1. Date - Lieu COMBINING HEF AND CBHI: BUILDING AN EFFICIENT MODEL Experience from Cambodia, SKY Project Insights regarding the linkage impact on utilization of health care services and cross-subsidization Marielle Goursat, SKY Project Director October 5, 2011

2. Background Within the scope of the objective to achieve social security nationwide coverage by 2015, the Ministry of Health encouraged combining HEF and CBHI schemes. (Health Strategic Plan 2008-15, Master Plan for Social Health Protection, Strategic Framework for Health Financing 2008-2015) 2 GRET started to pilot the first CBHI-HEF linkage in Cambodia in May 2008 in Kampot Health District.

3. Objectives of the linkage - Increase health services utilizations by removing stigma and improved information on benefits package through pagodas committees. 3 - Avoid unnecessary administration costs and management fragmentation. - Strengthen patients’ voices and increase awareness of patient’s rights.

4. Date - Lieu Institutional and Financial Arrangements

5. Principles -Pre-identified households receive the same booklet and therefore the same comprehensive health benefits package in the same health facilities than voluntary CBHI members. 5 -The Cambodian government and donors purchase premiums to the SKY CBHI scheme on behalf of the Poor. The premium covers medical expenses only. -The totality of the premium is transferred to facilities to cover the costs of HEF services utilizations. Same rates are paid to the providers for HEF and CBHI members. - No additional budget for administration is paid to the CBHI.

6. Management - GIZ-supported Pagodas Committees : Community work, follow HEF patients satisfaction, increase awareness on patient’s rights. 6 -SKY Field Agents: Facilitation at health facilities, distribution of transportation and food allowances, membership booklet updates -SKY Head Office : technical and financial overall management, contractual arrangements, monitoring of utilizations

7. Date - Lieu Results

8. Increased Utilizations by the Poor Average contact rate per capita per year in standards HEF model : 0,5 8 Did the linkage allow increasing utilization of health service by the Poor? Average contact rate per capita per year in SKY HEF-CBHI linkage: 1,47

9. Increased Utilizations by the Poor Why does CBHI-HEF linkage enable the Poor to use health facilities, more than the standard HEF model? 9 1.Absence of discrimination for HEF members; 2. Active information methodology to encourage HEF members to utilize contracted health facilities; 3. Stronger negotiation power towards health facilities to improve quality of care.

10. Increased Utilizations by the Poor Are there any remaining barriers to be addressed? 10 The CBHI-HEF linkage is believed to have considerably minimized the obstacles for HEF to access to health care. Yet, external factors still prevent HEF to use health services. Internal analysis identified that Distance, Mean of transportation, Lack of money, Opening hours and Waiting time are significantly correlated to HEF utilizations while they have no impact on Voluntary Members consumptions. These results highlight the vulnerability of HEF members. (Kempf, GRET, 2010) Quality of care is also strongly correlated to utilizations. Both opening hours and waiting time significantly impacts utilizations of service. (Kempf, GRET, 2010)

11. Avoiding negative cross subsidization Stakeholders fear that donors funds earmarked to finance health care for the poor actually subsidizes health care providers. 11 While indeed capitation amount exceed the level of consumptions for HEF, this transfer is believed to induce virtuous cycle: 1. Capitation paid to health care providers are used as staff incentives (60%), facilities running costs (39%), government taxes (1%). => extra payment to health providers participates to quality improvements, which benefit to the poor and near poor. 2. There is no evidence that the same access to health care would have been achieved at lower costs

12. Avoiding negative cross subsidization Considering the existence of transfer to health care providers, how to make the most of donors funds to better serve the poor? 12 1.Negotiations with Health Facilities: Subsidy transfer is decreasing over time with further adjustment of capitation (25% decrease in 2011) and significant increase of utilizations by the HEF members at Health Center and Provincial Hospital (65% increase from January 2010 to January 2011).

13. Avoiding negative cross subsidization 2. Close monitoring of perceived and actual quality of care by SKY CBHI scheme : 13 - Transparent performance-based contract are signed with public health facilities - Quality of care is strongly monitored by SKY field agents and SKY medical advisor. - Hotline 24/7, regular satisfaction survey, home visits and morning attendance at health center.

14. Date - Lieu Conclusion 14

15. Latest data from SKY CBHI and HEF linkage show that the current linkage model successfully increased utilization of health care for the Poor. Additional advantages of the current linkage model may also be regarded as promising since management costs monitoring tend to show that the linkage increases efficiency in implementation by combining administrative and operational resources and that transaction costs are significantly reduced Transfer of funds to providers is believed to induced virtuous cycle for quality improvement and increased utilizations

16. Thanks for your attention 16