1. Health Equity Fund Contracted to local NGOs in Cambodia A New Approach to Fee Exemptions Bruno Meessen & Wim Van Damme, ITM Antwerp, Belgium (bmeessen@itg.be)

2. Initial situation & challenges

3. Poor and the public health services, what we know in Cambodia... Economic growth... but rising inequality. 40 % of the total population under the poverty line. Higher mortality among poor households. Underfunding of public health facilities  Low quality of services  general low utilisation of public health facilities. Distribution is a secondary issue. Overspending by households in the informal private sector, catastrophic health care expenditure is a major problem.

4. Relevant intervention First objective: get the population using the public health services. No quality of services without staff accountability. More funds must be injected in exchange of better performance. Possible sources: Government, Aid and Users. New Deal by MSF (Sotnikum) / Contracting. Problem: rising the fees will exclude the poorest. The distribution issue then becomes serious!

5. Traditional waivers fail... Traditional solution: “Public hospitals should accept poor patients for free”. Experience has shown that such waivers don’t work: – –very few beneficiaries (many false negative). – –the few beneficiaries are not those who need the assistance (many false positive). As an institution, the hospital has indeed no interest to accept poor patients for free. Poor must be lucrative, as the better-off.

6. Moreover... The fee is only one of the barriers to access. Other obstacles are: – –uncertainty about eligibility, – –transportation costs, – –lost income (opportunity costs), – –food and basic items, – –social exclusion, Patient + accompanying persons !

7. The principles underlying the Health Equity Fund

8. The 1 st trick: a specific fund Creation of a fund dedicated to purchasing / providing the different services needed by the poor to access the hospital. Namely: – –user fees, – –transportation, – –food and basic items, – –social care & protection of rights. Funding: aid money.

9. A fund entrusted to whom? The hospital staff? – –no interest in a good targeting; – –no interest in protection of patient rights; – –no social welfare expertise; MSF? – –no expertise; – –not sustainable; – –expensive.

10. The 2 nd trick: a local social welfare NGO Commitment & expertise to identify the poor, Commitment to defend the poor and deliver social care, Not expensive, Sustainable, Strong interests to achieve a good job (development of a new activity, geographic extension, a quite competitive sector).

11. Implementation in Thmar Pouk and Sotnikum

12. Practically The local NGO has an office in the hospital compound, 2 social workers, 7 days a week. Service delivered: – –passive + active identification (interviews), – –holistic financial support, – –visit in the wards, – –outreach for follow-up, control of supported patients and promotion.

13. Criteria used for the individual targeting (not revealed) The NGO scores different dimensions: “Household economics” (# of dependents, children obliged to drop out school, widow). Household cohesion (violence, alcoholism…). Health status (disabled persons, chronic disease). Productive assets (rice field, oax…). Lack of food security; have to borrow to buy food. Limited social capital.

14. Methodology and Results

15. Methods Hospital utilisation data. Incidence Analysis: – –Interview of inpatients, – –A basic poverty score, Costing of Social Assistance + Hospital services.

16. > 100 Genuinely poor!

17. Quality of the targeting Yearly monitoring of the targeting. Results of the 10/2003 study (41 inpatients): –High specificity: 100 % (no inclusion error). –Sensibility: 55-70 % (still some exclusion errors). –A pro-poor hospital: 75 % of users (31/41)!

18. Breakdown of assistance expenditure Thmar Pouck Hospital (2002)

19. Others results observed locally Utilisation of hospital services is boosted. Prevention of poverty? Cf. Dengue outbreak. Hospital staff no longer discriminate poor patients nor deny their access or treatment. Equity Fund pays on average $11.5 per patient to get access to hospital treatment at average real cost of $48 = leverage effect. Technically and managerially sustainable.

20. Observed results: nationwide The idea finds strong interests among the donor & international NGO community in Cambodia. Rapid duplication through the country by other NGOs. Massive external funding promise for the coming years.

21. Policy Implications

22. Lessons learned. A holistic approach is needed: If you want to enhance utilisation of hospitals by the poor, tackle all the barriers they face: Transportation, Social care, User fees, Information, Social exclusion. Benefits can be multiple : better health, protected welfare and dignity. Stakeholders matter: the solution must be in line with the interests of the hospital manager, health staff, better-off users, donors, the local NGOs. Then you get a strong support!