1. Health Equity Funds: Improving access to health care for the poor MSF’s experience in Sotnikum, Cambodia Ir Por 18 December 2003

2. 2 Outline 1.Context: In Cambodia, in Sotnikum and the ‘New Deal’ 2.Rationale: Why a Health Equity Fund? 3.Objective 4.Who should be the implementer? 5.Implementation: strategies to reach the beneficiaries, selection criteria, benefit package 6.Results: beneficiaries, costs and benefits 7.Lessons learnt: strengths, limitations and requisites for effective Health Equity Fund 8.Future challenges

3. 3 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.

4. 4 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)

5. 5 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)

6. 6 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

7. 7 Objective Develop a sustainable solution to improve access to hospital care for the poor (addressing demand-side constraints)

8. 8 Who should be the implementer? The hospital? –Conflict of interests –Not enough social expertise, especially in dealing with the poor MSF/UNICEF? –Not sustainable –Relatively expensive => Need for a local social NGO

9. 9 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’

10. 10 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.

11. 11 Selection criteria Decision on support is made by NGO staff based on: 1.Lack of income (occupation, daily income & expenditure) 2.Lack of assets (ownership of land, animals, means of transport etc.) 3.Vulnerable households (many children, elderly, chronic illness, handicap) 4.Physical appearance (dirty or very old clothing, and so on) 5.Lack of social capital (no access to gifts or soft loans from relatives)

12. 12 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

13. 13 Number of patients assisted Sep 2000 – June 2003

14. 14 Quality of identification of the beneficiaries Based on 2 in-depth analyses: Inclusion error (false positive): null –The NGO has no incentive to be 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

15. 15 Costs and benefits Before Oct. 2002 After Oct. 2002 Average cost of hospital admission $48$53? Hospital admission fee$8$13 Average cost per HEF patient benefit $11$16 Total cost per HEF beneficiary $17$23 % HEF operating cost36%30%

16. 16 Breakdown of cost of patient benefits Sep 2000 – Dec 2002

17. 17 Strengths 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

18. 18 Limitations 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.

19. 19 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.

20. 20 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