Background
Contracting in general
External contracting: Contracting out | An external service provider is engaged through a contract to provide services with maximum control over the resources and how services should be delivered |
External contracting: Contracting in | An external service provider is brought in to manage and operate service provision institutions with some control over resources and services arrangements |
Internal contracting | Internal contracting is a form of relational contracting whereby responsibility is delegated to peripheral units under the same legal entity e.g. governments contract with public providers i.e. with autonomous institutions which remain under public ownership |
Contracting in fragile and post- conflict countries
Contracting in Cambodia
What is a Special Operating Agency? | Special Operating Agency (SOA) is a supply-side oriented mechanism developed from contracting and implemented by the Cambodian government through the use of government staff as contractors to improve the quality of health care services for people, mainly the poor and vulnerable. |
How does it operate? | In each Operational District (OD) there are government guidelines for the delivery of the Minimum Package of Activities and Complementary Package of Activities. The SOA is given a degree of autonomy in making decisions about the best use of their human, physical and financial resources to deliver the highest possible quality of services, in the most effective way and to enhance performance and accountability through streamlining administration to be more transparent and responsive to people’s needs. The SOAs are able to hire additional workforce, conduct performance monitoring and evaluation, and provide performance incentives. With the conditions set in the contract and penalties involved in underperformance at SOAs, contract monitoring at these ODs takes place more rigorously and with clear criteria for determining level of performance, a feature not usually seen in standard ODs. |
Sources of budget for SOA | A standard OD has two major income streams: the government budget and user fees. SOAs have these plus a package of budget from the Health Sector Support Program in the form of a Service Delivery Grant (SDG). This additional budget (approximately 40% of the total budget managed by ODs) is mainly used for performance monitoring and incentives. The Ministry of Health (MOH) signs a performance agreement with the Provincial Health Department (PHD), and the PHD in turn signs a services delivery management contract with the SOA. |
Role of MoH and PHD | The MOH is responsible for timely allocation of funds, provision of policies and guidelines, and enforcement of health legislation, professional ethics and codes of conduct to PHD. The PHD takes responsibilities for providing SOA with financial resources and assistance in human resources and performance management. Under the service delivery management contract, the SOA is responsible for ensuring the management of resources at all facilities. The PHD conducts monitoring of the SOA, usually on joint monitoring visits with the HSSP monitoring team. The HSSP monitoring team includes an external agency. |
Extent of SOA operation | Thirty SOAs were established by the end of 2010 and six more SOAs were introduced by 2013. |
Methods
Study design and site
District (province) | SOA | Previous contracting | Level of service covered | Geographical area | Population/number of health facilities |
---|---|---|---|---|---|
Memut (Kampong Cham) | Yes (2009) | • 1999–2002/3 contracting out managed by SCA • 2004–2008 contracting managed by SCA | Primary and secondary care | Lower east plateau bordering Vietnam | 135,500 1 referral hospital 10 health centres |
Peariang (Prey Veng) | Yes (2009) | • 1999–2002 contracting-in managed by Healthnet International • 2004–2008 contracting managed by Healthnet International | Primary and secondary care | Central south plains | 193,500 1 referral hospital 15 health centres |
Samrong (Oddor Meanchey) | Yes (2010) | • 2005/2006–2009: performance contract supported by BTC • 2006–2008: PMG | Primary care only | Upper North Mountainous | 219,000 1 referral hospital 23 health centres |
Bati (Takeo) | Yes (2010) | None | Primary and secondary care | Plain | 202,026 1 referral hospital 13 health centres |
Qualitative methods
Key informant interviews
In depth interview with managers and health workers
Data analysis
Secondary quantitative data
Results
Rationale for introduction of SOA
National and local ownership: Regaining ownership in managing health system
“Ownership!...there was no ownership at that time because they have managers to manage over us and we were just their staff...We are staff completely employed by NGO…It is normal that civil servant now have more freedom than working with NGO” (Facility chief, Memut).
Local capacity in managing contract
“At that time, we still had limited capacities, we are not good at budget management. Before that we only used the government’s budget which was only small amount...when contractor came in, they taught us...” (SOA manager, Memut).
“…The problem they found was that working with NGOs didn’t really help in capacity building for government officials…” (KII2, Male, MoH).
Cost and sustainability
“If we continue to hire NGO for contracting, MoH does not have money to pay for that, at the same time staff at lower level …were not happy because NGO took much money, so there is little money left for development” (KII7, Male, Donor).
Private practice
“Regulation was too strict… they were not allowed to work outside [private practice] but they were provided with incentive. But as usual, incentive was not enough for a decent living. They need it for life, they need it for their living, then they sold drugs and opened their clinic. This was against their contract, and NGO did not agree to allow staff to open their clinics, they fined staff 1 or 2 time then send name of staff to PHD, so some staff just asked to suspend by themselves” (SOA manager, Peariang).
