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Monitoring and Evaluation (MnE)

The overall goals of the BHS project dovetail with the Mission of the Ministry of Health in the Cambodian Health Strategic Plan 2008-2015 (HSP2) “to provide stewardship for the entire health sector and to ensure supportive environment for increased demand and equitable access to quality health services in order that all the peoples of Cambodia are able to achieve the highest level of health and well-being”.

BHS is what is called a “health systems strengthening” (HSS) project.  As such its goals are to strengthen the overall health system in various ways agreed upon with USAID and the MoH.  The long-term effect of this is ideally three-fold: 1) improvements in the quality of health care delivered by public health facilities, leading to; 2) increased utilization, while maintaining; 3) equity in access to public health services.

The logic of this over time is pretty solid, and the overall increase in utilization in public health facilities in Cambodia over the past years suggest that it is working.  However, the specific activities of the project do not always lead to the same results in the short-term.  One example would be the introduction of triage as part of the routine registration process at Cambodia hospitals.  Triaging patients is unquestionably appropriate behavior in a well-run hospital, partly because it increases efficiency and partly because it should lead to better care for the patients who are admitted because the hospital does not have to deal with patients who shouldn’t be there.  But the short-term result, clear in the 3 hospitals where BHS has introduced triage, is to lower the hospital’s utilization rate. The project’s intervention leads directly to potential patients being sent back to the health center near their village.  Thus increased utilization of the hospital, a long-term goal of the MoH, is hurt in the short-term by a quality of care activity that aims to increase the appropriateness of hospital admissions.  This is but one example of many.  Therefore the success of the project cannot be measured through increased utilization alone.

M&E of an HSS project faces two other obstacles.  Because HSS projects work directly with the MoH to improve their own monitoring and evaluation activities, there is considerable pressure to avoid M&E frameworks that are duplicative of the MoH’s systems.  This differentiates them from projects whose main goal is to improve the care and services offered to a defined target population.  These projects usually set up a stand-alone M&E system to measure their results and report it back to their funder.  The best-known examples of this are Global Fund and PEPFAR project M&E systems that, while cumbersome, tend to provide reasonably good evidence of their project’s successes and failures.

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