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Health Equity Fund Implementation in Cambodia

Dhaka,2-6 May 2012 Prof. KOUM KANAL MOH Advisor

Introduction
1996 User Fee schemes at facility level established .
User fees for poor and indigent patients was functioning relatively well at Health Centre level, but not as effectively at Hospital level.

Health Equity Funds were introduced as a demand-side financing mechanism to improve access for the poor.
Health Equity Funds first covered the user fees related to hospitalization (CPA health services),

Introduction
In 2003 HEFs became an integral component of:
the Health Sector Strategic Plan (2003-2007) and the National Poverty Reduction Strategy (2003-2006), and later the National Strategic Development Plan (2006-2010). Health Equity Funds are also an important element of the new Strategic Framework for Health Financing (2008-2015) and the second Health Sector Strategic Plan (2008-2015).

In 2007, Inter Ministerial Prakas 809 established a subsidization mechanism call Government Health Equity Fund

What is a Health Equity Fund?


A Strategy to Promote Access to Basic Public Health Services among the Poor
Equity fund is an alternative financing strategy initiated in selected areas in Cambodia to promote the use of priority public health services among the poorest by lowering financial barriers to access. Equity fund reimburse public facilities for health care expenses and associate cost of the poor.

HOW HEFs WORK ?


Funding
Government & DPs
Health Equity Fund Implementer (HEFI)/ Health Equity Fund Operators (HEFO) and PHD/ OD Office, National Hospitals

Management & operate schemes

Activities and Services

Identification of poor households

Purchasing services from HCPs

Models of HEF
Model 1: National hospitals
Operate on government subsidy No third party operator Direct medical benefit No transport, food or funeral allowance Pre- and Post-Identification Accountable for use of funds to MOH

Models of HEF (Cont)


Model 2: Operational District Offices
Operate on government subsidy Third party operator is the ODO who manages the fund used by facilities at district level Direct medical benefit No transport, food or funeral allowance Pre- and Post-Identification Accountable for use of funds to MOH

Models of HEF (Cont)


Model 3- 4: Health Equity Fund Implementers (HEFI) and Operators (HEFO)
Operate on donor funding (HEFI), some channelled through MoH, some are not channelled through MOH Third party operator is a local NGO (HEFO) Direct medical benefit Transport, food and funeral allowance Pre- and Post-Identification Accountable for use of funds to the MoH/ DPs

Models of HEF (Cont)


Voucher scheme (MNH)

Large NGOs purchase maternal health services for all clients: - 4 ANC visits - Delivery at facility - Postnatal check up (24 hrs) => free for client, facility gets 10 $

Models of HEF (Cont)


Voucher scheme (FP)

Large NGOs purchase FP services for all clients: - IUD - VSC => free for client, and transport, facility gets $ based on user fee scheme

Models of HEF (Cont)


Community Based Health Cooperation (CBHC) 1 district + 1 province only, yet Local authority creates CBO board, that combines services for all clients: - HEF - CBHI (insurance paid by non-poor) - Conditional cash transfers (CCT) => all basic care; CCT for pregnancy, birth, growth monitoring+immunization (5+5+5$)

Government incentive
In 02 February 2007 , RGC giving

the financial incentives to motivate the midwives to provide services. Samdech Decho HUN SEN, Prime Minister of The RGC has committed and supported these

Interventions for Maternal Health In Cambodia


Peace, growth, education Roads, phones Health centers, midwives

Source: National Health Statistics MoH 2002-2011. Mainly public sector

Interventions for Maternal Health In Cambodia


Peace, growth, education Roads, phones Health centers, midwives Removing financial barriers: - Health equity funds, vouchers - Live birth incentive ($15)

Source: National Health Statistics MoH 2002-2011. Mainly public sector

Maternal Mortality Ratio in Cambodia

MMR development in Cambodia 1990-2010. Estimates for 1990 and 1995 from WHO, the remainder from CDHS For 2005 and 2010 with 95% confidence intervals

Achievements 2011
Total ODs implemented HEF & Subsidy
Number ODs with Government subsidy-Group2 HEF with Gvt & DPs funding -Group 3&4 Total RHs with HEF & subsidy Total HCs With HEF NHs with government subsidy Group 1

58( voucher 9ODs)


12(implement.11ODs) 48 58 362 6

Total poor pop cover by HEF within 58ODs % poor pop with HEF coverage No,proportion of RHs with HEF Total CBHI beneficiaries New CBHI benificiaries registered Total CBHI benificiaries drop out

3,231,282/11,180359 79% 58(73% of total RH) 237,670 69,124 9,079

Challenges and policy questions


Benefit package Coverage and strategies for scaling-up Linkages Poverty identification National Agency