Factors Driving Changes in the Design, Implementation, and Scaling-Up of the Contracting of Health Services in Rural Cambodia, 1997–2015

Abstract

Contracting approaches have been used in various forms to improve the delivery of public health services in low-and middle-income countries. Cambodia has embarked on a publicsector reform that includes a model of internal contracting of health care through the Ministry of Health, supported by incentive payments for staff and facilities. Contracting for health care in Cambodia has evolved through three phases during 1997-2015, each with particular design features, arrangements, and structures; different levels of involvement of local and international stakeholders; and modifications based on evidence from operational research. Based on a review of published and gray literature and interviews with 29 local and international key informants, we identify national ownership, financial sustainability, and the need to strengthen service delivery institutions as the major forces that have shaped contracting in Cambodia, culminating in the move to internal contracting arrangements for public health care delivery. There remains a need to strengthen contracting governance arrangements.

From Scheme to System (Part 2): Findings from Ten Countries on the Policy Evolution of Results-Based Financing in Health Systems

“…One good example of this is Cambodia's choice of the hybrid contracting model over contracting out approaches, in the interest of financial sustainability and the long-term development of national technical capacity in contracting. 11 The findings from this program of research highlight the need for careful analysis of the political situation. Stakeholder analysis can help to gauge the most appropriate framing for RBF approaches to fit in the national context before deciding to introduce an RBF pilot, and to identify policy entrepreneurs among national level stakeholders, particularly within the MOH, to take the process forward.…”

“…In Armenia, this was apparent in the strong leadership and expertise displayed by the MOH and the State Health Agency. Cambodia likewise built up RBF expertise, increasing domestic responsibility for the management of health institutions using contracting arrangements, as described by Khim et al, 11 and developing greater national control.…”

From Scheme to System (Part 1): Notes on Conceptual and Methodological Innovations in the Multicountry Research Program on Scaling Up Results-Based Financing in Health Systems

“…The Cambodian case study provides a good example of content being transformed through a long scale-up and integration process. 34…”

Assessment of dual practice among physicians in Cambodia

“…Inadequate pay, scarcity of public sector jobs, lack of regulation, and new private sector opportunities all contributed to healthcare professionals seeking ways to make ends meet, and to gain clinical experience while at the same time continuing to work in the public sector [3,10,23]. The Ministry of Health's efforts to address poor public health services, poor job performance of health workers, and low retention of rural staff culminated in piloting a number of health financing schemes embedded in health reforms through the subsequent years [24]. There were trials of contracting-out and contracting-in between 1997 and 2002 [25], trial of hybrid contracting between 2004 and 2008 [14,26], and trial and scale-up of internal contracting from 2009 to the present [27,28].…”