Factors Contributing to he Discrepancy between Ex-Ante Assessment and Ex-Post Verification of Quality of Health Services at Health Centers in Cambodia

Sophoeun Tek — 2024-06-15

Introduction

To improve the quality of health services, the Ministry of Health (MoH) introduced the Performance-Based Grant (PBG) mechanism in 2007, a part of H-EQIP, in which payments were made based on health facility assessment scores. A score discrepancy (SD) between the ex-ante assessment and ex post verification was always found. No official study has been conducted to explore the possible factors explaining this high SD. Therefore, this study aimed to explore the possible factors contributing to this SD at health centers (HCs) in Cambodia.

Methods

This qualitative study used purposive and convenient sampling methods. In-depth interviews were conducted using three different semi-structured question guides from September to October 2023. We selected 25 participants for this interview. They consisted of operational district (OD) assessors, ex post assessors, HC staff, and key informants working at the Quality Assurance Office (QAO), MoH and World Bank. We managed and analyzed the recorded data and notes using Microsoft Excel and Microsoft Word with seven predefined themes (independency of assessors, readiness of HC, assessment methods, composition and assessor knowledge, perceived quality assessment, comment for improvement of assessment, and other factors).

Results

OD assessors had a greater level of conflict of interest than ex-post assessors because they assessed their own subordinates. They compromised both technical and administrative errors more than ex-post assessors did. Ex-ante assessment informed the assessment date in advance, but ex-post verification did not. Therefore, the HCs had preparations for assessment and verification. The OD assessors and PCA assessors had different judgments on the completion of the documents, approaches in staff selection for clinical vignette and competency tests, and independently selected the documents. The ex-post assessors had better knowledge and provided more accurate assessment scores. The HC staff performed the test during the ex-ante assessment better than during the ex-post verification because they mostly felt nervous when they met with the ex-post team. The increase in SD over time was due to many reasons: increased numbers of clinical vignettes, changes in clinical vignettes, selection approaches for clinical vignette tests, and staff busy schedules during the COVID-19 pandemic.

Conclusion

There were two main factors that led to the SD score: the subjectivity of the assessors and the readiness of the health center. Other factors also contributed to this discrepancy, such as time lag and the knowledge of assessors on assessment tools. Therefore, the subjectivity of assessors should be improved by shifting from within OD assessments to across OD assessments and enhancing the readiness of HCs by strengthening institutional and staff capacity to maintain good performance regularly. Additionally, the assessment time should not be informed beforehand. Finally, the cut-off point set for the SD should be increased to greater than -10.5%.

Cambodia Journal of Public Health (CJPH) of the School of Public Health at NIPH

Factors Contributing to he Discrepancy between Ex-Ante Assessment and Ex-Post Verification of Quality of Health Services at Health Centers in Cambodia