HEALTH EQUITY FUND in Sotnikum Thmar Pouk

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

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 2

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’ 3

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

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 5

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. 6

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’ 7

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 8

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. 9

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 10

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 11

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

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. 13

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

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

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

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

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

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

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

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

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

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. 23

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 24

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) 25