Despite substantial funding for tuberculosis (TB) prevention and treatment over the last 10 years, both by donors and governments, the worldwide incidence of TB remains troubling. Across lower- and middle-income countries, access to TB services is limited, and the quality of TB services is often substandard. Many countries face questions over the long-term financial sustainability of their efforts to prevent and treat the disease. Cambodia has one of the highest rates of TB in the world, with prevalence and incidence rates sitting at roughly 660 and 437 per 100,000 people, respectively (WHO 2015). Meanwhile, donor funding for TB is declining, the government is struggling to generate new resources for TB, and out-of-pocket spending still accounts for a significant share of health and TB expenditures. Cambodia needs to identify mechanisms to improve the efficiency of TB spending (i.e., mechanisms for spending money wisely). In the short term, this may mean finding ways to improve outputs – such as access, use of services, and quality – for a given level of spending on TB. In the long term, Cambodia and countries facing similar challenges may be interested in finding ways to achieve better outputs with fewer resources.
Cambodia was the subject of one of several country case studies linking strategic TB purchasing with improved efficiency and better outcomes. In May/June 2016, HFG conducted a brief but in-depth assessment of health purchasing/provider payment and PFM systems in Cambodia, to identify rigidities and barriers.
HFG Rapid Assessment of TB Payment and PFM Systems in the Philippines: Lesson...HFG Project
In the Philippines, there are roughly 290,000 new TB cases per year (WHO, 2016). Meanwhile, donor funding for TB has declined, health care costs are rising, and out-of-pocket spending accounts for roughly two-thirds of national TB expenditures. The Philippines needs to identify mechanisms to improve the efficiency of TB spending (i.e., mechanisms for spending money wisely). In the short term, this may mean finding ways to improve outputs—such as access, use of services, and quality—for a given level of spending on TB. In the long term, the Philippines and countries facing similar challenges may be interested in finding ways to achieve better outputs with fewer resources.
The Philippines was the subject of one of several country case studies linking strategic TB purchasing with improved efficiency and better outcomes. In April 2016, HFG conducted a brief but in-depth assessment of health purchasing/provider payment and PFM systems in the Philippines, to identify rigidities and barriers.
This document discusses workplace wellness programs and their potential to reduce workers' compensation costs by addressing employees' overall health issues. It also provides examples of strategies that have been shown to successfully contain health care costs for public sector employers. Key points include the importance of integrating efforts to manage medical and workers' compensation costs, and examples from Indiana of savings achieved through consumer-driven health plans that encourage preventive care and cost-conscious decision making.
The Global Fund's New Funding Model (NFM) was launched in early 2013 to streamline the application process and improve impact. Key decisions were made at the November 2013 Board meeting regarding eligibility criteria that could negatively impact funding for middle-income countries and key populations like men who have sex with men. The timeline for full implementation in 2014 was also outlined, including indicative country funding amounts being determined in March. Advocates are concerned about reduced funding availability and the sustainability of HIV programs in countries transitioning out of eligibility. Regional applications remain an option for cross-border work but less funding is expected to be available overall under the NFM.
Community Health Center Growth & Sustainability: State Profiles from the Northeastern and Mid-Atlantic United States analyzes key factors related to community health center (CHC) growth and sustainability in 13 states and DC. It finds that in 2012 CHCs collectively served over 5.3 million people, with a median annual growth rate of 4.2% from 2010-2012. CHCs typically served 1 in 5 Medicaid enrollees and 1 in 6 low-income residents. The document also examines CHC financial status using data from 2009-2011, finding mixed results with some states exceeding benchmarks for days cash on hand while others fell below. Revenue sources also varied between states.
The document provides information on country allocations from the Global Fund for 2014-2017:
- Total funding available is $16 billion, a 20% increase over previous levels, with an average of $3.9 billion per year.
- Most countries will receive more funding than previous periods, though some saw peaks in 2013. Grants will have flexible implementation periods determined through country dialogue.
- A methodology is described using disease burden, income, and other factors to determine country bands and initial allocations, which are then adjusted based on qualitative factors like performance, impact, and absorptive capacity.
The USAID Health Finance and Governance project helps developing countries expand access to healthcare through improving health financing, management of resources, and purchasing decisions. Led by Abt Associates, the project works with partner countries in over 40 countries to mobilize domestic funding for health, enhance governance and accountability, improve management systems, and advance universal health coverage. The project is funded by USAID from 2012-2018 and involves several organizations.
Presentation given by Sophie Witter at a satellite session on "Health financing in fragile & conflict affected settings - controversies and innovations" at the 5th Global Symposium on Health Systems Research in Liverpool, on 8th October 2018.
Improving the Customer Service Experience to Achieve Better Outcomes at a Low...mikewilhelm
The document discusses improving the customer service experience in healthcare to achieve better outcomes at a lower cost. It covers several topics:
1) External forces like the Affordable Care Act are pushing healthcare away from just focusing on volume of services provided toward focusing on the value of care through outcomes and costs.
2) Payment models are shifting from fee-for-service toward shared risk models like accountable care organizations and bundled payments to encourage improved outcomes at lower costs.
3) Access to behavioral healthcare treatment is improving through initiatives like certified community behavioral health clinics and health homes.
HFG Rapid Assessment of TB Payment and PFM Systems in the Philippines: Lesson...HFG Project
In the Philippines, there are roughly 290,000 new TB cases per year (WHO, 2016). Meanwhile, donor funding for TB has declined, health care costs are rising, and out-of-pocket spending accounts for roughly two-thirds of national TB expenditures. The Philippines needs to identify mechanisms to improve the efficiency of TB spending (i.e., mechanisms for spending money wisely). In the short term, this may mean finding ways to improve outputs—such as access, use of services, and quality—for a given level of spending on TB. In the long term, the Philippines and countries facing similar challenges may be interested in finding ways to achieve better outputs with fewer resources.
The Philippines was the subject of one of several country case studies linking strategic TB purchasing with improved efficiency and better outcomes. In April 2016, HFG conducted a brief but in-depth assessment of health purchasing/provider payment and PFM systems in the Philippines, to identify rigidities and barriers.
This document discusses workplace wellness programs and their potential to reduce workers' compensation costs by addressing employees' overall health issues. It also provides examples of strategies that have been shown to successfully contain health care costs for public sector employers. Key points include the importance of integrating efforts to manage medical and workers' compensation costs, and examples from Indiana of savings achieved through consumer-driven health plans that encourage preventive care and cost-conscious decision making.
The Global Fund's New Funding Model (NFM) was launched in early 2013 to streamline the application process and improve impact. Key decisions were made at the November 2013 Board meeting regarding eligibility criteria that could negatively impact funding for middle-income countries and key populations like men who have sex with men. The timeline for full implementation in 2014 was also outlined, including indicative country funding amounts being determined in March. Advocates are concerned about reduced funding availability and the sustainability of HIV programs in countries transitioning out of eligibility. Regional applications remain an option for cross-border work but less funding is expected to be available overall under the NFM.
Community Health Center Growth & Sustainability: State Profiles from the Northeastern and Mid-Atlantic United States analyzes key factors related to community health center (CHC) growth and sustainability in 13 states and DC. It finds that in 2012 CHCs collectively served over 5.3 million people, with a median annual growth rate of 4.2% from 2010-2012. CHCs typically served 1 in 5 Medicaid enrollees and 1 in 6 low-income residents. The document also examines CHC financial status using data from 2009-2011, finding mixed results with some states exceeding benchmarks for days cash on hand while others fell below. Revenue sources also varied between states.
The document provides information on country allocations from the Global Fund for 2014-2017:
- Total funding available is $16 billion, a 20% increase over previous levels, with an average of $3.9 billion per year.
- Most countries will receive more funding than previous periods, though some saw peaks in 2013. Grants will have flexible implementation periods determined through country dialogue.
- A methodology is described using disease burden, income, and other factors to determine country bands and initial allocations, which are then adjusted based on qualitative factors like performance, impact, and absorptive capacity.
The USAID Health Finance and Governance project helps developing countries expand access to healthcare through improving health financing, management of resources, and purchasing decisions. Led by Abt Associates, the project works with partner countries in over 40 countries to mobilize domestic funding for health, enhance governance and accountability, improve management systems, and advance universal health coverage. The project is funded by USAID from 2012-2018 and involves several organizations.
Presentation given by Sophie Witter at a satellite session on "Health financing in fragile & conflict affected settings - controversies and innovations" at the 5th Global Symposium on Health Systems Research in Liverpool, on 8th October 2018.
Improving the Customer Service Experience to Achieve Better Outcomes at a Low...mikewilhelm
The document discusses improving the customer service experience in healthcare to achieve better outcomes at a lower cost. It covers several topics:
1) External forces like the Affordable Care Act are pushing healthcare away from just focusing on volume of services provided toward focusing on the value of care through outcomes and costs.
2) Payment models are shifting from fee-for-service toward shared risk models like accountable care organizations and bundled payments to encourage improved outcomes at lower costs.
3) Access to behavioral healthcare treatment is improving through initiatives like certified community behavioral health clinics and health homes.
The document summarizes the County of Stanislaus' transition from purchasing fully insured health plans to becoming a self-funded healthcare purchaser. It describes how the county previously offered two HMO plans but faced rising costs of 11% annually. An evaluation found the lower premium plan actually had higher unit healthcare costs. The county then decided to self-fund, create a unified risk pool, own its data, and add a third plan with a competitive provider network. This transition allowed the county to gain transparency and control over costs while improving quality of care.
The document provides an overview of grants and sponsored programs at Barry University. It discusses Barry's grant profile and types of grants that are available. It also covers finding grant opportunities, reviewing announcements, deciding if a grant is a good fit, the importance of partnerships, and preparing applications. Key components of applications discussed include narratives, budgets, common flaws to avoid, and introducing the National Institutes of Health.
This webinar discusses how to be compliant and engaging in member communications for healthcare organizations. The agenda includes introductions, key findings from a 2019 health insurance report, and a presentation from guest speaker Professor Christopher Trudeau on connecting with members while complying with regulations through clear communication. The document provides background on the speaker and outlines tips for integrating health literacy into communications to improve customer experience and reduce organizational risk.
HFG DRM for Health Workshop: IntroductionHFG Project
Recently, the Health Finance and Governance (HFG) Project organized a multi-country workshop to support policymakers from public health and finance agencies in developing concrete action plans for mobilizing domestic resources for health. Marty Makinen led an introduction presentation focusing on the importance of relationships between Ministries of Finance and Health in mobilizing domestic resources.
GIZ Call for Proposals for BACKUP Health: The Three Grant ProgramsMuhammad Sherbaz
GIZ is seeking applications for its BACKUP health program in order to support a range of Global Fund processes at the country level.
The GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit) supports the German Government in achieving its objectives in the field of international cooperation for sustainable development. Most of GIZ’s activities are commissioned by the German Federal Ministry for Economic Cooperation and Development (BMZ).
Community-based health insurance achievements and recommendations for sustain...HFG Project
The document discusses community-based health insurance (CBHI) in Ethiopia. It provides details on:
- The goals and objectives of the USAID-funded project to implement CBHI across Ethiopia to improve access to and utilization of health services.
- The scale-up of CBHI from 13 pilot districts in 2010 to over 500 districts as of 2018, enrolling nearly 18 million people.
- The resources mobilized through CBHI, primarily from household contributions, with total funds increasing over twelve-fold from 2013-2017 to over 700 million Birr in 2016-2017.
Thanks to computers, it is easier to collect and obtain data for a grant proposal than ever before. There’s so much data, though, that it can difficult to determine which data to present—especially when grant applications only allow concise answers.
This webinar explains which data grantmakers are looking for, and where to present statistics and other information within the grant proposal. Multiple examples from actual, funded grant proposals will show how data solves grant writers’ most knotty problems by creating need statements, formulating project objectives, devising evaluation measures, and more.
This document discusses medical tourism, which refers to traveling abroad to obtain medical care. It is expected to experience explosive growth over the next few years due to rising healthcare costs in the US that are increasing faster than inflation. Some key points:
- An estimated 750,000 Americans traveled abroad for medical care in 2007, and this is projected to increase to 6 million by 2010.
- Medical care in countries like India, Thailand and Singapore can cost as little as 10% of the cost in the US for the same procedures.
- Increased deductibles and health care costs are making consumers more cost-conscious and more willing to consider medical tourism for savings of 50% or more.
- Many foreign countries are
This document summarizes a presentation on rising health care costs given to the Joint Commission on Health Care. It outlines that health care costs have been increasing at an average rate of 9.8% annually since 1970. The highest costs are concentrated among the sickest 10% of the population. While health insurance premiums continue to rise more slowly than in the past, they still outpace inflation and wage growth. Efforts to control costs include promoting consumer directed health plans, disease management programs, and reducing medical errors through health information technology.
The document provides a summary of the short-term implications of federal health reform. It discusses how the reform will impact public program enrollment, the private insurance market, high-risk pools, health insurance exchanges, and delivery system/payment reform in the short-term. Key points include that millions more may gain eligibility for Medicaid and subsidies, insurers face new regulations on premiums/benefits, a temporary high-risk pool is established, and delivery reforms aim to improve quality and reduce costs through various pilot programs. The source is an independent research center that assists states with health policy analysis.
The purpose of the USAID HFG TB Strategic Purchasing Activity is to identify and recommend small improvements in TB purchasing/provider payment and related public finance management (PFM) mechanism to better target country health budgets towards priority TB services for the poor in USAID TB priority countries. This technical report summarizes the rapid assessment findings, conclusions, recommendations, and possible next steps from stakeholder consultations held in Malawi from May 18-29.
