The Health Equity Fund an Insurance for the Poor

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This presentation was given by Bruno Meessen of the Institute of Tropical Medicine (Belgium) to a seminar on health insurance for the poor, November 2008. Bruno is part of the POVILL consortium …

This presentation was given by Bruno Meessen of the Institute of Tropical Medicine (Belgium) to a seminar on health insurance for the poor, November 2008. Bruno is part of the POVILL consortium (

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  • 1.
    • The Health Equity Fund:
    • An insurance for the poor
    • Seminar Health Insurance for the Poor
    • Utrecht 20/11/2008
    • Bruno Meessen & Por Ir , ITM, Antwerp
  • 2. Content
    • The context: Cambodia.
    • The institutional arrangement.
    • Results.
    • Lessons learned.
  • 3. Context in brief
    • >14 million inhabitants with 35% under poverty line
    • District-based health system with user fees:
      • Good coverage, but
      • Under funded & quality services remains to be improved.
    • Low utilisation of public facilities (0.42 cont/p. in 2004) & high utilisation of private sector
    • High out-of-pocket health expenditure (67% of total expenditure ~8% of GDP), mainly in private sector
    • 30% of expenditure financed by borrowing & asset sales.
  • 4. A highly fragmented health system Distribution of health seeking behaviors over respective providers (30 days recall period), RHS Public sector: 18%
  • 5. A few statistics
    • POVILL sites (3 rural districts, n=5,795 households)
      • Individuals reporting a ‘major illness’ < 12 months: 15%
      • Among adults reporting a major illnesses,those with a loss of more than 30 working days: 34%
  • 6. Health care financing in Cambodia (1996-2008)
    • Source: Ir, Bigdeli (2008)
    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
  • 7. Traditional waivers fail...
    • Traditional solution: “Public hospitals should accept poor patients for free”.
    • Experience has shown that such waivers do not work:
      • very few beneficiaries (many false negative).
      • the few beneficiaries are not those who need the assistance (many false positive).
    • As an organisa tion, the hospital has indeed no in centive to accept poor patients for free.
  • 8. 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 .
  • 9. Health Equity Funds: the basics
  • 10.
    • 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.
    The 1st trick: a specific fund
  • 11. 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;
  • 12.
    • 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 (bidding process).
    The 2 nd trick: a local social welfare NGO
  • 13.
    • The local NGO had 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.
  • 14. Criteria used for the individual targeting
    • The NGO scores different dimensions:
    • “ Household economics” (# of dependants, children obliged to drop out school, widow).
    • Household cohesion (violence, alcoholism…).
    • Health status (disabled persons, chronic disease).
    • Productive assets (rice field, ox…).
    • Lack of food security; have to borrow to buy food.
    • Limited social capital.
  • 15. > 100 Genuinely poor!
  • 16. 2 nd generation of HEF schemes: a real non-contributory insurance scheme
    • Pre-identification at community level.
    • Different approaches, but usually a combination of external expertise (e.g. welfare worker, list of indicators) and local knowledge (e.g. village leaders, pagoda).
    • Risk pooling among the poor who have been entitled.
  • 17. HEF boosts utilization of public hospitals (Logistic regression (of likelihood to go to public hospitals (vs other option) for seriously ill people who got the advice from a qualified expert to seek inpatient care (N=1567) RHS) Odds for a HEF card holder to go to the public hospital are 2.4 higher than someone with a same profile without a HEF card!
  • 18. Lessons learned
  • 19. Definition of HEF
    • Any mechanism or fund that
    • is operated by an independent organisation
    • in the interest of poor people
    • purchases health care for those poor people (from a public health care provider),
    • and also pays for all the associated costs (from non-medical providers).
    • Independent = purchaser-provider split , the organisation does not belong to the Ministry of Health.
  • 20. Regarding health of the very poor
    • 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.
  • 21. HEF: a bundle of functions Source: C.R. Men / M. Van Pelt
  • 22. Pre- vs. post-identification
    • Pre-identification
    • Information taken in the community is more reliable, easy to verify
    • Certainty of entitlement
    • Involvement of communities and local authorities creates ownership
    • Promote awareness of the scheme
    • HEF cards facilitate admin work at hospital
    • Snap-shot assessment does not address issues of poverty dynamic & mobile population
    • The cards may create stigma
    • Post-identification
    • Information taken at hospital is less reliable
    • Uncertainty of entitlement
    • Dependent on the capacity & availability of interviewer
    • Those not aware of the scheme, do not request, will not be identified
    • Permanent assessment allows identifying those not identified by pre-identification
  • 23. Pre-identification is a snap shot survey and does not address dynamic of poverty Poverty line The non-poor The near poor or relatively poor The poor The chronically poor or poorest Time Income/ consumption
  • 24. Regarding large scale adoption
    • A strategy that can be embraced by a variety of actors: donors, international NGOs and agencies, local NGOs, communities, central government, local government...
    • Decentralisation does not hurt: there are still a lot of questions upon the relevant design, a variety of experiences can help, at least at short term.
    • Civil society: Going through private (nonprofit) organisations for transfers to the poorest, the best option?
  • 25. Linking HEF to CBHI
    • Context: a policy framework for social health protection.
    • Rationale: complementary in terms of target groups; efficiency (return on scale on administration); efficiency (market power); sustainability (  pooling); ↓ stigma.
    • Linking: by administration; by financing.
    • Yet: premium <> post-identification; poor may subsidise the rich.
  • 26. Some readings
    • Our website:
    • Health and social protection: experiences from Cambodia, China and Lao PDR'
    • http:// =5
    • Eldis Dossier:
  • 27. Coping strategies with major illness 100 3068 Total of HH reported severe financial problem due serious illness 10.3 615 Seek additional work 3.9 234 Borrow money from credit institute 26.7 1594 Borrow money from informal money lender 15.2 911 Borrow money from friends/relatives 1.6 93 Sell land 5.3 317 Sell livestock 3.4 206 Sell production tools 1.7 99 Sell household assets 5.3 319 Sell stored food 0.3 19 Remove children from school 0.4 24 Reduce food expenditures 1.4 86 Using saving Percent Frequency