Nossal Institute for Global Health, The University of Melbourne, 4th Floor, Alan Gilbert Building, 161 Barry St., Carlton, 3010 VIC, Australia.
Soc Sci Med. 2013 Nov;96:241-9. doi: 10.1016/j.socscimed.2013.02.029. Epub 2013 Feb 28.
Following a decade of piloting different models of contracting, in mid-2009 the Cambodian Ministry of Health began to test a form of 'internal contracting' for health care delivery in selected health districts (including hospitals and health centers) contracted by the provincial health department as Special Operating Agencies (SOAs) and provided with greater management autonomy. This study assesses the internal contracting approach as a means for improving the management of district health services and strengthening service delivery. While the study may contribute to the emerging field now known as performance-based financing, the lessons deal more broadly with the impact of management reform and increased autonomy in contrast to traditional public sector line-management and budgeting. Carried out during 2011, the study was based on: (i) a review of the literature and of operational documents; (ii) primary data from semi-structured key informant interviews with 20 health officials in two provinces involved in four SOA pilot districts; and (iii) routine data from the 2011 SOA performance monitoring report. Five prerequisites were identified for effective contract management and improved service delivery: a clear understanding of roles and responsibilities by the contracting parties; implementation of clear rules and procedures; effective management of performance; effective monitoring of the contract; and adequate and timely provision of resources. Both the level and allocation of incentives and management bottlenecks at various levels continue to impede implementation. We conclude that, in contracted arrangements like these, the clear separation of contracting functions (purchasing, commissioning, monitoring and regulating), management autonomy where responsibilities are genuinely devolved and accepted, and the provision of resources adequate to meet contract demands are necessary conditions for success.
在经过十年的试点不同的承包模式之后，2009 年年中，柬埔寨卫生部开始在选定的卫生区（包括医院和卫生中心）测试一种“内部承包”形式，这些卫生区由省卫生部门作为特殊运营机构（SOA）承包，并提供更大的管理自主权。本研究评估了内部承包方法作为改善地区卫生服务管理和加强服务提供的手段。虽然这项研究可能有助于新兴的绩效融资领域，但这些经验教训更广泛地涉及管理改革和自主权增加对传统公共部门线管理和预算编制的影响。该研究于 2011 年进行，基于：（i）对文献和业务文件的审查；（ii）与两个参与四个 SOA 试点地区的省份的 20 名卫生官员进行的半结构化关键知情人访谈的主要数据；（iii）来自 2011 年 SOA 绩效监测报告的常规数据。确定了有效合同管理和改善服务提供的五个前提条件：承包方对角色和责任有明确的理解；实施明确的规则和程序；有效管理绩效；有效监测合同；以及充足和及时的资源供应。激励措施的水平和分配以及各级的管理瓶颈仍然阻碍着实施。我们的结论是，在这些承包安排中，明确分离承包职能（采购、委托、监测和监管）、真正下放和接受责任的管理自主权，以及提供足够的资源以满足合同需求，是成功的必要条件。