The three health financing functions are revenue collection, pooling and purchasing. Revenue collection is the source/level of funds, pooling is the accumulation of prepaid revenues on behalf of a population and purchasing is the transfer of pooled funds to providers on behalf of a population. The main focus of the HFG/TB Activity is the health purchasing function, specifically provider payment systems and PFM mechanisms. This rapid assessment focuses more on domestic revenue health purchasing and PFM at the district level as other USAID investments are supporting NTP and Global Fund grant implementation. This assessment emphasizes public funding as public funding is critical to pro-poor priority public health services especially TB.
This rapid assessment is not intended to be a literature review or formal study. Stakeholder consultations are the main vehicle for identifying and recommending small TB purchasing and PFM improvement steps for possible further in-depth analysis and implementation. The rapid assessment technical report is organized into five sections: 1) introduction; 2) TB continuum of care gaps; 3) overall strategy and sequencing; 4) shorter-term TB purchasing and PFM steps; and 5) relationship between shorter-term steps and longer-term public service and health reforms.
2016 04 29 MedSpan Research - POPs White Paper finalMedSpanResearch
This document provides an overview of provider-owned health plans (POPs). It discusses the history of POPs, including their brief popularity in the 1990s but failure then. Today, POPs are growing in popularity again as providers address earlier challenges. The document examines the current POP market profile, why providers develop POPs, case studies of successful and challenging POPs, and the future outlook for POPs, which remains uncertain despite interest from providers.
Fiscal Space and Financing for National Health Insurance in Botswana - ReportHFG Project
This document provides background on Botswana's macroeconomic and fiscal situation as it relates to fiscal space for health financing. It notes that while Botswana has relatively unconstrained fiscal space in the short-term due to diamond exports, economic growth has averaged only 4% in recent years and is highly dependent on minerals. As diamond revenues decline gradually, Botswana will need to generate new sources of export-led growth and increase domestic revenue generation. The long-term challenge is ensuring fiscal sustainability as Botswana transitions its economy away from reliance on minerals.
Fiscal Space and Financing for National Health Insurance in Botswana - BriefHFG Project
This document summarizes a fiscal space analysis conducted for Botswana's Ministry of Health and Wellness on establishing a national health insurance program. The analysis found that proposed health insurance contribution levies would only generate about 11.5% of the estimated costs of a universal health services package. Even doubling contribution rates only increased revenues to about 31% of costs. This indicates that Botswana would still need to subsidize most of the costs of a national health insurance program through the existing public health budget, reducing funds available for other health services. The analysis suggests that Botswana's national health insurance proposals in their current form are unlikely to significantly increase health funding or enable cross-subsidies between insurance plans as initially expected.
The Link between Provider Payment and Quality of Maternal Health Services: Ca...HFG Project
This paper presents case studies of provider payment systems in the Kyrgyz Republic, Nigeria, and Zambia that link a quality improvement initiative with provider payment. It documents these programs’ experience with design and implementation and lessons learned for other health care payers seeking to improve quality at the point of care through redesign of a provider payment system.
What Does it Take to Make Enrollment Efforts Permanent?Enroll America
This document discusses making health insurance enrollment efforts permanent through institutional partnerships. It provides examples of partnerships between hospitals and faith communities, criminal justice communities, and schools. These partnerships aim to make enrollment a regular practice. They benefit both the community and institutions by improving care coordination, reducing costs, and improving health. The document urges starting with a pilot program, engaging key stakeholders, and maintaining communication. It emphasizes finding shared benefits and starting small before expanding partnerships.
Presented during Day One of the 2016 Nigeria Health Care Financing Training Workshop. Presented by Dr. Elaine Baruwa. More: https://www.hfgproject.org/hcf-training-nigeria
The document discusses health systems and financing. It begins by defining a health system as all actors, institutions, and resources that undertake health actions, with the primary intent of improving health. Not all policies that influence health are part of the health system. The document then discusses the goals of health systems, including improving health and ensuring financial contribution. It outlines the key functions of health systems as stewardship, financing, resource generation, and service delivery. The document emphasizes the importance of aligning financing with national health plans to avoid fragmentation. It also discusses concepts of coverage, effectiveness, and factors that influence health outcomes.
The Maker Movement began in the early 2000s as a resurgence of do-it-yourself creativity fueled by new technologies like 3D printing and Arduino boards. Makers now number in the millions as people rediscover the satisfaction of making physical objects with their own hands. New low-cost tools and online communities have lowered barriers to entry, empowering a new generation of innovators and shifting production away from large corporations. The Maker Movement promises significant economic and social benefits by transforming industries, democratizing innovation, and inspiring self-sufficiency.
Cardin Partners' regularly updated sector report on HR Technology is provided to assist with tracking global capital flows and valuations in the sector.
If you would like an introduction to any company mentioned in this report please contact Andrew Jones at andrew@cardinpartners.com
The document summarizes the County of Stanislaus' transition from purchasing fully insured health plans to becoming a self-funded healthcare purchaser. It describes how the county previously offered two HMO plans but faced rising costs of 11% annually. An evaluation found the lower premium plan actually had higher unit healthcare costs. The county then decided to self-fund, create a unified risk pool, own its data, and add a third plan with a competitive provider network. This transition allowed the county to gain transparency and control over costs while improving quality of care.
The document provides an overview of grants and sponsored programs at Barry University. It discusses Barry's grant profile and types of grants that are available. It also covers finding grant opportunities, reviewing announcements, deciding if a grant is a good fit, the importance of partnerships, and preparing applications. Key components of applications discussed include narratives, budgets, common flaws to avoid, and introducing the National Institutes of Health.
This webinar discusses how to be compliant and engaging in member communications for healthcare organizations. The agenda includes introductions, key findings from a 2019 health insurance report, and a presentation from guest speaker Professor Christopher Trudeau on connecting with members while complying with regulations through clear communication. The document provides background on the speaker and outlines tips for integrating health literacy into communications to improve customer experience and reduce organizational risk.
HFG DRM for Health Workshop: IntroductionHFG Project
Recently, the Health Finance and Governance (HFG) Project organized a multi-country workshop to support policymakers from public health and finance agencies in developing concrete action plans for mobilizing domestic resources for health. Marty Makinen led an introduction presentation focusing on the importance of relationships between Ministries of Finance and Health in mobilizing domestic resources.
GIZ Call for Proposals for BACKUP Health: The Three Grant ProgramsMuhammad Sherbaz
GIZ is seeking applications for its BACKUP health program in order to support a range of Global Fund processes at the country level.
The GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit) supports the German Government in achieving its objectives in the field of international cooperation for sustainable development. Most of GIZ’s activities are commissioned by the German Federal Ministry for Economic Cooperation and Development (BMZ).
Community-based health insurance achievements and recommendations for sustain...HFG Project
The document discusses community-based health insurance (CBHI) in Ethiopia. It provides details on:
- The goals and objectives of the USAID-funded project to implement CBHI across Ethiopia to improve access to and utilization of health services.
- The scale-up of CBHI from 13 pilot districts in 2010 to over 500 districts as of 2018, enrolling nearly 18 million people.
- The resources mobilized through CBHI, primarily from household contributions, with total funds increasing over twelve-fold from 2013-2017 to over 700 million Birr in 2016-2017.
Thanks to computers, it is easier to collect and obtain data for a grant proposal than ever before. There’s so much data, though, that it can difficult to determine which data to present—especially when grant applications only allow concise answers.
This webinar explains which data grantmakers are looking for, and where to present statistics and other information within the grant proposal. Multiple examples from actual, funded grant proposals will show how data solves grant writers’ most knotty problems by creating need statements, formulating project objectives, devising evaluation measures, and more.
This document discusses medical tourism, which refers to traveling abroad to obtain medical care. It is expected to experience explosive growth over the next few years due to rising healthcare costs in the US that are increasing faster than inflation. Some key points:
- An estimated 750,000 Americans traveled abroad for medical care in 2007, and this is projected to increase to 6 million by 2010.
- Medical care in countries like India, Thailand and Singapore can cost as little as 10% of the cost in the US for the same procedures.
- Increased deductibles and health care costs are making consumers more cost-conscious and more willing to consider medical tourism for savings of 50% or more.
- Many foreign countries are
This document summarizes a presentation on rising health care costs given to the Joint Commission on Health Care. It outlines that health care costs have been increasing at an average rate of 9.8% annually since 1970. The highest costs are concentrated among the sickest 10% of the population. While health insurance premiums continue to rise more slowly than in the past, they still outpace inflation and wage growth. Efforts to control costs include promoting consumer directed health plans, disease management programs, and reducing medical errors through health information technology.
The document provides a summary of the short-term implications of federal health reform. It discusses how the reform will impact public program enrollment, the private insurance market, high-risk pools, health insurance exchanges, and delivery system/payment reform in the short-term. Key points include that millions more may gain eligibility for Medicaid and subsidies, insurers face new regulations on premiums/benefits, a temporary high-risk pool is established, and delivery reforms aim to improve quality and reduce costs through various pilot programs. The source is an independent research center that assists states with health policy analysis.
The purpose of the USAID HFG TB Strategic Purchasing Activity is to identify and recommend small improvements in TB purchasing/provider payment and related public finance management (PFM) mechanism to better target country health budgets towards priority TB services for the poor in USAID TB priority countries. This technical report summarizes the rapid assessment findings, conclusions, recommendations, and possible next steps from stakeholder consultations held in Malawi from May 18-29.
The three health financing functions are revenue collection, pooling and purchasing. Revenue collection is the source/level of funds, pooling is the accumulation of prepaid revenues on behalf of a population and purchasing is the transfer of pooled funds to providers on behalf of a population. The main focus of the HFG/TB Activity is the health purchasing function, specifically provider payment systems and PFM mechanisms. This rapid assessment focuses more on domestic revenue health purchasing and PFM at the district level as other USAID investments are supporting NTP and Global Fund grant implementation. This assessment emphasizes public funding as public funding is critical to pro-poor priority public health services especially TB.
This rapid assessment is not intended to be a literature review or formal study. Stakeholder consultations are the main vehicle for identifying and recommending small TB purchasing and PFM improvement steps for possible further in-depth analysis and implementation. The rapid assessment technical report is organized into five sections: 1) introduction; 2) TB continuum of care gaps; 3) overall strategy and sequencing; 4) shorter-term TB purchasing and PFM steps; and 5) relationship between shorter-term steps and longer-term public service and health reforms.
2016 04 29 MedSpan Research - POPs White Paper finalMedSpanResearch
This document provides an overview of provider-owned health plans (POPs). It discusses the history of POPs, including their brief popularity in the 1990s but failure then. Today, POPs are growing in popularity again as providers address earlier challenges. The document examines the current POP market profile, why providers develop POPs, case studies of successful and challenging POPs, and the future outlook for POPs, which remains uncertain despite interest from providers.
Fiscal Space and Financing for National Health Insurance in Botswana - ReportHFG Project
This document provides background on Botswana's macroeconomic and fiscal situation as it relates to fiscal space for health financing. It notes that while Botswana has relatively unconstrained fiscal space in the short-term due to diamond exports, economic growth has averaged only 4% in recent years and is highly dependent on minerals. As diamond revenues decline gradually, Botswana will need to generate new sources of export-led growth and increase domestic revenue generation. The long-term challenge is ensuring fiscal sustainability as Botswana transitions its economy away from reliance on minerals.
Fiscal Space and Financing for National Health Insurance in Botswana - BriefHFG Project
This document summarizes a fiscal space analysis conducted for Botswana's Ministry of Health and Wellness on establishing a national health insurance program. The analysis found that proposed health insurance contribution levies would only generate about 11.5% of the estimated costs of a universal health services package. Even doubling contribution rates only increased revenues to about 31% of costs. This indicates that Botswana would still need to subsidize most of the costs of a national health insurance program through the existing public health budget, reducing funds available for other health services. The analysis suggests that Botswana's national health insurance proposals in their current form are unlikely to significantly increase health funding or enable cross-subsidies between insurance plans as initially expected.
The Link between Provider Payment and Quality of Maternal Health Services: Ca...HFG Project
This paper presents case studies of provider payment systems in the Kyrgyz Republic, Nigeria, and Zambia that link a quality improvement initiative with provider payment. It documents these programs’ experience with design and implementation and lessons learned for other health care payers seeking to improve quality at the point of care through redesign of a provider payment system.
What Does it Take to Make Enrollment Efforts Permanent?Enroll America
This document discusses making health insurance enrollment efforts permanent through institutional partnerships. It provides examples of partnerships between hospitals and faith communities, criminal justice communities, and schools. These partnerships aim to make enrollment a regular practice. They benefit both the community and institutions by improving care coordination, reducing costs, and improving health. The document urges starting with a pilot program, engaging key stakeholders, and maintaining communication. It emphasizes finding shared benefits and starting small before expanding partnerships.
Presented during Day One of the 2016 Nigeria Health Care Financing Training Workshop. Presented by Dr. Elaine Baruwa. More: https://www.hfgproject.org/hcf-training-nigeria
The document discusses health systems and financing. It begins by defining a health system as all actors, institutions, and resources that undertake health actions, with the primary intent of improving health. Not all policies that influence health are part of the health system. The document then discusses the goals of health systems, including improving health and ensuring financial contribution. It outlines the key functions of health systems as stewardship, financing, resource generation, and service delivery. The document emphasizes the importance of aligning financing with national health plans to avoid fragmentation. It also discusses concepts of coverage, effectiveness, and factors that influence health outcomes.
The Maker Movement began in the early 2000s as a resurgence of do-it-yourself creativity fueled by new technologies like 3D printing and Arduino boards. Makers now number in the millions as people rediscover the satisfaction of making physical objects with their own hands. New low-cost tools and online communities have lowered barriers to entry, empowering a new generation of innovators and shifting production away from large corporations. The Maker Movement promises significant economic and social benefits by transforming industries, democratizing innovation, and inspiring self-sufficiency.
