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Multicenter Study
. 2018 May 22;18(1):375.
doi: 10.1186/s12913-018-3165-z.

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

Sreytouch Vong  1 , Joanna Raven  2 , David Newlands  3
Affiliations
Multicenter Study

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

Sreytouch Vong et al. BMC Health Serv Res. .

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.

Keywords: Cambodia; Contracting; Implementation challenges; Incentive; Special operating agency.

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Conflict of interest statement

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Liverpool School of Tropical Medicine (no.12.20) and the National Ethics Committee for Health Research in Cambodia. Informed consent was obtained from each participant prior to starting the interviews.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Evolution of contracting health services in Cambodia 1SOA status does exist. However, the Service Delivery Grant for SOA is re-designed and scale up across Cambodia, including the non-SOA districts
Fig. 2
Fig. 2
Framework for assessing impact of SOA in Cambodia (adapted from Mills (1998) & Caltadol and Kielmann (2016))
Fig. 3
Fig. 3
Average service coverage in SOA and non-SOA districts (2009–2012)
See this image and copyright information in PMC

References

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    1. Mills A, Broomberg J. HEFP working paper 01/98. London: LSHTM; 1998. Experience of contracting health services: an overview literature.

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