CBHI in Vientiane Capital The way forward Dr Aviva Ron Consultant 16 July 2010

The objectives of CBHI Provide the non-insured population with protection against the high costs of health care - decrease out-of-pocket payment health care, and reduce financial barriers to care Increase the utilization of health care by the population of Lao PDR Improve the quality of health care Channel health care expenditure to the public health care system in a stable and predictable way Accelerate achievement of MDG goals Reduce maternal, infant and child mortality

Accelerate reaching MDG goals WHO data 2007 Under 5 mortality: Lao PDR - 91/1000 children under 5 years Vietnam - 23/1,000 children under 5 years Maternal mortality ratio (maternal deaths/100,00 live births Lao PDR - 660:WHO estimate (reported 405) Vietnam - 139

What CBHI has achieved National SASS SSO CBHI OPD/visit /person/year 0.2* 1.19 0.83 1.0 Hospital days /person/year 0.03 0.06 0.05 0.3 * 0.8 visits/year -General population of Vientiane Capital 2009 - Amount transferred from CBHI to District and Central Hospitals in Vientiane Capital - 500,000,000 Kip When 2% of the target population were covered Hospitals report that patients seek health care earlier than before

The challenge for VC Total population: 780,000 in 9 Districts SASS, SSO – about 180,000 Target for CBHI - 600,000 persons Membership today - 17,000 - 3% of target How can we change to increase coverage? How can we increase satisfaction of the population and the providers? How can we move towards Universal Coverage? When can CBHI be compulsory for the non-salaried population?

Why CBHI needs to change Loss of members in existing schemes - too much “adverse selection” now with only 3% of target population covered. Loss of interest of the Central and also District hospitals- unstable and low capitation amount Loss of credibility of social health protection for the informal sector/non-salaried population Need to set an example for the rest of country

Proposals for CBHI change in VC Increase capitation and improve collection Single VC Management with pooled funds Fixed capitation Additional payment to Central Hospitals for outreach services and high cost services Selection of District Hospital and referral to Central Hospital Additional benefit of funeral grant

Contributions Update the amount of contribution according to the increase in the Consumer Price Index since 2005 increase of 42%:- about 43,000 kip as the amount for family of 5-7 members Collect contributions quarterly. Improve collection efficiency and compliance with regulations Allow for regular payment through the bank for members with bank accounts (10%?) Request subsidizes for poor and near poor families through District Government - 100% for poor and 50 % of contribution, on annual basis Update in the future on the same basis, every three years.

CBHI VC Management CBHI Management will be carried out through a single administration Funds pooled and managed for all the 9 Districts Registration and contribution collection will remain as district level responsibilities, with supervision by the CBHI VC Office The pooled fund management will allow: Fixed allocation of the contribution revenue to enable an appropriate level of capitation remuneration to the contracted hospitals Management of a reserve fund for high cost and other benefits/services

CBHI VC Office Essential CBHI VC Team: Minimum of 5 persons, with qualifications: Manager - provider contracts and quality of care Financial management Business administrator Accountant/auditor Promotion and monitoring staff Clerical support services Based on reaching 150,000 in 2 years

Capitation The capitation transferred to hospitals will be a fixed amount The fixed capitation will be split according to the burden between District and Central Hospitals An additional payment to the Central Hospitals for Outreach Services to improve the quality and scope of care in the District Hospitals - according to Outreach done by each Central Hospital. Additional payments for high cost services, to be negotiated Target - fix capitation at 65,000-70,000 kip for the CBHI population Link capitation to changes in the contribution amount, every 3 years.

Provider selection Each Family will select the District Hospital in accordance with travel time and cost Each District Hospital will be linked to a Central Referral Hospital Central Hospitals will be accessed by referral only, except in real emergencies Central Hospitals will select the Districts for Outreach Services.

New Benefits Funeral grant Motor Vehicle Accident Injuries - studies will be done on covering motor vehicle accident treatment, and discussion with government on compulsory insurance to cover injuries

What is needed? Acceptance of the principle changes by all the players -the VC Health Department and its District Hospitals and Health Centres, the Ministry of Health and the Central Hospitals, District Governors Creation of a strong Management Team at VC Health Dept level following training Effective management of registration, contribution collection and financial activities assisted by a computerized information system Continued support in the promotion of the scheme Subsidies for the poor and near poor families to allow for compulsory coverage –after reaching 35% coverage Monitoring and evaluation following defined indicators

In conclusion CBHI VC can make the effort to get a good contribution level and give a higher and fixed capitation amount The CBHI VC Management will take the responsibility for this revenue and provider contracting VC has good health care resources The actual success and extension of coverage will depend on member and provider satisfaction If coverage cannot be extended - the CBHI in VC may need to be suspended

We believe that CBHI VC can do it and be an example for Lao PDR Thank you and Chok Dee