Institutional strengthening for universal health coverage in Cambodia

HEALTH POLICY AND HEALTH
FINANCE 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

AUSAID KNOWLEDGE HUBS FOR HEALTH


Population coverage
FOR GLOBAL HEALTH

Per cent of population Coverage of
by income level target pop. Agency
Wealthy:
5% n.a. Private
Private coverage
Higher
income Urban formal sector:
NCSSF
10% SHI (civil servants, private 0% NSSF
employees)

Urban and rural near-poor:
50% Public health care, 2% NGOs/CBHI
user fees and CBHI

Rural and urban poor:
Lower
35% Fee exemptions, HEF 78-100% NGOs/HEF
income
and other subsidies


Problem statement
FOR GLOBAL HEALTH

• 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
FOR GLOBAL HEALTH

• Document analysis:
WHO, 2010. Health Systems Financing: The Path to Universal Coverage.
WPRO, 2010. Health Financing Strategy for the A-P Region 2010-2015
MOH, 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
FOR GLOBAL HEALTH

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



General analysis
FOR GLOBAL HEALTH

• 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
FOR GLOBAL HEALTH

Scheme Implementer/ Target group
Operator
Tax funding via MEF/MOH/PHD/OD/ All population sectors
Government budget RH/HC
1. GHIs and national National programs Patients with TB, malaria, AIDS, and children
programs for vaccination,
2. HEF schemes NGOs for HEF The eligible poor (those under the national
schemes poverty line)
4. Government Subsidy MOH The eligible poor (those under the national
schemes (SUBO) poverty line)
5. CBHI Mainly NGOs Mainly informal sector people living above
poverty line
6. Vouchers MOH/ NGOs Poor pregnant women
7. Occupational Risk MOLVT/NSSF Formal sector workers
8. Maternity Benefits MOLVT/NSSF Pregnant women formal sector workers and
MOSVY/NCSSF civil servants (spouses)
9. Social health insurance NSSF; NCSSF Formal sector workers and civil servants



Key findings
FOR GLOBAL HEALTH

• 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
FOR GLOBAL HEALTH

• 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
FOR GLOBAL HEALTH

• 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
FOR GLOBAL HEALTH

•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
FOR GLOBAL HEALTH

• 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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