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Ichd 2004 H Pol New Deal
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Ichd 2004 H Pol New Deal

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    Ichd 2004 H Pol New Deal Ichd 2004 H Pol New Deal Presentation Transcript

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