Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
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- Title
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Institutional and operational barriers
to strengthening universal coverage
in Cambodia: options for policy
development - extracted text
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THE
NOSSAL
INSTITUTE
THE UNIVERSITY OF
FOR GLOBAL
MELBOURNE
HEALTH
WORKING
PAPER
SERIES
HEALTH POLICY & HEALTH FINANCE KNOWLEDGE HUB
NUMBER 18, MARCH 2012
Institutional and operational barriers
to strengthening universal coverage
in Cambodia: options for policy
development
Peter Leslie Annear and Shakil Ahmed
Nossal Institute for Global Health
AusAIO KNOWLEDGE HUBS FOR HEALTH
' <4883
Institutional and operational barriers to
strengthening universal coverage in Cambodia:
options for policy development
First draft - March 2012
Corresponding author:
Shakil Ahmed
Nossal Institute for Global Health, University of
Melbourne
shakila@unimelb.edu.au
Other contributors:
Peter Annear
Nossal Institute for Global Health, University of
Melbourne.
This Working Paper represents the views of its author/s
and does not represent any official position of the
University of Melbourne, AusAID or the Australian
Government.
ABOUT THIS SERIES
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for Global Health at the University of Melbourne,
Australia.
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(AusAID) has established four Knowledge Hubs for
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ACKNOWLEDGEMENTS
This paper was prepared as a contribution to the
mid-term review of the Health Strategic Plan 200815 at the invitation of the Cambodian Department of
Planning and Health Information (DPHI), Ministry of
Health, in February 2012. We would like to thank Dr. Lo
Veasnakiry, director of the DPHI, and Mr. Ros Chhun
Eang, head of the Health Economics and Financing
Bureau, for their participation and support in the
preparation of the study. We thank Dr. Ir Por for his
participation in the data collection and data analysis
activities. Many people from the Ministry of Health,
the Council of Ministers, the Ministry of Economy and
Finance, development partner organisations and non
government agencies participated willingly in the study,
and we want to thank them all for their insight and
wisdom. The initial draft has been improved following
comments by Ros Chhun Eang, Ir Por and Net Neath.
The research was funded by the AusAID Health Policy
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
SUMMARY
The government of Cambodia and development
partners have indicated in different ways that it is timely
to move to greater integration in social health protection
schemes—in particular, health equity funds (HEFs) and
community-based health insurance (CBHI)—to provide
health coverage of the poor and the informal sector.
The possibility now exists to establish a national agency
for HEF, CBHI, voucher and other schemes as a step
towards universal coverage. This would constitute one
of the country’s major social reforms of the past two
decades.
Health equity funds cover three-quarters of the poor
population nationally with subsidised free access to
government health facilities. Voluntary CBHI schemes,
which aim to cover informal-sector people who can
afford to pay the premiums, are implemented in many
health operational districts (CDs). The government, the
Ministry of Health (MOH) and development partners
are preparing to scale up and move these schemes,
which are currently administered mainly through non
government agencies, under national institutions or
administration.
In this study, we identify the key barriers to policy
change and to strengthening national institutions for
implementation of universal coverage, and suggest
options for overcoming these barriers. The findings
indicate that policy makers are generally in favour
of establishing an interim social health protection
agency for the informal sector, including both HEF
and CBHI schemes. Representation of formal-sector
workers is being arranged separately through the
Ministry of Labour and Vocational Training (MOLVT)
and the Ministry of Social Affairs, Veterans and Youth
Rehabilitation. Preferably, the HEF-CBHI agency would
be autonomous, attached to but independent of the
MOH. Experiences from this arrangement would assist
in the reformulation and implementation of the broader
Master Plan for Social Health Protection (currently
in draft form and under consideration within the
government), which proposes a single national agency
for all sectors and all schemes
While there is as yet no clear, consistent strategic
direction for establishing a national agency, carefully
identifying the policy and institutional barriers and
working out an appropriate response through close
and effective collaboration between the government,
MOH and development partners is essential.
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
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Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
INTRODUCTION
Ensuring equity and affordable access to health
care for all without incurring catastrophic financial
consequences—universal health care coverage—
has been identified as a key health policy goal (WHO
2010). By strengthening financial protection through
addressing the three main health financing functions—
revenue collection, pooling of resources and
purchasing of services—all countries can move towards
universal coverage (Evans and Etienne 2010; WHO
2005; Mathauer and Carrin 2011; Poletti, Balabanova
et al 2007).
In Cambodia, out-of-pocket spending is more than
two-thirds of total health expenditure; more than onequarter of the population live below the poverty line
and are, by definition, unable to pay for health care.
Removing financial barriers at the point of care and
developing social health protection mechanisms
constitute one of the five objectives of the MOH’s health
financing framework (MOH 2008a). While HEFs now
provide financial access to government health services
for almost 80 per cent of the poor population (MOH
2011), and community-based health insurance (CBHI)
offers coverage of the non-poor informal sector in a
limited number of health ODs, social health insurance
mechanisms for the formally employed sector are yet
to be initiated.
Demand-Side Health Financing
Government funding for health care has increased
significantly in recent years, and further improvement
is possible. The greater part of government health
expenditures is provided through the government
budget (with donor support) for facilities, medical
equipment and supplies, drug supply and staffing.
Facilities have the right, however, to generate
supplementary revenue through user fees, which
are used for staff incentives and running costs. HEFs
and a variety of demand-side subsidies now fund
reimbursement of user-fee exemptions for the poor
and insured patients at government facilities. While this
has provided financial access to services for the poor
and the near poor, reduced health costs and minimised
impoverishment of households, taken together social
health protection schemes have not yet had a major
impact on reducing out-of-pocket spending overall
(Flores, Iret al 2011).