Cardin Partners' regularly updated sector report on HR Technology is provided to assist with tracking global capital flows and valuations in the sector.
If you would like an introduction to any company mentioned in this report please contact Andrew Jones at andrew@cardinpartners.com
Manual de Google Analytics, actualizado a diciembre de 2010. Otros manuales de Google Adwords, Facebook estratégico, marketing digital para pymes... en http://goo.gl/i0zXtb
1) The document discusses factors that determine the shelf life of foods, including intrinsic factors like pH, water activity, and natural barriers, as well as extrinsic factors like temperature, packaging, and storage conditions.
2) It defines key terms related to shelf life like "best before" date, "use by" date, and chilled vs. shelf-stable foods.
3) Determining shelf life involves characterizing the food product, considering factors that could cause deterioration, and testing to validate the estimated shelf life period. Regular monitoring is also important to ensure safety throughout the claimed shelf life.
Are you a good sales coach? Learn three methods to assess your effectiveness as a sales coach. View this presentation to review and improve your sales coaching skills.
It's easy to make assumptions about what our donors are thinking. When those assumptions are unrealistic, they can make us do silly, off-target, unsuccessful fundraising.
What I Have Learnt From The Content Marketers Who Have Walked The WalkedMark Masters
What if you brought some of the world's marketing influencers to one place and asked them questions for us to take on-board.
The 'Talking Content Marketing' project has been up and running since November 2013 with a curiosity and inquisitive slant on how we need to change our mindsets from the traditional ways of interruption and self promotion to a more content driven way of looking to be useful and informative to help build our audiences.
The project is an ongoing commitment, but here are 24 of the world's leading marketers and how they look at the world in a couple of sentences....enojy
Impact Your Audience: Presentations that Rock!Katie Morrow
Are students disengaged with your traditional presentation design? Are staff members turned off by your presentation delivery? Find out ways to improve your next presentation, whether for professional learning experiences or everyday classroom instruction. Explore concepts in layout & design, strategies for engaging your audience, and presentation techniques used by some of the world’s best speakers. Make your next presentation rock!
State, Society, and Tibetan Buddhism in Contemporary ChinaGerald Roche
Guest lecture given for ANTH30003 - Society, Politics, and the Sacred at University of Melbourne, 21 Sept 2016. References will probably be the most useful part :)
This presentation discusses the measurement of PFCs in drinking and tap water using LC-MS/MS. As contaminants of emerging concern, research on PFCs is ongoing to determine the impacts of these materials on human health and the environment. Perfluorinated compounds can be effectively and quickly measured directly from surface and drinking water using a modified configuration of the LCMS-8050. For more information, go to ssi.shimadzu.com and follow Shimadzu on Twitter @ShimadzuSSI. Thanks for viewing.
El documento describe las estructuras del aparato digestivo contenidas en la cabeza, incluyendo la cavidad oral, faringe y esófago superior. Describe en detalle la cavidad bucal, paladar, lengua, glándulas salivales y músculos de la lengua. También describe la faringe, sus porciones y estructuras asociadas como el velo del paladar y anillo linfático. Finalmente, resume brevemente la constitución del esófago, estómago, intestino delgado, intestino grueso, ciego
An algorithm is set of steps that perform calculations, process data, or automate tasks. Algorithms are everywhere we look (and even places we don’t look) controlling what we see, do, and where we go. They’re great for solving our problems and helping us make better and quicker decisions, or taking the decision-making out of our hands. Their guidance is perfect in their objective and unbiased calculation. Except they are not, actually. Like everything else, they are created by people, and people have biases that get encoded into the algorithms they create. Algorithms learn from data, which is also created by people, so the algorithms also learn biases from data. This can be a problem when algorithms encode these biases into their calculations and go on to perpetuate the bias.
In this talk you will hear why we should care about algorithmic accountability, and details on a case study on how computational journalism can be used to investigate algorithms and advocate the need for transparency and accountability.
This document summarizes a presentation about deploying Big Data as a Service (BDaaS) in the enterprise. It discusses how BDaaS can address conflicting needs of data scientists wanting flexibility and IT wanting control. It defines different types of BDaaS and requirements for enterprise deployment such as multi-tenancy, security, and application support. The presentation covers design decisions for BDaaS including running Hadoop/Spark unmodified using containers for isolation. It provides details on the implementation including network architecture, storage, and image management. It also discusses performance testing results and demos the BDaaS platform.
Apresentação elaborada pela equipe de Conteúdo / Comunicação da #Turma6141 #PoloOsasco do #EsproOficial #EsproOsasco para o Conteúdo programático Empreededorismo Social.
How to build a reliable checkout experiencePedro Teixeira
The checkout experience is usually the one part of the application that delivers the most value, but unfortunately, it's the one that usually contains the most friction. We've all been victims of this: a checkout experience that has spinner that spins indefinitely, or one that warns you to not move a muscle while the next page is loading, or even one that makes a double reservation.
Now that you have your shiny new micro-services architecture running and you're able to deploy new features and fixes several times a day, how do you deliver complex transactions to your customers? How do you deliver payments, trip reservations or purchasing an entire shopping cart with a good user experience?
HTTP has taken us far, but it's probably not the best transport to deliver complex transactions like these, specially when these transactions are performed over flaky mobile networks. A lot of error-handling logic must fall on the client: How does the client react to timeouts? Or gateway problems? Can it assume the transaction failed with no fear of duplication? Can the transaction survive client crashes? Can the client solve all these existing edge cases without making it overly complex and bug-prone?
This talk proposes an original architecture style that will sit in front of your micro-service stack and that you can attach to any existing service back-end. The author will show an implementation of this architecture pattern: a proof-of-concept application and a set of client and server open-source libraries built on top of PouchDB, and Node.js.
The case for agile intranets - James DellowIntranet Now
The document discusses how to take an agile approach to building intranets. It advocates thinking like a product owner, prioritizing coherence over elegance, and taking an iterative approach focused on business and user needs rather than technology constraints. The document also addresses how to overcome fragmentation, presents an agile intranet manifesto, and discusses whether SharePoint can support an agile intranet.
QE-MAGAZINE n°30: les news en Principauté de Monaco by AMP MonacoMaria Bologna
QE-MAGAZINE n°30 de la Principauté de Monaco est désormais en kiosque à partir d'aujurd'hui pendent 15 jours // www.qe-magazine.com Quindicinale d'informazione dal Principato di Monaco, in vendita nelle edicole della Costa Azzurra e del Principato di Monaco
Presentation of the EUSOMII/ESOI annual meeting in Valencia, Oct. 2016, about the impact of new communication tools on the communication between radiologists, clinicians and patients
Learn more about premetered slot die coating methods for specialized applications. For further information visit http://www.slotdies.com/technical_content/technical_content.phtml for helpful articles
Sustaining the HIV and AIDS Response in the Countries of the OECS: Regional I...HFG Project
In 2014, the six countries of the Organization of Eastern Caribbean States (OECS) of Antigua and Barbuda, Dominica, Grenada, St. Kitts and Nevis, St. Lucia and St. Vincent and the Grenadines developed HIV and AIDS Investment Case Briefs, with the support of USAID’s Health Finance and Governance (HFG) and Strengthening Health Outcomes through the Private Sector (SHOPS) projects. This document provides a summary of the findings of these briefs, which includes an analysis of the costs of HIV and AIDS programs that respond to the disease in the six countries, the resources that are available, the funding gaps, and the potential impact of different levels of investment in programming on the progression of the disease in the region.
Sustaining the HIV/AIDS Response in Dominica: Investment CaseHFG Project
The document summarizes an analysis of the HIV epidemic and response in Dominica using the Goals model. Three scenarios were modeled: 1) maintenance of current programs, 2) scale-up to levels outlined in the national strategic plan, and 3) achieving 90-90-90 targets by 2020. The analysis estimates the impact on new infections, deaths, and people receiving ART under each scenario. It also projects the financial resources needed and potential funding gaps for Dominica's HIV response through 2020. The results are intended to help prioritize resource allocation and identify opportunities to improve the efficiency and impact of Dominica's national HIV/AIDS program.
An Assessment of PEPFAR partnership frameworks and Partnership framework impl...HFG Project
The document summarizes a study that assesses Partnership Frameworks (PFs) and Partnership Framework Implementation Plans (PFIPs) between PEPFAR and partner governments. It finds that the PFs/PFIPs advanced partnership dialogue and alignment between USG mandates and national priorities. They helped scale up high impact HIV interventions and identified focus areas around supply chain, domestic financing, and human resources. The process of developing the agreements engaged a wide range of partners and epitomized country ownership. However, sustainability challenges remain around continued domestic resource mobilization and health systems strengthening.
Hfg barbados costing community hiv final reportHFG Project
Barbados is currently experiencing tight fiscal constraints due to the slowdown of economic growth coupled with the fact that as a high-income country, it now no longer qualifies for concessional loan arrangements and grants from development partners. The President’s Emergency Plan for AIDS Relief (PEPFAR) has indicated a plan to reduce, and eventually cease, funding for HIV programs in Barbados, within the next two years. Given the current funding environment, the Ministry of Health and Wellness is looking for ways to continue financing the program through improved efficiency and by making evidence-based investments into cost-effective interventions. They are also seeking ways to identify new approaches to financing, which will allow continued health coverage and maintain the gains seen in the sector.
Civil society organizations (CSOs) began offering community-level HIV interventions in 2017, including testing, treatment, and social support to key populations. Some of these populations are highly stigmatized, so community outreach is perceived as necessary. Community-based services are expected to result in improved outcomes for these populations (e.g., reduced loss to follow-up and higher retention in care, improved adherence to treatment). This outreach could be particularly valuable in supporting the government’s adoption of the WHO-recommended Treat All strategy by helping to link persons living with HIV (PLHIV) to treatment and promote adherence.
This study assesses the cost of HIV-related services provision at the CSO level. It aims to benefit both the CSOs themselves and the government of Barbados. The government will be able to consider the results in deciding whether or how to allocate funds to CSOs to enable the CSOs to provide some key services when PEPFAR funding ceases. This study is one of several HFG activities implemented in four countries in the Caribbean to prepare the countries for donor transition.
Strategic Health Purchasing Progress: A Framework for Policymakers and Practi...HFG Project
This document presents a framework for assessing the progression of strategic health purchasing (SHP) functions in countries. The framework identifies core SHP functions and organizes them into stages that represent increasing maturity and integration. Case studies of Canada, Germany, and Tanzania are used to illustrate how the framework can visualize a country's SHP progression over time. The framework is intended to help policymakers and practitioners understand their country's SHP strengths and weaknesses to guide reforms.
Sustaining the HIV and AIDS Response in St. Vincent and the Grenadines: Inves...HFG Project
National surveillance reports estimate that there were about 649 persons living with HIV in St. Vincent and the Grenadines at the end of 2011, which translates to 1.2% of the adult population (15-49 years) or 0.7% of the total population. The epidemic is male-dominant, illustrated by the fact that the cumulative case reporting from 1984-2013 indicates that 60.6% of new cases are reported among males and 38.1% females (1.3% unknown). In response to the growing epidemic, the country quickly scaled up its national HIV/AIDS program in 2004. While care and treatment remains a high priority, St. Vincent and the Grenadines has devoted significant resources to preventative activities, including HIV counseling and rapid testing, education and workplace programs, and other behavioral interventions.
Despite a marked decline in HIV and AIDS cases, significant challenges for the country’s response remain. Close to 20% of persons with advanced HIV infection discontinue treatment within 12 months of initiation, suggesting the need to reinforce adherence and retention to care. The country also faces an imminent decline in donor funding and domestic reprioritization of chronic and non-communicable diseases; without renewed sources of external funding or greater domestic resources allocated to HIV/AIDS, progress made since 2004 could regress.
In response to these challenges, key priorities outlined in the country’s strategic framework (2014-2025) include: 1) institutionalizing HIV education through collaborative programs with different sectors, 2) targeting high risk groups, 3) strengthening HIV testing and counseling, including routine testing for pregnant women and, 4) ensuring access and retention to care and treatment for those with HIV and AIDS and TB. St. Vincent and the Grenadines has also taken steps to integrate HIV and AIDS services into the broader health system and included the HIV and AIDS program as part of the Ministry of Health, Environment and Wellness’ overall health framework. These actions are the beginning of efforts to improve access to care, reduce costs, and improve efficiencies.
Barbados 2012-13 Health Accounts ReportHFG Project
This report presents the findings and policy implications of Barbados’ first Health Accounts estimation, conducted for the year April 2012 to March 2013. It captures spending from all sources: the government, non-governmental organizations, external donors, private employers, private insurance companies and households. The analysis presented breaks down spending to the standard classifications, as defined by the System of Health Accounts 2011 framework, namely sources of financing, financing schemes, type of provider, type of activity and disease/health condition.
Sustaining the HIV/AIDS Response in Antigua and Barbuda: Investment Case BriefHFG Project
Antigua and Barbuda has made great strides in organizing its response to HIV and AIDS in recent years, and has managed to control the growth of the epidemic. The National AIDS Program (NAP) is now at a critical juncture as the country plans to adapt to the changing donor funding landscape, new clinical guidelines, strategic objectives, and changes in policy including greater program integration into primary care, which are designed to increase access and reduce the cost of service delivery.
This document provides analytic inputs that support a case for investment in the Antigua and Barbuda HIV and AIDS response. This report provides a quantitative analysis of trends in the HIV epidemic and the impact of various prevention and treatment efforts to date, along with a projection of possible future programming scenarios, their costs, and their implications for the epidemic. The report describes estimated funding available and gaps in funding that The Goals and Resource Needs models – part of the Spectrum/OneHealth modeling system that estimates the impact and costs of future prevention and treatment interventions – were used for this analysis.
