Health Equity Funds: Improving access to health care for the poor
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Health Equity Funds: Improving access to health care for the poor MSF’s experience in Sotnikum, Cambodia. Ir Por 18 December 2003. Outline. Context: In Cambodia, in Sotnikum and the ‘New Deal’ Rationale: Why a Health Equity Fund? Objective Who should be the implementer?

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Health Equity Funds: Improving access to health care for the poorMSF’s experience in Sotnikum, Cambodia

Ir Por

18 December 2003

Outline poor

  • 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

Context in cambodia
Context: in Cambodia poor

  • 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.

Context sotnikum health district
Context: Sotnikum health district poor

  • 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)

The new deal in sotnikum
The ‘New Deal’ in Sotnikum poor

‘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)

Why a health equity fund
Why a Health Equity Fund? poor

  • 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

Objective poor

Develop a sustainable solution to improve access to hospital care for the poor

(addressing demand-side constraints)

Who should be the implementer
Who should be the implementer? poor

  • The hospital?

    • Conflict of interests

    • Not enough social expertise, especially in dealing with the poor


    • Not sustainable

    • Relatively expensive

      => Need for a local social NGO

Contractual arrangement
Contractual arrangement poor

  • 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’

Strategies to reach poor patients the beneficiaries
Strategies to reach poor patients, the beneficiaries poor

  • 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.

Selection criteria
Selection criteria poor

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)

Benefit package
Benefit package poor

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

Number of patients assisted sep 2000 june 2003
Number of patients assisted poorSep 2000 – June 2003

Quality of identification of the beneficiaries
Quality of identification of the beneficiaries poor

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

Breakdown of cost of patient benefits sep 2000 dec 2002
Breakdown of cost of patient benefits poorSep 2000 – Dec 2002

Strengths poor

  • 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

Limitations poor

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.

Requisites for effective hef
Requisites for effective HEF poor

  • 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.

Future challenges
Future challenges poor

  • Pre-identification

  • Decentralisation of support to health centre level

  • Alternative solution for moderately poor:

    • Pre-payment scheme: social health insurance

    • Health credit

  • Nationwide expansion