Ichd 2004 H Pol New Deal

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Ichd 2004 H Pol New Deal

  1. 1. New Deal in Cambodia by MSF-Cambodia Wim Van Damme Health Policy ICHD 2004
  2. 2. Overview of presentation <ul><li>Introduction: Health system in Cambodia </li></ul><ul><li>New Deal in Sotnikum (Thmar Pouck & Takéo): </li></ul><ul><ul><li>Part 1: Background, rationale, objectives, set up & strategies </li></ul></ul><ul><ul><li>Part 2: Process & Results </li></ul></ul><ul><ul><li>Part 3: Some issues & lessons learnt </li></ul></ul><ul><li>Discussion </li></ul>
  3. 3. Introduction: 3 sectors in health system in Cambodia <ul><li>“ beautiful” national health service </li></ul><ul><ul><li>in full development </li></ul></ul><ul><ul><li>utilisation very low; although “everything in place” (donor efforts+++) </li></ul></ul><ul><li>booming for-profit system </li></ul><ul><ul><li>many “clinics”, pharmacies, drug vendors, informal practises, &c everywhere </li></ul></ul><ul><ul><li>by all government staff & many more </li></ul></ul><ul><li>parallel NGO system </li></ul><ul><ul><li>charitable hospitals in Phnom Penh & Siem Reap </li></ul></ul><ul><ul><li>NGO clinics, mainly reproductive health </li></ul></ul>
  4. 4. Reputation of health services <ul><li>public services: very low credibility </li></ul><ul><ul><li>staff not available, often closed </li></ul></ul><ul><ul><li>payment and service unpredictable </li></ul></ul><ul><ul><li>MPA in health centre: ‘unacceptable’ </li></ul></ul><ul><li>private for-profit services </li></ul><ul><ul><li>very responsive to patients’ demands </li></ul></ul><ul><ul><li>cheap or expensive </li></ul></ul><ul><ul><ul><li>==> indebtedness, impoverishment (losing land) </li></ul></ul></ul><ul><li>private non-profit : charitable hospitals & NGO clinics </li></ul><ul><ul><li>free (or cheap) </li></ul></ul><ul><ul><li>good quality </li></ul></ul>
  5. 5. Health expenditure, 1998 100% $260M $26 4% $10M $1 Government 7% $20M $2 Private donors 14% $30M $3 Public donors 75% $200M $20 Out-of-pocket (%) total Per capita
  6. 6. Within this context <ul><li>Health Sector Reform (MOH & WHO) attempts to create a credible public service </li></ul><ul><li>Sotnikum New Deal = pilot project </li></ul><ul><ul><li>(1) to create credible public service at district level; & </li></ul></ul><ul><ul><li>(2) to boost health sector reform (provincial & national level) </li></ul></ul>
  7. 7. New Deal <ul><li>Part 1: </li></ul><ul><ul><ul><li>Rationale </li></ul></ul></ul><ul><ul><ul><li>Objectives </li></ul></ul></ul><ul><ul><ul><li>Approach </li></ul></ul></ul><ul><ul><ul><li>Set up </li></ul></ul></ul>
  8. 8. Basis: general dissatisfaction with ‘Old Deal’ <ul><li>Patients: do not access government health services </li></ul><ul><li>Personnel: not happy to work </li></ul><ul><ul><ul><li>Not enough income </li></ul></ul></ul><ul><ul><ul><li>Not enough resources (only drugs  sufficient supply) </li></ul></ul></ul><ul><ul><ul><li>Not properly trained </li></ul></ul></ul><ul><li>MOH: low utilization of government health services </li></ul><ul><li>Donors: low results of inputs </li></ul><ul><li>NGOs/IOs: frustrated with lack of improvement </li></ul>
  9. 9. Idea to start pilot experience <ul><li>Sotnikum, at start of New Deal, end 1999 </li></ul><ul><li>218,000 inhabitants </li></ul><ul><li>16 health centres reasonably functional (17 planned) </li></ul><ul><li>small hospital, being upgraded </li></ul><ul><li>no excess staff (30 in hospital, 14 in district office, 80 in health centres) </li></ul>
  10. 12. 90 / 110,000 District Hosp (80 beds) District office 4/11 Health centres Thmar Pouck 120 / 228,000 District Hosp (120 beds) District office 17 Health centres Sotnikum Staff / Population Facilities involved
  11. 13. Objectives of New Deal project(s) <ul><li>Improve access to quality health care in the public service for the population of Sotnikum </li></ul><ul><li>Build a sustainable district health system </li></ul><ul><li>Boost the Health Sector Reform process in Cambodia </li></ul>
  12. 14. Human resource management as an entry point in the system <ul><li>salaries very low: $10-12 per month </li></ul><ul><li>==> coping mechanisms: </li></ul><ul><ul><li>unofficial fees </li></ul></ul><ul><ul><li>taking medicines </li></ul></ul><ul><ul><li>poaching patients for private practice </li></ul></ul><ul><ul><li>poor quality of care (staff working 1 or 2 hours a day) </li></ul></ul><ul><li>public system = “under-funded” (in 1999) </li></ul>
