institutional strengthening for universal health coverage in cambodia

AUSAID KNOWLEDGE HUBS FOR HEALTH

HEALTH POLICY AND HEALTHFINANCE KNOWLEDGE HUB

THE NOSSAL INSTITUTE FOR GLOBAL HEALTH

Institutional strengthening for universal coverage in Cambodia: opportunities, barriers and policy options

Peter Annear and Shakil Ahmed

Presentation at the

Health System Reform in Asia Conference Hong Kong

10-11 December 2011



Population coverage


Per cent of population by income level

Coverage of target pop. Agency

Higher income

5%Wealthy:

Private coveragen.a. Private

10%Urban formal sector:

SHI (civil servants, private employees)

0%NCSSFNSSF

50%Urban and rural near-poor:

Public health care, user fees and CBHI

2% NGOs/CBHI

Lower income

35%Rural and urban poor:Fee exemptions, HEF and other subsidies

78-100% NGOs/HEF



Problem statement


• Cambodia has adopted a HCF Strategy and a Master Plan for moving towards universal coverage.

• Ready to move to full coverage of the poor: a major social reform.• Government and donors agree on the proposal to create

a national social security fund for HEF and CBHI.• The is no plan and no agreement on the form of the national fund or the process for creating it.• What are the barriers? How can they be overcome?



Methods


• Document analysis: WHO, 2010. Health Systems Financing: The Path to Universal Coverage.WPRO, 2010. Health Financing Strategy for the A-P Region 2010-2015MOH, 2008. Health Strategic Plan 2008-2015. MOH, 2008. Strategic Framework for Health Financing 2008-2015.MOH, 2009. Draft Master Plan on Social Health Protection.Martinez et al , 2011. Overall Assessment for Mid-Term Review of Health Strategic Plan 2008-15

• Key informant interviews (17):Ministry of Health (5)Ministry of Finance (3)Council for Administrative Reform (2)Council for Agricultural and Rural Development (1)Development partners working to assist health financing initiatives (6)



Analytical framework


Mathauer and Carrin, 2011. Health Policy. Vol. 99, pp. 183-192



General analysis


• All countries can move towards universal coverage through development of: collecting, pooling and purchasing functions (WHO 2010; Evans and Etienne 2010; Mathauer and

Carrin 2011)

• A critical need is to protect the poor (Gwatkin and Ergo 2010).

• A constraint on the effectiveness of health financing is fragmentation of schemes and risk pools.

• Need to investigate both the institutional arrangements for universal coverage and the nine major health care

financing indicators.



SHP in Cambodia


Scheme Implementer/ Operator

Target group

Tax funding via Government budget

MEF/MOH/PHD/OD/RH/HC

All population sectors

1. GHIs and national programs

National programs Patients with TB, malaria, AIDS, and children for vaccination,

2. HEF schemes NGOs for HEF schemes

The eligible poor (those under the national poverty line)

4. Government Subsidy schemes (SUBO)

MOH The eligible poor (those under the national poverty line)

5. CBHI Mainly NGOs Mainly informal sector people living above poverty line

6. Vouchers MOH/ NGOs Poor pregnant women7. Occupational Risk MOLVT/NSSF Formal sector workers8. Maternity Benefits MOLVT/NSSF

MOSVY/NCSSFPregnant women formal sector workers and civil servants (spouses)

9. Social health insurance NSSF; NCSSF Formal sector workers and civil servants



Key findings


• Respondents favoured an intermediate arrangement rather than full implementation of the Master Plan for Social Health Protection.

• General agreement in favour of a national agency for the informal sector covering both HEF and CBHI.

• Ideally an independent, autonomous agency (attached to the MOH).

• Experiences from this intermediate arrangement would assist achievement of the Master Plan.



Institutional challenges


• Providing leadership for a national agency.• Defining the role of the MOH as a steward.• Providing the technical infrastructure (office, equipment, staff).• Strengthening MOH capacity for planning and implementation.• Defining the role of third-party arrangements.•Training for agency managers and staff.• Standardization of guidelines, tools, M&E plan.• Developing financing and fund-management arrangements at the different levels.• Identifying administrative efficiencies.



HCF design issues


• Level of funding• Establishing arrangements for pooling funds from different sources (govt, donors, beneficiaries).

• Level of population coverage• Nature of coordination between HEF and CBHI and other schemes, such as vouchers.

• Equity and financial risk protection• Content and structure of the benefit package.• Nature of beneficiary contributions.

• Level of risk-pooling• Using discreet funds to avoid negative transfers.



HCF design issues


•Level of administrative efficiency• Contracting arrangements for Agency services.• Contracting arrangements for health providers and an appropriate provider-payment mechanism.

• Equity, efficiency and cost-effectiveness of the benefit package• Improving the quality of service delivery.



Conclusions


• A political decision is needed on the location of the Agency. • Leadership must come from the MOH in consultation with

other ministries.• External support is needed to develop capacity.• Financing from different sources could be pooled in a

single fund.• Agreement is needed on third-party arrangements with

roles clearly defined.• Integration will have a positive influence on the three

health financing functions.

institutional strengthening for universal health coverage in cambodia

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