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

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

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

Objective

Develop a sustainable solution to improve financial access to hospital

care for the poor

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

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

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

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

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

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

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

CFDS’ selection criteria1. Physically and mentally disabled persons2. Chronic disease in household3. No land, rice field, productive assets4. Not able to pay for schooling of children; they have to

work5. Many dependents (small children, elderly)6. Victim of alcoholism, violence, family conflict etc7. Widow with many dependents8. Lack of food security; have to borrow to buy food9. No outside support: apply to all

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

Number of patients assisted by CFDSSep 2000 – July 2002

0

50

100

150

200

250

300

350

400

Num

ber o

f in-

patie

nts

0%

5%

10%

15%

20%

25%

30%

35%

40%

Per

cent

age

IPD # patients assisted %

15

Number of patients assisted by CAAFWMay 2000 – July 2002

0

100

200

300

400

500

600

700

May Ju

n

Jul

Aug Sep Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Ju

n

Jul

Aug Sep Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Ju

n

Jul

2000 2001 2002

Num

ber

16

Percentage of admissions supported by CAAFW

May 2000 – July 2000

0

10

20

30

40

50

60

May Ju

n

Jul

Aug Sep Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Ju

n

Jul

Aug Sep Oct

Nov

Dec Ja

n

Feb

Mar

Apr

May Ju

n

Jul

2000 2001 2002

Per

cent

age

17

Distribution of direct project costs in Sotnikum

Sep 2000 – July 2002

Admission fees 74%

Transport costs19%

Patient subsidies

7%

18

Distribution direct project costs in TP May 2000 – December 2001

Admission fees27%

Transportation

20%

Food10%

Basic materials/oth

ers43%

19

Cost of the Health Equity Fund in TPMay 2000 – July 2002

Per diem staff 1600Administration costs 560Direct project costs 9201Total 11361

20

Breakdown of total expenditure of CAAFW

May 2000 – July 2002

Direct project costs81%

Per diem staff14%

Administration costs5%

21

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

$-

$2

$4

$6

$8

$10

$12

$14

$16

22

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

0

2

4

6

8

10

12

14

16

18

May Ju

nJu

lA

ug Sep Oct

Nov

Dec Ja

nF

ebM

arA

prM

ay Jun

Jul

Aug Sep Oct

Nov

Dec Ja

nF

ebM

arA

prM

ay Jun

Jul

Aug Sep Oct

Nov

Dec

Tot

al

2000 2001 2002

U$

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

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

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)