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

Vong, Sreytouch, Raven, Joanna ORCID: https://orcid.org/0000-0002-4112-6959 and Newlands, David (2018) 'Internal contracting of health services in Cambodia: drivers for change and lessons learned after a decade of external contracting.'. BMC Health Services Research, Vol 18, Issue 1, p. 375.

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Abstract

BACKGROUND
Since the late 1990s, contracting has been employed in Cambodia in an attempt to accelerate rural health system recovery and improve health service delivery. Special Operating Agencies (SOA), a form of 'internal contracting', was introduced into selected districts by the Cambodia Ministry of Health in 2009. This study investigates how the SOA model was implemented and identifies effects on service delivery, challenges in operation and lessons learned.

METHODS
The study was carried out in four districts, using mixed methods. Key informant interviews were conducted with representatives of donors and the Ministry of Health. In-depth interviews were carried out with managers of SOA and health facilities and health workers from referral hospitals and health centres. Data from the Annual Health Statistic Report 2009-2012 on utilisation of antenatal care, delivery and immunisation were analysed.

RESULTS
There are several challenges with implementation: limited capacity and funding for monitoring the SOA, questionable reliability of the monitoring data, and some facilities face challenges in achieving the targets set in their contracts. There are some positive effects on staff behaviour which include improved punctuality, being on call for 24 h service, and perceived better quality of care, promoted through adherence to work regulations stipulated in the contracts and provision of incentives. However, flexibility in enforcing these regulations in SOA has led to more dual practice, compared to previous contracting schemes. There are reported increases in utilization of services by the general population and the poor although the quantitative findings question the extent to which these increases are attributable to the contracting model.

CONCLUSION
Capacity in planning and monitoring contracts at different levels in the health system is required. Service delivery will be undermined if effective performance management is not established nor continuously applied. Improvements in the implementation of SOA include: better monitoring by the central and provincial levels; developing incentive schemes that tackle the issues of dual practice; and securing trustworthy baseline data for performance indicators.

Item Type:	Article
Subjects:	WA Public Health > WA 30 Socioeconomic factors in public health (General) WA Public Health > Health Problems of Special Population Groups > WA 395 Health in developing countries WA Public Health > Health Administration and Organization > WA 540 National and state health administration WA Public Health > Health Administration and Organization > WA 546 Local Health Administration. Community Health Services
Faculty: Department:	Clinical Sciences & International Health > International Public Health Department
Digital Object Identifer (DOI):	https://doi.org/10.1186/s12913-018-3165-z
Depositing User:	Stacy Murtagh
Date Deposited:	25 May 2018 10:36
Last Modified:	13 Sep 2019 17:44
URI:	https://archive.lstmed.ac.uk/id/eprint/8679

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