The government, donors and NGOs have worked
together in recent years to create different OD social
health protection mechanisms for the poor and the
informal sector. Table 1 summarises these demand
side financing schemes, including HEFs, CBHI, user
fee exemptions, the government subsidy schemes
(SUBO), vouchers and conditional cash transfers (Ros
2011). These demand-side schemes are considered
intermediate social protection measures for the poor
and the informal sector and as preparation for a longer
term move to a unified national program under the
Draft Master Plan for Social Health Protection now
under consideration by the government (Kingdom of
Cambodia 2009).
Health Equity Funds, Subsidy Schemes
and Community-Based Health Insurance
Health equity funds are a demand-side, social health
protection (SHP) mechanism designed to provide
access to government health services for the poor and
to protect them from catastrophic health expenditure
(MOH 2008a; MOH 2011). The poor are pre-identified
(priorto service) or post-identified (at the point of service)
according to objective criteria. The HEF operators
fully reimburse contracted public health facilities for
exemptions from user fees for services provided to
eligible poor patients. The fund also reimburses patient
and carer food and transportation costs, limited funeral
expenses and other basic items (MOH 2011).
Beginning in 2000, Cambodia was the first country
to introduce this form of HEF, as a third-party payer
for services at public health facilities. Until now, each
HEF has been managed at OD level by a local agent
(commonly a local NGO, known as the HEF operator)
and supervised at the national level by an international
NGO (known as the HEF implementer). HEFs are
funded mainly by donor and government counterpart
funds through the national MOH-donor Health Sector
Support Program (HSSP). Through the MOH, the
government also solely funds its own subsidy schemes
for the poor (SUBO) at selected facilities. Donors
include the World Bank, USAID, AusAID, UNFPA,
UNICEF and BTC, most of the funding passing through
a pooling arrangement under the HSSP.
Currently, HEFs operate in 44 ODs in 23 provinces and
Phnom Penh municipality (including 42 referral hospitals
and 323 health centres), covering approximately 78 per
cent of the population living below the poverty line (MOH
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
OVERVIEW OF HEALTH FINANCING SCHEMES IN CAMBODIA
TABLE 1.
Scheme
Implementer/
Operator
Target group
Benefit/Service
Coverage/Location
Tax funding via
government budget
MEF/MOH/
provincial health
department /OD/
referral hospital/
health centre
All population sectors
Recurrent funding, drug and
material supplies
Nationwide public health
facilities
User fee" exemptions
MOH/health facilities
Poor patients
User fees
Nationwide
Global health
initiatives and national
programs
National programs
Patients with TB,
malaria, AIDS
and children for
vaccination
Free of charge
Nationwide
HEFs
NGOsfor HEFs
The eligible poor
(those under the
national poverty line)
User fees, food, transport,
limited funeral expenses and
other basic items
In 46 referral hospitals
and 318 health centres,
covering approx. 78% of
the target group
Government subsidy
schemes
MOH/ provincial
health department/
OD
The eligible poor
(those under the
national poverty line)
User fees
In 6 national hospitals
and 10 referral hospitals
and 89 health centres
CBHI
Mainly NGOs
Mainly informal sector
living above poverty
line
User fees
Limited food and transport,
funeral cost
In 16 hospitals and 164
health centres, covering
< 1 % of the population
Vouchers
MOH/NGOs
Poor pregnant
women
User fees and transport for 3
ANCs, delivery and PNC at
health centres
In 5 CDs
Occupational risk
MOLVT/ National
Social Security Fund
(NSSF)
Formal sector
workers
User fees (medical care),
transportation, temporary/
permanent disability benefits,
funeral expenses and survivor
benefit
In 3 national hospitals
and 12 referral hospitals
in 7 provinces, covering
approx. 40% of formal
sector workers
Maternity benefits
MOLVT/NSSF
Ministry of Social
Affairs, Veterans and
Youth Rehabilitation
/NCSSF"
Pregnant women
formal sector workers
and civil servants
(spouses)
3 month maternity leave
with 50% salary for workers.
For civil servants, 3 month
maternity leave with full
salary and cash incentive of
USD150 per newborn
Nationwide
Social health
insurance
NSSF
NCSSF
Formal sector
workers and civil
servants
Still to be defined
Being developed
A pilot for formal sector
workers is being tested in
Phnom Penh
Special Operating
Agency facilities
MOH/donors/
Health Sector
Support Program
All population in the
coverage area
Decentralised and
performance-based incentives
for providers
In 30 operational health
districts
User fees do not provide for full cost recovery but are set according to affordability by the majority of people, in principle with the involvement and support of the community and
local authorities before approval by the MOH
**
National Civil Servant Social Security Fund.
Source: Ros 2011.
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
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Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
2011). A review of the literature on HEFs in Cambodia
2001-10 found that HEFs are an effective means of
providing financial access to public health facilities for
the poor and an effective form of financial protection for
health (i.e. social health protection) (Annear 2010). The
MOH's Health Strategic Plan 2008-15 aims to promote
and finance the expansion of HEFs to achieve national
coverage (MOH 2008b).12
The government subsidy scheme, SUBO, is described
as one type of HER The MOH provides direct funding
for OD- and hospital-based subsidies as a line in
the annual budget. Currently, the schemes directly
reimburse health facilities for user fees exempted for the
poor at six national hospitals, 10 referral hospitals and
89 health centres in 12 ODs (Social Health Protection
2011; Men, Ir et al 2011). There is no third-party operator
for these schemes, and the concerned health facilities
are responsible for the schemes’ operation. The SUBO
does not cover food, transportation or other social
support.
Community-based health insurance schemes were
initiated in a few districts in 1998. There are now 18
CBHI schemes in 17 ODs in 10 provinces, with a total
membership of 170,490; these schemes are available in
the catchment areas of 164 health centres, 13 primary
referral hospitals and nine secondary referral hospitals
(MOH 2011; Ros 2011; Annear 2008; Annear, Bigdeli
et al 2008). All CBHI schemes cover both hospital and
health centre services and associated treatment costs.
