Ir Por 18 December 2003

1. Health Equity Funds: Improving access to health care for the poorMSF’s experience in Sotnikum, Cambodia Ir Por 18 December 2003

2. Outline • Context: In Cambodia, in Sotnikum and the ‘New Deal’ • Rationale: Why a Health Equity Fund? • Objective • Who should be the implementer? • Implementation: strategies to reach the beneficiaries, selection criteria, benefit package • Results: beneficiaries, costs and benefits • Lessons learnt: strengths, limitations and requisites for effective Health Equity Fund • Future challenges

3. Context: in Cambodia • Despite progress being made, the public health facilities still continue to provide poor quality health care. • The utilisation rate remains low (0.39 cont/inh/y in 2002), but high utilisation of private sector • High out-of-pocket health expenditure (75% of total expenditure = 9% of GDP) • Catastrophic health expenditure leading to indebtedness, loss of assets and poverty.

4. Context: Sotnikum health district • Rural area, among the poorest of Cambodia • 230,000 inhabitants • 17 health centers, 1 referral hospital • All health facilities charge lump sum user fees (approx. $0.5 HC and $10 Hospital)

5. The ‘New Deal’ in Sotnikum ‘Better income for staff in exchange for better service to the population’ • Staff receives a living wage income • The health facilities are open 24 hours • No under-the-table payment • No poaching of patients • No misappropriation of drugs (addressing provider-side constraints)

6. Why a Health Equity Fund? • Poor patients cannot access hospital care because they face many demand-side constraints: • Cost including use fees, transport and food • Distance & geographical access • Information & health beliefs • Intra-household constraints => Better service to the population?? • The hospital to exempt and support poor patients => Better income for staff?? Need for a separate fund = ‘Health Equity Fund’ funded by MSF/UNICEF

7. Objective Develop a sustainable solution to improve access to hospital care for the poor (addressing demand-side constraints)

8. Who should be the implementer? • The hospital? • Conflict of interests • Not enough social expertise, especially in dealing with the poor • MSF/UNICEF? • Not sustainable • Relatively expensive => Need for a local social NGO

9. Contractual arrangement • MSF/UNICEF contracted a local NGO, CFDS, to implement a HEF in Sotnikum in September 2000 because the NGO has: • Expertise in social welfare • Ability to identify the poor • Interested in serving the poor • Reasonable administrative cost • Good knowledge of socio-economic background of the catchment's area, language • The contract was made on ‘quarterly basis’ in the beginning and later on ‘every six months’

10. Strategies to reach poor patients, the beneficiaries • Passive phase (Sep 2000…) • NGO staff interviews patients referred by the hospital staff and provides support accordingly. • Active phase (Sep 2001…) • regular visits to hospital wards. • active promotion and follow-up through outreach to health centres and home visits. • Pilot extension (June 2002…) • Identification at health centre and village level ‘Health Cards’ & ‘Vouchers’. • Recruit a local social worker to provide support at health centre level.

11. Selection criteria Decision on support is made by NGO staff based on: • Lack of income (occupation, daily income & expenditure) • Lack of assets (ownership of land, animals, means of transport etc.) • Vulnerable households (many children, elderly, chronic illness, handicap) • Physical appearance (dirty or very old clothing, and so on) • Lack of social capital (no access to gifts or soft loans from relatives)

12. Benefit package Once entitled to the support, the patient and his/her family receive benefits from CFDS: • Hospital admission fees, • Transport cost to from the health facility, • Additional food, • Basic items: bed net, blanket, clothing, and cooking utensils …according to need

13. Number of patients assistedSep 2000 – June 2003

14. Quality of identification of the beneficiaries Based on 2 in-depth analyses: • Inclusion error (false positive): null • The NGO has no incentive tobe non-specific • Exclusion error (false negative): very limited among the hospital patients, but still many poor do not reach the hospital => The supported patients are genuinely poor

15. Costs and benefits

16. Breakdown of cost of patient benefitsSep 2000 – Dec 2002

17. Strengths • Access to hospital care is no longer denied to the poor. • Promote utilisation of hospital services • Potential to prevent inappropriate expenditure in private sector & unnecessary indebtedness & loss of assets => poverty reduction • Good solution for both consumers & providers: • poor patients have access • hospital staff does not loose income

18. Limitations 1- Some barriers to access remain for the poorest: • Opportunity cost of lost time • Physical access • Intra-household barriers 2- Sustainability, mainly financial and socio-political, is still questioned. 3- Implementer is not locally based, leading to relatively high administrative cost and staff turn over.

19. Requisites for effective HEF • Health facility is credible in the eyes of population (well functioning) • A transparent and committed implementer • Benefit package should be comprehensive: fees, transport, food, basic items.

20. Future challenges • Pre-identification • Decentralisation of support to health centre level • Alternative solution for moderately poor: • Pre-payment scheme: social health insurance • Health credit • Nationwide expansion