Tapley Jordanwood, MSc USAID Better Health Services Project September 14, 2012

1. PRACTICAL IMPLEMENTATION OF SOCIAL HEALTH PROTECTION IN CAMBODIA Tapley Jordanwood, MSc USAID Better Health Services Project September 14, 2012

2. 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

3. PUBLIC HEALTH SYSTEM 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 Facilities • 8 National Hospitals • 81 Referral Hospitals • 1,021 Health Centers • 89 Health Posts

4. PUBLIC HEALTH SYSTEM UTILIZATION

5. INCREASING USE OF HOSPITALS

6. INCREASING USE OF HEALTH CENTERS

7. PUBLIC HEALTH CARE FINANCING • User Fees Introduced in 1996 • Provide a Direct Incentive to Health Providers • Improved Quality but Created Barriers which can lead to Impoverishment

8. 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

9. 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

10. RELATIVE SIZE OF CURRENT SCHEMES

11. 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

12. 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

13. EQUITY CARDS – MINISTRY OF PLANNING

14. 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

15. PRIORITY ACCESS CARDS – MINISTRY OF HEATLH

16. 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.

17. 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

18. 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

19. 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

20. TYPES OF HEALTH EQUITY FUND SCHEMES Operational Districts Covered by HEFs +6 • 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) Note: There are 77 MOH “Operational Districts”

21. 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 +6

22. HEF Facilitation of RH Access HEFO Office RH • Admission • Identity confirmed: HEF Database • On admission: 50% of transport • IPD and OPD services paid by the HEF • If IPD, caretaker food allowance provided every day (5,000r/day) • 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

23. HEALTH EQUITY FUND HOSPITAL COVERAGE

24. 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

25. HEALTH EQUITY FUND HEALTH CENTER COVERAGE

26. Benefit Package of HEF IPD (In-patient discharge), OPD (Out-patient discharge)

27. 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

28. 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

29. COMMUNITY BASED HEALTH INSURANCE COVERAGE

30. COMMUNITY BASED HEALTH INSURANCE Admin Marketing Subsidies Benefits Premiums

31. 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

32. 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

33. VOUCHERS (2)

34. 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

36. 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

37. 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