Gerry Panel Bigdeli

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

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

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  • 1. Roles of NGOs in innovation, implementation and policy dialogue Examples from Cambodia Maryam Bigdeli- WHO Cambodia Vientiane, October 2008
  • 2. Introduction
    • Cambodia has been the ground for multiple health financing innovations to improve access to health services:
      • Contracting health services
      • Health Equity Funds
      • Community-Based Health Insurance
    • NGOs have played an important role in these innovations, in scaling-up implementation and in translating knowledge from pilots into policy
  • 3. 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
  • 4. Context : a rich history of health financing reform Free care for all 1996 1999-2000 2002 National Health Financing Charter 2005 2007
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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)
  • 9. Role of NGOs in innovation Example of Health Equity Funds - Early Pilots
    • 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 .
    • Original DFID funding through Phnom Penh Municipal Health Department
    • How to manage the Health Equity Funds?
      • Cambodian NGO: Urban Sector Group
      •  Establish a third party purchasing mechanism and facilitate access to health services for the urban poor
    • Originally: Medecins Sans Frontieres and UNICEF
    • Thmar Pouk
      • HEF now implemented by a Cambodian NGO: CAAFW (Cambodian Association for Assistance to Families and Widows)
    • Sotnikum
      • Funding by BTC
      • Implementation through Cambodian NGO: CFDS-CHHRA
  • 10. Role of NGOs in innovation Example of Health Equity Funds – New Models
    • Svey rieng
      • NGO fund holder replaced by a local mix committee
    • Kirivong
      • Pagoda-based Equity Funds
      • Collecting donations at the pagoda to pay for health care costs for the poor at health centers
    • Supported by UNICEF
    • Technical support from Swiss Red Cross
    • Cambodian NGO: Buddhism for Health (BFH)
    Example of Health Equity funds – brokering evidence from early pilots
    • MSF and UNICEF
      • Sotnikum New Deal Steering Committee including policy makers
      • Local publication of results
      • Publications in international journals
    • WHO – Health Sector Reform Project partners
    • Health Sector Support Project partners
  • 11. Role of NGOs in implementation Health Equity Funds: NGO Implementation Model Donor and Government funding Health Equity fund Implementer HEFO HEFO HEFO RH HC RH HC Funding Monitoring Oversee implementation Monitoring and supervision Quality assurance (Pre-identification) Report to Donor and Gov Policy dialogue RH HC (Pre- and) Post-ID Purchasing of services Community network Service delivery USAID INGOs URC LNGOs AFH
  • 12. Role of NGOs in implementation Health Equity Funds: NGO Implementation model Donor and Government funding Health Equity fund Implementer HEFO HEFO HEFO RH HC RH HC Funding Monitoring Oversee implementation Monitoring and supervision Quality assurance (Pre-identification) Report to Donor and Gov Policy dialogue RH HC (Pre- and) Post-ID Purchasing of services Community network Service delivery USAID LNGO RACHA LNGOs RACHA
  • 13. Role of NGOs in implementation Health Equity Funds: NGO Implementation model Donor and Government funding Health Equity fund Implementer HEFO HEFO HEFO RH HC RH HC Funding Monitoring Oversee implementation Monitoring and supervision Quality assurance (Pre-identification) Report to Donor and Gov Policy dialogue RH HC (Pre- and) Post-ID Purchasing of services Community network Service delivery Gov of Bel BTC BTC LNGOs CFDS
  • 14. Role of NGOs in implementation Health Equity Funds: Gov Implementation model Government funding National Hospitals Operational District Office Funding Monitoring Implementation RH HC Service delivery
  • 15.
    • Third party purchasing mechanism
    • Quality of care
      • Initial assessment of facilities
      • Ongoing monitoring of quality
      • Rewards and sanctions
    • Transport and food costs
    • Poverty identification
      • Cost and effectiveness of national Pre-ID guidelines
      • Combination with Post-ID
      • Community participation
    • More innovations
      • Linkages with CBHI (BFH, CAAFW, GRET, …)
      • Voucher schemes for reproductive health (BTC)
    • Pushing the policy agenda further
      • Portability
      • Institutional arrangements at central level: national HEF agency
    Essential ideas supported by NGOs in the policy dialogue around HEF
  • 16.
    • Strengths
      • More freedom for innovation
      • More flexible and quicker in implementation
      • Advocacy advantage
        • Humanitarian mandate
        • Neutral
        • Not-for-profit
      • Presence at community level (various degrees)
    • Weaknesses
      • Sustainability
      • Limited coverage: can influence expansion through policy dialogue but do not achieve national coverage
      • Fragmentation, duplication  coordination
    NGO strengths and weaknesses
  • 17. Au Kun Kop Chai Thank You