EQUITABLE PRO-POOR HEALTH OUTCOME Coverage Quality: Structures Process Outcome Access to health services Determinants of Health Socioeconomic & demographic factors Environmental and behavioral risk factors Utilization of services

Q1.What Does Cambodian HEALTH SYSTEM look like? Q2.How HARD is the health system striking for equitable access to quality health services? Q3.How WELL is the health system functioning? Q4.How can equitable access to quality health services and equitable pro-poor health outcome be BETTER improved? Q5.What are key messages? Please KISS

Health System Reform started 1993 Main objective:“to improve and extend primary health care through the implementation of a district based health system.” (The MoH’s Master Plan, ). The MoH implements the reform to meet the peoples essential health needs by: Improving the population’s confidence in public health services. Clarifying and reinforcing the role of hospitals and health centers. Establishing each facility’s catchment area to ensure coverage of the population. Rationalizing the allocation and use of resources. The reform implies entails important transformations, both organizational and financial.

“Operational District Health System” Central Level Provincial Level Referral Hospitals Health Centers  Community Changing from administrative based to population based system organization. Health Coverage Plan is a tool to guide health infrastructure development. A two tier sub-health system comprises of referral hospital(s) and a number of health center and is under overall management of OD Office.

Policies, legislations, strategic planning Resource mobilization and allocation Monitoring, evaluation, research, HIS Training, support to provinces/districts Multi-sectoral coordination, external aid Link MoH and ODs Implement health policies, HSP Ensure equitable distribution and effective use of resources Support development of OD (M&E, in-service training, coordination) “Operational District Health System” Central Level Provincial Level Referral Hospitals Health Centers  Community

“Operational District Health System” Central Level Provincial Level Referral Hospitals Health Centers  Community Complementary Packages of Activity Distinct and complementary to HC care Specialized services Treatment for complex health problems Follow-up/continuing care Support HC in clinical training & supervision Minimum Packages of Activity Encourage community participation Have close contact with the population Be efficient and affordable Provide integrated high quality Ensure accessibility: financial, geographically, and culturally appropriate

HEALTH STRATEGIC PLAN POLICY AGENDA 1.Implement decentralized service delivery and management functions 2.Strengthen sector-wide governance 3.Scale up access to and coverage of health services 4.Implement pro-poor health financing systems 5.Reinforce health legislation, professional ethics and code of conduct, and strengthen regulatory mechanisms 6.Improve quality in service delivery and management 7.Increase competency and skills, including allied technical skills, of health workforce 8.Strengthen and invest in health information system and health research for evidence- based policy-making, planning, monitoring performance and evaluation ” 9.Increase investment in physical infrastructures and medical care equipment and advanced technology with improvement of non-medical support services 10.Promote quality of life and healthy lifestyles of the population 11.Prevent and control communicable and chronic and non-communicable diseases, and strengthen disease surveillance systems 12.Strengthen public health interventions to deal with cross-cutting challenges 13.Promote effective public and private partnerships in service provision 14.Encourage community engagement in health service delivery and quality improvement 15.Systematically strengthen institutions at all levels

“A WHOLE-HEALTH SYSTEM APPROACH” HSP HSP (HSP2) Strategic plans at programming level Operational plans at implementing level HSP2’s Operational Framework HSG HSD HSF HRH HIS RMNHC 2 CD 3 NCD Reproductive health Nutritional status Maternal newbornChild health HIV/AIDS, STIs Tuberculosis MalariaOther com. diseases chronic diseasesPublic health related

Pro-poor Policy Response from Demand-side Financing View Point Community based Health Insurance Community based Health Insurance *Health Equity Funds, **Subsidy *Health Equity Funds, **Subsidy User charges wt Exemption for the poor User charges wt Exemption for the poor User charges wt Exemption for the poor User charges wt Exemption for the poor  1996  1998  *2000, **2006  User charges wt Exemption for the poor User charges wt Exemption for the poor Community based Health Insurance Community based Health Insurance  NSSF-C  NSSF Compulsory contribution (formal sector) Voluntary contribution CBHI (informal sector) Universal Coverage 20XX?

