1. HEALTH EQUITY FUND in Sotnikum & Thmar Pouk operational districts Dr. Ir Por, Deputy Medical Coordinator MSF H/B & Mr Sour Iyong, Director of CAAFW Presented at Medicam on 06 September 2002

2. 2 NEW DEAL ‘Better income for staff in exchange for better service to the population’ Staff receives a living wage income The hospital is functioning: –24 hours services –No extra-payment

3. 3 Why Equity Fund? Poor patients cannot access to the hospital care because of financial constraints => Better service to the population?? The hospital to exempt and support poor patients => Better income for staff?? Need for a separate fund = ‘Equity Fund’

4. 4 Objective Develop a sustainable solution to improve financial access to hospital care for the poor

5. 5 Why managed by local NGO? The hospital? –No time –Conflict of interests –Not enough social supporting skills MSF/UNICEF? –Expensive –Not sustainable Need for a local social NGO –Good ability to identify the poor –Not expensive –Replaceable

6. 6 Constraints to access to adequate basic health care Demand-side constraints: –Cost including use fees, transport and food –Distance & geographical access –Information –Health beliefs –Intra-household constraints Supply-side constraint is limitation of quantity and quality of services provided.

7. 7 Contractual arrangement In Thmar Pouk, MSF contracted CAAFW to implement an Equity Fund in May 2000, and In Sotnikum, MSF/UNICEF contracted CFDS to implement an Equity Fund in Sotnikum in September 2000 because these NGOs –are well structured local NGOs –have good social welfare background of the catchment's area –have good reputation –interested in working with the poor (in line with their mission statement) The contract was made on ‘quarterly basis’ in the beginning and later on ‘every six months’

8. 8 Monitoring & evaluation MSF field staff working in the hospital who can see and hear what is going on around the Equity Fund Regular meetings between MSF/UNICEF and CFDS and CAAFW managers. Report regularly to partners involved (e.g. in the Steering Committee meetings). Casual in-depth analysis and evaluation

9. 9 How to reach poor patients Phase I: passive phase –NGO staff interviews patients referred by the hospital staff and provide support accordingly. Phase II: active phase –regularly visit hospital wards. –active promotion and follow-ups through outreach to health centres and home visits. Phase III: pilot extension (only in Sotnikum) –Identification at village level ‘Health Cards’ & ‘Vouchers’. –Recruit a local social worker to finally provide support at health centre level.

10. 10 Support of CFDS to the beneficiaries Once identified as poor, the patient and his/her family receive support from CFDS for: Hospital admission fees and/or, Transport cost and/or, Additional food and basic items …according to need

11. 11 Support of CAAFW to the beneficiaries Transportation, including ambulance Admission fees Cost of medical imaging (X-Ray, ultrasound) Basic materials Supplementary food Cost of cremation Financial support transfers to provincial hospital

12. 12 CFDS’ selection criteria 1.Physically and mentally disabled persons 2.Chronic disease in household 3.No land, rice field, productive assets 4.Not able to pay for schooling of children; they have to work 5.Many dependents (small children, elderly) 6.Victim of alcoholism, violence, family conflict etc 7.Widow with many dependents 8.Lack of food security; have to borrow to buy food 9.No outside support: apply to all

13. 13 CAAFW’s Selection criteria Jobless No guaranteed income (daily labor) No relatives or caretaker No land and/or farming equipment Many dependents, lack of food Poor living conditions (shelter) No starting capital or other assets No skills (Chronic) disease Family crisis, etc.

14. 14 Number of patients assisted by CFDS Sep 2000 – July 2002

15. 15 Number of patients assisted by CAAFW May 2000 – July 2002

16. 16 Percentage of admissions supported by CAAFW May 2000 – July 2000

17. 17 Distribution of direct project costs in Sotnikum Sep 2000 – July 2002

18. 18 Distribution direct project costs in TP May 2000 – December 2001

19. 19 Cost of the Health Equity Fund in TP May 2000 – July 2002

20. 20 Breakdown of total expenditure of CAAFW May 2000 – July 2002

21. 21 Average total cost per admission supported by Health Equity Fund in Sotnikum

22. 22 Average total cost per admission supported by Health Equity Fund in TP

23. 23 Strengths Supported patients are really poor Promote utilisation of hospital services Potential to prevent irrational expenditure in private sector & unnecessary indebtedness & loss of assets => poverty reduction Good solution for both consumers & providers: –poor patients get support –hospital staff does not loose income =>no longer discriminate poor patients, nor deny their access or treatment.

24. 24 Weaknesses Not all poor patients arrived at the hospital get supported. Some potential poor patients are not reached because of other socio-economic constraints. Limited awareness of & uncertainty of access to Equity Fund in the community. Sustainability is still questioned

25. 25 Conclusion & recommendations Equity Fund is a very cost-effective way to improve financial access to hospital care & a very good investment on poverty reduction. Equity Fund is only effective if it is part of a much broader package of reforms: hospital provides adequate health care and no un-official payment To address the remaining constraints => –bring identification of & support to the poor closer to the community (health cards, vouchers, support in HCs) –micro-credit or health insurance should be explored. For funding: –Short-term => NGO or private charitable donor –Medium-term => institutional donor –Long-term => government (social affairs)