bigdeli translating knowledge into policy (2)

Translating knowledge into Policy and Action

A case study on Health Equity Funds in Cambodia

Maryam Bigdeli- WHO CambodiaVientiane, October 2008

Acknowledgments

The case study was developed in 2007 by Dr. Ir Por (ITM), who is the first author of the report and publication submitted to the WHO Bulletin.

Mr. Bruno Meessen and Dr. Wim Van Damme (ITM) co-author the publication with us.

We worked under the guidance of a review team: Dr. Lo Veasna Kiry (MOH), Dr. Saphorn Vonthanak (NIPH), Dr. Benjamin Lane (WHO).

We received comprehensive comments from Dr. Anjana Bhushan and Reijo Salmela (WHO) as well as Dr. Steve Fabricant

Introduction

Cambodia has been the ground for multiple health financing innovations to improve access to health services

Health Equity Funds (HEF), in particular address the problem of access for the poorest segment of population

HEF have grown from a few pilots to become national policy

We examine how the evidence from early pilots was used to feed stages and elements of national policy on Health Equity Funds

Definitions

Health Equity Fund Health Equity Funds (HEFs) emerged after 2000 as

third-party payers for indigent patients.

A fund is managed at district level by a local agent.

Identified poor patients receive free health care at the facility. Facilities are reimbursed by the fund for foregone user fees

Patients are reimbursed transport and food costs and may also receive a funeral grant

Conceptual Framework

4-K Framework – Meessen and Van Damme

Describes 4 stages of policy process: K1 – Exploiting existing knowledge K2 – Creating new knowledge K3 – Brokering new knowledge K4 – Adopting and using new knowledge

Within a defined context, at each stage, actors play a role in feeding the ‘stock of knowledge’

The ‘stock of knowledge’ feeds policy

Methods

Document analysis Published papers Project evaluation reports Royal Government of Cambodia and Ministry of Health

documents Key Informant Interviews

Stakeholders : MOH, Economy and Finance, Planning; donor agencies; NGOs (local and international); researchers and managers from academic institutions

Semi-structured questionnaires based on findings of the document analysis

Review team Regular meetings to triangulate information above

Context : a rich history of health financing reform

Fre

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1996 1999-2000 2002 2005 2007


Fre

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1996 1999-2000 2002

National Health Financing Charter

2005 2007


Fre

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UF and exemptionsPilots

1996 1999-2000 2002


2005 2007


Fre

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UF and exemptionsExpansion

ContractingPilots

CBHIPilots

HEFPilot

1996 1999-2000 2002


2005 2007


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UF and exemptionsNational Coverage

ContractingPilots

ContractingExpansion

CBHIPilots

HEFPilot

HEFExpansion

1996 1999-2000 2002


2005 2007


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ContractingPilots


CBHIPilots

HEFPilot

HEFExpansion

1996 1999-2000 2002


2005

HEF Implementation And Monitoring Framework

2007

HEF StrategicFramework

Health Sector strategic Plan 1 2003-2007


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ContractingPilots


CBHIPilots

HEFPilot

HEFExpansion

1996 1999-2000 2002


2005 2007

Strategic Framework HF 2008-2015Health Sector Strategic Plan 2 2008-2015 Social Health Protection Master Plan (2009)

Sub-Decree 809 (2007)HEF Implementation Guidelines 2008HEF Financial Manual 2008

The policy processK1 – Exploiting existing knowledge: birth of HEF idea

Urban Health Project – 1999 Health rooms in Phnom Penh (health centres) Cost of referral 2000 : Equity fund to cover cost of referral and 70% of user

fees at hospital Thmar Pouk and Sotnikum New Deal -1999

Address issues of underpaid health staff, low quality of care, underutilized health service

Special fund, entrusted to a local NGO: identify poor patients and pay for user fees and related costs for them

Both initial pilots were born within a supply-side approach, aiming to provide health services to the population. Limitations of access within these projects lead to creation of special arrangements for the poor.

