Better HealtH ServiceS Project (BHS)2009–2013

Project Brief

august 2011 the project brief is made possible by the support of the american People through the United States agency for international Development (USaiD). the contents of this project brief are the sole responsibility of Urc and do not necessarily reflect the views of USaiD or the United States Government

Who we are

The Better Health Services Project (BHS) is funded by the U.S. Agency for International Development

(USAID) and managed by University Research Co., LLC, (URC). BHS continues the work of the USAID Health Systems Strengthening in Cambodia (HSSC) Project, which URC implemented from 2002–2008.

The five-year BHS project’s goals dovetail with the mission of the Ministry of Health (MOH) as stated in the Cambodian Health Strategic Plan 2008–2015: “to provide stewardship for the entire health sector and to ensure a supportive environment for increased demand and equitable access

to quality health services in order that all the peoples of Cambodia are able to achieve the highest level of health and well-being.” BHS supports this mission through a variety of efforts to 1) improve the quality of public health care services; 2) increase the utilization of and demand for such services while pursuing the MOH’s pro-poor goals; and 3) support on-going and new health reform efforts aimed at increasing the transparency and accountability of health services through decentralized, contractual structures.

focus areasBHS’s overall aim is to improve the quality of care and use of public health facilities, with a particular emphasis on increasing equity of access for the poor. BHS focuses on:

¡ Health financing and community-based health,

¡ Health informatics,

¡ Hospital improvement,

¡ Maternal and newborn health,

¡ Monitoring and evaluation,

¡ Behavior change communications, and

¡ Support to other government-led health reform efforts, such as Special Operating Agencies and Service Delivery Grants.

HIV/AIDS is not a BHS focus area but the project does support several important HIV/AIDS efforts. The “Highlights” section below describes these efforts and work in the above-listed focus areas.

a cambodian family heads home after a visit to the health center.

2 Better Health Services: Project Brief

Where we workThe project works at the national level and has more-focused efforts in in the 11 provinces supported by USAID.

HighlightsHealth financing and community Based Health BHS is building on the success of Health Equity Funds (HEFs), largely developed by URC, as the main strategy to reduce financial barriers to health care for the poor. HEFs are a health financing scheme that pays for health and support services for the approximately 35% of Cambodian families that the Ministry of Planning identifies as poor. BHS is assisting the MOH to support nationwide scale-up of HEFs and succeeded, during its first two years, in greatly improving HEF coverage, access to health services by those covered by HEFs, and the efficiency of HEF administration. Thanks to HEFs, the numbers of health center contacts and hospitalizations by the poor have increased significantly (Figures 1 and 2, respectively). The utilization rate of hospital services by the poor has more than tripled and now exceeds that of the non-poor. Recent evaluations show that HEFs have greatly increased use of health care by the poor while significantly diminishing their catastrophic health expenditures and debt burdens.

a cambodian mother and baby rest.

Oddar Meanchey

Preah Vihear

Kampong Thom

Stung Treng Ratanak Kiri

Mondul KiriKratie

Kampong Cham

KampongChhnang

KampongSpeu

Kampot

Takeo

Svayrieng

Siam ReapBanteay

Meanchey

Battambong

Pailin

Koh Kong

Pursat

Sihanoukville

Preyveng

KandalPHN

How we workBHS harnesses and builds on the existing resources and expertise of the government, non-governmental organizations (NGOs), and local authorities at the operational and service delivery levels. The project works closely with numerous departments of the national MOH, including the Department of Planning and Health Information (DPHI); the Hospital Department (including the Quality Assurance Office); the National Maternal and Child Health Center (NMCHC); the National Center for HIV/AIDS, Dermatology and STD (NCHADS); the National Center for Tuberculosis and Leprosy Control (CENAT); the Communicable Disease Control Department, the Human Resources Department; and provincial health departments (PHDs) and operational districts (ODs) in USAID-supported provinces.

BHS draws on clinical expertise from the Angkor Hospital for Children in Siem Reap and collaborates closely with a wide range of local and international development partners, including the other two major USAID maternal and child health projects implemented by two Cambodian NGOs, the Reproductive Health Association of Cambodia (RHAC) and the Reproductive and Child Health Alliance (RACHA), as well as the main USAID HIV/AIDS project implemented by Family Health International (FHI).

