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Evaluation report

2002 CBD: The New Deal in Cambodia: The Second Year - Confirmed Results, Confirmed Challenges

Author: Meessen, B.; Van Damme, W.; Por, I.; Van Leemput, L.; Hardeman, W.

Executive summary

The New Deal is a specific strategy adopted in Cambodia by the Ministry of Health (MoH), MSF, UNICEF and the WHO in order to find a way out for a public health system stuck in a crisis of under-utilisation and low efficiency. In a nutshell, the New Deal is a consensual approach to winning commitment from all the major actors to invest more resources in the rural health system. Real efforts are being made to understand institutional and individual constraints, but the respective obligations of those involved are clearly stated. The backbone of the New Deal is a set of contracts that frees resources from donors and users, to pay a bonus to the staff. These bonuses are performance-related. Different projects in Cambodia are using this New Deal approach, although only Sotnikum and Thmar Pouk explicitly employ the New Deal name. There are also three New Deal-like experiences in provincial hospitals (Takeo, Svay RJeng and Kratie) and two in district hospitals (Mong Russey and Stung).

Purpose/Objective:

The present document intends to draw lessons from similar experiences elsewhere in Cambodia.

Methodology:

This document describes and analyses the New Deal experiments as they have been taking place in 2001. This report is thus the continuation of the report "Sotnikum New Deal: The first year", which was written in May 2001.

Findings and Conclusions:

After more than four years in Takeo, two years in Sotnikum and Svay Rieng and one year in Thmar Pouk, there is enough evidence today to confirm the relevance of the approach. In all of these places, activities have significantly increased. Better rewarded for their efforts, health staff are more committed to improving the services they deliver to the population. In Sotnikum and Thmar Pouk, the New Deal prompted the introduction of new institutional arrangements: a Steering Committee to pilot each experiment, management committees for the facilities concerned and a Health Equity Fund to enhance access to the hospital for the poor. Health Equity Funds have yielded quite impressive results. This document is divided into five chapters.

The New Deal in Sotnikum documents the strategies adopted in 2001 to boost the positive results already obtained in 2000. It reports a reorientation of the MSF approach: keeping a greater distance in regard to assessment, control and management, and developing a greater proximity in regard to clinical care. The outsourcing of clinical training seems particularly fruitful. The second year has confirmed that the New Deal is good for health, even if accountability and transparency remain sensitive points for the mid-level managers.

The New Deal in Thmar Pouk - After reviewing some of the specific characteristics of the district, such as a poorer population, overstaffing but more motivated staff, it summarises the implementation of this approach. This second experiment has obviously benefited from experience gained elsewhere. The New Deal has had a very impressive impact at the hospital level, despite the absence of surgical services there. The experience of 2001 is less conclusive in the health centres.

The Health Equity Funds develop the rationale behind the introduction of these funds and their sub-contracting to local non-governmental organisations (NGO). The superiority of a purchaser-provider split over a simple waiver is confirmed by the results in both hospitals. Today, the poor account for more than 20% of patients. Nevertheless, some further improvements are still desirable.

Recommendations:

Three important lessons for the national health service in Cambodia emerge:

1. The New Deal experiments show that major improvements in terms of coverage, utilisation and the responsiveness of health services will not be possible without a fundamental reshaping of incentives and accountability mechanisms in the public health service. Such reforms are particularly necessary for district and hospital managers, who also still need significant support in terms of capacity building.
2. The second major lesson concerns the place of the poor in the public health facilities in Cambodia. Our belief is that Health Equity Funds are indeed a step in the right direction, but a more general policy in favour of the poor still has to be elaborated.
3. The last lesson concerns the place of pilot projects in the health sector reform. The New Deal shows that experimentation pays. We plead for a continuation of the very open-minded exploration prevailing in Cambodia today.

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