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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

  • 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
  • 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
  • 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

‘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 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


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?
  • 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
  • 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
  • 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

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

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

quality of identification of the beneficiaries
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

  • 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

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