Better Health Services: Project Brief 3

figure 1. Number of health center contacts by HEF beneficiaries in URC-supported districts

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

2008 2009 2010

HEF Contacts

Non-HEF Contacts

figure 2. Number of inpatient cases supported by HEFs in URC-supported districts

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

2008 2009 2010

HEF Cases

Non-HEF Cases

BHS’s work in health financing includes:

¡ Output-based contracting of HEF operators (HEFOs) in co-funded areas,

¡ Playing an ongoing role as the HEF implementer for HEFs that are part of the MOH’s Second Health Sector Support Project (HSSP2),

¡ Testing dynamic payment strategies linked to quality of care, and

¡ Standardizing price structures and payments for health services.

BHS has been successful in having the MOH assume many HEF costs: By early 2011, the Ministry was paying all direct benefits in 24 ODs and management costs in 15. This was

an important step in ensuring the long-term sustainability of HEFs in Cambodia. In agreement with USAID and formalized through a memorandum of understanding signed by MOH, HEFOs, and URC, BHS will serve as HEF implementer for all HEFs in the country, covering all 77 ODs. This largely involves BHS acting as the HEF monitor nationwide, which will give BHS unparalleled insight into the workings of HEFs under various models.

The MOH has long desired to link HEFs to community-based health insurance (cBHi). BHS has expanded this idea to involve local government officials and to establish community-based organizations to manage combined HEF/CBHI programming, a model called “community-based health cooperatives” or CBHCs. CBHCs provide a mechanism to tie health care quality improvement and improved management systems to payments for services. CBHCs also include a robust behavior change and communication component to improve health literacy in the public. A separate model has been developed for urban areas, which have a very different context from rural areas.

Main activities of BHS in community-based health include:

Rural Community-based Health Cooperatives

¡ Developing and operationalizing two CBHC models: one for Angkor Chum OD in Siem Reap province and another in Pursat province,

¡ Incorporating conditional cash transfers into the CBHC model, and

¡ Improving the quality of health services in CBHC health facilities.

Urban-based Community Health

¡ Developing an urban community-based social health protection (SHP) strategy;

¡ Operationalizing the urban SHP/HEF model in Khan Meanchey (urban district) as a pilot;

¡ Creating a community-based health marketing and communication mechanism;

¡ Implementing quality assurance of health facilities under the scheme, with the possibility of including private sector providers; and

¡ Establishing new enrollment strategies for the urban poor.

4 Better Health Services: Project Brief

Health informaticsBHS has taken the lead in MOH efforts to rationalize its health management information systems (HMIS). The HMIS was formerly a mix of stand-alone databases with a Microsoft Access HIS database at its center. BHS partnered with the MOH/DPHI to design and implement a web-based HMIS that uses open-source software (MySQL, PHP, and Apache). BHS is now working with other MOH departments and programs to integrate their data into the new platform so that more health information will be available to all partners at all levels of the health system.

The main BHS activities in health informatics include:

Web-based databases

¡ Continued development of the web-based HMIS for public, NGO, and for-profit private providers (www.hiscambodia.org);

¡ Developing an additional, linked HEF and social health protection database;

¡ Establishing a registration and membership database for the Cambodian Medical Council;

¡ Providing technical assistance to the MOH Human Resources Department and development partners to upgrade the MOH human resource database; and

¡ Creating the web-based database for the BHS project information system, which includes the results of hospital and health center assessments, quarterly assessments, and laboratory assessments as well as hospital and maternal and child health dashboards.

Unique patient identifiers

The advantages of using unique patient identifiers (that is, patient identification [ID] numbers) include improving 1) clinical care records and 2) the ability to track multiple services provided to targeted populations. BHS is introducing the use of unique identifiers into work on patient registration and hospital admissions. Such identifiers also fit with the need of the President’s Emergency Plan for AIDS Relief (PEPFAR) to track the number of prevention interventions provided to any high-risk client. BHS is piloting fingerprint identification in Siem Reap Provincial Hospital as part of a larger project that will enable the hospital to create and maintain proper patient case files.

