title: Exploring the influence of context and policy on health district productivity in Cambodia.
abstract: BACKGROUND
  Cambodia has been reconstructing its economy and health sector since the end of conflict in the 1990s. There have been gains in life expectancy and increased health expenditure, but Cambodia still lags behind neighbours One factor which may contribute is the efficiency of public health services. This article aims to understand variations in efficiency and the extent to which changes in efficiency are associated with key health policies that have been introduced to strengthen access to health services over the past decade.
  
  
  METHODS
  The analysis makes use of data envelopment analysis (DEA) to measure relative efficiency and changes in productivity and regression analysis to assess the association with the implementation of health policies. Data on 28 operational districts were obtained for 2008-11, focussing on the five provinces selected to represent a range of conditions in Cambodia. DEA was used to calculate efficiency scores assuming constant and variable returns to scale and Malmquist indices to measure productivity changes over time. This analysis was combined with qualitative findings from 17 key informant interviews and 19 in-depth interviews with managers and staff in the same provinces.
  
  
  RESULTS
  The DEA results suggest great variation in the efficiency scores and trends of scores of public health services in the five provinces. Starting points were significantly different, but three of the five provinces have improved efficiency considerably over the period. Higher efficiency is associated with more densely populated areas. Areas with health equity funds in Special Operating Agency (SOA) and non-SOA areas are associated with higher efficiency. The same effect is not found in areas only operating voucher schemes. We find that the efficiency score increased by 0.12 the year any of the policies was introduced.
  
  
  CONCLUSIONS
  This is the first study published on health district productivity in Cambodia. It is one of the few studies in the region to consider the impact of health policy changes on health sector efficiency. The results suggest that the recent health financing reforms have been effective, singly and in combination. This analysis could be extended nationwide and used for targeting of new initiatives. The finding of an association between recent policy interventions and improved productivity of public health services is relevant for other countries planning similar health sector reforms.
authors.affiliation: International Health Systems, Leeds Institute of Health Sciences, Leeds, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Ensor
authors.affiliation: Cambodia Development and Research Institute, Phnom Penh, Cambodia.
authors.forename: Sovannarith
authors.initials: S
authors.lastname: So
authors.affiliation: International Health Financing and Systems, IIHD, Queen Margaret University, Edinburgh, UK.
authors.forename: Sophie
authors.initials: S
authors.lastname: Witter
keywords: Cambodia; Data envelopment analysis; Efficiency; Health districts; Health sector reform; Productivity; Regression analysis