Translating knowledge into  Policy and Action A case study on Health Equity Funds in Cambodia Maryam Bigdeli- WHO Cambodia...
Acknowledgments <ul><li>The case study was developed in 2007 by Dr. Ir Por (ITM), who is the first author of the report an...
Introduction <ul><li>Cambodia has been the ground for multiple health financing innovations to improve access to health se...
Definitions <ul><li>Health Equity Fund </li></ul><ul><ul><li>Health Equity Funds (HEFs) emerged after 2000 as third-party ...
Conceptual Framework <ul><li>4-K Framework  –  Meessen and Van Damme </li></ul><ul><li>Describes 4 stages of policy proces...
Methods <ul><li>Document analysis </li></ul><ul><ul><li>Published papers </li></ul></ul><ul><ul><li>Project evaluation rep...
Context : a rich history of health financing reform Free care for all 1996 1999-2000 2002 2005 2007
Context : a rich history of health financing reform Free care for all 1996 1999-2000 2002 National Health  Financing Chart...
Context : a rich history of health financing reform Free care for all UF and exemptions Pilots 1996 1999-2000 2002 Nationa...
Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion...
Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion...
Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion...
Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion...
The policy process K1 – Exploiting existing knowledge: birth of HEF idea <ul><li>Urban Health Project – 1999 </li></ul><ul...
The policy process K2 – Creating new knowledge or innovations: results from HEF pilots (1) <ul><li>UHP and TP and S New De...
The policy process K2 – Creating new knowledge or innovations: results from HEF pilots (2) <ul><li>Requisites for replicat...
The policy process K3 – Brokering new knowledge: dissemination of HEF pilots results <ul><li>Sector Wide Management (SWiM)...
The policy process K4 – Adopting and using new knowledge: expansion and harmonization of HEFs <ul><li>Health Sector Strate...
The policy process K4 – Adopting and using new knowledge: expansion and harmonization of HEFs (3) <ul><li>The HEF final po...
The policy content Community participation, linkage with CBHI Operated by local authorities to reduce overhead costs Exter...
Conclusion <ul><li>What kind of knowledge? </li></ul><ul><ul><li>Problem of access to health services for the poor, failur...
Au Kun Kop Chai Thank You
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Bigdeli Translating Knowledge Into Policy (2)

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From Health and Social Protection: Meeting the needs of the poor, 9-10 October 2008, www.povill.com

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Bigdeli Translating Knowledge Into Policy (2)

  1. 1. Translating knowledge into Policy and Action A case study on Health Equity Funds in Cambodia Maryam Bigdeli- WHO Cambodia Vientiane, October 2008
  2. 2. Acknowledgments <ul><li>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. </li></ul><ul><li>Mr. Bruno Meessen and Dr. Wim Van Damme (ITM) co-author the publication with us. </li></ul><ul><li>We worked under the guidance of a review team: Dr. Lo Veasna Kiry (MOH), Dr. Saphorn Vonthanak (NIPH), Dr. Benjamin Lane (WHO). </li></ul><ul><li>We received comprehensive comments from Dr. Anjana Bhushan and Reijo Salmela (WHO) as well as Dr. Steve Fabricant </li></ul>
  3. 3. Introduction <ul><li>Cambodia has been the ground for multiple health financing innovations to improve access to health services </li></ul><ul><li>Health Equity Funds (HEF), in particular address the problem of access for the poorest segment of population </li></ul><ul><li>HEF have grown from a few pilots to become national policy </li></ul><ul><li> We examine how the evidence from early pilots was used to feed stages and elements of national policy on Health Equity Funds </li></ul>
  4. 4. Definitions <ul><li>Health Equity Fund </li></ul><ul><ul><li>Health Equity Funds (HEFs) emerged after 2000 as third-party payers for indigent patients. </li></ul></ul><ul><ul><li>A fund is managed at district level by a local agent. </li></ul></ul><ul><ul><li>Identified poor patients receive free health care at the facility. Facilities are reimbursed by the fund for foregone user fees </li></ul></ul><ul><ul><li>Patients are reimbursed transport and food costs and may also receive a funeral grant </li></ul></ul>
  5. 5. Conceptual Framework <ul><li>4-K Framework – Meessen and Van Damme </li></ul><ul><li>Describes 4 stages of policy process: </li></ul><ul><ul><li>K1 – Exploiting existing knowledge </li></ul></ul><ul><ul><li>K2 – Creating new knowledge </li></ul></ul><ul><ul><li>K3 – Brokering new knowledge </li></ul></ul><ul><ul><li>K4 – Adopting and using new knowledge </li></ul></ul><ul><li>Within a defined context, at each stage, actors play a role in feeding the ‘stock of knowledge’ </li></ul><ul><li>The ‘stock of knowledge’ feeds policy </li></ul>
