Translating Clinical Guidelines into Knowledge-guided Decision Support
Bigdeli Translating Knowledge Into Policy (2)
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Transcript of Bigdeli Translating Knowledge Into Policy (2)
Translating knowledge into Policy and Action
A case study on Health Equity Funds in Cambodia
Maryam Bigdeli- WHO CambodiaVientiane, October 2008
Acknowledgments
The case study was developed in 2007 by Dr. Ir Por (ITM), who is the first author of the report and publication submitted to the WHO Bulletin.
Mr. Bruno Meessen and Dr. Wim Van Damme (ITM) co-author the publication with us.
We worked under the guidance of a review team: Dr. Lo Veasna Kiry (MOH), Dr. Saphorn Vonthanak (NIPH), Dr. Benjamin Lane (WHO).
We received comprehensive comments from Dr. Anjana Bhushan and Reijo Salmela (WHO) as well as Dr. Steve Fabricant
Introduction
Cambodia has been the ground for multiple health financing innovations to improve access to health services
Health Equity Funds (HEF), in particular address the problem of access for the poorest segment of population
HEF have grown from a few pilots to become national policy
We examine how the evidence from early pilots was used to feed stages and elements of national policy on Health Equity Funds
Definitions
Health Equity Fund Health Equity Funds (HEFs) emerged after 2000 as
third-party payers for indigent patients.
A fund is managed at district level by a local agent.
Identified poor patients receive free health care at the facility. Facilities are reimbursed by the fund for foregone user fees
Patients are reimbursed transport and food costs and may also receive a funeral grant
Conceptual Framework
4-K Framework – Meessen and Van Damme
Describes 4 stages of policy process: K1 – Exploiting existing knowledge K2 – Creating new knowledge K3 – Brokering new knowledge K4 – Adopting and using new knowledge
Within a defined context, at each stage, actors play a role in feeding the ‘stock of knowledge’
The ‘stock of knowledge’ feeds policy
Methods
Document analysis Published papers Project evaluation reports Royal Government of Cambodia and Ministry of Health
documents Key Informant Interviews
Stakeholders : MOH, Economy and Finance, Planning; donor agencies; NGOs (local and international); researchers and managers from academic institutions
Semi-structured questionnaires based on findings of the document analysis
Review team Regular meetings to triangulate information above
Context : a rich history of health financing reform
Fre
e ca
re f
or
all
1996 1999-2000 2002 2005 2007
Context : a rich history of health financing reform
Fre
e ca
re f
or
all
1996 1999-2000 2002
National Health Financing Charter
2005 2007
Context : a rich history of health financing reform
Fre
e ca
re f
or
all
UF and exemptionsPilots
1996 1999-2000 2002
National Health Financing Charter
2005 2007
Context : a rich history of health financing reform
Fre
e ca
re f
or
all
UF and exemptionsPilots
UF and exemptionsExpansion
ContractingPilots
CBHIPilots
HEFPilot
1996 1999-2000 2002
National Health Financing Charter
2005 2007
Context : a rich history of health financing reform
Fre
e ca
re f
or
all
UF and exemptionsPilots
UF and exemptionsExpansion
UF and exemptionsNational Coverage
ContractingPilots
ContractingExpansion
CBHIPilots
HEFPilot
HEFExpansion
1996 1999-2000 2002
National Health Financing Charter
2005 2007
Context : a rich history of health financing reform
Fre
e ca
re f
or
all
UF and exemptionsPilots
UF and exemptionsExpansion
UF and exemptionsNational Coverage
ContractingPilots
ContractingExpansion
CBHIPilots
HEFPilot
HEFExpansion
1996 1999-2000 2002
National Health Financing Charter
2005
HEF Implementation And Monitoring Framework
2007
HEF StrategicFramework
Health Sector strategic Plan 1 2003-2007
Context : a rich history of health financing reform
Fre
e ca
re f
or
all
UF and exemptionsPilots
UF and exemptionsExpansion
UF and exemptionsNational Coverage
ContractingPilots
ContractingExpansion
CBHIPilots
HEFPilot
HEFExpansion
1996 1999-2000 2002
National Health Financing Charter
2005 2007
Strategic Framework HF 2008-2015Health Sector Strategic Plan 2 2008-2015 Social Health Protection Master Plan (2009)
Sub-Decree 809 (2007)HEF Implementation Guidelines 2008HEF Financial Manual 2008
The policy processK1 – Exploiting existing knowledge: birth of HEF idea
Urban Health Project – 1999 Health rooms in Phnom Penh (health centres) Cost of referral 2000 : Equity fund to cover cost of referral and 70% of user
fees at hospital Thmar Pouk and Sotnikum New Deal -1999
Address issues of underpaid health staff, low quality of care, underutilized health service
Special fund, entrusted to a local NGO: identify poor patients and pay for user fees and related costs for them
Both initial pilots were born within a supply-side approach, aiming to provide health services to the population. Limitations of access within these projects lead to creation of special arrangements for the poor.