South Africa HIV and TB Expenditure Review 2014/15 - 2016/17. Executive SummaryHFG Project
The South African Government (SAG) and its development partners have mounted a formidable response to the world’s largest HIV epidemic and a persistent burden of tuberculosis (TB), the country’s leading killer. Nearly 4 million South Africans initiated antiretroviral therapy (ART) by the end of financial year 2016/17, helping to curtail new infections and reduce the number of annual HIV-related deaths. Mortality from TB has also declined thanks, in part, to improved treatment success.
Despite progress, challenges remain. Roughly 3 million people living with HIV (PLHIV) lack treatment, and each year more than a quarter million are newly infected. Moreover, nearly a half million South Africans contract TB every year, with an increasing share affected by drug-resistant strains.
To effectively plan and steward the health system, the SAG routinely monitors programmatic and financial performance of the response to HIV and TB, including by tracking expenditure. Analysis of spending, including trends in sources, levels, geographic and programmatic distribution and cost drivers can help policymakers to assess whether resources are reaching priority populations, interventions, and hotspot geographies; to identify potential opportunities to improve allocative and technical efficiency; and to stimulate more productive dialogue at multiple levels of the system.
This review of HIV and TB expenditure in South Africa is an input to policy, planning and management processes within and amongst spheres of government and between government and development partners. The data have been especially useful to national and provincial programme managers as they perform their oversight functions, leading to improved spending of available resources. With 52 annexes, it also serves as an authoritative reference document detailing levels and trends in HIV and TB spending by the three main funders of the disease responses: the SAG, the United States Government (USG), primarily via the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund). The findings have informed South Africa’s report to the UNAIDS Global AIDS Monitor and the country’s forthcoming funding request to the Global Fund.
Alternative approaches for sustaining the HIV and AIDS response in Dominican ...HFG Project
The purpose of this report is to capture and consolidate the suggestions of the Sustainability Group for consideration by the Government of Dominican Republic (GODR) and other relevant stakeholders. GODR will be able to draw from this report when developing its HIV sustainability strategy, revising the National Strategic Plan for HIV (PEN), and developing other planning and policy documents.
Case study: Zambia Integrated Systems Strengthening Program (ZISSP)HFG Project
The Zambia Integrated Systems Strengthening Program (ZISSP) was a USAID-funded health systems strengthening project implemented from 2010-2014 in Zambia. ZISSP worked closely with the Ministry of Health and other partners to improve access and utilization of key health services. It used a whole-systems approach, focusing on strengthening specific program areas like HIV/AIDS, family planning, malaria, and maternal and child health. At the national level, ZISSP worked through technical working groups and with subcontractors to build capacity. It also decentralized training and seconded staff to provincial and district levels. In targeted districts, ZISSP improved community involvement through behavior change communication, small grants, and working
Getting Health’s Slice of the Pie: Domestic Resource Mobilization for HealthHFG Project
Many low- and middle-income countries have experienced strong economic growth in recent years, resulting in increased capacity for social sector spending. Net energy importers have further benefited from falling fossil fuel prices. At the same time donors are preparing to scale back development assistance, including support for global health initiatives. Responding to a lack of practical guidance on how countries can mobilize more domestic resources for the health sector, the Health Finance and Governance (HFG) project organized a series of joint learning workshops to promote knowledge exchange, share new and existing resources, and support countries in a DRM-for-health action planning process.
The Health Finance and Governance Briefing KitHFG Project
Resource Type: Brief
Authors: Megan Meline, Lisa Tarantino, Jeremy Kanthor, and Sharon Nakhimovsky
Published: September 2015
Resource Description: Getting access to affordable, quality health care is a universal story that touches virtually every family in the world. At the same time, providing quality health services and access to trained health professionals is a challenge for governments. The World Health Organization (WHO) estimates that 150 million people worldwide face “catastrophic expenditure” because of high costs of health care. In other words, they may have to forgo paying for basic needs, such as food, housing, or education to pay for medical treatment instead. These costs include transportation, doctors’ fees, medicine, hospitalization bills, and days lost from work.
Behind these sobering statistics lies a wealth of news and feature stories waiting for the media to investigate and share with national leaders and policymakers as well as civil society groups who can advocate for changes to health budgets and policies. At the heart of these stories are important questions about the financing of health care and the quality of governance that ensures responsive and effective management of those resources and services.
But writing health finance and governance stories can be challenging. Health finance is riddled with complex language, technical economic terms, and numbers – not necessarily a journalist’s comfort zone. The right sources for these stories can be difficult to identify and unwilling to talk. Data may be difficult to locate or to understand. And while corruption makes for splashy headlines, the broader systemic challenges of health governance are not widely understood — and yet they are important.
The Health Finance and Governance Briefing Kit is designed to help journalists and their editors uncover and tell these important health stories that affect people all around the world.
The Health Finance and Governance Briefing KitHFG Project
The Health Finance and Governance Briefing Kit is designed to help journalists and their editors uncover and tell these important health stories that affect people all around the world.
Evaluating the Costs and Efficiency of Integrating Family Planning Services i...HFG Project
Integrating the delivery of health services is viewed as a priority in the fight for an AIDS-free generation, because this integration has the potential to improve access to HIV, family planning (FP), and other services and provide continuity of care for those living with HIV. At the request of USAID’s Office of HIV/AIDS and the USAID Zambia mission, the Health Finance and Governance (HFG) project conducted a study examining the costs and efficiencies involved in integrating family planning and antiretroviral therapy (ART) services.
Measuring Technical Efficiency of the Provision of Antiretroviral Therapy Amo...HFG Project
Botswana has made great strides in combating the HIV epidemic. Deaths due to AIDS have declined dramatically since 2005 (UNAIDS 2014; 2016) and the country is on its way to achieving its 90-90-90 targets. As Botswana implements its ambitious Treat All Strategy and expands treatment to nearly 330,000 people living with HIV, the country will need to critically assess its efficient use of all available resources to sustain gains and continue progress towards an AIDS-free generation. To support the Ministry of Health with evidence regarding the efficiency of antiretroviral therapy (ART) service delivery, the USAID-funded Health Finance and Governance project estimated the overall and component-specific costs and utilization figures of adult outpatient ART care at Botswana’s public health facilities.
Describing the new CDCF project for tagging Systematic reviews - synergistic plan with the MASCOT (Multilateral Association for Studying Health Inequalities and Enhancing North-South And South-South Cooperation – is funded by the European Commission under the Seventh Framework Programme for Research and Technological Development (FP7).f7th project
Capital Investment in Health Systems: What is the latest thinking?HFG Project
Capital investment in health typically refers to large expenditures in construction of hospitals and other facilities, investment in diagnostic and treatment technologies, and information technology platforms. These investments are characterized by their longevity and they are critical to efforts to improve healthcare quality and efficiency. Contrary to developed countries where there is well documented experience on capital investment in the health sector, including use of public private partnerships for the investment; there is little evidence on capital investment in health from low and middle income countries.
This work was undertaken to add to the HFG’s knowledge and learning strategy by clarifying what good practice guidance exists in capital benchmark in LMICs health sectors, as well as the HFG project’s experience in the area. This brief will be of value to all those interested in the planning and financing the capital investment in the health sector. This includes politicians, planners, managers, health professionals, architects, designers, and researchers in both the public and private sectors.
Similar to HFG Rapid Assessment of TB Payment and PFM Systems in Cambodia: Lessons Learned and Policy Implications (20)
This document outlines a training manual for a hospital costing workshop. It provides an agenda for the 3-day workshop covering topics like the fundamentals of costing, the MASH costing tool, and calculating unit costs. The workshop aims to teach participants how to conduct costing exercises to understand their hospital's costs and improve management. Sessions include introductions, an overview of costing concepts, the costing process, and a demonstration of the MASH tool which is an Excel-based framework for tracking and analyzing hospital resources, services, and costs.
Trinidad and Tobago 2015 Health Accounts - Main ReportHFG Project
This document summarizes the key findings of the 2015 health accounts report for Trinidad and Tobago. It finds that total health expenditure was 4.5 billion TT dollars in 2015, equivalent to 4.1% of GDP. The government financed 41% of health spending, while households financed 35% through direct out-of-pocket payments. Noncommunicable diseases accounted for the largest share of recurrent health spending at 42%. Out-of-pocket payments remain high, comprising over a third of total health expenditure. The report recommends strengthening government commitment to health financing, increasing risk pooling to reduce out-of-pocket spending, improving access to services, and institutionalizing ongoing health accounts estimations.
Guyana 2016 Health Accounts - Dissemination BriefHFG Project
The 2016 Guyana Health Accounts study found that:
1) Total health expenditure in Guyana was $28.6 billion (Guyanese dollars), with the government contributing 81% of funding.
2) The majority (71%) of health funds were spent on public health facilities like hospitals and clinics.
3) Most funds (64%) were spent on curative care services, while non-communicable diseases received the largest share (34%) of funds.
4) Government funding represents the largest source of financing for HIV/AIDS programs and services in Guyana, providing 62% of funds.
Guyana 2016 Health Accounts - Statistical ReportHFG Project
The document provides an overview of Guyana's 2016 Health Accounts methodology. It summarizes key aspects of the System of Health Accounts 2011 framework used, including boundaries, classifications, and definitions. Data was collected from government, households, NGOs, employers, insurers, and donors to track financial flows for health for 2016. The results help understand Guyana's health financing and answer questions on spending patterns.
Guyana 2016 Health Accounts - Main ReportHFG Project
The document summarizes the key findings of Guyana's first Health Accounts exercise for fiscal year 2016. It found that total health expenditure was G$ 28.6 billion, with the government contributing 81% of funding. Household out-of-pocket spending accounted for 9% of total spending. Non-communicable diseases received the largest share of spending at 34%. The analysis aims to inform strategic health financing decisions and assess domestic resource mobilization as external donor funding declines. Recommendations include increasing prevention spending and strengthening financial commitment to HIV programs.
The Next Frontier to Support Health Resource TrackingHFG Project
The document discusses challenges and opportunities for institutionalizing health resource tracking (HRT) in low- and middle-income countries. It identifies three key elements needed for institutionalization: strong demand for HRT data; sustainable local capacity to produce HRT data; and use of HRT results in policy and decision making. It outlines remaining challenges in each area and suggestions for future investments to address challenges, such as building understanding of HRT's value, maintaining local expertise, improving health information systems, and strengthening communication and use of HRT findings.
Rivers State has a population of over 7 million people from various ethnic groups. The main occupations are fishing, farming, and trading. The state has high rates of tuberculosis, neonatal and under-5 mortality, and HIV prevalence. Key stakeholders in health include the Ministry of Health, Ministry of Finance, and various agencies. The USAID Health Finance and Governance project worked to increase domestic health financing through advocacy, establishing a health insurance scheme, and capacity building. These efforts led to increased health budgets, establishment of healthcare financing units, and improved sustainability of health financing in Rivers State.
ASSESSMENT OF RMNCH FUNCTIONALITY IN HEALTH FACILITIES IN BAUCHI STATE, NIGERIAHFG Project
This document summarizes an assessment of reproductive, maternal, newborn and child health (RMNCH) services in health facilities in Bauchi State, Nigeria. It found that infrastructure like electricity, water and toilets were lacking in many facilities. There were also shortages of skilled healthcare workers, especially midwives, and staff training. While many facilities offered antenatal care and immunizations, availability of emergency obstetric and newborn care and services like postnatal care and post-abortion care were more limited. Supplies of essential medicines, equipment and guidelines were also often inadequate. Community outreach was provided by some facilities but could be expanded.
BAUCHI STATE, NIGERIA PUBLIC EXPENDITURE REVIEW 2012-2016 HFG Project
This document summarizes a public expenditure review of health spending in Bauchi State, Nigeria from 2012 to 2016. It finds that while Bauchi State's health budget increased over this period, actual health spending lagged behind budgeted amounts. Specifically, health spending accounted for a small and declining share of the state's total budget and expenditure. The review recommends that Bauchi State increase and better target public health funding to improve health outcomes and progress toward universal health coverage goals.
HEALTH INSURANCE: PRICING REPORT FOR MINIMUM HEALTH BENEFITS PACKAGE, RIVERS ...HFG Project
This document provides a pricing report for a Minimum Health Benefit Package (MHBP) being developed by Rivers State government in Nigeria. It analyzes the cost of 6 scenarios for the package, including individual and household premiums, based on medical claims data from hospitals in Rivers State from 2014-2017. The recommended annual premiums range from N14,026 to N111,734 for individuals and N79,946 to N636,882 for households, depending on the benefits included and the percentage of the state's population covered. The report provides context on data sources and actuarial assumptions used to determine the premiums.
The document is an actuarial report for Kano State's contributory healthcare benefit package in Nigeria. It analyzes 4 scenarios for the package - a basic minimum package alone or plus HIV/AIDS, tuberculosis, or family planning services. The report finds that the estimated annual premium per individual would be between N12,180-N12,600 depending on the scenario, while the estimated annual premium per household of 6 would be between N73,081-N75,595. It provides these estimates by analyzing the state's population data, healthcare facilities, utilization rates, and costs to determine the risk premiums, administrative costs, marketing costs, and contingency margins for each scenario. The report recommends rounding the premium estimates and includes
Supplementary Actuarial Analysis of Tuberculosis, LAGOS STATE, NIGERIA HEALTH...HFG Project
This document provides an actuarial analysis of including tuberculosis (TB) coverage in the Lagos State Health Scheme in Nigeria. It analyzes 3 different TB treatment regimens and estimates the additional premium required. Based on historical TB case data from 2013-2016, it projects the number of cases and costs for the next 3 years. The analysis finds the additional premium to be 488.79 Naira on average per person to cover TB screening tests and the 3 treatment regimens. It acknowledges limitations in the source data and outlines key assumptions made in the projections.