  6. 6. Methods <ul><li>Document analysis </li></ul><ul><ul><li>Published papers </li></ul></ul><ul><ul><li>Project evaluation reports </li></ul></ul><ul><ul><li>Royal Government of Cambodia and Ministry of Health documents </li></ul></ul><ul><li>Key Informant Interviews </li></ul><ul><ul><li>Stakeholders : MOH, Economy and Finance, Planning; donor agencies; NGOs (local and international); researchers and managers from academic institutions </li></ul></ul><ul><ul><li>Semi-structured questionnaires based on findings of the document analysis </li></ul></ul><ul><li>Review team </li></ul><ul><ul><li>Regular meetings to triangulate information above </li></ul></ul>
  7. 7. Context : a rich history of health financing reform Free care for all 1996 1999-2000 2002 2005 2007
  8. 8. Context : a rich history of health financing reform Free care for all 1996 1999-2000 2002 National Health Financing Charter 2005 2007
  9. 9. Context : a rich history of health financing reform Free care for all UF and exemptions Pilots 1996 1999-2000 2002 National Health Financing Charter 2005 2007
  10. 10. Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion Contracting Pilots CBHI Pilots HEF Pilot 1996 1999-2000 2002 National Health Financing Charter 2005 2007
  11. 11. Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion UF and exemptions National Coverage Contracting Pilots Contracting Expansion CBHI Pilots HEF Pilot HEF Expansion 1996 1999-2000 2002 National Health Financing Charter 2005 2007
  12. 12. Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion UF and exemptions National Coverage Contracting Pilots Contracting Expansion CBHI Pilots HEF Pilot HEF Expansion 1996 1999-2000 2002 National Health Financing Charter 2005 HEF Implementation And Monitoring Framework 2007 HEF Strategic Framework Health Sector strategic Plan 1 2003-2007
  13. 13. Context : a rich history of health financing reform Free care for all UF and exemptions Pilots UF and exemptions Expansion UF and exemptions National Coverage Contracting Pilots Contracting Expansion CBHI Pilots HEF Pilot HEF Expansion 1996 1999-2000 2002 National Health Financing Charter 2005 2007 Strategic Framework HF 2008-2015 Health Sector Strategic Plan 2 2008-2015 Social Health Protection Master Plan (2009) Sub-Decree 809 (2007) HEF Implementation Guidelines 2008 HEF Financial Manual 2008
  14. 14. The policy process K1 – Exploiting existing knowledge: birth of HEF idea <ul><li>Urban Health Project – 1999 </li></ul><ul><ul><li>Health rooms in Phnom Penh (health centres) </li></ul></ul><ul><ul><li>Cost of referral </li></ul></ul><ul><ul><li>2000 : Equity fund to cover cost of referral and 70% of user fees at hospital </li></ul></ul><ul><li>Thmar Pouk and Sotnikum New Deal -1999 </li></ul><ul><ul><li>Address issues of underpaid health staff, low quality of care, underutilized health service </li></ul></ul><ul><ul><li>Special fund, entrusted to a local NGO: identify poor patients and pay for user fees and related costs for them </li></ul></ul><ul><li> 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 . </li></ul>
  15. 15. The policy process K2 – Creating new knowledge or innovations: results from HEF pilots (1) <ul><li>UHP and TP and S New Deal evaluation reports </li></ul><ul><ul><li>HEF helped patients overcome financial barriers to access health services </li></ul></ul><ul><ul><li>Limitation of post-identification </li></ul></ul><ul><ul><li>Fund management by an NGO is effective </li></ul></ul><ul><li>New HEF schemes, new models tested </li></ul><ul><ul><li>Reinforced evidence of impact on access </li></ul></ul><ul><ul><li>Produced new evidence: </li></ul></ul><ul><ul><ul><li>Pre-identification feasible and cost-effective </li></ul></ul></ul><ul><ul><ul><li>Limited benefit package may undermine access </li></ul></ul></ul><ul><ul><ul><li>HEF can be effectively managed through other implementation arrangements: eg. mixed committees, pagodas </li></ul></ul></ul>
  16. 16. The policy process K2 – Creating new knowledge or innovations: results from HEF pilots (2) <ul><li>Requisites for replication </li></ul><ul><ul><li>User fees for poor patients should be charged to a special fund created for this purpose (HEF) </li></ul></ul><ul><ul><li>Facility where HEF is operating must be well functioning and trusted by the population </li></ul></ul><ul><ul><li>Other access costs such as transport and food should be supported </li></ul></ul><ul><ul><li>HEF should be managed be managed by a transparent and committed third party that has the capacity to identify and support the poorest patients </li></ul></ul>
