PRACTICAL IMPLEMENTATION OF
SOCIAL HEALTH PROTECTION
IN CAMBODIA
Tapley Jordanwood, MSc
USAID Better Health Services Project
September 14, 2012
WHAT’S NEXT....
• Public Health System
• Social Health Protection Schemes
• Targeting the Poor
• Health Equity Funds
• Community Based Health Insurance
• Vouchers and Conditional Cash Transfers
• Emerging Issues
PUBLIC HEALTH SYSTEM
•
•
•
•
Facilities
8 National Hospitals
81 Referral Hospitals
1,021 Health Centers
89 Health Posts
Staff
• 1,730 Central MOH
• 2,077 National Hospitals
• 14,789 Provincial/District
–
–
–
–
2,114 Doctors/Med Asst.
7773 Nurses/Pharm/Assts
3787 Midwives
1115 Medical Support
PUBLIC HEALTH SYSTEM UTILIZATION
Demographic Health Survey - 2010
60%
50%
40%
30%
20%
10%
0%
No
Non-Medical
Treatment
Public
Services
Private
Services
Outside of
Country
INCREASING USE OF HOSPITALS
Total Hospital Discharges
600,000
500,000
400,000
300,000
200,000
100,000
0
2007
2008
2009
2010
2011
2012
INCREASING USE OF HEALTH CENTERS
Total Health Center Consultations
9,000,000
8,500,000
8,000,000
7,500,000
7,000,000
6,500,000
6,000,000
5,500,000
5,000,000
2007
2008
2009
2010
2011
2012
PUBLIC HEALTH CARE FINANCING
• User Fees Introduced in 1996
Hospital Cash Income
70%
• Provide a Direct Incentive to Health Providers
• Improved Quality but Created Barriers which
can lead to Impoverishment
60%
50%
MoEF
1%
40%
30%
Operating
Costs
39%
20%
10%
0%
MOH Budget
User Fees
Staff
Incentives
60%
WHAT’S NEXT....
• Public Health System
• Social Health Protection Schemes
• Targeting the Poor
• Health Equity Funds
• Community Based Health Insurance
• Vouchers and Conditional Cash Transfers
• Emerging Issues
SOCIAL HEALTH PROTECTION EFFORTS
• Ministry of Health
–
–
–
–
Health Equity Funds
Community Based Health Insurance
Direct Government Subsidies (Prakas #809)
Targeted Schemes
• Conditional Cash Transfers
• Vouchers
• Ministry of Labor and Vocational Training
– National Social Security Fund - Formal Sector Workers
• Ministry of Social Affairs, Veterans, and Youth
– National Social Security Fund - Civil Servants
RELATIVE SIZE OF CURRENT SCHEMES
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
HEFs
NSSF - MOL
CBHI
WHAT’S NEXT....
• Public Health System
• Social Health Protection Schemes
• Targeting the Poor
• Health Equity Funds
• Community Based Health Insurance
• Vouchers and Conditional Cash Transfers
• Emerging Issues
NATIONAL POVERTY IDENTIFICATION
• Ministry of Planning IDPoor Program Started in 2007
• Full National Coverage for Rural Areas
• Urban Poverty Identification Piloted in 2012
• Identifies ~30% Rural HHs as Poor
• Approximately 3.6 Million individuals
identified
• Any HH member holding an “Equity
Card” is eligible as a HEF Beneficiary
EQUITY CARDS – MINISTRY OF PLANNING
POST-IDENTIFICAITON OF THE POOR
• Interview Process in Referral Hospitals by HEFs
• Functional in all Health Equity Fund sites (except Phnom
Penh)
• 15 Minute Interview Process
• Applied in Cases of Suspected Poor Patients
• Entitles poor HH to full HEF benefits