Operated entirely by international and local NGOs and
subsidised with donor funding under MOH guidelines,
the CBHI schemes provide coverage mainly for the
non-poor in the informal sector. They do not target the
poor. The CBHI schemes contract only with public
health facilities to provide services to their members.
The Policy Challenge
The operation of these schemes by government, donors
and various international and local NGOs has resulted
in a fragmented system with high overhead costs (MOH
2008c; Jacobs, Price and Sam 2007; Crossland and
Conway 2002), high monitoring and evaluation costs
and complex reporting requirements. Fragmentation
has complicated the stewardship functions of the MOH,
stretches the capacity of the MOH to coordinate and
support the different arrangements and undermines
the financial sustainability of the schemes (Jacobs,
Price and Sam 2007; Jacobs and Price 2006).
More importantly, the rapid expansion of HEFs both
provides the opportunity to move to national coverage
of the poor and presents challenges concerning
institutional capacities for national administration.
While the MOH provides national guidelines for HER
SUBO and CBHI implementation and is responsible for
funding passed through the HSSP, consultation and
approval between the MOH, development partners
and scheme implementers commonly precede
their implementation. The different implementation
arrangements have weakened planning, monitoring
and management information systems.
The imminent expansion of HEFs to national coverage
raises the unique opportunity to address fragmentation
in demand-side schemes, expand population coverage
and achieve greater administrative efficiencies through
the establishment of a national HEF-CBHI agency, either
through the MOH or as an autonomous government
agency. This recommendation has been noted already
in several documents (Men, Ir et al 2011; Annear 2008;
Annear, Bigdeli et al 2008; MOH and World Bank 2011;
Martinez, Simmonds et al 2011). A national HEF-CBHI
agency would take over responsibility for regulation
and national administration of these schemes.
Paralleling these institutional challenges, a national
agency would also be responsible for managing the
three key health-financing functions and accelerating
progress towards universal coverage:
•
Revenue collection and resource mobilisation:
Harmonise and align donor and government funding
for sustainable financing of HEFs and CBHI.
• Fund pooling: Pooling of funds from different
sources (government and donor) to scale up HEFs
and increase coverage of the poor and vulnerable
populations; manage linkages between HEF and
CBHI schemes in a way that avoids unwanted
cross-subsidies that favour the better off (Annear,
Bigdeli and Jacobs 2011).
• Purchasing of services: Using pooled funds and
the purchasing power of a uniform national agency
as leverage to provide improved quality of health
service.
These are challenging tasks, and planners face
numerous constraints. By identifying the main policy
and operational barriers to a national agency, and
developing policy options that help to overcome these
barriers, the MOH and partners can form a common
strategy and discover a way forward. In this process,
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
it is necessary to examine critically the views and
values of government policy makers, development
partners and scheme implementers, who may have
different interests and may respond differently to new
opportunities and to change (Antunes and Saksena
2009; Brenzel and Naimoli 2009).
METHODS
The findings of this report are based on a review of
policy documents and on qualitative data collected
through key informant interviews. The principal official
documents reviewed included the MOH’s Health
Strategic Plan 2008-15, the draft Master Plan for Social
Health Protection and the Strategic Framework for
Health Financing 2008-15. Supplementary publications
and documents were also assessed, including the
Overall Assessment for Mid Term Review of Health
Strategic Plan 2008-15, the Evaluation of Subsidy
Schemes Under Prakas 809, the MOH’s Annual Health
Financing Report 2010 and the MOH’s Guideline
for Implementation of Health Equity Funds and
Government Subsidy Schemes. Different NGOs and
donor-partner documents were reviewed, including
the draft MOH-World Bank Synthesis Assessment
of Supply- and Demand-side Issues for the Mid-term
Review of the Health Strategic Plan 2008-15.
The key documents were sourced from the MOH,
development partners and NGOs. The policy
documents were reviewed against a prepared list of
topics to determine the level and nature of support for
establishing a national agency, to understand the most
common constraints and to identify possible options
for policy development. Gaps in understanding or
information were noted for further analysis.
Key informant interviews were carried out to collect
the perspectives of health financing policy makers and
program implementers. Purposive sampling was used
to select informants from:
• national policy makers at various ministries (including
the MOH, the Ministry of Economics and Finance,
the Council for Agriculture and Rural Development
and the Council for Administrative Reform)
• development partners
• scheme implementers and operators.
The research team interviewed 18 key informants,
comprising 10 national policy makers, four
representatives of development partner organisations
and four program mangers. Informants were
guaranteed anonymity to encourage an open
expression of their views.
Interviews were carried out in September 2011 using
a semi-structured questionnaire to collect information
on the policy and operational barriers to establishing a
national agency and to investigate the policy options.
The instrument was designed to collect data on both
the institutional barriers related to administration and
management, including agency location, staffing,
capacity strengthening and financial management,
and health financing challenges related to the three
principal health financing functions.
Data were analysed using the OASIS conceptual
framework proposed by Mathauer and Carrin (2011)
(see Figure 1), which identifies stewardship functions
related to resource collection, fund pooling and
service provision at two levels: (1) institutional design
and organisational practice and (2) nine key health
financing performance indicators. This provides a
strong analytical framework for policy making within
the context of moving towards universal coverage.
FINDINGS
Documentary Analysis
The recent World Bank Synthesis Assessment echoes
an increasingly common view among domestic and
international policy makers in Cambodia that ‘it is now
of the highest priority to begin establishing a national
institution to implement HEFs and CBHI, and to hand
over capacity and systems from the national HEF
implementers to this system. ’ The key documents carry
a common message, building from the commitment to
universal coverage in the broad Health Strategic Plan
and working consistently through appropriate stages
in establishing achievable and appropriate social health
protection mechanisms. The main documents reflect
the institutional and financial challenges involved:
• The Health Strategic Plan: proposes a ‘mixed
model’ of health financing that combines public
and private revenue collection and service delivery
with fee-based pre-payment and social-transfer
mechanisms, including HEF, CBHI and social
health insurance schemes; the ultimate objective is
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
FIGURE 1. SUMMARY OF THE PROPOSED ANALYTICAL FRAMEWORK
Stewardship
health
FINANCING
FUNCTIONS
HEALTH
FINANCING
PERFORMANCE
INDICATORS
HEALTH
FINANCING
OBJECTIVES
HEALTH
FINANCING
POLICY GOAL
Universal coverage
ULTIMATE
HEALTH SYSTEM
GOAL
Improved and equitable health outcomes
’BP = Benefit package
Source: Mathauer and Carrin (2011).