  17. 17. The policy process K3 – Brokering new knowledge: dissemination of HEF pilots results <ul><li>Sector Wide Management (SWiM) creates a network for transfer of knowledge to policy makers </li></ul><ul><li>Sotnikum New Deal </li></ul><ul><ul><li>Steering Committee, including policy makers and supporting partners </li></ul></ul><ul><ul><li>Local and international publications </li></ul></ul><ul><ul><ul><li>MSF Cambodia Sotnikum New Deal 1 st and 2 nd year reports: Van Damme et al 2001 , Meessen et al 2002 </li></ul></ul></ul><ul><ul><ul><li>Health Policy and Planning 2004 : Hardeman et al </li></ul></ul></ul><ul><ul><ul><li>The Hague Institute of Social Studies 2001: Hardeman et al </li></ul></ul></ul><ul><li>Other pilot projects evaluation reports </li></ul><ul><li>Joint Health Sector Review Report 2001 </li></ul><ul><ul><li>Discussed extensively all the new health financing innovations, including HEF </li></ul></ul><ul><li>MOP National Forum on Identification of Poor Households 2005 </li></ul><ul><ul><li>Supporting pre-identification process </li></ul></ul><ul><li>MOH National Forum on Health Equity Funds 2006 </li></ul><ul><ul><li>First attempt to assemble all knowledge on HEF, with a participative process from all stakeholders </li></ul></ul><ul><ul><li>Consensus on impact of HEF on improving access for the poor </li></ul></ul>
  18. 18. The policy process K4 – Adopting and using new knowledge: expansion and harmonization of HEFs <ul><li>Health Sector Strategic Plan 2003-2007 </li></ul><ul><ul><li>Strategy 15 on allocating financial resources for access to health services by the poor </li></ul></ul><ul><ul><li>Indicators 12 and 13 on HEF coverage (#ODs and #patients) </li></ul></ul><ul><li>HEF Strategic Framework 2003 </li></ul><ul><ul><li>Guiding principles for design, implementation and evaluation </li></ul></ul><ul><li>HEF National Implementation and Monitoring Framework 2005 </li></ul><ul><ul><li>Practical implementation and monitoring arrangements </li></ul></ul><ul><ul><li>Large consultative process </li></ul></ul><ul><li>MOH/MOEF joint Sub-decree on subsidies for the poor (Prakas 809) – 2006 </li></ul><ul><ul><li>First regulatory application of the National Framework for HEF Implementation and Monitoring </li></ul></ul><ul><ul><li>Allocation of state budget to subsidize health services delivered to the poor in public health facilities </li></ul></ul><ul><li>Health Sector Strategic Plan 2008-2015 </li></ul><ul><ul><li>Health Care Financing Strategy (1 of 5 strategic areas in HS) </li></ul></ul><ul><ul><ul><li>Strategic Component 3: Reduce barriers at the point of care and develop social health protection mechanisms </li></ul></ul></ul>
  19. 19. The policy process K4 – Adopting and using new knowledge: expansion and harmonization of HEFs (3) <ul><li>The HEF final policy package will include : </li></ul><ul><ul><li>HEF Implementation guidelines (2008) </li></ul></ul><ul><ul><li>HEF Financial Manual (2008) </li></ul></ul><ul><ul><li>Social Health Protection Master Plan (2009) – HEF as part of a larger health financing and social health protection system </li></ul></ul>
  20. 20. The policy content Community participation, linkage with CBHI Operated by local authorities to reduce overhead costs External resources should continue State budget allocated Funding and sustainability Protect the poor from impoverishing effect of health care cost Poverty reduction Improved access for the poor Impact M&E Prakas 809 application National core indicators and monitoring system Monitoring and Evaluation Health center user fees Tertiary care Chronic diseases Hospital user fees Transport and food costs Benefit package Frequency of pre-ID Best combination Portability Combination of pre and post-ID gives best results National pre-identification process Beneficiary identification Prakas 809 – government subsidies do not use third party arrangements – direct disbursement to facilities or ODs Third party payer (local or international NGO, local committee, faith-based organization, other) HEF operator Poor Level 1 or Level 2 or both (MOP Poverty identification guidelines ) The “poor” Target population No consensus Further knowledge required Consensus supported by knowledge Policy element
  21. 21. Conclusion <ul><li>What kind of knowledge? </li></ul><ul><ul><li>Problem of access to health services for the poor, failure of the exemption system </li></ul></ul><ul><ul><li>Effectiveness of HEF early pilots </li></ul></ul><ul><ul><li>Conditions for replication and expansion </li></ul></ul><ul><li>What influenced policy uptake? </li></ul><ul><ul><li>Political context, conducive to production and dissemination of evidence </li></ul></ul><ul><ul><li>Credibility and timeliness of evidence </li></ul></ul><ul><ul><li>Strong commitment and good relationship between actors </li></ul></ul><ul><li>Why did it work? </li></ul><ul><ul><li>HEF does no go against interest of any actor </li></ul></ul><ul><ul><li>Pragmatic concept reaching a dual objective: access for the poor and income for facilities </li></ul></ul><ul><ul><li>New way to channel donor funding and account for equity in donor projects and programs </li></ul></ul><ul><ul><li>Locally generated evidence, local success story </li></ul></ul>
  22. 22. Au Kun Kop Chai Thank You

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