Key features of the SOA and their implementation
Assessment and selection of SOA
“We already select the better facilities to run SOA, so its nature is already good. In general, if we have 10 students, there must be 2 or 3 outstanding students. Thus, these outstanding ones already have their potential. So does SOA” (KII11, Male, Donor)
Setting and reaching targets
“Those migrants were not in the target population, so the target increased. However, they came temporarily and went back, so the number decreased, and even more people moved out, for instance, there were 100 people moved in, but 200 moved out. This is what we are worried about” (Manager, Memut).
“… so far our results have been high and they do not allow us to set them down...they never think that once we reach the peak, how can we reach more?” (Manager, Memut).
“My place is facing issue of outpatients, because other facilities rarely let their clients pass by to use services here, they have achieved their target already too. While my facility is in the middle of other facilities, so the population around this area is the same, but many health centres absorb the clients.” (Manager, Samrong).
Monitoring of SOA
“The SDMG monitoring group from ministry is supposed to conduct monitoring every quarter, but in fact, they only did twice per year. The SDMG consists of 4 members, but sometimes only 1 of them went for monitoring. They have more work, and sometimes they have job outside [private practice], as the per-diem for monitoring is $20/day, if they stay in Phnom Penh and do one operation, they earn $300.” (KII1, Male, MoH).
“…In general, PHD doesn’t receive any incentive… Sometimes the PHDs complain… We can see that their work load has increased and they have to work harder, but have no incentive” (KII12, Male, Donor).
“In the past, we didn’t have a monitoring system, so the data provided might not be true or might not be clear. After the implementation of SOA, we established proper monitoring system…when our monitoring team went to inspect ANC, we…took the name list and went to inspect. In the morning we were in the health centre and in the afternoon we went to inspect in the village. So they didn’t dare to make false report” (Manager, Bati)
“It is very important. If there is no such evaluation and monitoring, the work cannot be done smoothly and we cannot work effectively. Sometimes we have mistakes, when they come, they will give us advice. Thus, we improve ourselves for better performance…For instance, now we have mistakes, so what should we do to be better for next quarter and further… it is really important” (Manager, Memut).
Incentives from SOA
“The benefits for staff in health centre is not much, but it is just... to supplement their daily livelihood, it is quite a big amount for them” (Health worker, Peariang).
“I’d be happy if SOA continues. Because when having SOA, they provide us some bonus and additional incentive for staff, that’s also good that they have training for us as well” (Health worker, Memut).
Implications of SOA
Changes in health workers’ behaviour
“…SOA is different from non-SOA. For non-SOA, no matter where it is, if you visit there at 3 or 4pm, you will see no one there and they only leave the phone number. Sometimes when people phone staff, they would answer that they are still on the way. So what is the quality? In addition, they also have changed their habits and attitudes and the way they speak to the patients. In the past, they used to get up at 7 or 8 am, but now they change – they have to come to work on time, and be on duty… In the past, they used to come late and treat the patients badly… Now, they have slogan that, ‘Services are to serve people.’” (KII4, Male, MoH).
“We have signed the contract with them, so we need to work even though we have a lot of work at home. We need to wait until we finish work at the health centre, then we can do private work at home.” (Facility chief, Peariang).
“There were no permanent 24 hours service here before, like there were services but there was no staff.... in the past, there was only name, no staff...” (Health worker, Bati).
“If that unit is too strict and does not allow staff to work in private sectors, they would all quit. Sometimes we have to do it differently from the contract, which states that staff have to work 8 hours a day. We even allow the specialists to work for 4 hours a day in order to avoid their resignation. For example, if we do not allow a surgeon to operate in any other clinics besides the state hospitals, they will all quit work.” (KII3, Male, MoH).
Quality of care
“Before, in consultation we just asked a few things, and then just wrote the prescription. But when having SOA, we have to measure blood pressure, measure body temperature. Later, we note on the paper. For example, if a patient is having fever, we just ask them to do blood testing before we can provide them prescription…before SOA, we just often did short cut ways [for the treatment]... there was no monitoring from upper level, there were no incentives, [we] were just lazy too, that’s why…” (Health worker, Samrong).
“[diagnosis] has changed, in the past they all tried to squeeze in…like ten patients tried to get examination at one time. Today no! One person at a time, with number order” (Health worker, Bati).
“Staff change the way they talk to patients because before we had low sense of responsibility..., in short it was because of little money [incentive]. Our work is better than before. Having the incentive from SOA, makes us work better.” (Health worker, Samrong).
Utilization of services
“They just know that our staff work here regularly so that they come to use services here...because when they come they always meet our staff so they just like to come more. But before when they came, they didn’t meet our staff so they didn’t like to come any more” (Health worker, Samrong).
Key informants | Health managers and providers |
---|---|
Public have more trust in the SOA facilities | Improved public trust in health facilities – provide better quality of care (improved staff attitude and better treatment) |
Facilities are now open for 24 h per day | Staff being available 24 h per day |
Staff are more punctual and stay at facilities because of incentives attached to punctuality and availability of services | Outreach programmes have increased community awareness of the availability of and need for services |
Staff have received more training since being in SOA and this has improved the services that they deliver | Clear contracts with targets for provision of services, incentives and monitoring in the SOA scheme |
Low service fees because of HEF and CBHI |