6
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
to bring all pre-payment schemes under a common
institutional umbrella that combines the different
elements of the current health financing system
into a single strategy and moves towards universal
coverage.
• The Strategic Framework for Health Financing:
within the 'mixed model', focuses on strengthening
government funding (Strategic Objective 1) and on
reinforcing interim measures to protect households
(Strategic Objective 3); as immediate measures,
recommends the strengthening of the different
existing SHP mechanisms, in particular the scaling
up of HEFs along with the expansion of CBHI as an
intermediate measure leading to implementation of
compulsory health insurance; proposes to prepare
existing schemes for an eventual move to universal
coverage.
0 The draft Master Plan on Social Health
Protection: proposes steps including consolidation
of existing demand-side financing schemes for
the poor and the informal sector before a long
term strategy to consolidate all existing schemes
(particularly HEFs and CBHI and the proposed
formal-sector social health insurance scheme) under
a single national administration; and proposes the
establishment of a national, inter-ministerial Social
Health Protection Committee under the direction
of the central government to formulate strategy,
develop policy and coordinate the implementation
of the social health protection system.
The Overall Assessment for Mid-Term Review of
Health Strategic Plan: significantly, recommends
scaling up HEFs to cover the poor population in all
CDs nationally, increasing government funding to
HEFs and developing an institutional arrangement
to transfer national HEF management and funding
functions to a government-led institution; proposes
expanding coverage of the proposed compulsory
private-sector employee health insurance scheme
under the National Social Security Fund and
implementation of the proposed compulsory health
insurance scheme under the National Civil Servants
Social Security Fund (NCSSF); recommends
defining the scope of work of a joint MOH and
health partners technical group for health financing
matters.
The Evaluation of Subsidy Schemes Under
Prakas 809: having found a number of gaps and
challenges in the design and implementation of
the government’s subsidy scheme, recommends
continuing the scheme only with improved design
consistent with HEFs, or using the SUBO budget
line to pay user fee exemptions through the HEFs,
or replacing the SUBO with HEFs supported by
government funding; eventual integration with HEFs
was the preferred option; a government third-party
agency will be required in this case because the
government does not favour an NGO third-party
arrangement.
• The Synthesis Assessment of Supply- and
Demand-side Initiatives: the MOH-World Bank
document sees the highest priority as beginning
now to establish a public institution to implement
HEFs and CBHI and to hand over capacity and
systems from current NGO implementers to this
institution; among detailed recommendations,
proposes the establishment of a National Social
Security Fund for Subsidy Schemes (NSSF-S)
comprising HEFs and CBHI for the poor and the
informal sector, together with developing regional
structures in line with decentralisation; also sees as
a high priority establishing a national SHP umbrella
structure in line with the Master Plan.
The documentary analyses found that a significant
institutional shortfall undermines the effectiveness of
the different SHP schemes. The expansion of SHP
coverage of the poor and the informal sector through
demand-side schemes is widely regarded as the
next step along the path towards universal coverage.
The documents are, however, prescriptive and not
analytical, and propose policies and initiatives that
reflect a wider discussion among the main stakeholders.
A deeper understanding of the concrete measures
needed for further reform, and the means for identifying
the pathways available for these measures, can be
achieved only by a critical investigation of the views
and values of the main health financing stakeholders.
These include both the key institutional and
organisational design issues and the health financing
issues identified by Mathauer and Carrin (2011). While
the main documents refer to such questions, they do
not investigate them critically or define solutions. The
investigation of key stakeholder and policy maker
attitudes provides evidence for further policy making.
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
Key Informant Analysis
While the key reports propose initiatives for moving to
national responsibility for implementation, institutional
strengthening and combination of demand-side
schemes, progress in this direction has been
constrained by a lack of clarity and agreement on the
precise measures required to move ahead. The Master
Plan is yet to be officially adopted, arrangements for
transferring HEF implementation to the government
have not been agreed on, and institutional and
organisational capacity to govern and implement
the demand-side arrangements has not yet been
developed.
Key informants provided a deeper understanding and
additional information both on the institutional and
policy barriers that constrain implementation of the
recommendations of the key reports and on the health
financing practices that are necessary for achieving
effectiveness and equity in universal access to health
services.
Institutional and policy barriers
Key informants responded to questions on institutional
design related to the draft Master Plan, the proposed
location of a national agency, the institutional
and organisational structure, its mandate and its
responsibilities, institutional and human resources
capacity development, management information
systems and procedures for financial management
and accountability.
Draft Master Plan on Social Health Protection:
Many informants saw the Master Plan (which is yet to
be adopted by the government) only as a long-term
plan and understood it would take a long time to bring
the formal and informal sector schemes under a single
institutional arrangement. Some thought the Master
Plan may appear too ambitious and this could explain
the delay in adopting the draft.
The main aim of the Master Plan is not to
centralise management power to any single
institution, but [to propose] a multi-sectoral
approach within a common strategic
framework {Key informant #4).
/ don't support the idea of the Master Plan.
HEF is a subsidy program, and CBHI is
based on an insurance mechanism; the
context is different. There would be conflicts
of interest among the ministries. Complete
integration is not possible and not realistic
(Key informant #7).
Establishing a national HEF-CBHI agency: Key
informants favoured the establishment of a national
HEF-CBHI agency as an intermediate arrangement,
rather than waiting for the implementation of the draft
Master Plan. The informants emphasised the political
will and leadership and commitment needed to
establish such an agency. While there is agreement on
such a course within government, the mechanisms to
achieve it are yet to be found.