Supplementary Actuarial Analysis of HIV/AIDS in Lagos State, NigeriaHFG Project
This document provides a supplementary actuarial analysis of including HIV/AIDS coverage in the Lagos State Health Scheme benefit package in Nigeria. It estimates the total additional medical cost to cover HIV/AIDS services would be 209.40 Naira per person per year, broken down into costs for HIV testing and counseling (13.60), antiretroviral therapy (133.05), and preventing mother-to-child transmission (15.96). The analysis is based on HIV service data from 2012-2016 and projected population and drug cost data from the Lagos State Ministry of Health. It assumes a 90% continuation and conversion rate for antiretroviral therapy and a 6.5% annual medical cost trend.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
share - Lions, tigers, AI and health misinformation, oh my!.pptx
HFG Rapid Assessment of TB Payment and PFM Systems in Cambodia: Lessons Learned and Policy Implications
1. July 2016
This publication was produced for review by the United States Agency for International Development.
It was prepared by Matt Kukla of the Health Finance and Governance Project.
HFG RAPID ASSESSMENT OF TB
PAYMENT AND PFM SYSTEMS IN
CAMBODIA: LESSONS LEARNED AND
POLICY IMPLICATIONS
3. HFG RAPID ASSESSMENT OF TB
PAYMENT AND PFM SYSTEMS IN
CAMBODIA: LESSONS LEARNED AND
POLICY IMPLICATIONS
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency
for International Development (USAID) or the United States Government.
4. i
CONTENTS
Contents .................................................................................................................... i
Acronyms.................................................................................................................. 3
Acnowledgements................................................................................................... 4
1. Background ............................................................................................... 5
1.1 Problem Statement..............................................................................................................5
1.2 General Activity Description............................................................................................5
2. Objectives and Methodology................................................................... 6
2.1 Country Objectives and Outcomes ...............................................................................6
2.2 Methodology .........................................................................................................................7
3. TB Pooling and Funding Flows ............................................................... 8
3.1 Overview................................................................................................................................8
3.2 Issues.....................................................................................................................................10
4. Public Sector TB Financing................................................................... 12
4.1 MoH Roles and Responsibilities ....................................................................................12
4.2 Public Financial Management and Budgeting...............................................................14
5. TB Strategic Purchasing: Health Equity Funds .................................. 17
5.1 Accreditation/Contracting ..............................................................................................17
5.2 Benefit Package...................................................................................................................18
5.3 Provider Payment Mechanisms......................................................................................20
5.4 Prices.....................................................................................................................................21
5.5 Cost Sharing........................................................................................................................23
5.6 Claims/Reimbursement....................................................................................................24
5.7 Referrals ...............................................................................................................................25
Annex A: Stakeholders Interviewed by HFG..................................................... 27
Annex B: Bibliography .......................................................................................... 29
List of Tables
Table 1: Total Health Expenditures, by Year and Source...........................................................8
Table 2: Case Rates by Care Type and Facility Type .................................................................21
List of Figures
Figure 1: TB Funding Flows, by Source and Destination.............................................................9
Figure 2: NTP Funding, by Source and Year.................................................................................10
Figure 3: NTP Funding, by Line Item and Year ............................................................................15
5. 3
ACRONYMS
CENATNational Center for TB and Leprosy Control
DPHI Department of Planning and Health Information
DRG Diagnostic-Related Group
HEF Health Equity Fund
HEF-O Health Equity Fund Operators
HFG Health Finance and Governance project
MDR Multi-Drug Resistant
MoEF Ministry of Economy and Finance
MoH Ministry of Health
NSSF National Social Security Fund
NTP National TB Program
OD Operational District
PFM Public Financial Management
PFMRP Public Financial Management Reform Program
PHD Provincial Health Department
PMRS Patient Medical Record System
PPM Public-Private Mix
SOA Special Operating Agency
UHC Universal Health Coverage
USD United States Dollar
TB Tuberculosis
URC University Research Company, LLC
USAID United States Agency for International Development
XDR Extremely Drug Resistant
6. ACNOWLEDGEMENTS
The authors would like to acknowledge USAID Cambodia for facilitating meetings with stakeholders in Cambodia.
None of the key informant interviews with ministry officials or development partners would have been possible
without their time, networks, and collaboration. Special thanks also go to University Research Company, which
was a critical reference for HFG during its in-country assessment and whose TB expertise in Cambodia was
invaluable. Finally, HFG would like to thank the individuals who took their time to meet with HFG and share their
knowledge and experience on TB financing/purchasing issues.
7. 5
1. BACKGROUND
1.1 Problem Statement
Despite substantial funding for tuberculosis (TB) prevention and treatment over the last 10 years, both by
donors and governments, the worldwide incidence of TB remains troubling. Across lower- and middle-
income countries, access to TB services is limited, and the quality of TB services is often substandard.
Many countries face questions over the long-term financial sustainability of their efforts to prevent and
treat the disease.
Cambodia has one of the highest rates of TB in the world, with prevalence and incidence rates sitting at
roughly 660 and 437 per 100,000 people, respectively (WHO 2015). Meanwhile, donor funding for TB is
declining, the government is struggling to generate new resources for TB, and out-of-pocket spending still
accounts for a significant share of health and TB expenditures. Cambodia needs to identify mechanisms to
improve the efficiency of TB spending (i.e., mechanisms for spending money wisely). In the short term,
this may mean finding ways to improve outputs – such as access, use of services, and quality – for a given
level of spending on TB. In the long term, Cambodia and countries facing similar challenges may be
interested in finding ways to achieve better outputs with fewer resources.
Global evidence suggests that increased TB costs, inequitable access to care, lower rates of case detection
and case holding, worse treatment outcomes, and an increased burden of disease due to TB – including
the increasingly prevalent multi- and extremely drug resistant TB (MDR-TB and XDR-TB) – are often tied
to gaps in the continuum of TB service delivery, inadequate coordination of policies across payers, and
weak financial incentives for health care providers (Figueras et al. 2005, Langenbrunner et al. 2009).
1.2 General Activity Description
The Health Finance and Governance (HFG) project’s TB strategic purchasing activity is intended to better
target country health budgets and national health insurance funds toward priority TB services and the
poor. The three health financing functions are revenue collection, pooling, and purchasing. Revenue
collection concerns the source of funds and level of funding. Pooling is the accumulation of pre-paid
revenues on behalf of a population, and purchasing is the transfer of pooled funds to providers on behalf
of a population. Strategic purchasing focuses on the purchasing function, specifically provider payment and
public financial management (PFM) systems. While not discounting private investment, the activity focuses
on public funding, as it is critical for public health services (such as TB services). Public funding can be used
to buy services from both public and private providers, and is best suited to increase access for the poor.
The HFG TB strategic purchasing activity contributes to increasing technical efficiency – that is, achieving
the maximum possible improvement in outcomes from a set of resource inputs – and allocative efficiency,
which refers to allocating resources in a way that maximizes the welfare of a society. The strategy achieves
this by identifying ways, both globally and within countries, to improve financial incentives to providers,
reduce PFM barriers, and increase provider autonomy. If the nature of provider payment and PFM systems
creates conflicting financial incentives, or barriers to spending money wisely and improving TB service
delivery, those conflicting incentives and/or barriers should be removed.
8. 2. OBJECTIVES AND METHODOLOGY
2.1 Country Objectives and Outcomes
Cambodia was the subject of one of several country case studies linking strategic TB purchasing with
improved efficiency and better outcomes. In May/June 2016, HFG conducted a brief but in-depth
assessment of health purchasing/provider payment and PFM systems in Cambodia, to identify rigidities and
barriers. The assessment had a twofold purpose:
1. HFG would observe and learn from key stakeholders in Cambodia, with the aim of synthesizing
information on PFM barriers and provider payment bottlenecks.
2. Where these issues were not already being addressed, HFG would make recommendations for
removing barriers and bottlenecks.
The following outcomes were to be achieved through this assessment:
University Research Company (URC);
Department of Planning and Health Information (DPHI), Ministry of Health (MoH)
1. HFG learned from URC and DPHI about:
a. The benefits and limitations of the Health Equity Funds’ (HEFs’) existing provider payment
system as it pertains to primary, outpatient, and inpatient services.
b. Gaps in TB service delivery that HEFs are currently targeting or would like to.
c. Improvements that HEFs are making in TB service delivery, and mechanisms by which public
providers are being incentivized to make these improvements.
2. HFG assessed whether and to what extent
a. There is potential to refine the HEFs’ provider payment system.
b. Improvements in the HEFs’ provider payment mechanisms are needed to coordinate and align
incentives among contracted public providers.
c. There is potential to improve the HEFs’ information and operating systems (PMRS) which,
through the collection of patient/provider data, are used to purchase TB services.
National Center for TB and Leprosy Control (CENAT), MoH
1. HFG learned from CENAT about:
a. The benefits and limitations of TB financing in Cambodia, with a focus on PFM barriers to
purchasing public or individual TB services. This would include purchasing mechanisms, level
and flow of funding, budget formation, payments to and contracting of providers, and financial
management.
2. HFG assessed whether and to what extent
a. Improvements could be made in how TB services are financed, with a focus on budgeting
processes and purchasing.
Both DPHI and CENAT
1. Through meetings with development partners (e.g., URC) and health providers, HFG learned about:
9. 7
a. Conflicting roles of and relationships between CENAT and HEFs as they pertain to purchasing
of TB services;
b. The extent to which TB service purchasing mechanisms by CENAT and HEFs create gaps in
the TB continuum of care and possible solutions for filling these gaps;
c. The extent to which conflicting financial incentives stem from differences in CENAT and HEFs
purchasing mechanisms and payment systems;
d. Public providers’ satisfaction with existing payment mechanisms and rates for TB services;
a. Obstacles providers face with regard to existing payment mechanisms and information
systems; and
b. PFM and purchasing improvements that could help health care providers deliver higher-quality
TB services more efficiently and effectively.
2.2 Methodology
Data for this assessment came from three sources:
1. Key informant interviews
2. Policy documents
3. Secondary data
Key informant interviews were conducted with the MoH (DPHI and CENAT) and development partners.
Data from public providers were also collected so as to better understand how issues associated with TB
financing impact TB service delivery. Annex A provides the complete list of interviewed stakeholders.
Policy documents included guidelines and circulars published by the government, assessments conducted
by development partners, and peer-reviewed journal articles related to TB purchasing in Cambodia.
Sources of secondary data included TB and health expenditure data published in National Health Accounts
reports as well as publicly available data from the World Health Organization and World Bank.
10. 3. TB POOLING AND FUNDING FLOWS
3.1 Overview
Risk pooling constitutes one of the three health financing functions. It refers to the consolidation of pre-
paid funds by individuals; that is, funds that are pooled prior to the point of service and ultimately used to
purchase health services on behalf of the enrolled or covered population. There are several common
modes of risk pooling for health: social health insurance; private health insurance; public financing (via
general tax revenues) at national or locals levels; and community-based health insurance (WHO 2010).
For many low- and middle-income countries, such as the Philippines, TB financing is also pooled by donors.
Pre-payment is an important component of improving financial risk protection and a critical component
of Universal Health Coverage (UHC). UHC is intended to provide equity in coverage and efficiency in
health spending (Boerma et al. 2014; McIntyre and Kutzin 2016). Pre-payment allows consumer payments
for health care to be more predictable and spread across time, rather than incurred at the time of illness.
Put another way, pre-payment increases the odds that lack of financial resources at the time of need does
not cause people to forfeit care (Wagstaff et al. 2015; Wagstaff et al. 2014). Pooling can also spread
financial risk across population groups and allow cross-subsidization between the rich and the poor, the
healthy and the sick, and the employed and unemployed. Pre-payment and pooling can address equity and
risk within a single risk pool, or across risk pools if the financing structure allows for this. The degree of
equity enhancement and risk reduction depends on the particular arrangements of the financing
mechanisms in place. Finally, more consolidated risk pooling can improve efficiencies by reducing
administrative costs, fragmentation in purchasing, and prices for health services.
Table 1 presents total health expenditures, by source, in Cambodia from 2012 to 2014 (WHO 2015).
Total health expenditures remained stable during the three-year period, rising from USD 1.032 billion in
2012 to USD 1.057 billion in 2014. This was driven by increased government spending (USD 199 million
to USD 210 million) and out-of-pocket expenditures (USD 622 million to USD 658 million). Donor
spending fell over this period (USD 209 to USD 188 million), as did private health insurance spending
(USD 2.4 million to 0). However, as a percentage of total health expenditures, government spending
remained between 19 and 20 percent, while the rise in out-of-pocket spending offset the decline in donor
spending. Government spending is funded by both general tax revenue and social health insurance; the
latter consists of HEFs for the poor and the National Social Security Fund (NSSF) for the formal, private
sector. In addition to direct funding to the government, donors and NGOs also finance social insurance
funds such as HEFs and community-based health insurance schemes.
Table 1: Total Health Expenditures, by Year and Source
Source of Revenue
2012 2013 2014
Amount
(USD
million)
Share of
total (%)
Amount
(USD
million)
Share of
total (%)
Amount
(USD
million)
Share of
total (%)
Government 199.10 19.3 218.20 20.5 210.00 19.9
Donor and NGOs 209.00 20.2 183.00 17.2 188.70 17.9
Out-of-pocket
expenditure
622.20 60.3 662.30 62.3 658.50 62.3
Health insurance 2.40 0.2 1.70 0.2 0.00 0.0
11. 9
Total 1032.7 100 1065.2 100 1057.2 100
The sources and flow of funding to health care providers for TB are presented in Figure 1. Public health
care providers obtain funding that can be used for TB services from three sources: the MoH (via the
National Tuberculosis Program, or NTP), HEFs, and out-of-pocket payments. The MoH (via the NTP)
cover’s Cambodia’s entire public TB system and is the primary source of public financing for TB. In addition
to funding, it provides technical assistance, drugs, supplies, and staff to public facilities. Public facilities also
receive reimbursements from HEFs for TB and general health services delivered to enrolled members
(the poor). Finally, public health facilities can collect user fees from non-TB patients and spend that revenue
on TB service delivery (at the facility’s discretion). Private health insurance, community-based health
insurance, and the NSSF do not currently cover TB and are thus not included in the diagram below
(MoLVT 2016).