  13. 15. Approach: New Deal with staff <ul><li>Reasonable income, in exchange for better service to population </li></ul><ul><li>Strict adherence to internal regulation </li></ul><ul><ul><li>Working hours (24-hour service) </li></ul></ul><ul><ul><li>No under-the-table payments </li></ul></ul><ul><ul><li>No diversion of resources, esp. drugs </li></ul></ul><ul><ul><li>No poaching of patients </li></ul></ul>
  14. 17. Clarify role of different entities in Operational District <ul><li>District office </li></ul><ul><li>1 referral hospital </li></ul><ul><li>17 health centres </li></ul><ul><li>Referral system </li></ul><ul><li>Equity fund (local NGO) </li></ul>
  15. 18. Funding of New Deal <ul><li>Increased patient fees </li></ul><ul><li>Increased & more reliable state budget </li></ul><ul><li>MSF/UNICEF: cash subsidy </li></ul><ul><li>All resources from vertical programmes & other NGOs </li></ul>
  16. 19. Basic approach <ul><li>Work within MOH system, with NGO support </li></ul><ul><li>Agreement to improve staff income to living wage </li></ul><ul><li>Agreement on using all resources available: </li></ul><ul><li>Govt budget + CMS drugs + patient fees + NGO cash (need for results for the population) </li></ul><ul><li>For limited period (2 to 4 years): need to work towards sustainability: financial, technical, managerial & socio-political. </li></ul><ul><li>Use curative care as entry point for financial sustainability </li></ul>
  17. 20. How? Basics: <ul><li>Involve everybody </li></ul><ul><li>NEGOTIATIONS – « Deal » - agreement </li></ul><ul><li>Takéo: one well-established provincial hospital at start: clear detailed agreement </li></ul><ul><li>Sotnikum/Thmar Pouck: complex district health system, many things unclear at start: open agreement to create dynamic, build-up, expand; strategies still to be defined </li></ul>
  18. 21. Main actors All staff involved Health facilities District team; district governor NGO District PHD & PHA (WHO/UNICEF) Prov governor & Prov treasury NGO Provincial MoH: DG Health & DG Admin/fin MoEF WHO / UNICEF NGO Central
  19. 22. Management principles <ul><li>Decentralisation & increased autonomy in decision-making </li></ul><ul><li>Financial transparency & accountability (consolidated bookkeeping) </li></ul><ul><li>Participatory management in management committees in health facilities </li></ul>
  20. 23. Management mechanisms <ul><li>Contracting </li></ul><ul><li>Performance-based incentives </li></ul><ul><li>Negotiations </li></ul>
  21. 24. Special financial mechanisms <ul><li>Bonus partly related to income from patient fees of health facility </li></ul><ul><li>Bonus for (justified) referral ($1.25) </li></ul><ul><li>5% of patient fees from hospital & Health centres to District Office for ‘quality support’ </li></ul><ul><li>Equity fund for poor people (only for hospital services) </li></ul>
  22. 25. Management: two levels <ul><li>Level A: management of health facilities : </li></ul><ul><li>increased autonomy & accountability in health facilities: co-operative-type of management within each health facility (elections, individual contracts & self-control, encourage staff to pursue collective self-interest...) </li></ul><ul><li>Level B: steering in district health system : </li></ul><ul><li>short term contracting between health facility and Steering Committee </li></ul>
  23. 26. Steering Committee: members <ul><li>MOH: district, province & national </li></ul><ul><li>MOEF: national & provincial </li></ul><ul><li>Local authority: prov governor’s office & district level </li></ul><ul><li>MSF, UNICEF, NIPH </li></ul><ul><li>Other interested parties as observers </li></ul>
  24. 27. P erformance - related pa y <ul><li>In hospitals : </li></ul><ul><ul><li>Bonus per category of staff </li></ul></ul><ul><ul><li>Based on attendance (50-70%) + quality assessment (50-30%) </li></ul></ul><ul><ul><li>Vary with the income from user’s fees & NGO direct support </li></ul></ul><ul><li>In district o ffices : </li></ul><ul><ul><li>Bonus per category of staff </li></ul></ul><ul><ul><li>Based on attendance + some quality assessment </li></ul></ul><ul><ul><li>Variable bonus : 5% user’s fees reimbursed from Health Centre & Referral Hospital </li></ul></ul><ul><li>In h ealth c enters : </li></ul><ul><ul><li>Fix bonus : Chief (40$), staff (30$) </li></ul></ul><ul><ul><li>Variable bonus : (49% user’s fees doubled by MSF/Unicef + income from referrals) equally distributed among the staff </li></ul></ul>
