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