Implementation of the Master Plan is not easy
and may not be feasible in the short run. We
must go step by step, and we know in other
countries this process takes a very long time.
It is better to be more realistic for any future
plan, and it should be based on a feasibility
study and experience from pilot projects and
proper studies (Key informant #18).
We don’t need to wait for a long-term
arrangement for all insurance schemes at
this stage; we should go ahead for the [poor
and the] informal sector (Key informant #11).
For any new initiative or proposal, the most
realistic thing for me is a gradual expansion
plan, starting in a few places as a pilot and
drawing the lessons and then gradually
expanding it. If we can do that, the request
for government funding will be easier
(Key informant #6).
One informant explained that HEFs, which can be
established relatively quickly in new ODs through the
current NGO programs, can be expanded into new
geographic areas without waiting for new institutional
arrangements or establishment of a national agency.
This would create little additional burden following
transfer to government-led administration. In the
meantime, the processes needed for reform and
institutional change towards an autonomous national
structure could take place. Some key informants,
though, thought it may be dangerous to move too
quickly to set up a national HEF-CBHI agency because
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
it may lead to competition and diverse actions among
different health financing stakeholders.
I am not sure whether we need an
autonomous HEF agency. From a SHP
perspective, there is no need for MOH
to create an autonomous agency (Key
informant #8).
Location of the national agency: Most informants
stressed the need for an autonomous agency, rather
than one placed within the MOH internal structures.
There was, however, considerable confusion about its
location, whether within the MOH or alongside it. Some
informants recommended the Council of the Minsters
(the executive body of the government) as a location
for the agency.
The MOH will face a conflict of interest,
because it is responsible for delivering
quality health services, and so it cannot also
be the same institution that is responsible
for paying for these health services. The
payment for health services must be with
an independent institution outside of the
MOH, but this problem is not yet solved (Key
informant #15).
The MOH, especially the DPHI [Department
of Public Health Information], is doing
its job relatively well regarding these
tasks compared to other ministries. The
implementation and the scaling up of
HEFs seem to go well and they are better
performing and less fragmented than CBHI.
Let the MOH and the DPHI continue to do
their job, while giving more technical and
financial support to and more collaboration
with them (Key informant #2).
The MOH does not have sufficient capacity
to implement and monitor the activities of a
national HEF-CBHI agency. The MOH will
need enough human capacity and other
resources. The agency at the beginning
could be located at the MOH and later could
be converted to an independent agency
attached to the MOH (Key informant #16).
Organisational
structure,
including
reporting:
According to most informants, a sub-decree (legal
authorisation), terms of reference and organogram will
be needed for the proposed national HEF-CBHI agency,
which should be governed by an independent board.
A sub-decree could establish the national agency as
a Public Administrative Enterprise. The board could
include higher level policy makers from the Council of
Ministers, MOH, Ministry of Economy and Finance, the
Ministry of Labour and Vocational Training's NSSF, the
Ministry of Social Welfare, Veterans and Youth Affairs'
NCSSF, HEF implementers, CBHI implementers
and community representatives. Reporting could be
directly to the Office of the Prime Minster, regardless of
the location of the agency.
Capacity
development: Stronger administrative,
management and technical capacities are needed
for operational tasks, monitoring and evaluation,
contracting
arrangements
and
management,
procurement and managing NGOs, community
based organisations and private organisations.
The agency requires qualified
professionals,
including health economists, financing specialists,
coordinators, technical professionals, public health
doctors, accountants, IT professionals and evaluation
specialists.
The lack of funding and capacity in
implementation of the HEFs and CBHI within
the government structure are the two main
challenges for the government to take over
this role completely (Key informant #10).
Initially, the required staff and infrastructure could be
seconded, under contract, from the existing NGO
administrators. The proposed board could identify
staff requirements and initiate staff recruitment.
Interdepartmental transfers could be used to bring
experienced professionals from other areas of
government administration, though this would require
a high level of cooperation and trust and initiatives
at the political level. Some informants proposed
recruitment from the private sector, but cautioned
against recruitment of employees from the existing
HEF and CBHI schemes to avoid conflict of interest.
Management information system: Most informants
recognised the need foracommon, central membership
and reporting database for all HEF and CBHI schemes,
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
but also expressed concern that the required capacity
may not exist.
We do not have a common national
monitoring and evaluation framework for
SHP schemes, including key indicators for
different levels of activities. So far, very few
institutions or line ministries have a clear
monitoring and evaluation system for their
schemes, and data on only a few indicators
have been collected. This results from a lack
of a central data management system (Key
informant #1).
However, key Informants believed that developing
a common database between schemes would be
challenging and require standardised reporting formats.
Currently, each scheme has its own database, though a
single IT system could handle different data sets.
Contracting out the IT requirements at
the beginning could be an option. IT
professionals of the national agency will get
the opportunity to work with the experienced
professionals of the contracted agency (Key
informant #12).
Funding management: The Royal Government of
Cambodia and donors each provide funds to the HEFs
through the Second Health Sector Support Project. The
contributions of the government and donors are 20 per
cent and 80 per cent [of project funding] respectively...
The government contribution depends on the financial
arrangements of the donors. There should be a sub
decree for the informal sector so that government
funds can be channelled through an account like the
National Social Security Funds of the Ministry of Labour
and the Ministry of Social Welfare. This type of account
should be opened in the MOH (Key informant #3).
Agency funds need to be managed at both national and
local levels. A Ministry of Economy and Finance (MEF)
sub-decree will be required to decentralise provincial
and district fund management, administered possibly
through the structures of the MEF. Arrangements would
be needed to overcome complications related to the
third-party purchasing role of the national agency, the
involvement of the MEF and the control of provider pre
payment mechanisms. Transfers between the accounts
of the agency and health providers and payment of
10
patient benefits could be managed centrally and routed
to the decentralised units. But administrative delays in
the release of funds under decentralisation could be
a concern. One informant suggested the preparation
of financial management guidelines and building the
capacity of the management team would be the keys
to success, though current government administrative
practices may not be sufficient.
