HEALTH EQUITY FUND in Sotnikum & Thmar Pouk operational districts

1. HEALTH EQUITY FUNDin Sotnikum & Thmar Pouk operational districts Dr. Ir Por, Deputy Medical Coordinator MSF H/B & Mr Sour Iyong, Director of CAAFW Presented at Medicam on 06 September 2002

2. NEW DEAL ‘Better income for staff in exchange for better service to the population’ • Staff receives a living wage income • The hospital is functioning: • 24 hours services • No extra-payment

3. Why Equity Fund? • Poor patients cannot access to the hospital care because of financial constraints => Better service to the population?? • The hospital to exempt and support poor patients => Better income for staff?? Need for a separate fund = ‘Equity Fund’

4. Objective Develop a sustainable solution to improve financial access to hospital care for the poor

5. Why managed by local NGO? • The hospital? • No time • Conflict of interests • Not enough social supporting skills • MSF/UNICEF? • Expensive • Not sustainable • Need for a local social NGO • Good ability to identify the poor • Not expensive • Replaceable

6. Constraints to access to adequate basic health care • Demand-side constraints: • Cost including use fees, transport and food • Distance & geographical access • Information • Health beliefs • Intra-household constraints • Supply-side constraint is limitation of quantity and quality of services provided.

7. Contractual arrangement • In Thmar Pouk, MSF contracted CAAFW to implement an Equity Fund in May 2000, and • In Sotnikum, MSF/UNICEF contracted CFDS to implement an Equity Fund in Sotnikum in September 2000 because these NGOs • are well structured local NGOs • have good social welfare background of the catchment's area • have good reputation • interested in working with the poor (in line with their mission statement) • The contract was made on ‘quarterly basis’ in the beginning and later on ‘every six months’

8. Monitoring & evaluation • MSF field staff working in the hospital who can see and hear what is going on around the Equity Fund • Regular meetings between MSF/UNICEF and CFDS and CAAFW managers. • Report regularly to partners involved (e.g. in the Steering Committee meetings). • Casual in-depth analysis and evaluation

9. How to reach poor patients • Phase I: passive phase • NGO staff interviews patients referred by the hospital staff and provide support accordingly. • Phase II: active phase • regularly visit hospital wards. • active promotion and follow-ups through outreach to health centres and home visits. • Phase III: pilot extension (only in Sotnikum) • Identification at village level ‘Health Cards’ & ‘Vouchers’. • Recruit a local social worker to finally provide support at health centre level.

10. Support of CFDS to the beneficiaries Once identified as poor, the patient and his/her family receive support from CFDS for: • Hospital admission fees and/or, • Transport cost and/or, • Additional food and basic items …according to need

11. Support of CAAFW to the beneficiaries • Transportation, including ambulance • Admission fees • Cost of medical imaging (X-Ray, ultrasound) • Basic materials • Supplementary food • Cost of cremation • Financial support transfers to provincial hospital

12. CFDS’ selection criteria • Physically and mentally disabled persons • Chronic disease in household • No land, rice field, productive assets • Not able to pay for schooling of children; they have to work • Many dependents (small children, elderly) • Victim of alcoholism, violence, family conflict etc • Widow with many dependents • Lack of food security; have to borrow to buy food • No outside support: apply to all

13. CAAFW’s Selection criteria • Jobless • No guaranteed income (daily labor) • No relatives or caretaker • No land and/or farming equipment • Many dependents, lack of food • Poor living conditions (shelter) • No starting capital or other assets • No skills • (Chronic) disease • Family crisis, etc.

14. Number of patients assisted by CFDSSep 2000 – July 2002

15. Number of patients assisted by CAAFWMay 2000 – July 2002

16. Percentage of admissions supportedby CAAFWMay 2000 – July 2000

17. Distribution of direct project costs in SotnikumSep 2000 – July 2002

18. Distribution direct project costsin TPMay 2000 – December 2001

19. Cost of the Health Equity Fund in TPMay 2000 – July 2002

20. Breakdown of total expenditure of CAAFWMay 2000 – July 2002

21. Average total cost per admission supported by Health Equity Fund in Sotnikum

22. Average total cost per admission supported by Health Equity Fund in TP

23. Strengths • Supported patients are really poor • Promote utilisation of hospital services • Potential to prevent irrational expenditure in private sector & unnecessary indebtedness & loss of assets => poverty reduction • Good solution for both consumers & providers: • poor patients get support • hospital staff does not loose income =>no longer discriminate poor patients, nor deny their access or treatment.

24. Weaknesses • Not all poor patients arrived at the hospital get supported. • Some potential poor patients are not reached because of other socio-economic constraints. • Limited awareness of & uncertainty of access to Equity Fund in the community. • Sustainability is still questioned

25. Conclusion & recommendations • Equity Fund is a very cost-effective way to improve financial access to hospital care & a very good investment on poverty reduction. • Equity Fund is only effective if it is part of a much broader package of reforms: hospital provides adequate health care and no un-official payment • To address the remaining constraints => • bring identification of & support to the poor closer to the community (health cards, vouchers, support in HCs) • micro-credit or health insurance should be explored. • For funding: • Short-term => NGO or private charitable donor • Medium-term => institutional donor • Long-term => government (social affairs)