3. Strengthening Health Systems

An NGO contracted to manage a district in Cambodia introduced contracts between the NGO's managers and facility staff members involving a monthly incentive payment, a punctuality incentive, and a performance bonus. The contracts were initially introduced in three facilities, which subsequently experienced significantly higher use levels than those that did not have the incentive payments. Because individual contracts were too demanding to manage and excluded health center and hospital directors from staff management, the system was changed to one of subcontracting with facility managers. Output improved even more. Subcontracts were made competitive: if a health center's management or output was poor, other health workers or managers were asked to apply to take over the contract. During 2001, four contracts were replaced. Monitoring activities, especially spot checks at the household level to verify that recorded visits had taken place, were considered vital to ensuring quality and transparency. Soeters and Griffiths (2003) argue that outsiders—in this case the NGO—are better able to introduce new management procedures than a ministry of health, which tends to be risk averse.

Source: Soeters and Griffiths 2003.