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COMBINING HEF AND CBHI: BUILDING AN
EFFICIENT MODEL
Experience from Cambodia, SKY Project
Insights regarding the linkage impact on utilization of health care
services and cross-subsidization
Marielle Goursat, SKY Project Director
October 5, 2011
Background
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Within the scope of the objective to achieve social security nationwide
coverage by 2015, the Ministry of Health encouraged combining HEF
and CBHI schemes.
(Health Strategic Plan 2008-15, Master Plan for Social Health Protection,
Strategic Framework for Health Financing 2008-2015)
GRET started to pilot the first CBHI-HEF linkage in Cambodia in May
2008 in Kampot Health District.
Objectives of the linkage
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- Increase health services utilizations by removing stigma and
improved information on benefits package through pagodas committees.
- Avoid unnecessary administration costs and management
fragmentation.
- Strengthen patients’ voices and increase awareness of patient’s
rights.
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Institutional and
Financial Arrangements
Principles
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-Pre-identified households receive the same booklet and therefore the
same comprehensive health benefits package in the same health
facilities than voluntary CBHI members.
-The Cambodian government and donors purchase premiums to the
SKY CBHI scheme on behalf of the Poor. The premium covers medical
expenses only.
-The totality of the premium is transferred to facilities to cover the
costs of HEF services utilizations. Same rates are paid to the providers
for HEF and CBHI members.
- No additional budget for administration is paid to the CBHI.
Management
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-SKY Field Agents: Facilitation at health facilities, distribution of
transportation and food allowances, membership booklet updates
-SKY Head Office : technical and financial overall management,
contractual arrangements, monitoring of utilizations
- GIZ-supported Pagodas Committees : Community work, follow HEF
patients satisfaction, increase awareness on patient’s rights.
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Results
Increased Utilizations by the Poor
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Did the linkage allow increasing utilization of health service by the
Poor?
Average contact rate per capita per year in standards HEF model : 0,5
Average contact rate per capita per year in SKY HEF-CBHI linkage: 1,47
Increased Utilizations by the Poor
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Why does CBHI-HEF linkage enable the Poor to use health facilities,
more than the standard HEF model?
1. Absence of discrimination for HEF members;
2. Active information methodology to encourage HEF members to utilize
contracted health facilities;
3. Stronger negotiation power towards health facilities to improve quality
of care.
Increased Utilizations by the Poor
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Are there any remaining barriers to be addressed?
The CBHI-HEF linkage is believed to have considerably minimized the
obstacles for HEF to access to health care.
Yet, external factors still prevent HEF to use health services.
Internal analysis identified that Distance, Mean of transportation,
Lack of money, Opening hours and Waiting time are significantly
correlated to HEF utilizations while they have no impact on Voluntary
Members consumptions. These results highlight the vulnerability of
HEF members. (Kempf, GRET, 2010)
Quality of care is also strongly correlated to utilizations. Both opening
hours and waiting time significantly impacts utilizations of service.
(Kempf, GRET, 2010)
Avoiding negative cross subsidization
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Stakeholders fear that donors funds earmarked to finance health care
for the poor actually subsidizes health care providers.
While indeed capitation amount exceed the level of consumptions for
HEF, this transfer is believed to induce virtuous cycle:
1. Capitation paid to health care providers are used as staff incentives
(60%), facilities running costs (39%), government taxes (1%).
=> extra payment to health providers participates to quality
improvements, which benefit to the poor and near poor.
2. There is no evidence that the same access to health care would have
been achieved at lower costs
Avoiding negative cross subsidization
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Considering the existence of transfer to health care providers, how
to make the most of donors funds to better serve the poor?
1. Negotiations with Health Facilities:
Subsidy transfer is decreasing over time with further adjustment of
capitation (25% decrease in 2011) and significant increase of
utilizations by the HEF members at Health Center and Provincial
Hospital (65% increase from January 2010 to January 2011).
Avoiding negative cross subsidization
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2. Close monitoring of perceived and actual quality of care by SKY
CBHI scheme :
- Transparent performance-based contract are signed with public health
facilities
- Quality of care is strongly monitored by SKY field agents and SKY
medical advisor.
- Hotline 24/7, regular satisfaction survey, home visits and morning
attendance at health center.
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Conclusion
Latest data from SKY CBHI and HEF linkage show that the current
linkage model successfully increased utilization of health care for the
Poor.
Transfer of funds to providers is believed to induced virtuous cycle for
quality improvement and increased utilizations
Additional advantages of the current linkage model may also be regarded
as promising since management costs monitoring tend to show that the
linkage increases efficiency in implementation by combining
administrative and operational resources and that transaction costs are
significantly reduced
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Thanks for your attention