• Identified poor HHs provided with a “Priority Access Card”
• Valid for 1 year
PRIORITY ACCESS CARDS – MINISTRY OF HEATLH
OTHER TARGETING
• Community Based Health Insurance Targets the Non-Poor
• National Social Security Fund
– 3,000 + Private Businesses (>8 Employees)
• Specific Vulnerable Segments of the Population
– Women, Children, etc.
WHAT’S NEXT....
• Public Health System
• Social Health Protection Schemes
• Targeting the Poor
• Health Equity Funds
• Community Based Health Insurance
• Vouchers and Conditional Cash Transfers
• Emerging Issues
HEATLH EQUITY FUNDS
• Pilot Projects Began in 2000
• Response to User Fee Barriers for the Poor
• HEFs Are a MOH Priority for National Coverage
• 3rd Party Purchasers of Health Services for the Poor
– HEFs are the “Purchaser”, MOH is the “Provider”
• Benefits Include:
– Payment of User Fees for Health Services
– Transport Reimbursements
– Caretaker Food Allowances
HEATLH EQUITY FUNDS (2)
• Local NGOs and CBOs Operate HEFs
• Purchase of Health Services is Contractual
• All Cover Hospital Services, Some Health Center
• Pre-Identification of the Poor Has a Strong Effect
– Higher Utilization by the Poor
• Other Benefits Include:
– Incentives for Quality Improvement of Health Services
– Reduction of Informal Payments in Public Health Facilities
– Increases in Patient Satisfaction
TYPES OF HEALTH EQUITY FUND SCHEMES
Operational Districts
Covered by HEFs
• Direct Govt. Subsidies (Prakas 809)
– MOH (11 ODs, 6 NHs)
• Community Managed HEFs
– URC and UNICEF (4 ODs)
• “Standard” HEFs
– URC and HSSP 2 (38 ODs)
• “Mixed” Models
– GTZ CBHI/HEF Model (3 ODs)
– BFH Pagoda-based HC scheme (3 ODs)
40
35
30
25
20
15
10
+6
5
Note: There are 77 MOH “Operational Districts”
0
Govt.
Subsidy
Community "Standard"
Managed
HEFs
Mixed
Model
SOURCES OF FUNDING in 2013
• Royal Government of Cambodia
Support through HSSP2 Counterpart
Funding = 40%
• HSSP2 Donor Funding = 60%
Donors Include:
AusAID
World Bank
AFD
DFID
UNICEF
UNFPA
60
55
50
45
40
35
30
25
20
15
10
5
+6
0
Govt.
Subsidy
Community "Standard"
Managed
HEFs
Mixed
Model
HEF Facilitation of RH Access
HEFO Office
RH
Admission
• Identity confirmed: HEF Database
• On admission: 50% of transport
•
•
•
•
Discharge
On discharge: 50% of transport
Case details entered: HEF Database
Documentation of benefits kept on file
Beneficiary provided with a medical
certificate of treatment
• IPD and OPD services
paid by the HEF
• If IPD, caretaker food
allowance provided
every day (5,000r/day)
HEALTH EQUITY FUND HOSPITAL COVERAGE
HEF Facilitation of HC Access
HC
• MOH HC staff confirm identity using the “HEF book”
• Round trip transportation for deliveries paid by HC
• All HEF utilization data recorded into standard MOH
registers
• End of month: HC submits detailed invoice of services
provided to HEF beneficiaries
HEALTH EQUITY FUND HEALTH CENTER COVERAGE
Benefit Package of HEF
Item
National & CPA 1-3
Referral Hospitals
Former District
Hospitals
Health
Centers
IPD
OPD
IPD
OPD
OPD
Service Fees





