone outside of the research team. The
information that we collect from this research project will be kept private. Any information
about you will have a number on it instead of your name. Only the researchers will know what
54
your number is and we will lock that information up with a lock and key. It will not be shared
with or given to anyone except the other investigators (Dr. Sok Kanha, Dr. Vun Ratanak and
Dr. Peter Annear) who will have access to the information.
Sharing the Results
Nothing that you tell us today will be shared with anybody outside the research team, and
nothing will be attributed to you by name. The knowledge that we get from this research will
be shared with you before it is made widely available to the public. Each participant will
receive a summary of the results through mails and they will be inquired through telephone if
they have any feedback on the results which will be incorporated in the final report. There will
be a dissemination meeting through an existing forum, such as the MOH Technical Working
Group for Health. Following the meeting, we will publish the results so that other interested
people may learn from the research.
Right to Refuse or Withdraw
You do not have to take part in this research if you do not wish to do so, and choosing to participate will not affect your job or job-related evaluations in any way. You may stop participating in the interview at any time that you wish without your job being affected. At the end of the interview I will play the records of interview so that you can review your remarks, and you can ask to modify or remove portions of those, if you do not agree with the records. Who to Contact
If you have any questions, you can ask me now or later. If you wish to ask questions later, you
may contact any of the following: Keovathanak Khim, phone: 012-333-145; e-mail:
This proposal has been reviewed and approved by the MOH’s National Ethics Committee for
Health Research (NECHR), which is a committee whose task it is to make sure that research
participants are protected from harm. If you wish to find about more about the NECHR,
contact Che Vannak (023880345). It has also been reviewed by the Ethics Review Committee
of the World Health Organization (WHO), which is funding/sponsoring/supporting the study.
You can ask me any more questions about any part of the research study, if you wish to. Do you have any questions?
Part II: Certificate of Consent
The foregoing information has been read to me. I have had the opportunity to ask
questions about it and any questions I have been asked have been answered to my
satisfaction. I consent voluntarily to be a participant in this study
Print Name of Participant_____________________________
Signature of Participant ______________________________
Date ___________________________
Day/month/year
55
Statement by the researcher/person taking consent I have accurately read out the information sheet to the potential participant, and to the best of my ability made sure that the participant understands that the following will be done:
1. An interview will be conducted with the participant on PBF schemes
2. The interview will be recorded
3. The views expressed in the interview will be confidential and will be used as specified
in the information sheet.
I confirm that the participant was given an opportunity to ask questions about the
study, and all the questions asked by the participant have been answered correctly and
to the best of my ability. I confirm that the individual has not been coerced into giving
consent, and the consent has been given freely and voluntarily.
A copy of this ICF has been provided to the participant.
Print Name of Researcher/person taking the consent________________________
Signature of Researcher /person taking the consent__________________________
Date ___________________________
Day/month/year
