Improving Health Sector Performance: Institutions, Motivations and Incentives - The Cambodia Dialogue

Appendix: Health Equity Funds Implemented by URC and Supported by USAID

URC’s Health Equity Funds Supported by USAID 387 HEALTH EQUITY FUNDS IMPLEMENTED BY URC AND SUPPORTED BY USAID* Tapley Jordanwood, Maurits van Pelt, and Christophe Grundmann INTRODUCTION Cambodia has been experimenting with health equity funds (HEFs) for almost a decade. University Research Co., LLC (URC) has been supporting the implementation of HEFs since 2003 as part of the “Health Systems Strengthening in Cambodia” (USAID-HSSC 2002–08) and the “Better Health Services” (URC-BHS 2009–13) pr ojects funded by USAID. HEFs are a pr o-poor health financing scheme, operated by national NGOs, which identify the poor households in an area and then provide financial support to those poor in procuring public health services. This is done by purchasing health services on behalf of these poor , providing them with reimbursements for transport to health facilities, and pr oviding the patients’ caretakers with money to cover food expenses. Since their first intr oduction, the number of HEFs has incr eased significantly. Figure A.1 illustrates this growth, showing that of the thirtytwo HEF schemes in place by 2007, half ar e two years old or less. Some HEF schemes have not run continuously since implementation and several schemes have changed donors. For simplicity , colours represent current donor and breaks are not shown. 16 Improving Health App 8/24/11, 4:29 PM 387 388 Tapley Jordanwood, Maurits van Pelt, and Christophe Grundmann FIGURE A.1 Starting Dates of Schemes in Cambodia, 1999–2008 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Preah Net Preah Memut Ponhea Krek Smach Meanchey Sre Ambal O'Chrov Thbeng Meanchey Kampot Bakan Tbong Kmum Boribo Kampong Chhnang Kampong Tralach Angkor Chum Stoung Sihanouk Battambang Kratie Sangke Kralanh Chamkar Leu-Stung Treng Cheung Prey-Batheay Prey Chhour-Kong Meas Kampong Thom K. Cham-K. Siem Ang Roka Siem Reap Samrong Stung Treng Takeo Province Banlung Mung Russey Chhlong Sampov Meas Mongkol Borei Kirivong Senmonorom Pearaing Preah Sdach Svay Rieng Sotnikum Cheung Kandal Lech Tbong Thmar Pouk HEFI: URC Donor: USAID HEFI: URC Donor: Other HEFI: Other Donor: Other Source: Adapted from Peter Annear et al. 2008, “Providing access to health services for the poor: Health equity in Cambodia”, in Studies in Health Services Organisation & Policy, 23, p. 203 HEF schemes are popular with many stakeholders. Almost all poor people using the scheme report that they appreciate the assistance and say they would use the same service again in the futur e (MoH Monitoring Group Reports 2007 and 2008). Mor eover, many public health service 16 Improving Health App 8/24/11, 4:29 PM 388 URC’s Health Equity Funds Supported by USAID 389 providers welcome the HEF scheme in their facility because it generates regular income for their facility and staf f. Cambodia’s public health system is managed by the Ministry of Health, with authority delegated to twenty-four provincial and municipal health departments (PHDs), which are further divided into seventy-six operational districts (ODs). Each of these ODs operates public health centr es and most manage a district referral hospital. The PHD manages a provincial referral hospital and the central MoH manages tertiary national referral hospitals. Cambodia’s public health service is under utilized. Those who can afford to frequently use private services, while the poor , who in many cases would like to use public health services, ar e prevented by a variety of barriers. HEFs are meant to help r emove the barriers so that the poor can use public health services to the same extent as the non-poor . A related issue is that heath expenses can be a cause of poverty , often because poor people have to borrow money at high monthly interest rates when they require medical services. HEFs are meant to reduce this problem by facilitating access to public health services for people who ar e vulnerable to falling into debt and poverty as a r esult of borrowing for health care. These two issues ar e well r ecognized nationally. According to the Ministry of Health’s “National Equity Fund Implementation and Monitoring Framework”, published in September 2005, HEFs have two objectives: (i) to increase the utilization of priority health services by the poor; and (ii) to r educe health-related poverty (catastr ophic health expenditures). This evaluation uses the above two objectives to assess the ef fectiveness of HEFs as implemented by URC. The evaluation also attempts to estimate efficiency by...