The current state budget disbursement
for health is not good enough. We learn
about some negative feedbacks from our
tracking survey. I think that introducing
banking transfer can improve disbursement
quality. But there will be a lot of reaction from
those who benefit from the existing system.
Moreover, this may need strong leadership
from the MOH to initiate such change and to
propose a comprehensive and convincing
plan for that. As a leader, we should say
everything is possible (nothing is impossible,
depending on the context and time) (Key
informant #13).
Third-party status: The status of the proposed agency
as a third-party purchaser of health services from
government facilities is still not clearly defined, nor is
there yet agreement on this in principle. The role of the
MOH in service delivery and its possible management
of the national agency are as yet unresolved. It is not
clear whether the proposed agency would act as both
an implementer and an operator of HEF and CBHl
schemes. And no decision has yet been made on the
potential for using CBOs (rather than local NGOs) as
district operators. However, many key informants,
especially among current HEF/CBHI implementers,
strongly support a third-party role through the agency.
The national agency must consider thirdpartyarrangements in implementation. These
would facilitate smooth implementation and
monitoring (Key informant #17).
Health financing policy barriers
Reflecting the nine indicators presented in the Mathauer
and Carrin (2011) framework, key informants provided
a range of views on health financing issues associated
with the work of the proposed national agency.
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
Level of funding: All informants recognised the
need for additional funding for the establishment and
functioning of the national agency and the expansion
of HEF and CBHI schemes, and the proposed
national agency was seen as an opportunity for further
aligning government and donor funding. Informants
indicated that there is general agreement between
the government and development partners, but
also saw the need to regulate the common funding
arrangements in a way that satisfies the funding
agencies. The expected expansion of HEFs and CBHI
under a common funding arrangement would require
increased government budget allocation for health
along with the additional contribution from households
(specifically for CBHI).
Most of the donors are willing to provide
funds to a common pot. Additional funding
will be necessary for the expansion of the
HEFand CBHIschemes (Key informant #5).
questions are vital for ensuring equity in financing and
to provide financial protection: (1) the content and
structure of the benefit package and (2) the nature
of beneficiary contributions. The way in which these
questions are resolved will have serious implications
for the management of membership under the national
agency.
Level of population coverage: One of the key
objectives of the proposed national HEF-CBHI agency
is to expand social health protection coverage to the
informal sector through expansion of HEFs and CBHI.
Accurately targeting the poor and enrolling the non
poor in a voluntary insurance scheme both present
challenges.
poor to receive
subsidy remains
and challenging.
Currently, CBHI schemes have high costs
to reach the middle 50 per cent of the
population [the non-poor informal sector] for
enrolment in the schemes. [These] ... costs
can be reduced through joint identification
Key informants reported that both pre- and post
identification procedures for the poor have problems.
While the national pre-identification program conducted
from 2008 through a community survey by the Ministry
of Planning helps to identify the poor, gaps were found
in the pre-identification procedure due to internal
displacement and migration of families, reflecting the
need to survey households repeatedly. In some cases,
implementing NGOs have their own pre-identification
processes, which can be costly. Informants also
reported that relying only on post-identification at
health facilities did not promote utilisation by the poor
(who may be unaware of the possible benefits).
Level of equity in financing and degree of
financial protection: Decisions about two critical
Sometimes donors are not on the same
ground, and disagreements are found
among them. All of them may not agree on
common funding arrangements. Therefore,
donors have to be motivated by the plan,
estimated budget and arrangements. They
have to be assured that proper use of funds
will be monitored effectively (Key informant
#14).
Identification of the
free services and
always problematic
(Key informant #4).
and management systems [between HEF
and CBHI] (Key informant #7).
The poor and unemployed need access
to expensive health services, especially
inpatient services, and at the same time
basic primary health care services should be
free for them (Key informant #14).
Often, the informal-sector population are
unable to pay the premium for the CBHI
scheme due to their irregular income. They
easily drop out from the scheme [when
income is short] (Key informant #6).
Key informants had no clear idea how these two design
issues could be resolved under a common institutional
arrangement to ensure equity and financial protection.
There was a common lack of clarity among informants,
too, when the question of possible cross-subsidisation
between HEF and CBHI schemes arose. Understanding
the need to subsidise CBHI membership, some
informants thought that cross-subsidies from the HEF
schemes could be a good idea, but were not sure how
that would work or exactly what benefit it would bring to
He-Uo
\q.
P’-Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
11
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
the CBHI schemes. Others referred to the recent study
that identified evidence of negative cross-subsidisation
from poorer (HEF) beneficiaries to less poor (CBHI)
beneficiaries (Annear, Bigdeli and Jacobs 2011).
Level of pooling: HEFs and CBHI schemes have
diverse financing mechanisms—one a direct subsidy
and the other an insurance mechanism—and CBHI
generally has a limited pre-payment mechanism.
Informants understood that the opportunity for pooling
risk between these two different schemes was limited.
One informant commented that the 'pooling of funds
would be difficult; no fund to pool' (Key informant #1)
and another that 'pooling of funds ideally will not be
possible; may not be easy' (Key informant #5). Many
informants therefore favoured separate funds for HEFs
and CBHI. Consequently, it appears that the proposed
national agency would not play a role in equalising risk
between these schemes.
Level of administrative efficiency: The anticipated
integration of administrative, management and
information systems within the proposed national
agency is expected to reduce costs and provide
efficiencies. Even so:
[Achieving]
administrative
efficiency
will depend on the [precise] role of
the autonomous agency. The current
administration of HEF and CBHI schemes
through international and national NGOs is
expensive, and transaction costs are high
due to the different arrangements. We must
minimise these costs (Key informant #16).