HSP2’s Framework for Monitoring and Evaluation Policy Resources Systems Information Infrastructure Increased Access Utilization Coverage Quality Reduced Risk factors Morbidity Financial risk Social safety net Reduced Mortality Morbidity Disability STRENGTHENING HEALTH MANAGEMENT INFORMATION SYSTEM Facility and Population base data collection, Evidence based researches System and service performance Annual Progress Review Health status Final Evaluation Health outcome Mid Term Evaluation Input/process Output OutcomeImpact

INPUTS: INFRASTRUCTURE, RESOURCES, SYSTEMS 29.1% 20.1% 24.5% 19% 15.7%

OUTPUT: ACCESS, COVERAGE,QUALITY OPD (New Cases) per capita increased from 0.45 to 0.64 in 2008 and 2011, respectively 78% of population living under poverty line are currently protected HEFs

Survey 2011 MoH, GIZ Sample: 3,723 interviewees HC= RH= NH= 23 provinces (% Unsatisfied) % who answered “NO” to YES/NO question Consumer careFacilitiesCommunicationCost (services) SATISFACTION INDEX Customer care Facilities Communi cation CostOverall OUTPUT: ACCESS, COVERAGE,QUALITY *

OUTCOME: Financial risk and social safety net: A study on Health Care Utilization Patterns and Financial Burden of Health Payment in Cambodia * Analyzed the CSES 2004, 2007 and 2009 using methods developed by the World Health Organization ​ (MoH, WHO, GIZ).

IMPACT

Source: CDHS 2010

1. From epidemiological view point: Despite significant reduction, maternal and child mortality in Cambodia remain high if compared with that of the countries in Western Pacific Region (of WHO). HIV, TB and Malaria continue to pose a major public health problem. Prevention, control, treatment and care of these diseases require sophisticated clinical expertise and considerable financial resource. The most important areas that deserve attention are non- communicable and chronic diseases and traffic accidents (deaths and injuries).

2. From health system view point Key policy decision: vision needed for sustaining the current “rationalized health system” (alignment with administrative boundary Vs. economy of scale). Health infrastructure development requires considerable capital investment (physical infrastructure, medical technology, ICT, clinical expertise...) Adequate staffing and skills, appropriate remuneration and right incentive with improved accountability and performance monitoring (potential impact on strengthening of public health system, effectiveness of health service delivery, and health financing strategy). licensing, accreditation, quality control mechanisms-well regulated private sector participation linked to a national accreditation and quality improvement system.

3. From health system financing view point Adequate funds for scaling up HEFs to cover all peoples living under the poverty line (currently 77% of those are protected) Cover the entire country with Health Equity Funds (HEF) and integrated Social Health Protection mechanism by rationalizing, harmonizing and transforming the existing financing schemes. Harmonize common components such as benefit packages, prices, provider payment mechanisms etc. Institutionalize oversight and funding of HEF & CBHI and safety- nets

SOUND HEALTH FINANCING POLICY IN THE CONTEXT OF PUBLIC FINANCIAL MANAGEMENT REFORM AND DnD: On-going process 1. Financial risk protection 2. Equitable and fair funding 3. Efficiency of service delivery 4. Quality services 5. Transparency Resource mobilization Pooling: who will manage them Purchasing: buy services (supply or demand) Stewardship: regulation and monitoring Policy Objectives Financing functions Considering: Broader context

EQUITABLE PRO-POOR HEALTH OUTCOME Coverage Quality: Structures Process Outcome Access to health services Determinants of Health Socioeconomic & demographic factors Environmental and behavioral risk factors Utilization of services

4 “ OR/AND” Policy Questions: HARD CHOICES AND TOUGH DECISION 1.Scaling up access for equitable coverage of health services at basic level OR/AND continued piloting for innovation and improvement? 2.Reliable basic level of quality services for all people OR/AND excellence in selected health priorities? 3. Nationwide coverage of safety net for the poorest people OR/AND improved protection for near poor in selected areas? 4.Most relevant models for reaching Universal Coverage OR/AND models most easily funded by development assistance ?

1. Cambodian health system was re-organized in the post-conflict environment and scarce-resource setting. The system has been changed from administrative based to population based health system organization (population size and accessibility). 2. New and interesting initiatives have been implemented in health systems and health care delivery over the past decade – both supply and demand side financing- with, somehow and some what, systematic monitoring and evaluation. 3. Cambodia is currently on the right track toward achieving MDG 4, 5 and 6 by However, institutional development and capacity, and financial sustainability pose great challenges for health system to deal with. 4. Improving equitable access to quality health services need to pay attention to service delivery expansion and quality improvement, safety net for the poor and vulnerable, as well as near-poor, reduction of household catastrophic health expenditures, and development of social health protection in formal sector, eventual expansion to social health insurance with economic growth.