Figure 1: TB Funding Flows, by Source and Destination
Funds for TB only flow to private health care providers by way of patient out-of-pocket spending, which
accounts for nearly all of a private facility’s revenue. Because it is illegal for private facilities or pharmacies
to deliver TB services or sell TB drugs, any formal TB treatment (post-diagnosis) must occur in the public
sector. A 2014 CENAT report nonetheless suggests that roughly 75 percent of TB suspects first seek
treatment for TB symptoms in the private sector (MoH 2014a). This figure may actually underestimate
private sector TB utilization rates. Data from the same report highlight that the private sector contributed
only 6 percent of all TB cases in operational districts (ODs), which are local governments (MoH 2014a).
It is therefore likely that a substantial number of TB patients continue to receive treatment in the private
sector, because they are never formally diagnosed with TB and referred to public facilities.
TB spending thus originates from three of the four primary sources cited in Table 1: donors, government,
and out-of-pocket expenditures. As previously mentioned, with the exception of HEFs, health insurers do
not cover TB. Data on total TB expenditures, by source, are limited and thus it is difficult to compare
those expenditures with trends in total health expenditures. According to Figure 2, the NTP had a budget
of roughly USD 8-9 million in 2013, USD 11-12 million in 2014, and USD 18.5 million in 2015. Only 10-
20 percent of the NTP’s budget comes from the MoH, while the remaining 80-90 percent of the budget
comes from grants and donors (e.g., Global Fund) (WHO 2015). Financing for HEFs is also split between
donors and government. Government spending on health overall accounts for 20 percent of total health
expenditures; government spending on TB is therefore a lesser percentage of total TB spending, and donor
funding for TB is a greater percentage. Out-of-pocket expenditures on TB are not known; they likely
12. account for a non-trivial portion of total TB spending given the large amount of undiagnosed TB care that
occurs in the private sector as well as evidence from an upcoming URC study (URC 2016).
Figure 2: NTP Funding, by Source and Year
3.2 Issues
While risk pooling is not the focus of this report, the implications of risk pooling on TB purchasing, care
coordination, and health system performance are likely significant. There are two issues of concern in
Cambodia.
1) Neither HEFs nor the MoH contract with private providers to deliver TB services or drugs, nor have
they implemented comprehensive reforms to encourage private providers to refer TB patients to the
public sector (this will be discussed later in the report). The absence of policies persists despite the
fact that roughly 70 percent of all health care utilization occurs in the private sector.
2) Global evidence suggests that fragmented financing systems, including those involving TB, often result
in provider payment systems that are not coordinated across payers (Langenbrunner et al. 2009;
Gottret et al. 2008). Compared with some of its regional counterparts (e.g., the Philippines and
Indonesia), Cambodia has fewer health insurers and public financing is less decentralized. Nonetheless,
TB expenditures still vary across provinces and ODs given different priorities for where and how
much is spent on TB. Such priorities will ultimately impact the incentives and capacity of public
providers to deliver and coordinate TB services (Annear et al. 2013).
Moreover, the Ministry of Economy and Finance (MoEF), in collaboration with the MoH, Ministry of
Labor, and Ministry of Social Affairs, is developing a Social Health Protection framework. Through this
framework a short-, medium-, and long-term health financing strategy for achieving UHC will be
developed. It is likely that other insurance schemes (e.g., NSSF) will be developed to cover specific
populations, some of which may be tasked with covering TB. Such has been the path of neighboring
countries, including Vietnam, Thailand, and the Philippines. Under such a scenario, Cambodia will need
to carefully design these schemes to ensure that fragmented risk pooling for TB does not hinder key
outcomes/outputs.
The absence of private sector engagement and fragmented risk pooling will likely have three effects on
health system performance as it relates to TB. First, these issues could lead to conflicting provider
incentives that accentuate inequities in access to and utilization of TB services. They may already be driving
variation in case detection rates and treatment success rates. Second, if upcoming social health protection
reforms do result in multiple insurers that cover TB and are not coordinated, inefficiencies in TB spending
would almost certainly be created (Langenbrunner et al. 2009; Gottret et al. 2008). Finally, they probably
13. 11
contribute to the growing share of out-of-pocket costs for TB care, which in turn can limit financial risk
protection.
14. 4. PUBLIC SECTOR TB FINANCING
4.1 MoH Roles and Responsibilities
4.1.1 Overview
The NTP covers Cambodia’s entire public TB system, including CENAT, 25 provincial and city health
departments, 82 ODs, and 1,325 health facilities (MoH 2014a). The latter include 86 referral hospitals and
1,215 health centers and health posts, as well as national hospitals. Leadership and managerial responsibility
for the NTP lies with CENAT, which is responsible for developing policies and plans, training, supervision,
monitoring and evaluating the NTP, drug procurement for the country, and coordinating with other
partners supporting the NTP (MoH 2014a). Provincial governments are responsible for all TB services in
the province, especially planning, training, coordination and supervision of the ODs, TB microscopy
centers, and health centers. ODs are tasked with maintaining the OD TB registry; planning, training,
coordinating, and supervising health centers; and interacting with the clinical TB teams. ODs have referral
hospitals, which have TB units with beds, a few TB staff, and TB microscopy centers.
Public health facilities, which include health centers, referral hospitals, and national hospitals, are managed
by the MoH (MoH 2014a). The MoH thus provides TB drugs, supplies, and staff salaries to public facilities
(URC 2016). In general, public facilities must allocate resources by line item; that is, they are not allowed
to shift resources across line items. However, the MoH has implemented a number of incentive schemes
that are exceptions to this rule. They include:
1. To incentivize public providers to capture new TB cases and improve TB service delivery, the MoH
had been offering salary bonuses to TB staff and supplemental funding for outreach initiatives. These
pay-for-performance initiatives have largely disappeared (URC 2016). However, MoH guidelines allow
public facilities to distribute 60 percent of their revenue as staff incentives. Facility revenue comes
from user fees, insurance reimbursements, MoH budgets, and donors. Moreover, 39 percent of this
revenue must be spent on improving health facility quality (e.g., infrastructure), while another 1
percent is given to the national budget. The MoH has provided a resource allocation formula for public
facilities, though they also are free to determine their own formula. Guidelines stipulate only that
incentives cannot vary across staff by more than 2-3 times (MoH 2014b). As such, variation exists
across facilities in how funds are allocated.
2. In 2005, the MoH launched a Public-Private Mix (PPM) strategy to engage private providers and
stimulate greater case detection rates and better care coordination across sectors (MoH 2014a).
Specifically, in 2007, a Private-Public Mix Directly Observed Therapy, Short course (PPM-DOTS) was
established in 35 ODs and in 16 garment factories. The first phase set up referral mechanisms for
private facilities and pharmacies to refer TB suspects to the public sector for diagnosis and treatment.
The second phase aimed to allow private providers to play a more active role in TB diagnosis and
treatment.
3. In 2010, the MoH implemented a pilot whereby local governments from 20 ODs could internally
contract with public health facilities. These local governments, called Special Operating Agencies
(SOAs), have semi-autonomous status within the MoH; the MoH signs an agreement with provincial
15. 13
health departments (PHDs), which in turn contract the SOAs. The SOAs then manage the
performance-based contracts with public facilities. These contracts allow public facilities greater
managerial autonomy to hire/fire staff and allocate finances, labor, and capital where needed.
Facilities must adhere to three constraints: no under-the-table payments, no pilfering of clients or
conduct of private services in the public facilities, and no stealing of drugs and medical supplies from
public facilities (Khim and Annear 2013). Financial incentives are paid by the SOA (i.e. OD) in full when
the facilities’ performance targets are achieved and are reduced when the level of achievement falls
short. Unlike funding to standard ODs, funding to SOAs comes from three sources: MoH line-item
budgets, user fees and HEF/community-based health insurance reimbursements, and a service delivery
grant from donors. These account for roughly 50 percent, 10 percent, and 40 percent of total SOA
funding, respectively.
4.1.2 Issues
1) Provider Autonomy: Initiatives such as SOAs and the staff incentive resource allocation formulas have
proven highly successful in Cambodia. However, no steps have been taken to roll out SOAs nationally
or to completely contract-out public service (Khim and Annear 2013). Most public facilities lack the
managerial autonomy to move funds across budget line items and shift resources (e.g., hiring and firing
staff, setting wages, procuring supplies). The implications of these restrictions are twofold: (a) public
facilities face increased administrative and service delivery costs, which in turn drive inefficiencies in
health spending; and (b) facilities cannot align capital and labor in ways that effectively meet patient
demand (e.g., by delivering essential TB services and drug to patients). For instance, if a facility’s budget
for certain medical supplies has been spent, and demand for TB services that require the use of those
medical supplies is high, facilities will not be able to use existing funds to purchase the needed supplies.
In the absence of organizational and managerial autonomy, the clinical quality of TB services may
decline and patient access to such services may be inhibited (Kutzin et al. 2010).
2) Performance Incentives: The MoH has designed and implemented a number of provider payment
incentives aimed at improving the performance of public facilities. Unfortunately, no schemes exist
that explicitly encourage public facilities to capture new TB cases and improve the quality of TB service
delivery. Three examples highlight this point:
a) SOAs offer financial incentives to public facilities for achieving performance targets, but these
targets are not specific to TB.
b) Pay-for-performance initiatives aimed at improving TB outreach have largely ended.
c) HEF reimbursements and user fees incentivize facilities to treat more patients; however,
payments are not based on a patient’s diagnosis and thus provide no incentive for facilities to
target TB patients. (See Section 5.)
3) Public-Private Collaboration: Cambodia’s PPM strategy addresses a critical obstacle to better TB
case detection rates and should be expanded. However, the strategy does not include financial
incentives to private providers for referring TB-suspect patients to public facilities. This has almost
certainly limited the program’s effectiveness, as has been noted in several, high-level presentations in
Cambodia. Global evidence suggests that financial incentives can dramatically increase providers’
willingness to refer patients (Langenbrunner et al. 2009). In the absence of such incentives, patient
referrals will only reduce the total revenue brought in by those facilities. In the case of TB, providers
will also be less active in searching for TB cases. Public and private health insurers in the Philippines,
Indonesia, Vietnam, Thailand, and China have addressed this issue through provider payment reforms.
16. 4) Purchaser-Provider Split: A purchaser-provider split is a joint health financing and service delivery
model in which the payer (typically a third-party entity, such as a national health insurer) is kept
organizationally separate from contracted health care providers. The purpose of this split is to
improve competition among service providers and enhance purchasing incentives, which can lead to
improved service delivery and achieve strategic objectives such as cost containment, better clinical
quality and responsiveness, and greater efficiency and organizational/management autonomy
(Tynkkynen et al. 2013; Gottret et al. 2008). While often applied to third-party payers, a purchaser-
provider split model is equally relevant to public entities such as the MoH. Global evidence suggests
that in the absence of this split, weak accountability mechanisms can further hinder the above health
system objectives (Savedoff and Gottret 2008). In Cambodia, the MoH lacks both a purchaser-
provider split and many of the necessary accountability mechanisms (audits, quality assurance systems).
It is unlikely that such a split is politically feasible or technically desirable at present; however, it may
become a growing concern as Cambodia’s health care system matures (Bossert et al. 1998).
4.1.3 Recommendations
Policy Recommendations for MoH Roles/Responsibilities
The MoH should consider strategies (e.g., expand SOAs; allow facilities to shift funding across
line items) for increasing the organizational and managerial autonomy of public health facilities.
The MoH should consider purchasing schemes, such as pay-for-performance initiatives, that
improve provider incentives to identify new TB cases and improve the quality of TB service
delivery.
To improve the effectiveness of Cambodia’s PPM strategy (i.e., increase TB referrals), the MoH
should consider financial incentives for private facilities and pharmacies.
In regard to the first recommendation, greater financial autonomy would be a critical step toward both
output-based purchasing and a purchaser-provider split in the public health sector. It would improve the
efficiency of health and TB spending by allowing facilities to allocate inputs in a way that minimizes costs
while maximizing service delivery outputs/outcomes. As discussed above, such reforms could also lead to
improvements in the quality of and access to essential TB services. Nonetheless, experiences from
neighboring countries (e.g., Vietnam) suggest that in the absence of adequate regulations, monitoring
systems, or enforcement, public facilities with full management autonomy can behave in ways that hinder
public health objectives (Somanathan et al. 2014). This includes risk selecting healthy or high-income
patients, balance billing patients for services that should be free, and allocating inputs for only those health
services that bring in the greatest revenue.
4.2 Public Financial Management and Budgeting
4.2.1 Overview
The MoEF has been undergoing major PFM reforms, officially called the Public Financial Management
Reform Program (PFMRP), since 2004. It receives a substantial amount of technical assistance from the
World Bank. The reform has multiple components. The first component was successfully achieved in 2008
and aimed to strengthen budget credibility (WYG International and Khmer Management 2015). The MoEF
has since been implementing the second component, or the achievement of effective financial
17. 15
accountability. The second component includes the rolling out of PFM reforms, such as program-based
budgeting, to line ministries. The MoEF has considerable control over the MoH’s expenditures against its
approved budget. As has been mentioned, the MoH, like all line ministries, is only allowed to switch funds
between activities within the same sub-program and within the same chapter without MoEF approval. Any
other budgetary changes require the MoEF’s approval. In 2012, the MoH accounted for 23 of the 173
approved applications (MoEF 2015). The MoEF has not yet begun to design or pilot components three
and four of the PFMRP, which will include development of a performance-based budgeting system. Delays
are largely due to political resistance and data limitations.
