Nossal Institute for Global Health - Theses

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    Strengthening the management and provision of public health services: an investigation of the recent healthcare reform using internal contracting in Cambodia
    Introduction: Contracting, regarded as one of innovative approaches, has been used to address these issues. As part of larger national reform strategies to address poor public services, Cambodian government has piloted internal contracting as an approach to improve the management of district health system and services. The approach means parties from the same legal entity enter into a contract that is relational and based on trust and existing relationship. In Cambodia, a third of health districts, nominated as “Special Operating Agency - SOA”, are granted a semi-autonomous status with a greater degree of flexibility for decision-making. They receive additional funding to provide staff with financial incentives, recruit additional staff and engage communities and users. Using the Cambodian reform as a case study, this thesis examines the effectiveness of this approach in improving the management and provision of district health services. The effectiveness is judged by its being appropriate to and implementable in the context and able to overcome constraints and improve the conditions of staff and organisations, and the performance of service provision. It describes the design of the internal contracting arrangement, examines the implementation, changes in staff income and motivation, and assesses changes in the provision of primary health services. Methods: I reviewed the literature and available documents related to the reform, analysed data from interviews with officials and from a cross-sectional survey of 266 primary health care staff. Routine service data on child immunisation, antenatal care at second visit, newborn delivery by trained staff and outpatient consultation from four SOA districts were used to assess changes in primary care services before and after the reform. Findings: The implementation of internal contracting enabled facilities to maintain service delivery outputs elevated through other forms of contracting before the introduction of the current reform. The additional funding, carefully managed and utilised, made it possible to pay staff incentive; it along with performance contract made it possible to improve accountability addressing their underperformances and the functioning of health facilities. The incentive, albeit low, contributed to staff income and motivation. Coupled with job monitoring, incentive dissuaded many from private practice. Several challenges remained. System, tools and resources for management of performance and incentive and for contract monitoring were inadequate. Resource provision has been improved, but transparency of funding flow and information sharing was insufficient to tackle delays and cuts. Improvement in working conditions and organisational conditions was not optimal and their deficiencies continued to constrain staff performance. Analysis of provision primary care services (outpatient consultation, child immunisation, antenatal care and newborn delivery) showed mixed results, with most of the services increasing and stabilising after the introduction of the internal contracting. Conclusions: Internal contracting, when carefully packaged and designed, is effective in enhancing and sustaining service delivery for the long term. Adequate systems and tools for implementing performance contracts and managing resources are pre-requisites for improving staff performance and service delivery. Fine-tuning of the governance structure and the arrangements to ensure integrity of resource management and improve monitoring function would likely result in increased effectiveness of the local health system and service provision.