Transport
Reimbursement


Delivery
Only
No
Delivery
Only
Caretaker Food
Support

No

No
No
Funeral Support


No
No
No
IPD (In-patient discharge), OPD (Out-patient discharge)
WHAT’S NEXT....
• Public Health System
• Social Health Protection Schemes
• Targeting the Poor
• Health Equity Funds
• Community Based Health Insurance
• Vouchers and Conditional Cash Transfers
• Emerging Issues
COMMUNITY BASED HEALTH INSURANCE
• Pilots Started in 1999
• CBHI is an MOH Strategy for Coverage of the Non-Poor in
the Informal Sector
• 3rd Party Purchaser of Services for Paying Members
– CBHIs are the “Purchaser”, MOH is the “Provider”
• CBHI Schemes Operated by NGOs and CBOs
• Currently 12 Schemes Operational
• Approximately 143,000 Non-Poor Beneficiaries
COMMUNITY BASED HEALTH INSURANCE COVERAGE
COMMUNITY BASED HEALTH INSURANCE
100%
90%
Admin
80%
Marketing
70%
60%
Subsidies
50%
40%
Benefits
30%
20%
10%
Premiums
0%
Income
Expense
WHAT’S NEXT....
• Public Health System
• Social Health Protection Schemes
• Targeting the Poor
• Health Equity Funds
• Community Based Health Insurance
• Vouchers and Conditional Cash Transfers
• Emerging Issues
VOUCHERS
• Vouchers: Targeting for Specific Services
• Started in 1997
• Used by 3rd Party Purchasers of Health Services
– With HEFs, CBHI Schemes, or Stand Alone
• Primarily for Reproductive Health in Cambodia
– UNFPA, BTC, RHAC, KFW-EPOS
VOUCHERS (2)
CONDITIONAL CASH TRANSFERS
• Encourage Positive Health
Seeking Behavior
• Support MOH “Fixed Facility”
Strategy
• Cash is Given Directly to a
Beneficiary Based on
Conditions
• Encourage Membership in
CBHI Scheme
• Started in 2011 by URC in
Siem Reap and Pursat
Schedule, Payment Amounts, Conditions & Verification of CCTs
#1
20,000
KHR
#2
20,000
KHR
#3
20,000
KHR
#4
20,000
KHR
After 4th ANC
•At Birth
At 6 Weeks
At 6 Months
• 4 ANC Visits
• Delivery
at a health
facility
• 3 PNC
Visits for
mother and
for newborn
• 4 Growth
Monitoring &
Promotion (GMP)
visits by 6 months
 First ANC
must be
before 20th
week of
gestation
Confirm #1 from
MOH Mother’s
pink book:
• 4 ANC visits
entered in MOH
Mother’s pink
book, and
 gestational age
recorded at first
ANC is <20
weeks
•Birth is
registered
with
commune
#5
20,000
KHR
At 9-12 Months
• Fully
Immunized
 Feeding
Enriched Bobor
•At least 2
must take
place after
discharge
from facility
delivery
Confirm #2 from
CBHC Book:
Confirm #3 from
CBCH Book:
• Place of birth
on page 47 (Birth
Registration) is
Hospital or HC
• 3 visits entered
on pages 48-49
(Postpartum
Mother), and
•Box for
commune
council on page
47 is signed by
Commune
Council
 3 visits entered
on pages 50-51
(Newborn
record)
At least 2 of 3
visits took place
after discharge
from a facility
birth
#6
20,000
KHR
At 12 Months
• 4 Growth
Monitoring &
Promotion (GMP)
visits from
months 7-12
#7
20,000
KHR
#8
20,000
KHR
At 18 Months
At 24 Months
• 4 Growth
Monitoring &
Promotion (GMP)
visits from
months 13-18
• 4 Growth
Monitoring &
Promotion (GMP)
visits from
months 19-24
 Still
breastfeeding
at 18 months
 Still
breastfeeding
at 2 years
Confirm #4 from
Yellow Card &
CBHC Book:
Confirm #5 from
Yellow Card &
CBHC Book:
Confirm #6 from
Yellow Card &
CBHC Book:
Confirm #7 from
Yellow Card &
CBHC Book:
Confirm #8 from
Yellow Card & CBHC
Book:
• At least 4
weights plotted
on Yellow Card
between 0-6
months
•All
immunizations
completed and
recorded on
Yellow Card
•At least 4
weights plotted
on Yellow Card
between 7-12
months
•At least 4 weights
plotted on Yellow
Card between 1318 months
•At least 4 weights
plotted on Yellow
Card between 19-24
months
•Actual Feeding
Practice and
Advice for same
visits recorded
on page 60 of
CBHC Book
 ‘Borbor
Kroeung’
recorded as
Actual Feeding
Practice at 9
month GMP visit
on page 60 in
CBHC Book
•Actual Feeding
Practice and
Advice for same
visits recorded
on page 60-61 of
CBHC Book
Actual Feeding
Practice and Advice
for same visits
recorded on page
61 of CBHC Book
•Actual Feeding
Practice and Advice
for same visits
recorded on page 61
of CBHC Book
 ‘BF’ recorded as
Actual Feeding
Practice at 18
month GMP visit in
CBHC Book
 ‘BF’ recorded as
Actual Feeding
Practice at 2 year
GMP visit in CBHC
Book
WHAT’S NEXT....
• Public Health System
• Social Health Protection Schemes
• Targeting the Poor
• Health Equity Funds
• Community Based Health Insurance
• Vouchers and Conditional Cash Transfers
• Emerging Issues
EMERGING ISSUES
• Long-Term Institutional Arrangements for MOH
related SHP Schemes
• Coordinated Purchasing of Services between MOH,
MOSVY and MOLVT Schemes
• Dedicated Government Budget Funding
• Improved Pre-Identification Accuracy
• Improved Coverage for the Non-Poor Informal Sector