The policy processK2 – Creating new knowledge or innovations: results from HEF pilots (1)

UHP and TP and S New Deal evaluation reports HEF helped patients overcome financial barriers to

access health services Limitation of post-identification Fund management by an NGO is effective

New HEF schemes, new models tested Reinforced evidence of impact on access Produced new evidence:

Pre-identification feasible and cost-effective Limited benefit package may undermine access HEF can be effectively managed through other

implementation arrangements: eg. mixed committees, pagodas

The policy processK2 – Creating new knowledge or innovations: results from HEF pilots (2)

Requisites for replication User fees for poor patients should be charged to a

special fund created for this purpose (HEF) Facility where HEF is operating must be well functioning

and trusted by the population Other access costs such as transport and food should

be supported HEF should be managed be managed by a transparent

and committed third party that has the capacity to identify and support the poorest patients

The policy processK3 – Brokering new knowledge: dissemination of HEF pilots results Sector Wide Management (SWiM) creates a network for transfer of

knowledge to policy makers Sotnikum New Deal

Steering Committee, including policy makers and supporting partners Local and international publications

MSF Cambodia Sotnikum New Deal 1st and 2nd year reports: Van Damme et al 2001 , Meessen et al 2002

Health Policy and Planning 2004 : Hardeman et al The Hague Institute of Social Studies 2001: Hardeman et al

Other pilot projects evaluation reports Joint Health Sector Review Report 2001

Discussed extensively all the new health financing innovations, including HEF MOP National Forum on Identification of Poor Households 2005

Supporting pre-identification process MOH National Forum on Health Equity Funds 2006

First attempt to assemble all knowledge on HEF, with a participative process from all stakeholders

Consensus on impact of HEF on improving access for the poor

The policy processK4 – Adopting and using new knowledge: expansion and harmonization of HEFs

Health Sector Strategic Plan 2003-2007 Strategy 15 on allocating financial resources for access to health services by the poor Indicators 12 and 13 on HEF coverage (#ODs and #patients)

HEF Strategic Framework 2003 Guiding principles for design, implementation and evaluation

HEF National Implementation and Monitoring Framework 2005 Practical implementation and monitoring arrangements Large consultative process

MOH/MOEF joint Sub-decree on subsidies for the poor (Prakas 809) – 2006

First regulatory application of the National Framework for HEF Implementation and Monitoring

Allocation of state budget to subsidize health services delivered to the poor in public health facilities

Health Sector Strategic Plan 2008-2015 Health Care Financing Strategy (1 of 5 strategic areas in HS)

Strategic Component 3: Reduce barriers at the point of care and develop social health protection mechanisms

The policy processK4 – Adopting and using new knowledge: expansion and harmonization of HEFs (3)

The HEF final policy package will include: HEF Implementation guidelines (2008) HEF Financial Manual (2008) Social Health Protection Master Plan (2009) – HEF as part

of a larger health financing and social health protection system

The policy contentPolicy element Consensus supported by

knowledgeNo consensus

Further knowledge required

Target population The “poor” Poor Level 1 or Level 2 or both(MOP Poverty identification guidelines)

HEF operator Third party payer (local or international NGO, local committee, faith-based organization, other)

Prakas 809 – government subsidies do not use third party arrangements – direct disbursement to facilities or ODs

Beneficiary identification

Combination of pre and post-ID gives best resultsNational pre-identification process

Frequency of pre-IDBest combinationPortability

Benefit package Hospital user fees

Transport and food costs

Health center user feesTertiary careChronic diseases

Monitoring and Evaluation

National core indicators and monitoring system

M&E Prakas 809 application

Funding and sustainability

External resources should continue

State budget allocated

Community participation, linkage with CBHI

Operated by local authorities to reduce overhead costs

Impact Improved access for the poor Protect the poor from impoverishing effect of health care cost

Poverty reduction

Conclusion

What kind of knowledge? Problem of access to health services for the poor, failure of the

exemption system Effectiveness of HEF early pilots Conditions for replication and expansion

What influenced policy uptake? Political context, conducive to production and dissemination of

evidence Credibility and timeliness of evidence Strong commitment and good relationship between actors

Why did it work? HEF does no go against interest of any actor Pragmatic concept reaching a dual objective: access for the poor and

income for facilities New way to channel donor funding and account for equity in donor

projects and programs Locally generated evidence, local success story

Au KunKop Chai

Thank You

bigdeli translating knowledge into policy (2)

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