  25. 28. Part 2: Process & results <ul><li>Public health </li></ul><ul><ul><li>User rates </li></ul></ul><ul><ul><li>Quality of care </li></ul></ul><ul><li>Financial results </li></ul>
  26. 29. Key issues during negotiation <ul><li>How many people concerned? </li></ul><ul><li>Negotiate with a representative delegation </li></ul><ul><li>Facilitator for simulations: total cost; workload; fees & number of patients </li></ul><ul><li>Negotiation = talking business </li></ul><ul><li>External reference (need for approval) </li></ul><ul><li>‘ Cultural’ issues </li></ul>
  27. 30. Progressive build-up of operational district
  28. 34. Sotnikum: Referrals from health centres to the hospital
  29. 35. Sotnikum hospital +65% C-sections +300% to +600% Technical exams (lab, X-ray, Ultrasound, &c) +21% Hospitalisations 2001 compared to 2000
  30. 36. Health centres <ul><li>Open 24 hours – 7 days </li></ul><ul><ul><ul><li>User rates  </li></ul></ul></ul><ul><ul><ul><li>Deliveries  </li></ul></ul></ul><ul><ul><ul><li>Referrals  </li></ul></ul></ul>
  31. 37. Perceived quality of care <ul><li>Patient satisfaction: increased, both at health centre level & in the hospital </li></ul><ul><li>According to staff: quality of care has increased </li></ul><ul><li>MSF/UNICEF: quality of care = problematic!! </li></ul>
  32. 39. Hospital costs <ul><li>Costing: $53 / admission </li></ul><ul><li>Running costs expenditures represent a high proportion of total costs (39%) </li></ul><ul><ul><li>High potential for rationalization </li></ul></ul><ul><ul><li>Investments made with budgets for operating costs </li></ul></ul>
  33. 40. Budget 2000 30%?? Government: cash 30% Govt: drugs (in kind) 20% MSF/UNICEF 20% Patients
  34. 41. Level of staff income <ul><li>Salary: $10-12 per month </li></ul><ul><li>Average monthly bonus per staff </li></ul><ul><ul><li>Hospital staff: $70 ($96 at end of year) </li></ul></ul><ul><ul><li>Health centre staff: $78 </li></ul></ul><ul><ul><li>District office staff: $54 </li></ul></ul><ul><li>But: working hours very different!! </li></ul>
  35. 42. Problems with financial management <ul><li>Still substitution for bookkeeping by MSF/UNICEF </li></ul><ul><li>Big difficulties with transition to new government financing system </li></ul><ul><li>Still no financial transparency </li></ul>
  36. 43. Results <ul><li>It (partly) works: </li></ul><ul><li>Patients react favourably </li></ul><ul><li>Health staff largely comply </li></ul><ul><li>Mid-level staff continue diversion of budget </li></ul><ul><li>But, despite this: enough budget arrived to make it work </li></ul>
  37. 44. P erception of New Deal by MOH staff <ul><li>Hospital & health centre staff are more satisfied than District Office staff (this is certainly linked to the bonus level), </li></ul><ul><li>Complaints are much more about management weaknesses than about bonus, </li></ul><ul><ul><li>Lack of transparency, </li></ul></ul><ul><ul><li>Lack of fairness, </li></ul></ul><ul><ul><li>Poor organization </li></ul></ul>
  38. 45. Part 3: Some questions – issues – lessons learnt … <ul><li>Income is never satisfactory </li></ul><ul><li>HIS = unreliable, as long as there are positive incentives for inflating data </li></ul><ul><li>Development = 2 steps forward; 1 step back </li></ul><ul><li>Resistance to change = strong </li></ul><ul><li>Management of change is difficult, especially in a cross-cultural environment </li></ul><ul><li>Expats come and go; Khmers stay </li></ul><ul><ul><li>different perceptions of change </li></ul></ul><ul><ul><li>different time-perspectives </li></ul></ul><ul><ul><li>different attitudes to risk-taking, &c </li></ul></ul>
  39. 46. New Deal can work in a rural district in Cambodia <ul><li>Staff accept the New Deal, & respect internal regulation. User rates increase +++ </li></ul><ul><li>New incentive system is a one-step process; but, improved management and improved quality of care is a slower process (labour intensive) </li></ul><ul><li>Initial idea (once New Deal running, support will yield better results) has yet to be proven. All energy went into micro-management, not in training or quality improvements. </li></ul>
  40. 47. New Deal = labour intensive <ul><li>Why? </li></ul><ul><li>New Deal is </li></ul><ul><li>new way of public management; </li></ul><ul><li>a complex sociological process; & </li></ul><ul><li>occurs in an open environment (that is not necessarily conducive to such changes) </li></ul><ul><li>New Deal = profound change </li></ul>
