Initial situation & challenges

1. Health Equity Fund Contracted to local NGOs in CambodiaA New Approach to Fee ExemptionsBruno Meessen & Wim Van Damme, ITM Antwerp, Belgium (bmeessen@itg.be)

2. Initial situation & challenges

3. Poor and the public health services,what we know in Cambodia... • Economic growth... but rising inequality. • 40 % of the total population under the poverty line. • Higher mortality among poor households. • Underfunding of public health facilities  Low quality of services  general low utilisation of public health facilities.Distribution is a secondary issue. • Overspending by households in the informal private sector, catastrophic health care expenditure is a major problem.

4. Relevant intervention • First objective: get the population using the public health services. • No quality of services without staff accountability. • More funds must be injected in exchange of better performance. • Possible sources: Government, Aid and Users. • New Deal by MSF (Sotnikum) / Contracting. • Problem: rising the fees will exclude the poorest. The distribution issue then becomes serious!

5. Traditional waivers fail... • Traditional solution: “Public hospitals should accept poor patients for free”. • Experience has shown that such waivers don’t work: • very few beneficiaries (many false negative). • the few beneficiaries are not those who need the assistance (many false positive). • As an institution, the hospital has indeed no interest to accept poor patients for free.Poor must be lucrative, as the better-off.

6. Moreover... • The fee is only one of the barriers to access. • Other obstacles are: • uncertainty about eligibility, • transportation costs, • lost income (opportunity costs), • food and basic items, • social exclusion, Patient + accompanying persons !

7. The principles underlying the Health Equity Fund

8. The 1st trick: a specific fund • Creation of a fund dedicated to purchasing / providing the different services needed by the poor to access the hospital. • Namely: • user fees, • transportation, • food and basic items, • social care & protection of rights. • Funding: aid money.

9. A fund entrusted to whom? • The hospital staff? • no interest in a good targeting; • no interest in protection of patient rights; • no social welfare expertise; • MSF? • no expertise; • not sustainable; • expensive.

10. The 2nd trick: a local social welfare NGO • Commitment & expertise to identify the poor, • Commitment to defend the poor and deliver social care, • Not expensive, • Sustainable, • Strong interests to achieve a good job (development of a new activity, geographic extension, a quite competitive sector).

11. Implementation in Thmar Pouk and Sotnikum

12. Practically • The local NGO has an office in the hospital compound, 2 social workers, 7 days a week. • Service delivered: • passive + active identification (interviews), • holistic financial support, • visit in the wards, • outreach for follow-up, control of supported patients and promotion.

13. Criteria used for the individual targeting (not revealed) The NGO scores different dimensions: • “Household economics” (# of dependents, children obliged to drop out school, widow). • Household cohesion (violence, alcoholism…). • Health status (disabled persons, chronic disease). • Productive assets (rice field, oax…). • Lack of food security; have to borrow to buy food. • Limited social capital.

14. Methodology and Results

15. Methods • Hospital utilisation data. • Incidence Analysis: • Interview of inpatients, • A basic poverty score, • Costing of Social Assistance + Hospital services.

16. Genuinely poor! > 100

17. Quality of the targeting • Yearly monitoring of the targeting. • Results of the 10/2003 study (41 inpatients): • High specificity: 100 % (no inclusion error). • Sensibility: 55-70 % (still some exclusion errors). • A pro-poor hospital: 75 % of users (31/41)!

18. Breakdown of assistance expenditureThmar Pouck Hospital (2002)

19. Others results observed locally • Utilisation of hospital services is boosted. • Prevention of poverty? Cf. Dengue outbreak. • Hospital staff no longer discriminate poor patients nor deny their access or treatment. • Equity Fund pays on average $11.5 per patient to get access to hospital treatment at average real cost of $48 = leverage effect. • Technically and managerially sustainable.

20. Observed results: nationwide • The idea finds strong interests among the donor & international NGO community in Cambodia. • Rapid duplication through the country by other NGOs. • Massive external funding promise for the coming years.

21. Policy Implications

22. Lessons learned. • A holistic approach is needed: If you want to enhance utilisation of hospitals by the poor, tackle all the barriers they face: Transportation, Social care, User fees, Information, Social exclusion. • Benefits can be multiple: better health, protected welfare and dignity. • Stakeholders matter: the solution must be in line with the interests of the hospital manager, health staff, better-off users, donors, the local NGOs. Then you get a strong support!