Health management information systems

BHS is also working with both Battambang and Siem Reap Provincial Hospitals to develop a hospital management information system that builds on the OpenMRS platform to ensure scalability. OpenMRS is a community-developed, open source, electronic medical record system platform. It includes both administrative (patient registration; unique patient ID number; and inpatient, pharmacy, and patient dashboards) and clinical (electronic patient record) systems. OpenMRS has traditionally been used to manage systems related to the provision of antiretroviral therapy (ART); BHS is one of the first to attempt to use OpenMRS to create an integrated, comprehensive hospital information system in a developing country.

Strengthening data quality at hospitals

BHS successfully revised and helped the MOH introduce a unified antenatal care (ANC) register in 2010 to replace three overlapping registers (an ANC register, a separate register for the prevention of mother-to-child transmission of HIV (PMTCT), and a third register for Linked Response) that were used by various MOH programs. BHS brought together the different stakeholders and helped them develop a more rational data collection mechanism that met all of their various needs while simplifying and streamlining the work of health facility staff. The single, unified ANC register is now being used nationwide.

The BHS Health Informatics team is working closely with the Hospital Improvement Program to move hospitals forward on improving data quality, collection, and use. As part of this work, BHS is helping to transition health facilities from episodic, register-based reporting systems to longitudinal patient records that will track patients over time, using paper-based or computer-based records. This process requires that many steps be taken over time. BHS

this ambulance is about to take a referred patient from a health center to a hospital. BHS is working to ensure that patients are appropriately referred to higher levels of the health system and that referrals are handled in a quality manner.

Better Health Services: Project Brief 5

BHS is implementing all hospital improvement interventions in Battambang Referral Hospital with the objective of developing a comprehensive and replicable model for hospital improvement in Cambodia. BHS is also helping to implement specific interventions in a dozen other hospitals countrywide.

BHS works on many issues at the national level. Working closely with the MOH and other development partners, BHS has had a key role in the development of national policies, protocols, and guidelines in multiple technical and management areas. The main activities include:

¡ Continued efforts to improve quality assurance tools and approaches and institutionalize their use;

¡ Technical and management improvements built on “pay for performance”;

¡ Developing new level-appropriate clinical practice guidelines for hospitals;

¡ Updating the Comprehensive Package of Activities (CPA) guidelines, which articulate the structural and management standards by which hospitals operate;

¡ Activities to improve pediatric, nutrition, and family planning services at referral hospitals;

¡ Developing a comprehensive approach to CME;

¡ Licensing and certifying physicians, midwives, and nurses; and

¡ National level policy development and roll-out of the first infection control guidelines and trainings, A/H1N1 control guidelines and protocols, HMIS training and data quality audits, social health protection monitoring framework, and safe motherhood protocols for health centers and hospitals.

has designed and is introducing revised and/or combined registers and new patient records at targeted hospitals. Patient IDs will help link register data from multiple hospital wards. In addition, data from patient records will be entered into an electronic medical record to simplify referrals.

Hospital improvementBHS is strengthening the quality of care at health facilities through strengthened supervision and the use of quality assurance tools and approaches. The project is promoting a patient-centered approach that enables essential case management, including referrals. A new area of work focuses on continuing medical education (CME), where BHS is collaborating with the MOH, the Cambodian Medical Council, and the University of Health Sciences to develop a comprehensive approach to CME and the licensing of physicians, midwives, and nurses.

BHS’s hospital improvement activities will improve three levels of management: patient, ward, and hospital, through targeted interventions that lead to improved competency covering a wide range of technical and managerial areas:

¡ Patient management activities are designed to improve the quality of clinical care and include the development of practice guidelines, clinical pathways, and standardized approaches to patient charting.

¡ Ward and department management activities focus on key processes needed to ensure the smooth functioning of individually managed units, such as a clinical ward, support department, or lab.

¡ Hospital management activities focus on the hospital as a whole and tie the previous two areas of management together.

a midwife takes the blood pressure of a pregnant woman in a health center in Siem reap province.

MoDel HoSPital StrateGy

BHS is undertaking the first effort in cambodia

to bring together hospital financing, quality of

care improvement, and hospital management

practices. the project is using a Special operating

agency and a Service Delivery Grant (MoH

health reform strategies) to provide a structure

for a performance-based incentive scheme, the

“Battambang Model Hospital.”