The MoH has therefore been piloting a program-based budget since 2008. This program-based budget
accounts for roughly 20 percent of the MoH’s total budget (MoEF 2015). Neither the MoH nor the NTP
has begun developing or piloting performance-based budgets. A significant challenge for the MoH, as with
the MoEF, is both political resistance and the lack of data to inform performance- or outcome- based
budgets.
HFG was not able to meet with the MoH Department of Budget. However, per discussions with the
MoEF, the World Bank, DPHI, and CENAT, budget allocations by the MoH for TB in the current year (t)
are largely based on the previous year’s budget (t-1) plus inflation. CENAT receives an annual budget
from the MoH broken down by line item, but CENAT cannot shift funds across line items. The CENAT
uses prevalence and other need-based data to allocate TB funds to PHDs and ODs. However, the
availability of data is limited and the quality weak. For instance, utilization and encounter data may be
based entirely on a sample of public, rather than both public and private, facilities.
NTP budget line items are presented in Figure 3; the primary categories are DOTS, MDR-TB, TB-HIV,
PPM, Research/Other (WHO 2015). DOTS accounted for roughly 66 percent of the NTP’s total budget
in 2014, up from 45 percent in 2010-2011. The remainder of the budget is spent on PPM (25 percent),
MDR-TB (5-10 percent), and TB-HIV (2 percent). Since 2007, the NTP’s budget execution rate, defined
as the percent of the total budget that was spent in a given year, has been close to 100 percent.
Figure 3: NTP Funding, by Line Item and Year
4.2.2 Issues
A dual approach is required to improve CENAT’s budgeting process. One is analytical, while the other
structural. Reforms to both areas are needed:
1) For the analytical approach, CENAT must assess the Cambodia’s TB needs and identify gaps in the TB
care continuum. This will help it identify where the budget should be spent, thereby improving value
for money. Identifying TB needs and gaps requires quality, timely data. At present, CENAT, PHD,
18. and OD budgets are only determined by previous years’ budgets and TB prevalence data. Such data
is insufficient. The MoH needs a resource allocation model that accounts for additional variables, uses
more data, and uses data of higher quality.
2) Structural reforms are also needed to improve CENAT’s budget planning process. The current MoH
and CENAT budgeting process prevents government agencies within the NTP from shifting funds
across line items. For instance, if CENAT needs to allocate additional funding for TB drugs and less
for technical assistance, it is unable to do so. These restrictions will impact the efficiency and
effectiveness of the NTP’s spending, which in turn can lower its budget execution rates and future
years’ budget from the MoH. CENAT must move towards program based budgets, which can ensure
that budgets align with strategic priorities and the purchasing of health services. Such a model will
enable health managers to switch their thinking away from funding infrastructure to financing based
on need (and eventually performance).
4.2.3 Recommendations
Policy Recommendations for TB Budgeting
CENAT should develop a more comprehensive, data-intensive resource allocation model that
identifies TB needs and gaps in the care continuum;
CENAT should undergo program based budgeting reforms, which will help it shift from
budgeting by line item to budgeting by strategic priority (need and performance)
19. 17
5. TB STRATEGIC PURCHASING: HEALTH EQUITY FUNDS
5.1 Accreditation/Contracting
5.1.1 Overview
Cambodian laws require public and private health facilities to be accredited by the MoH in order to deliver
services. Per interviews with URC and DPHI, as well as MoH circulars, HEFs contract with all public health
facilities; in practice, this means that HEFs do not selectively contract with any public providers (MoH
2014b). HEFs are not allowed to contract with private health facilities. It is illegal for private facilities or
pharmacies to sell TB drugs or deliver TB services. Thus, even if HEFs were allowed to selectively contract
private facilities to provide general health services, the use of contracting would not impact TB financing
or service delivery in the private sector.
5.1.2 Issues
Accreditation systems, when designed and implemented well, enable payers to selectively contract with
health care providers that meet certain quality standards. Through key informant interviews, HFG was
not able to assess the standards set by the MoH’s accreditation system for public and private providers.
It was also not able to determine whether the Royal Government of Cambodia has set or can successfully
enforce regulations for providers that continue to deliver health services but do not meet these standards.
Regardless, HEFs face two, critical issues related to contracting.
1) By law, HEFs are not permitted to contract with private facilities. Laws also prohibit private health
care facilities and pharmacies from delivering TB services and selling drugs (URC 2016). There are
likely political and regulatory constraints that have prevented the removal of these laws. Nonetheless,
recent National Health Accounts data indicate that over 70 percent of health service utilization and
expenditures occur in the private sector (MoH 2015). While some variation in use and expenditures
exists across wealth quintiles, such trends hold among low-income households. Demand for private
sector services remains strong despite the presence of free public health services and subsidized
transportation/food costs.
From an equity perspective, HEFs were designed to increase financial protection for Cambodia’s poor
and expand utilization of essential health services, including TB. The inability to contract with private
sector providers for TB and other health services hinders these objectives by limiting patient choice.
Unlike out-of-pocket payments, payers – by wielding greater purchasing power and more nuanced
payment mechanisms – are better able to shape provider incentives. In turn, these incentives can
encourage better coordination of TB services across public and private sectors. They can also improve
TB case detection rates, treatment success rates, and quality of care. For instance, at present, private
providers have few financial incentives to identify TB-suspect patients or refer them to a public facility
for further testing and treatment. Households only pay providers from whom they receive a service,
whereas HEFs can split payments and include a referral fee to the referring facility.
2) General contracting, as discussed above, allows health care providers to access new, more stable
revenue streams than out-of-pocket payments. However, general contracting is a blunt tool for
20. shaping provider incentives, because all accredited providers are eligible to receive HEF payments. On
the other hand, selective contracting enables payers to strategically purchase health and TB services
from only those providers that meet additional performance (quality or cost) standards. At present,
HEFs contract with all public health facilities in Cambodia. While selective contracting can reduce
access to health services by limiting the size of provider networks, it can also stimulate competition
among health care providers. In turn, greater competition can improve efficiencies by lowering costs
and improving quality of care.
5.1.3 Recommendations
Policy Recommendations for Contracting
The MoH should consider piloting reforms that will allow HEFs to selectively contract with
private providers, while leaving public facilities open to general contracting.
Selective contracting with public facilities would require those facilities to compete on quality and cost
grounds. This would be both challenging and impede reaching TB objectives, such as expanding access to
and utilization of TB services. However, if HEFs were allowed to contract with only the best performing
private facilities – which would be required to meet high-quality standards – access to health and TB
services for the poor could be improved and better coordination across public and private providers
achieved. Historical barriers between sectors would be broken down. Such a pilot could also as a model
for future public-private partnerships in Cambodia and expanded over time.
5.2 Benefit Package
5.2.1 Overview
HEFs are health insurance schemes for the poor. Benefits include transportation and food subsidies for
members at the point of care, as well as fully subsidized insurance coverage for health and TB services
(MoH 2014c). DPHI has not yet developed a benefit package for services to be covered by HEFs; in theory,
HEFs should cover any service received by its members from a public health facility. CENAT guidelines
specify three distinct benefit packages for TB care that are free to individuals utilizing public health facilities:
primary care, outpatient/inpatient care (TB DOTS intensive phase), and outpatient care (TB DOTS
maintenance phase). In a sense, HEFs thus contract with public health centers and hospitals to deliver all
three benefit packages (MoH 2014c).
The primary care package targets the “investigation of patients with TB symptoms who are or are not
producing sputum.” Primary care services include consultations (history exams), investigations (sputum
tests, lab transport, and x-ray), treatments (antibiotics), counseling (overview of TB), and follow-up. The
outpatient DOTS intensive phase covers all newly diagnosed TB patients and includes consultations
(monitoring drug effects and physician consults), investigations (lab and sputum analysis), treatments (first
line TB DOTS, drugs and inpatient admission where necessary), counseling (compliance), and follow-up
(MoH 2014c). While labeled as an “outpatient” care package, it covers TB services delivered in both
outpatient and inpatient settings. The outpatient DOTS maintenance phase covers patients who have
completed the intensive phase; covered services are similar but focus on DOTS maintenance and
compliance as per CENAT clinical guidelines. This phase technically includes care provided in an inpatient
21. 19
setting, though in practice most TB care during the maintenance phase should be delivered in an outpatient
setting.
Findings from a forthcoming study (URC 2016) indicate that, on average, roughly 87 percent of HEF
operators (HEF-Os) and 71 percent of managers/directors at public health centers and public hospitals
are aware of HEF benefits, including those for TB. Of particular importance, nearly 100 percent of HEF-
Os and mangers/directors are also aware that poor TB-suspect patients are eligible for HEF benefits.
5.2.2 Issues
The TB benefit packages, as outlined in CENAT’s benefit package circular (MoH 2014b), are not linked to
the HEFs as they would for a traditional health insurer. However, the separation of TB services into three
distinct benefit packages makes it easier for providers to submit claims to HEFs by care type (primary,
outpatient, inpatient) and HEFs to reimburse facilities accordingly. The TB benefit package is generally
clear and comprehensive; there are few gaps in what services are covered.
5.2.3 Recommendations
Policy Recommendations for the Benefit Package
HEF guidelines should articulate that patients who are diagnosed with TB be covered for all
related services rendered prior to diagnosis.
The MoH should harmonize its independent TB benefit packages once HEFs begin reimbursing
providers based on diagnostic conditions.
1) To improve financial risk protection for Cambodia’s TB population, particularly the poor, HEF
guidelines will eventually need to articulate that patients who are diagnosed with TB should be covered
for all related services rendered prior to diagnosis. In many neighboring countries, benefit package
guidelines for social health insurance schemes lack this clarity (PhilHealth 2012; PhilHealth 2014;
Somanathan et al. 2014). As a result, providers frequently bill insured patients for primary, outpatient,
and inpatient services delivered prior to TB diagnosis. This behavior accounts for a large share of TB
out-of-pocket costs in developing countries (the other being utilization of health facilities that are not
contracted by or included in a health insurer’s network) (Kutzin et al. 2010; McIntyre and Kutzin
2016).
There is limited empirical evidence of this happening in Cambodia, in part because the HEFs’ current
provider payment mechanisms have not created the incentive to do so. HEFs use a simple, case-based
payment system to reimburse health facilities, which disaggregates payments only by facility type and
care type (e.g., outpatient, inpatient). Cases are not yet broken down by diagnostic condition. Public
health facilities will therefore receive the same reimbursement for an inpatient care episode regardless
of the patient’s medical condition. As HEF provider payment models become more complex and cases
are instead made by diagnostic group, providers will look for ways to bill TB patients for other
conditions – unless benefit package guidelines/regulations are in place to prevent this from happening.
2) The MoH should harmonize its benefit packages once HEFs begin reimbursing providers based on
diagnostic conditions. In failing to do so, providers will be more inclined to deliver only those services
22. that maximize revenue, which can fragment TB service delivery and weaken care coordination across
providers. In the absence of a benefit package that spans the TB care continuum (from diagnosis
through inpatient care), patients are more likely to shift care across private and public sectors for TB
services/drugs (Langenbrunner et al. 2009). Multiple providers are unlikely to communicate with one
another to ensure that the patient’s care is timely, clinically appropriate, and not duplicated. Such
behavior can thus lead to excessive health spending, poor quality of care, loss to follow-up, and
possibly even increased MDR-TB rates due to uncompleted treatments (Langenbrunner et al. 2009;
Figueras et al. 2005).
5.3 Provider Payment Mechanisms
5.3.1 Overview
The MoH has developed a case-based payment system to reimburse services provided at public health
facilities (health centers; hospitals). HEFs will reimburse a health facility for each case, or patient or HEF
member, treated by that facility. While most countries have developed multiple payment systems for care
delivered in different settings (e.g., primary, outpatient, inpatient), Cambodia only uses one (MoH 2014b).
Under this system, the MoH prospectively sets prices for a set of health services and reimburses health
facilities after those services have been delivered. Case-based payments represent a type of prospective
payment system, which has been rolled out in many lower- and middle-income countries. Governments
have adopted these systems to contain costs and drive efficiencies in health spending (Langenbrunner et
al. 2009, Gottret et al. 2008).
HEF case-based payments are completely bundled. Put another way, a single payment is expected to cover
facility costs (clinical and administrative), physician/provider costs, and any other non-service related cost
(e.g., drugs, lab tests). Per MoH guidelines, HEF reimbursements for the TB outpatient/inpatient DOTS
intensive phase are released following the completion of treatment, or roughly 2-3 months (MoH 2014b).
The same occurs for the outpatient TB DOTS maintenance phase in the event of a patient’s death,
treatment failure, or cure. HEFs will not reimburse a facility if its TB patient is lost to follow-up or
treatment fails to align with CENAT protocols.
5.3.2 Issues
1. Many low- and middle-income countries interested in containing costs and improving efficiency have
adopted case-based payment systems as an initial step. At the most rudimentary level, such payment
systems bundle services at the highest level – each case or patient (Langenbrunner et al. 2009; Gottret
et al. 2008). As these systems advance, cases will become more refined. In Cambodia, DPHI guidelines
stipulate that public health facilities be reimbursed for each HEF member treated, regardless of their
medical condition (MoH 2014b). As will be discussed in Section 5.4, reimbursement rates only vary
by the setting under which a patient was treated (outpatient, inpatient) and the type of facility (hospital,
health center). Countries like Cambodia are often initially unable to develop more complex case-
based payment systems, such as diagnostic-related groups (DRGs), which set reimburse rates by a
patient’s diagnosis or medical condition at the time of admission. This is in large part due to a lack of
data on patients’ clinical conditions, utilization trends, and costs, which require more mature health
information systems (Langenbrunner et al. 2009). Case-based payment systems that are more refined
tend to result in payments that more closely reflect the actual cost of delivering a service. Because
HEF case rates are not well refined, health facilities are likely to risk select healthier, less costly patients
(Langenbrunner et al. 2009; McIntyre and Kutzin 2016). This results in greater inequities in access to
health and TB services; it also hinders public health challenges, such as eradicating MDR-TB.