The agency initially may have to face
complex
coordination,
administrative
and management arrangements. Only
strong leadership and capacity can make
the agency administratively efficient (Key
informant #10).
The national agency may reduce costs by standardising
contracts with implementers and with health providers
and by applying uniform provider payment mechanisms
with a carefully negotiated rate across both HEF and
CBHI schemes. Different types of provider payment
(mixed payment, capitation payment, flat rate) were
recommended by informants. The agency could use
its power as a single national purchaser to negotiate
12
appropriate rates with the providers. Efficiencies
would also be possible, according to informants, as
the national agency developed standard operational
guidelines, improved management tools, implemented
effective monitoring and resolved outstanding design
issues.
Equity, efficiency and cost-effectiveness of the
benefit package: Key informants regarded the design
of a standard benefit package, consistent between
population groups and demand-side schemes, as
desirable, though a complex issue. Ultimately, the
availability of funding and the need for longer term cost
control will determine the nature of the benefit package.
A key consideration is that HEFs cover food, transport
and other ancillary costs. Another concern, according
to informants, is to tailor appropriate benefit packages
for health centres, referral hospitals and provincial
hospitals.
Current benefit packages can be reviewed
and based on a minimum package that can
be introduced at the beginning. The second
option could be a comprehensive benefit
package, according to the availability of
funding and services at the different levels
(Key informant #15).
The low average quality of service is a critical issue.
Informants were hopeful that the purchasing and
contracting powers of a national agency could
leverage better quality of care. There may be a case
for accreditation procedures for contracted providers
and for penalties for failure to meet contract conditions.
Additional funding will be needed to monitor the quality
of care, which could be carried out centrally to reduce
the likelihood of misreporting. The correct incentives
will also be important.
Facilities can have income generation
activities, and this income can be used for
improving the quality of care. Providers
should have [a source of] income and [the
right] incentives. Operators can also play a
big role as they supervise certain aspects
of the quality of care. Sometimes operators
don't show interest to ensure quality of
care as they don't like conflict with hospital
management (Key informant #18).
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for po'cy
P
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Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
DISCUSSION
There is now a unique opportunity in Cambodia to
establish the institution for a national social health
protection mechanism for the poor and near-poor by
placing HEF and CBHI administration under a new
national agency. This rare opportunity arises from the
consistent work that began in 1998 and especially after
2000 and is made possible, in fact necessary, by the
unparalleled success in extending coverage of HEFs
across most CDs in the country. The government has
declared its support for scaling up HEFs to national
coverage, and the Prime Minister in mid-2011 publicly
endorsed the proposal. Donors and NGOs—including
those principally responsible for creating structures
for the national administration of the existing HEF
system—also understand the need to transfer the
NGO-established SHP mechanisms to government
administration.
The study found clear and broad agreement in favour of
establishing a national agency for the informal sector.
The views of key informants were consistent with the
proposal by the World Bank Synthesis Assessment to
establish a National Social Security Fund for Subsidy
Schemes. There is, however, as yet no clear strategic
direction for establishing the national agency. The
task is complex, and further work needs to be done
to prepare an agreed plan. There is agreement that
establishing a national agency is possible and practical,
and that it is proposed as an intermediate arrangement
until conditions allow a further move towards fulfilling
the objectives of the Master Plan for Social Health
Protection, including the creation of a national SHP
agency. An intermediate NSSF-S, together with the
NSSF and NCSSF in the formal sector, would provide
the building blocks for a later single structure.
Both the proposal for a national HEF-CBHI agency and
the wider objectives of the Master Plan are based on
principles of universal health coverage, the leadership
and ownership of the MOH and the government in the
health sector and equity and efficiency in the delivery of
health services to the whole population. Moving further
along this path implies the need to establish, within
or alongside ministry structures, the institutional and
health financing capacities to manage and regulate
a national SHP structure. The process, therefore, of
moving to a national HEF-CBHI agency is itself an
opportunity to extend significantly the public sector
reform already under' way within government services.
The MOH has a strong record in health planning,
developing strategies and creating guidelines. These
skills are invaluable for the new stage. Creating a
national agency is, however, an unprecedented
initiative, involving challenges for which the MOH has
no previous experience. Creating a national HEF-CBHI
agency will require new, purposeful and well-resourced
planning and design that will add to MOH capacity for
leadership in this area. The process of creating a legal
structure, building an office, recruiting or contracting
staff, negotiating with existing HEF-CBHI implementers
and operators, reinforcing government budgeting
processes and confronting the challenges that arise
will itself reinforce government capacity to lead such an
agency.
The will to move ahead is apparent among all
stakeholders. It is less clear, however, exactly how the
process will unfold. To move ahead, certain barriers
need to be identified and navigated:
• Inter-ministerial discussions leading up to the
approval of the Master Plan for Social Health
Protection are taking place, and in the Council
of Ministers, and the draft plan is currently under
review; the proposal for a national HEF-CBHI agency
is consistent with the Master Plan and can proceed
immediately through the MOH in collaboration with
the broader process.
• Respecting the existing decision-making structures
within the MOH and the government can slow the
process, but is essential if the preferred outcomes
are to be realised; leadership by those best
placed to meet the challenges is possible with
appropriate support; ultimately, a social reform of
this significance can be achieved only with political
support from the highest levels.
• The decentralised nature of the proposed
autonomous national agency places new demands
on the MOH and its staff to meet the challenges
related to both implementation and stewardship;
this is a new role of which there is little previous
experience and will require well-balanced and welltimed support from government and from partner
agencies.
• The technical apparatus and infrastructure needed
to house a national agency do not currently exist;
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
13
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
further time and resources will be needed to acquire
the office space, equipment, information technology
and trained staff; drawing on the structures and
resources currently supporting HEF and CBHI
administration will be necessary.
• No decision has yet been made about the legal
structures required to support a national agency,
either as a department of the MOH or as an
autonomous institution; ministerial or government
sub-decrees will be needed to authorise the creation
of a new structure.