6 Better Health Services: Project Brief

Maternal and Newborn Health (MNH)Due to relatively high levels of maternal and newborn mortality, the Cambodian Government has placed a particular emphasis on MNH. After years of limited progress, three factors have converged to make a comprehensive program more likely to succeed: facility births are increasing significantly,

fertility is dropping, and public interest and awareness in the problem have risen significantly. BHS has contributed to these developments, and BHS is working with MOH, donors, and other USAID partners to support the implementation of proven interventions, from the village to health center to hospital levels.

BHS’s MNH team supports improvements in clinical care provided at health centers and hospitals with guidelines, protocols, training, and coaching in selected life-saving clinical interventions, including emergency obstetric and newborn care. BSH supported the national development of Safe Motherhood Protocols (SMPs) for health centers, adopted nationally in 2010, and is involved in a similar process for hospital SMPs in 2011.

BHS is leading a collaborative effort with the National Maternal and Child Health Center, local partners, and UNICEF to prioritize the “key interventions” for reducing maternal and neonatal deaths: prevention and treatment of postpartum hemorrhage, including the active management of the third stage of labor or AMSTL; prevention and treatment of eclampsia and severe pre-eclampsia (including magnesium sulfate); essential newborn care and immediate postpartum care; and helping babies breathe, including newborn resuscitation. BHS is also holding national and regional workshops to train health staff and gain consensus around and support for improved implementation.

The reduction of financial barriers to MNH care at provincial, district, and local levels is a key component of the Government of Cambodia’s Fast Track Initiative Road Map for Reducing Maternal and Newborn Mortality. HEFs, described above as having significantly reduced financial barriers to care for the most needy Cambodian families, have also resulted in increased access to and use of facility deliveries by the poor.

BHS’s MNH activities include:

¡ Training, coaching, and mentoring of midwives, nurses, and doctors;

¡ Institutionalizing quality improvement processes, such as quarterly Midwifery Coordination Alliance Team meetings (MCATs) where hospital midwives and physicians, health center midwives, and provincial and district maternal and child health managers meet to discuss supervision results, referrals, cases reviews, near misses, and technical updates;

¡ Strengthening referral and communication links between health centers and hospitals;

¡ Strengthening maternal death surveillance and maternal death audits;

¡ Providing technical assistance and advocating for national level policy development (to update national protocols, guidelines, and policies);

¡ Developing a national integrated in-service training curriculum for midwives by combining the various existing training packages into seven agreed-upon modules that will be used by all partners training midwives in Cambodia; and

¡ Developing hospital-based family planning services, including for people living with HIV/AIDS (PLWHA).

Hiv/aiDS Although BHS does not focus on HIV/AIDS, it supports important HIV/AIDS-related efforts in Cambodia:

¡ Care for orphans and vulnerable children (OVC): BHS supports OVC care in Phnom Penh and its suburbs through a sub-award to New Hope for Cambodian Children, which provides a comprehensive care package to over 400 HIV/AIDS orphans.

¡ HIV/AIDS care: BHS participated in the hand-over of the opportunistic infection (OI)/ART program in the BHS-supported Khmer-Soviet Friendship hospital after Médecins Sans Frontières, France, left Cambodia. While the National Center for HIV/AIDS, Dermatology and STD (NCHADS) pays for much of ART care, many aspects of needed care are not subsidized and poor families may not seek care due to financial barriers. BHS is conducting a special “ID Poor” screening process for the cohort of approximately 3700 OI/ART patients to give Phnom Penh HEF cards to patients (and families) who qualify as poor. BHS is also piloting a new approach to targeting PLWHA for HEF benefits using other HIV/AIDS clinics in Phnom Penh.

Better Health Services: Project Brief 7

¡ Infection control: BHS is implementing activities to improve infection control practices in Cambodia hospitals and health centers, an important contribution to HIV/AIDS prevention and control. BHS is also working closely with USAID partner FHI in the Battambang referral hospital to implement TB-specific infection control guidelines that were adapted from the national standards that in turn had been developed with BHS support.

¡ Family planning and HIV integration: BHS is working with NCHADS, FHI, and other partners to provide family planning services to HIV-positive women enrolled in the national OI/ART program. This work is complicated by the manner in which family planning commodities are provided through the system, but early efforts suggest that these barriers can be overcome.

