Health Equity Funds: Improving access to health care for the poor MSF

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Health Equity Funds Improving access to health
care for the poor MSFs experience in Sotnikum,
Cambodia

• Ir Por
• 18 December 2003

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Outline

1. Context In Cambodia, in Sotnikum and the New
   Deal
2. Rationale Why a Health Equity Fund?
3. Objective
4. Who should be the implementer?
5. Implementation strategies to reach the
   beneficiaries, selection criteria, benefit
   package
6. Results beneficiaries, costs and benefits
7. Lessons learnt strengths, limitations and
   requisites for effective Health Equity Fund
8. Future challenges

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Context in Cambodia

• Despite progress being made, the public health
  facilities still continue to provide poor quality
  health care.
• The utilisation rate remains low (0.39 cont/inh/y
  in 2002), but high utilisation of private sector
• High out-of-pocket health expenditure (75 of
  total expenditure 9 of GDP)
• Catastrophic health expenditure leading to
  indebtedness, loss of assets and poverty.

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Context Sotnikum health district

• Rural area, among the poorest of Cambodia
• 230,000 inhabitants
• 17 health centers, 1 referral hospital
• All health facilities charge lump sum user fees
  (approx. 0.5 HC and 10 Hospital)

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The New Deal in Sotnikum

• Better income for staff in exchange for better
  service to the population
• Staff receives a living wage income
• The health facilities are open 24 hours
• No under-the-table payment
• No poaching of patients
• No misappropriation of drugs
• (addressing provider-side constraints)

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Why a Health Equity Fund?

• Poor patients cannot access hospital care because
  they face many demand-side constraints
• Cost including use fees, transport and food
• Distance geographical access
• Information health beliefs
• Intra-household constraints
• gt Better service to the population??
• The hospital to exempt and support poor patients
• gt Better income for staff??
• Need for a separate fund
• Health Equity Fund funded by MSF/UNICEF

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Objective

• Develop a sustainable solution to improve access
  to hospital care for the poor
• (addressing demand-side constraints)

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Who should be the implementer?

• The hospital?
• Conflict of interests
• Not enough social expertise, especially in
  dealing with the poor
• MSF/UNICEF?
• Not sustainable
• Relatively expensive
• gt Need for a local social NGO

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Contractual arrangement

• MSF/UNICEF contracted a local NGO, CFDS, to
  implement a HEF in Sotnikum in September 2000
  because the NGO has
• Expertise in social welfare
• Ability to identify the poor
• Interested in serving the poor
• Reasonable administrative cost
• Good knowledge of socio-economic background of
  the catchment's area, language
• The contract was made on quarterly basis in the
  beginning and later on every six months

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Strategies to reach poor patients, the
beneficiaries

• Passive phase (Sep 2000)
• NGO staff interviews patients referred by the
  hospital staff and provides support accordingly.
• Active phase (Sep 2001)
• regular visits to hospital wards.
• active promotion and follow-up through outreach
  to health centres and home visits.
• Pilot extension (June 2002)
• Identification at health centre and village level
  Health Cards Vouchers.
• Recruit a local social worker to provide support
  at health centre level.

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Selection criteria

• Decision on support is made by NGO staff based
  on
• Lack of income (occupation, daily income
  expenditure)
• Lack of assets (ownership of land, animals, means
  of transport etc.)
• Vulnerable households (many children, elderly,
  chronic illness, handicap)
• Physical appearance (dirty or very old clothing,
  and so on)
• Lack of social capital (no access to gifts or
  soft loans from relatives)

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Benefit package

• Once entitled to the support, the patient and
  his/her family receive benefits from CFDS
• Hospital admission fees,
• Transport cost to from the health facility,
• Additional food,
• Basic items bed net, blanket, clothing, and
  cooking utensils
• according to need

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Number of patients assistedSep 2000 June 2003
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Quality of identification of the beneficiaries

• Based on 2 in-depth analyses
• Inclusion error (false positive) null
• The NGO has no incentive to be non-specific
• Exclusion error (false negative) very limited
  among the hospital patients, but still many poor
  do not reach the hospital
• gt The supported patients are genuinely poor

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Costs and benefits
Before Oct. 2002 After Oct. 2002
Average cost of hospital admission 48 53?
Hospital admission fee 8 13
Average cost per HEF patient benefit 11 16
Total cost per HEF beneficiary 17 23
HEF operating cost 36 30
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Breakdown of cost of patient benefits Sep 2000
Dec 2002
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Strengths

• Access to hospital care is no longer denied to
  the poor.
• Promote utilisation of hospital services
• Potential to prevent inappropriate expenditure in
  private sector unnecessary indebtedness loss
  of assets gt poverty reduction
• Good solution for both consumers providers
• poor patients have access
• hospital staff does not loose income

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Limitations

• 1- Some barriers to access remain for the
  poorest
• Opportunity cost of lost time
• Physical access
• Intra-household barriers
• 2- Sustainability, mainly financial and
  socio-political, is still questioned.
• 3- Implementer is not locally based, leading to
  relatively high administrative cost and staff
  turn over.

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Requisites for effective HEF

• Health facility is credible in the eyes of
  population (well functioning)
• A transparent and committed implementer
• Benefit package should be comprehensive fees,
  transport, food, basic items.

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Future challenges

• Pre-identification
• Decentralisation of support to health centre
  level
• Alternative solution for moderately poor
• Pre-payment scheme social health insurance
• Health credit
• Nationwide expansion