1. CAMBODIAN COUNTRY PROJECT IMPLEMENTATION Towards consolidating the existing social health protection schemes in Cambodia: assessment of best practices on provider payment methods Final evaluation workshop 10-13 May 2010 Hanoi, Vietnam

2. 2 Angkor Health Team 1.Mr. Saneth Vathna 2.Dr. Sum Sophorn 3.Mr. Ros ChhunEang 4.Mr. Mok Chantra 5.Dr. Sok Sovannarith 6.Dr. Ir Por (National Coordinator)

3. 3 Introduction PPM refers to the way in which money is distributed from a source of funds (government, insurance company…) to a health care provider (individual or facility) PPMs can generate powerful incentives affecting health care providers’ behaviour in terms of type, quantity, quality and cost of health services they offer, and consequently the efficiency, equity and quality outcomes of broader health financing reforms. In Cambodia, existing healthcare financing system is fragmented and 2/3 of the total health expenditure is OOP To address this problem, the government is developing a unified SHP system aimed at achieving universal health coverage. Consolidating the many existing SHP schemes is a first necessary step towards developing this unified SHP system. We mapped these schemes and assessed their best practices on PPMs.

4. 4 Objectives General objective To provide policy recommendations on appropriate PPMs for the consolidation Specific objectives 1.To map the existing SHP schemes covering different elements. 2.To analyse PPMs of some selected SHP schemes

5. 5 Context in brief A low-income country with a population of 13.4 million A district-based healthcare system + loosely regulated private providers, financed through –government tax-based payments –OOP –limited prepayments through SHP schemes: HEF, CBHI Despite considerable improvement, health indicators remain among the poorest in the region

6. 6 Methodology Data collection: –Literature review –Routine data –Primary data through self-administered questionnaires and in-depth informant interviews Data analysis: best practices on PPMs were assessed against 5 criteria –Acceptability by health providers –Admin complexity from the insurers’ perspective –Coverage of the scheme –Cost/member balanced with benefit package –Outpatient care utilisation rate

7. 7 Results: literature review on PPMs PPMs vary around the world and have been changing over time Each PPM carries a set of incentives affecting healthcare providers’ behaviour The more aggregated unit of payment, the higher level of financial risk to healthcare providers A combination of different PPMs allows the strengths of one method to compensate for the weaknesses of the others There are 7 common PPMs: line item budget, global budget, salary (also in line item budget), capitation, case- based, per diem, and fee-for-service Table 2.doc Table 2.docTable 2.doc Many countries, mainly high and middle-income countries (be it tax-based or SHI-based), use a combination of capitation, case-based payment (often case mix and/or DRGs) and FFS with or without a fixed fee schedule

8. 8 Results: SHP schemes in Cambodia and their key characteristics SHP is defined as a series of public or publicly organized and mandated private measures against social distress and economic loss caused by the reduction of productivity, stoppage or reduction of earnings, or the cost of necessary treatment that can result from ill health Based on this definition, several schemes or programs under implementation or being developed in Cambodia can be considered as SHP schemes Table 3.doc Table 3.doc Table 3.doc Of these schemes, we selected only the demand- side schemes with a real third party purchaser, including HEF, CBHI, Occupational Risk, and SHI for further analysis of best practices on PPMs

9. 9 Results: best practices on PPMs for SHP schemes in Cambodia All SHP schemes in Cambodia pay contracted (mostly public) health facilities (not individual providers) only part of the real cost (user fees) The most commonly used PPMs: –Adjusted capitation –Cased-based payment (in a flat rate per case or according to a fee schedule) –Fee-for-service with a fixed fee schedule They are mainly used in combination: –Adjust capitation for contracted health centres and referral hospital + FFS with a fixed fee schedule for referrals to national hospitals –Case-based payment for contracted health centres and referral hospital + FFS with a fixed fee schedule for referrals to national hospitals Table 6.doc Table 6.docTable 6.docTable 6.doc

10. 10 Conclusions and recommendations The findings suggest that the current best practices on PPMs for SHP schemes in Cambodia are: capitation or case-based payment for all services provided at the contracted public health centres or referral hospitals and fee-for-service with a fixed fee schedule for referral services at national hospitals Any of these PPMs seems to weakened by three factors: –No competition among providers (contract with only public health facilities) –There are many payers to the public health facilities and the strongest one is not SHP schemes (which pay only user fees, not the real cost), but government through line item budget –Health care providers as well as SHP scheme operators (purchasers) have limited knowledge about PPMs To develop optimal PPMs for future SHP schemes: –Address the above 3 factors –Carefully assess the existing innovative PPMs (quality/performance- based payment) and experiment new PPMs There is no single PPM appropriate for all solutions. The best is to choose the right best combination, which depends on the type of the providers and timeframe Table 8.doc Table 8.docTable 8.doc