Equity in Health and Health System: a long journey.... from P olicy to Implementation..... ....... to

1. Equity in Health and Health System: a long journey....from Policy to Implementation..... ....... to Health Outcome LO Veasnakiry, M.D.; MA.HMPP Director, Planning & Health Information Dpt. Ministry of Health, Cambodia

2. Entry point of Talk 3 1 2 Equitable Access to Quality Health Services is a Matter ofRemoving Geographical, Financial and Bureaucratic BARRIERS Access to health services Utilization of services • Coverage • Quality: • Structures • Process • Outcome • Determinants of Health • Socioeconomic & demographic factors • Environmental and behavioral risk factors EQUITABLE PRO-POOR HEALTH OUTCOME

3. Please KISS 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? Talking Points

4. 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’sMaster Plan, 1994-1996). • 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. A1:Health System Organization

5. Central Level Provincial Level Referral Hospitals Health Centers JKLJKL Community “Operational District Health System” • Changing from administrative based to population based system organization. • Health Coverage Plan is a tool to guide health infrastructure development. A1: Health System Organization 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.

6. Central Level Provincial Level Referral Hospitals Health Centers JKLJKL Community “Operational District Health System” ROLES OF EACH LEVEL • Policies, legislations, strategic planning • Resource mobilization and allocation • Monitoring, evaluation, research, HIS • Training, support to provinces/districts • Multi-sectoralcoordination, external aid A1: Health System Organization • 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)

7. Central Level Provincial Level Referral Hospitals Health Centers JKLJKL Community “Operational District Health System” ROLES OF HEALTH CENTER AND REFERRAL HOSPITAL SERVICE DELIVERY & MANAGEMENT • 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 A1: Health System Organization • 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

8. HEALTH STRATEGIC PLAN 2008-2015 POLICY AGENDA • Implement decentralized service delivery and management functions • Strengthen sector-wide governance • Scale up access to and coverage of health services • Implement pro-poor health financing systems • Reinforce health legislation, professional ethics and code of conduct, and strengthen regulatory mechanisms • Improve quality in service delivery and management • Increase competency and skills, including allied technical skills, of health workforce • Strengthen and invest in health information system and health research for evidence-based policy-making, planning, monitoring performance and evaluation ” • Increase investment in physical infrastructures and medical care equipment and advanced technology with improvement of non-medical support services • Promote quality of life and healthy lifestyles of the population • Prevent and control communicable and chronic and non-communicable diseases, and strengthen disease surveillance systems • Strengthen public health interventions to deal with cross-cutting challenges • Promote effective public and private partnerships in service provision • Encourage community engagement in health service delivery and quality improvement • Systematically strengthen institutions at all levels A2. Policy Response

9. HEALTH PROGRAM AREAS A2. Policy Response 1 RMNHC 2 CD 3 NCD HSP2’s Operational Framework 1 HSG HSD HSF HRH HIS 2 STRATEGIC AREAS 3 “A WHOLE-HEALTH SYSTEM APPROACH” HSP 2003-07 HSP 2008-15 (HSP2) Strategic plans at programming level Operational plans at implementing level 4 Nutritional status Reproductive health Tuberculosis Maternal newborn Child health chronic diseases Public health related HIV/AIDS, STIs Malaria Other com. diseases 5

10. Pro-poor Policy Response from Demand-side Financing View Point Voluntary contribution CBHI (informal sector) • *Health Equity • Funds, **Subsidy • Community based • Health Insurance • Community based • Health Insurance A2. Policy Response Universal Coverage 20XX? • User charges wt • Exemption for the • poor • User charges wt • Exemption for the • poor • User charges wt • Exemption for the • poor  *2000, **2006  1998  1996  NSSF-C Compulsory contribution (formal sector)  NSSF

11. HSP2’s Framework for Monitoring and Evaluation Output Input/process Outcome Impact • Increased • Access • Utilization • Coverage • Quality • Reduced • Risk factors • Morbidity • Financial risk • Social safety net • Policy • Resources • Systems • Information • Infrastructure • Reduced • Mortality • Morbidity • Disability A2. Policy Response System and service performance Annual Progress Review Health outcome Mid Term Evaluation Health status Final Evaluation STRENGTHENING HEALTH MANAGEMENT INFORMATION SYSTEM Facility and Population base data collection, Evidence based researches

12. A3.Health System Performance 15.7% 19% 24.5% 20.1% INPUTS: INFRASTRUCTURE, RESOURCES, SYSTEMS 29.1%

13. OPD (New Cases) per capita increased from 0.45 to 0.64 in 2008 and 2011, respectively A3.Health System Performance • 78% of population living under poverty line are currently protected HEFs OUTPUT: ACCESS, COVERAGE,QUALITY

14. A3.Health System Performance Survey 2011 MoH, GIZ Sample: 3,723 interviewees HC= RH= NH= 23 provinces OUTPUT: ACCESS, COVERAGE,QUALITY (% Unsatisfied) Consumer care Facilities Communication Cost (services) (% Unsatisfied) % who answered “NO” to YES/NO question % who answered “NO” to YES/NO question

15. A3.Health System Performance 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).

16. A3.Health System Performance IMPACT

17. Equitable pro-poor health outcome: infant and child mortality Source: CDHS 2010

18. A3. Challenges 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 diseasesrequire 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).

19. 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. A3. Challenges

20. 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 A3. Challenges

21. Financial risk protection Equitable and fair funding Efficiency of service delivery Quality services Transparency FINANCING OPTIONS 1. Medium term Along policy objectives and Financing functions 2. Long term Considering: UC of Social health Protection Policy Objectives Financing functions Considering: Broader context POLICY OBJECTIVES Resource mobilization Pooling: who will manage them Purchasing: buy services (supply or demand) Stewardship: regulation and monitoring FINANCING FUNCTIONS FINANCING INRELATION TO A4.Future Outlook SOUND HEALTH FINANCING POLICY IN THE CONTEXT OF PUBLIC FINANCIAL MANAGEMENT REFORM AND DnD: On-going process

22. Exit​point: Key messages 3 1 2 Equitable Access to Quality Health Services is a Matter ofRemoving Geographical, Financial and Bureaucratic BARRIERS Access to health services Utilization of services • Coverage • Quality: • Structures • Process • Outcome • Determinants of Health • Socioeconomic & demographic factors • Environmental and behavioral risk factors EQUITABLE PRO-POOR HEALTH OUTCOME

23. 4 “ OR/AND” Policy Questions: HARD CHOICES AND TOUGH DECISION • Scaling up access for equitable coverage of health services at basic level OR/AND continued piloting for innovation and improvement? • Reliable basic level of quality services for all people OR/AND excellence in selected health priorities? • Nationwide coverage of safety net for the poorest people OR/AND improved protection for near poor in selected areas? • Most relevant models for reaching Universal Coverage OR/AND models most easily funded by development assistance ? A5. Key Messages

24. 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). 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. Cambodia is currently on the right track toward achieving MDG 4, 5 and 6 by 2015. However, institutional development and capacity, and financial sustainability pose great challenges for health system to deal with. 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. A5. Key Messages

25. THANK YOU