• While agreement exists on the proposal to create a
national agency, there is no agreed plan; producing
a plan for the concept, design and working
procedures of a national agency is a necessary
prerequisite to moving ahead; agreement on
providing the time and resources for such a task is
needed between the government and development
partners.
• Perhaps the most critical policy decision is
agreement on the status of a national agency as a
third-party purchaser of health services; the MOH
faces a conflict of interest in the provision of services
and the management of demand-side payment
for those services (one that does not exist for
current supply-side budget line funding of facilities);
confidence needs to be established that the
purchasing role of a national agency is independent
from the service provision responsibilities of the
MOH.
There are a range of options for dealing with these
policy challenges, and all will require planning and
negotiation. While the general direction is clear, the
details are yet to be worked out, and the critical task
is to find an immediate way forward. To make further
progress, agreement on a single approach (even
one that is varied and complex) is required. Working
out what that agreed approach might be is the next
task, one that will lay the basis for establishing mutual
commitment and the motivation to succeed. Options
for further consideration include:
• Building on what exists is the most productive
approach; rather than waiting for adoption of
the Master Plan, it is possible to strengthen
existing programs and implement intermediate
arrangements that are consistent with the longer
term goal of universal coverage.
• The mid-term review of the Health Strategic
14
•
•
•
•
•
Plan 2008-15 provides a starting point; by using
the findings of the Overall Assessment and the
Synthesis Assessment, together with this study,
the main elements and key questions that remain to
be resolved can be identified and a process put in
place to address those issues.
Currently, the national administration of HEFs
is centred mostly on an international NGO,
the University Research Company (URC); one
possibility is to find an appropriate way to transfer
the management of that apparatus to the MOH
(or possibly to an autonomous body), with URC
continuing to provide technical advice; a patient
and constructive process of negotiation between
the DPHI and URC would facilitate this process.
It is not necessary to wait forthe creation of a national
agency to scale up HEFs to national coverage, and
such an expansion would create relatively little
additional burden on future requirements under
the MOH; it is likely the administrative resources
needed for national expansion are already available
within URC’s current national program for HEFs;
careful consideration of URC capacities and MOH
capabilities is needed.
Recent studies have highlighted the constraints on
CBHI expansion as a pre-payment mechanism for
the informal sector, including the cost of premiums
to families, the lack of complete trust in the
insurance system and concerns about the quality
of service delivery at government facilities; moving
immediately to reform the CBHI system in a way
that overcomes these constraints (perhaps with
responsibilities transferred to some degree to the
government system, and appropriate subsidies on
the demand side) is possible and necessary; careful
negotiation with current CBHI providers could
begin.
The most direct route to establishing an independent
agency using the existing legal and administrative
structures of the government is to establish a Public
Administrative Enterprise attached to the MOH; this
would be a consistent part of the government's
public administration reform and would run in parallel
with the existing NSSF and NCSSF agencies.
Under current conditions, moving to a national
agency will require clear support from both
government and donors and a program of
additional support to the MOH; MOH capacity for
policy, management and administration (including
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
IT) needs to be supplemented and additional
resources guaranteed; the Health Sector Support
Project may be a vehicle to achieve this, based on
the findings of the mid-term review.
the means for addressing the institutional requirements
for universal coverage and will provide an impetus for
strengthening the key health financing functions related
to equity and efficiency.
The next steps will benefit from strong leadership
through the DPHI at the MOH that produces a single
common and agreed approach. Appropriate technical
support from development partners can facilitate
such an outcome. One possibility suggested by some
key informants was to use the process of a formal
feasibility study to develop a response to the most
important concrete questions related to implementing
a national HEF-CBHI program through an autonomous
government agency. This could be a first step in a more
detailed design process to determine the mission of the
proposed agency, its organisational structure, function
and so on. Such a process could define the content
and practice of a national agency and provide the basis
for project support that will make its establishment
possible.
Our analysis confirms that the OASIS framework
offered by Mathauer and Carrin (2011) is a useful tool
for carrying out the policy work related to the creation
of such a national agency in or through the MOH.
While the key policy issues still need to be resolved
in Cambodia, the framework underlines the need to
balance institutional with health financing requirements
and directs attention to the major policy questions that
must be answered.
CONCLUSION
The extensive coverage of the poor population achieved
by Cambodia’s HEFs, together with recent increases
in government funding for health care (a product of
impressive economic growth) and commitment from
development partners provide the foundation for a
major social reform in the health sector. The conditions
are right, the time is right and there is a consensus
on establishing a national agency for HEF and CBHI
(including also voucher and other demand-side
financing schemes).
The challenge facing health planners now is to
determine the process by which this reform can be
implemented. No one group, acting alone, can create
such an agency; rather, a common agreed plan is
needed. A national agency for demand-side financing
in the informal sector (principally HEFs and CBHI) is not
only called for, but its establishment will also provide
The creation of an autonomous agency of this type—
which will depend also on strong regional links, the
participation and support of local government and
new forms of public administration—will fit well with the
government’s decentralisation and deconcentration.
Developing a common framework for administration,
financial management and monitoring through the
agency will help to create the basic administrative
structures for universal coverage.
As well, moving to a national agency involves policy
design that will harmonise the practices, tools and
guidelines of the various HEF and CBHI schemes
and bring greater uniformity to a range of health
financing indicators. These include arrangements
for financing and fund management at the different
levels, resolving the nature of coordination between
HEF and CBHI schemes, avoiding overlap with other
financing mechanisms (like voucher schemes), defining
an affordable and sustainable benefit package with
minimal or co-payments, finding an appropriate provider
payment mechanism and potentially improving the
quality of service.
The need now, through a process of collaboration and
consensus, is to establish the feasibility of creating a
national agency and to begin the necessary design.
Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
Health Policy and Health Finance Knowledge Hub WORKING PAPER 18
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Institutional and operational barriers to strengthening universal coverage in Cambodia: options for policy development
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