23. 21
2. Insurers tend to adopt multiple payment mechanisms for care delivered in different settings
(Langenbrunner et al. 2009; McIntyre and Kutzin 2016). By using many payment “levers,” health
insurers have greater ability to shape the behavior of health care providers, which can result in better
health system performance and the achievement of critical policy objectives. While the exact mix of
payment systems varies by country, there are common themes across them. For instance, insurers
often adopt capitation-based payment models, whereby both prices are set and payments made before
services are delivered, for primary care services, because the cost of such services is easy to predict
(Langenbrunner et al. 2009; McIntyre et al. 2016). Alternatively, preventive care may be critical for
addressing public health threats (e.g., HIV/AIDS and TB), in which case insurers may stimulate
utilization of preventive services by adopting a fee-for-service payment model. In Cambodia, HEFs
only use a case-based payment system. While appropriate for outpatient and inpatient care settings,
the absence of alternative payment models limits the depth and breadth of incentives that HEFs can
create for health care facilities.
5.3.3 Recommendations
Policy Recommendations for Provider Payment Mechanisms
The MoH should consider improving the design of HEFs’ existing case-based payment system.
The MoH should consider the adoption of additional payment mechanisms, such as capitation
or pay-for-performance initiatives, alongside its case-based payment system.
If designed and implemented well, such reforms could have a significant, positive impact on case detection
rates, patient out-of-pocket costs and financial risk protection, quality of and access to TB services, as well
as the coordination of TB service delivery (Langenbrunner et al. 2009).
5.4 Prices
5.4.1 Overview
HEF reimbursement rates for a given case are adjusted only for facility type and care type. Specifically, risk
adjusters for facility type include health centers, referral hospitals CPA1, CPA2, and CPA3, as well as
national hospitals (MoH 2014b). Risk adjusters for care type include the average cost of an outpatient
service, the average cost of an inpatient service, long-acting contraception (e.g., IUDs/implants), the
average cost of a major surgery, and permanent contraceptive methods. Reimbursement rates are shown
in Table 2 (MoH 2014b). HEFs make a single payment to the facility regardless of a patient’s diagnosis (e.g.,
co-morbidities and clinical severity), discharge ward, services provided, or length of stay. In the case where
members are admitted to a facility with multiple co-morbidities, the higher payment rate will be given to
the facility.
Table 2: Case Rates by Care Type and Facility Type
Care Type
MPA (Health
Center)
FDH (Health
Center)
CPA1 CPA2 CPA3
National
Hospital
Average Outpatient Cost N/A N/A 6,000 8,000 10,000 18,000
Average Inpatient Cost 60,000 60,000 60,000 100,000 120,000 300,000
Average Surgery Cost N/A N/A N/A 320,000 400,000 1,120,000
24. MPA Services 2,000 to 4,000 2,000 to 4,000 N/A N/A N/A N/A
5.4.2 Issues
1) Per key informant interviews, payment rates are likely far below the cost to public health facilities of
delivering health and TB services. This is almost certainly the case for private facilities, whose costs
almost always exceed those in the public sector. As HEFs (and possible other funds, such as NSSF)
take on a greater share of TB financing, cost data from health facilities will become even more
important, because they will shape the payment mechanisms used to purchase services and inform the
rates at which HIV/AIDS and TB services are reimbursed. This is particularly true if social health
insurers in Cambodia eventually decide to contract with private health care providers. Evidence from
Indonesia, the Philippines, Thailand, and Vietnam suggest that without up-to-date cost data, public
payers tend to set reimbursement rates that are below the actual costs needed to deliver services
(Langenbrunner et al. 2009; Kutzin et al. 2010; Somanathan et al. 2014). In response, health care
providers are either less likely to treat members insured by those funds or more likely to bring in
supplemental revenue from other, less equitable sources (e.g., patient out-of-pocket costs).
2) The MoH has not applied any “advanced” modeling techniques to set HEF payment rates for primary,
outpatient, or inpatient care. This includes the lack of risk-adjustment for patient case mix
(diagnosis/clinical condition), geography (urban/rural), facility type (public/private), or other factors.
Risk adjustment is a process by which the average price for a given service (e.g., 20,000 Riel) is adjusted
to account for variations in provider costs. For instance, the underlying cost structure for a teaching
hospital or urban health center is higher than the one for a non-teaching institution or rural facility
delivering the same service. HEF reimbursement is adjusted only by generic facility characteristics
(health center/referral hospital/national hospital) and type of service (OP/IP/surgery). The result is that
some facilities have less or little incentive to treat patients or provide high-quality services, while
others have greater incentive to do so (Langenbrunner et al. 2009).
5.4.3 Recommendations
Policy Recommendations for Pricing
A third-party agency should conduct a new costing study of TB (or health) services from public
and private facilities. This study, coupled with better communication between payers and
providers, would inform new base payment rates and expedite the development of a DRG
system for HEFs (and the NSSF).
The MoH should be trained to apply risk-adjustment models to its base payments, to better
match payments for health and TB services with the actual costs of delivering those services
at different facilities.
The MoH should initiate efforts to collect new patient and facility level data, as well as use
existing data (e.g., PMRS), to inform risk-adjustment models (and thus HEF reimbursement
rates).
25. 23
5.5 Cost Sharing
5.5.1 Overview
CENAT guidelines specify that TB drugs and services at public facilities are free of charge for patients
(MoH 2014c). However, public facilities may charge user fees for other health services. As a social health
insurance scheme for the poor, HEF members are not required to pay premiums or other forms of cost-
sharing (deductibles, co-pays, co-insurance) to receive benefits. As previously mentioned, HEF members
also receive transportation and food subsidies for utilizing health and TB services. While TB- suspect
patients, regardless of income, should receive free preventive TB services (e.g., tests) at public facilities,
those facilities are allowed to charge hospitalized (inpatient) patients who have not yet received a TB
diagnosis.
A recent URC (2016) study asked HEF-Os and public hospital directors/managers about user fees for TB
services charged to all patients (not only the poor). Results indicated that 6 percent of public hospitals
charge patients for TB testing, 62.5 percent charge for sputum negative x-rays, 53 percent for broad
spectrum antibiotics, 6 percent for TB medications, 41 percent for TB-related lab tests, 82 percent for
pre-confirmation inpatient care (hospitalizations), 6 percent for other TB services, and 24 percent for
non-TB services to TB patients. No facilities charged user fees for TB patients receiving inpatient care.
These findings suggest that public hospitals generally abide by MoH and CENAT guidelines for inpatient
care, and do not charge patients for TB services once a TB diagnosis is given. However, a number of
hospitals charge user fees to HEF and non-HEF members for TB services (e.g., tests) that should be free.
Similar questions were asked of HEF-Os and public health center directors/managers. On average, 23
percent charge user fees for TB-related services: 25 percent for TB testing, 5 percent for DOTS, 60
percent for other medications, 5 percent for TB-related lab tests, 5 percent for TB referrals, and 35
percent for non-TB services. Again, many of these services should, per CENAT guidelines, be free of
charge for TB-suspect and TB patients, regardless whether or not they are poor. Quantitative data from
the HEF’s PMRS system suggest that findings from these interviews may slightly overestimate the percent
of public facilities that charge user fees for TB services.
5.5.2 Issues
CENAT benefit package guidelines state that TB services should be free for all patients using public health
facilities, regardless of income or payer status. This includes patients who have been clinically diagnosed
with TB as well as TB-suspect patients. Nonetheless, URC (2016) data suggest that not all health centers
and hospitals abide by these guidelines. These findings raise two issues for policymakers to address:
1) Once formally diagnosed with TB, the likelihood of a (non-poor) patient incurring user fees will vary
by facility (hospital/health center) and type of service (primary/outpatient/inpatient). However, with
the exception of inpatient services, the odds of a non-poor TB patient incurring user fees are greater
than zero. Put another way, facilities are charging user fees for TB services across most of the TB care
continuum. It is not clear whether this finding holds true for HEF members, who are technically
exempt from all public sector user fees. User fees in the public sector erode financial risk protection
for patients with TB and trust in the public health system. In turn, they will inhibit patients’ access to
and utilization of TB services; it is also likely that TB case detection and treatment success rates will
be negatively impacted.
2) A significant portion of hospitals charge user fees for inpatient visits if patients have not yet been
formally diagnosed with TB. Similarly, most health centers and hospitals charge users fees to patients
26. for primary care services, particularly when those services aim to diagnose or confirm a patient’s TB
status. As discussed in Section 5.2, health facilities will always look for ways to generate revenue. In
the absence of clear benefit guidelines, public facilities will continue to charge patients prior to
confirmation of TB status. The implications are that TB suspect patients are less likely to seek care at
a public facility, which in turn reduces case detection, treatment success rates, and long term
outcomes.
5.5.3 Recommendations
Policy Recommendations for Cost Sharing
The MoH should identify strategies to better regulate and enforce TB user fees guidelines.
HEF guidelines should articulate that patients who are diagnosed with TB are to be covered
for all related services rendered prior to diagnosis.
5.6 Claims/Reimbursement
5.6.1 Overview
MoH guidelines state that public facilities should submit claims to HEFs for TB patients who have been
treated, particularly when HEF payments would fill the gap between MoH funding and the cost of TB
service delivery (MoH 2014b). The guideline explicitly mentions inpatient TB services, for which this gap
is likely to be positive and larger than for primary or outpatient TB services.
URC (2016) found that, on average, only 43 percent of hospitals charge HEFs for TB services delivered
to HEF members. Broken down by clinical services, 24 percent of hospitals submitted a claim to HEFs for
TB testing, 50 percent for sputum negative x-rays, 55 percent for antibiotics, 0 percent for TB medications,
55 percent for TB lab tests, 95 percent for pre-TB inpatient care, 8 percent for inpatient services for TB
patients, 24 percent for other TB services, and 65 percent for non-TB services to TB patients. Similarly,
only 29 percent of public health centers, on average, filed claims to HEFs for TB-related services: 25
percent for TB tests, 10 percent for DOTS, 16 percent for antibiotics, 5 percent for TB lab tests, 10
percent for TB referrals, and 60 percent for non-TB services.
5.6.2 Issues
Per findings from the data and discussions with URC staff, the primary hypothesis is that public facilities
(HEF-Os and administrators) do not understand MoH guidelines for when to submit a HEF claim for
enrolled low-income TB patients (URC 2016). URC also stated that HEF-Os and facility administrators
worry that their facility could be penalized by the MoH for submitting HEF claims. PMRS
(encounter/utilization) data indicate that such issues have resulted in far fewer claims than would be
expected given the actual utilization of TB services by HEF members. This tends to be the case more for
outpatient than inpatient TB services. It is impossible to directly compare user fee and claims data for HEF
members, because the former were only discussed for all TB patients, regardless of payer status or income
group.
27. the long run as donors reduce (and eventually eliminate) their contributions. The benefit of this policy is
that it increases both the referring and referral providers’ incentives to coordinate care.
A more immediate concern is the policy that public hospitals receiving a referral patient will not be
reimbursed by the HEFs without a letter from a health center. Depending on the relationship that the
facilities have with one another, it may be difficult for a hospital to obtain this letter – and it could end up
penalized for something that is out of its control. Health centers are only required to submit admissions
forms for that patient in order to receive reimbursement; they have no financial incentive to write a
referral letter to the hospital. The implications of this policy then are that hospitals may lack the incentive
to accept and treat TB patients without an upfront letter from the health center. This could have
profoundly negative effects on HEF patients’ access to critical TB services and could worsen care
coordination across health providers. It also increases the probability of TB patients being lost to follow-
up, lower treatment success rates, and increased prevalence of MDR-TB.
5.7.3 Recommendations
Policy Recommendations for Referrals
The MoH should develop or improve systems to monitor the behavior of health facilities and
enforce regulations around referrals.
The MoH should consider reforms that strengthen incentives for providers to refer TB-suspect
and TB patients without compromising fund solvency and efficiencies.
The MoH should eliminate existing guidelines that prevent public hospitals from being
reimbursed without a referral letter.
1) Monitoring and regulatory systems are critical for ensuring that patients have access to and are
receiving TB services, are not incurring excessive out-of-pocket costs, and are not receiving care that
is below quality standards. Examples of such systems include facility audits for quality assurance, or
putting in place systems for managing patient grievances or complaints. These should be coupled with
an increase in the collection and use of claims/encounter data to track patients, the care they receive,
and the costs of delivering those services.
2) Globally, these tend to be reforms to provider payment mechanisms. Most public and private health
insurers have policies in place to ensure that some portion of reimbursements is earmarked to the
referring provider. In the Philippines, for instance, the facility receiving PhilHealth payments is required
to forward a portion of the payment (e.g., 10-20 percent) to the referring provider (PhilHealth 2014).
28. 27
ANNEX A: STAKEHOLDERS INTERVIEWED BY HFG
List of Interviewed Stakeholders
Ministry of Health, Department of Planning and Health
Information
Ministry of Health, National Center for TB and Leprosy Control
U.S. Department of Treasury, Public Financial Management
University Research Company
GIZ
World Bank, Health Financing Unit
World Bank and Ministry of Economy and Finance, Public
Financial Management
29. 29
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