  41. 48. The New Deal is attractive, for whom? <ul><li>Compared to the Old Deal, the New Deal introduces many changes: </li></ul><ul><ul><li>income, work environment, workload, and possibility to earn other income (coping mechanisms & private practise) </li></ul></ul><ul><ul><li>power relations, transparency & accountability </li></ul></ul><ul><li>For some aspects: everybody can gain; for other aspects: there are winners & losers. </li></ul>
  42. 49. Balance (gains vs. losses)
  43. 50. Structural bottle-necks <ul><li>government funding: level of salaries & access to budget </li></ul><ul><li>human resources: distribution & qualification </li></ul><ul><li>general environment: “island of New Deal in an ocean of Old Deals” (lack of transparency & accountability) </li></ul>
  44. 51. Conditions for sustainability (1) <ul><li>Changes in human resource management </li></ul><ul><ul><li>re-distribution </li></ul></ul><ul><ul><li>appoint people where needed </li></ul></ul><ul><ul><li>important investment in capacity building; or </li></ul></ul><ul><ul><li>in decentralisation of qualified staff </li></ul></ul><ul><li>Mid-level management?? </li></ul>
  45. 52. Conditions for sustainability (2) <ul><li>Access to budget </li></ul><ul><ul><li>total amount disbursed; </li></ul></ul><ul><ul><li>correctly spread over the year; & </li></ul></ul><ul><ul><li>used for improving services </li></ul></ul><ul><li>More flexibility in use of budget (to replace MSF/UNICEF subsidy to support the income of the health staff) </li></ul><ul><li>Improved transparency & accountability in use of budget </li></ul>
  46. 53. Strong interest from national level: why? <ul><li>“ New Deal = good solution” </li></ul><ul><li>Why? </li></ul><ul><li>Participatory: “everybody”  involved in Steering Committee  sense of ownership </li></ul><ul><li>Politically more acceptable than ADB project (=“privatisation”) </li></ul><ul><li>Change within MOH system </li></ul><ul><li>DG of Health: “New Deal pushes towards improved utilisation of government budget; no substitution of government budget” </li></ul>
  47. 54. But: problems with government budget… <ul><li>Government budget = unbalanced </li></ul><ul><li>(running costs >>> salaries) </li></ul><ul><li>Budget allocation = disincentive to good performance </li></ul><ul><li>(hardly linked to utilisation) </li></ul>
  48. 55. Issues pending … <ul><li>Use of contracting </li></ul><ul><ul><li>From broad agreement towards detailed contract? (fine-tune?) </li></ul></ul><ul><ul><li>Steering Committee = artificial body </li></ul></ul><ul><li>“ Better Deal” for mid-level managers?? </li></ul><ul><li>Quality of care & performance management </li></ul><ul><li>Role of MSF/UNICEF (pilot project) </li></ul><ul><ul><li>Certain degree of substitution (NGO-isation of public service??) </li></ul></ul><ul><ul><li>How to reach managerial sustainability? </li></ul></ul><ul><ul><li>(mid-level management = very weak) </li></ul></ul>
  49. 56. Limitations <ul><li>Qualitative issues: ‘kindness for patients’; ‘quality of care’; ‘commitment’, … </li></ul><ul><li>Issues that do not depend only on the people involved in the negotiation: transparent bookkeeping; access to government funding </li></ul><ul><li>Fair deal for managers? </li></ul><ul><ul><li>Responsibility bonus? </li></ul></ul><ul><ul><li>Prime de position? </li></ul></ul>
  50. 57. Lessons learned <ul><li>Performance-related incentives at all levels </li></ul><ul><li>New role for administration?? </li></ul><ul><li>Importance of internal transparency & accountability (‘fair’ management) </li></ul><ul><li>Need for build-in auditing / monitoring </li></ul><ul><li>Need for equity fund </li></ul><ul><li>& Pilot equity funds managed by local NGOs work… </li></ul>
  51. 58. Lessons not learned (yet?) <ul><li>How to use government budget for staff incentives? </li></ul><ul><li>How to deal with over-staffing? </li></ul><ul><ul><li>Need to reach critical treshold for income of staff!!! </li></ul></ul><ul><li>How to attract more out-of-pocket expenditure to public service? </li></ul><ul><ul><li>$2 per capita total expenditure in public service </li></ul></ul><ul><ul><li>$20 per capita in private… </li></ul></ul><ul><li>Public system still very under-funded </li></ul><ul><ul><li>Minimum need in district: $5 per capita - $10? </li></ul></ul><ul><ul><li>Continued need for donor input </li></ul></ul>

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