¡ Integrating elements of the HMIS: BHS is leading the transition to a set of web-based software platforms and database standards that will permit various MOH databases to link to each other through a common HMIS. As part of this overall effort, BHS is working closely with NCHADS to integrate their HIV/AIDS data and information into the national HMIS.

¡ Unique patient ID numbers: BHS will continue to work with PEPFAR prevention partners to develop a patient-tracking system that will allow PEPFAR to track individual clients using single or multiple services - so that they can better analyze information on beneficiaries. This system will also help the health system to know whether HIV clients referred for other health or non-health services actually use those services. USG PEPFAR partners are keenly interested in this new patient-tracking system as it will enable them to assess the extent to which different efforts are making a difference in preventing HIV/AIDS and reducing its impact.

Monitoring and evaluation (M&e)BHS measures the success of its interventions through three primary outcome measures: increased utilization of public health services; increased quality of care, both technical and interpersonal; and improved equity in access to health services. To do this, the project has designed a robust M&E strategy.

The strategy builds on and is aligned with the day-to-day management of health services so as to minimize the M&E burden on MOH staff. BHS builds on the tools and processes that are part of health facilities’ routine supervision and management. The strategy is seamlessly integrated with MOH programs and works across multiple programs. It includes governmental counterparts in monitoring and evaluating project progress against outputs and outcomes.

M&E data come from multiple sources, including the HMIS, hospital and health center management processes, MOH quality and performance assessments, patient records, social health protection financial reports, and targeted evaluations. BHS project monitoring tracks the data to monitor quality of care, hospital management, and progress in strengthening health services. Regular spot checks are carried out by M&E staff to ensure that forms are properly filled out and that specified tasks are being carried out appropriately.

Behavior change communication (Bcc)BHS uses BCC to promote health-seeking behavior, increase demand for quality care, and improve key household practices. Although significant increases have occurred in the number of deliveries at public health care facilities, antenatal care, and use of family planning, continued improvements in these and other areas are still needed. BHS’s BCC strategy uses multiple communication channels to reach different target audiences and provides messages that will change the beliefs of individuals and health providers to help them adopt healthy behaviors and practices. It aims to increase demand for services by strengthening community understanding of reproductive and sexual health needs and rights. The messages and approach are harmonized with national strategies for addressing family planning, maternal and child health and nutrition, hygiene, infection control, and financing. BCC approaches complement other approaches to stimulate demand, such as conditional cash transfers, community-based health insurance, and HEFs.

The project’s main BCC activities include:

¡ Developing and delivering mass media messages to support continued breastfeeding for at least two years, a key child health and nutrition practice that has declined significantly in Cambodia in the past five years;

¡ Increasing the awareness and use of HEF/CBHC cards;

¡ Promoting good infection control practices at health facilities;

¡ Increasing awareness of key health risks in communities;

¡ Developing and promoting the use of the integrated Mother/Child Book for health education and combined home-based records; and

¡ Linking conditional cash transfers to the Mother/Child Book in operational districts as part of CBHCs.

Special operating agencies (Soa)BHS is also supporting the MOH health reform measures established in late 2008. These include SOAs and their accompanying funds transfer mechanism, service delivery grants (SDGs). SOAs are operational districts or hospitals that receive limited autonomy from the MOH to manage their own affairs. They enter into a contractual relationship with various MOH levels to receive an SDG. BHS has worked to introduce elements of pay-for-performance into this contractual relationship.

BHS activities include:

¡ Analyzing SOA implementation,

¡ Designing a pay-for-performance SOA contract in two operational districts in one province,

¡ Enhancing the quality of health services in the SOA operational districts through the pay-for-performance approach,

¡ Strengthening the contract management component of SOAs, and

¡ Supporting the MOH for various assessments and procedures that are necessary to obtain and maintain SOA status.

BHS is using the information gained from this activity to inform the other components of the program as the question of how to effectively steer more resources to health facilities remains primary in Cambodia. For example, the “model hospital” strategy described above builds on the SOA/SDG structure and implements it in a new and innovative way. Government partners recognize BHS initiatives in this area as playing an important health system-strengthening role. BHS continues to work closely with numerous MOH departments, the Health Sector Support Program 2 (“pooled funds”), the Global Fund principal recipients, and multilateral and bilateral donor agencies to strengthen Government-led health reforms.

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for more information, please contact:

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