The policy processK2 – Creating new knowledge or innovations: results from HEF pilots (1)
UHP and TP and S New Deal evaluation reports HEF helped patients overcome financial barriers to
access health services Limitation of post-identification Fund management by an NGO is effective
New HEF schemes, new models tested Reinforced evidence of impact on access Produced new evidence:
Pre-identification feasible and cost-effective Limited benefit package may undermine access HEF can be effectively managed through other
implementation arrangements: eg. mixed committees, pagodas
The policy processK2 – Creating new knowledge or innovations: results from HEF pilots (2)
Requisites for replication User fees for poor patients should be charged to a
special fund created for this purpose (HEF) Facility where HEF is operating must be well functioning
and trusted by the population Other access costs such as transport and food should
be supported HEF should be managed be managed by a transparent
and committed third party that has the capacity to identify and support the poorest patients
The policy processK3 – Brokering new knowledge: dissemination of HEF pilots results Sector Wide Management (SWiM) creates a network for transfer of
knowledge to policy makers Sotnikum New Deal
Steering Committee, including policy makers and supporting partners Local and international publications
MSF Cambodia Sotnikum New Deal 1st and 2nd year reports: Van Damme et al 2001 , Meessen et al 2002
Health Policy and Planning 2004 : Hardeman et al The Hague Institute of Social Studies 2001: Hardeman et al
Other pilot projects evaluation reports Joint Health Sector Review Report 2001
Discussed extensively all the new health financing innovations, including HEF MOP National Forum on Identification of Poor Households 2005
Supporting pre-identification process MOH National Forum on Health Equity Funds 2006
First attempt to assemble all knowledge on HEF, with a participative process from all stakeholders
Consensus on impact of HEF on improving access for the poor
The policy processK4 – Adopting and using new knowledge: expansion and harmonization of HEFs
Health Sector Strategic Plan 2003-2007 Strategy 15 on allocating financial resources for access to health services by the poor Indicators 12 and 13 on HEF coverage (#ODs and #patients)
HEF Strategic Framework 2003 Guiding principles for design, implementation and evaluation
HEF National Implementation and Monitoring Framework 2005 Practical implementation and monitoring arrangements Large consultative process
MOH/MOEF joint Sub-decree on subsidies for the poor (Prakas 809) – 2006
First regulatory application of the National Framework for HEF Implementation and Monitoring
Allocation of state budget to subsidize health services delivered to the poor in public health facilities
Health Sector Strategic Plan 2008-2015 Health Care Financing Strategy (1 of 5 strategic areas in HS)
Strategic Component 3: Reduce barriers at the point of care and develop social health protection mechanisms
The policy processK4 – Adopting and using new knowledge: expansion and harmonization of HEFs (3)
The HEF final policy package will include: HEF Implementation guidelines (2008) HEF Financial Manual (2008) Social Health Protection Master Plan (2009) – HEF as part
of a larger health financing and social health protection system
The policy contentPolicy element Consensus supported by
knowledgeNo consensus
Further knowledge required
Target population The “poor” Poor Level 1 or Level 2 or both(MOP Poverty identification guidelines)
HEF operator Third party payer (local or international NGO, local committee, faith-based organization, other)
Prakas 809 – government subsidies do not use third party arrangements – direct disbursement to facilities or ODs
Beneficiary identification
Combination of pre and post-ID gives best resultsNational pre-identification process
Frequency of pre-IDBest combinationPortability
Benefit package Hospital user fees
Transport and food costs
Health center user feesTertiary careChronic diseases
Monitoring and Evaluation
National core indicators and monitoring system
M&E Prakas 809 application
Funding and sustainability
External resources should continue
State budget allocated
Community participation, linkage with CBHI
Operated by local authorities to reduce overhead costs
Impact Improved access for the poor Protect the poor from impoverishing effect of health care cost
Poverty reduction
Conclusion
What kind of knowledge? Problem of access to health services for the poor, failure of the
exemption system Effectiveness of HEF early pilots Conditions for replication and expansion
What influenced policy uptake? Political context, conducive to production and dissemination of
evidence Credibility and timeliness of evidence Strong commitment and good relationship between actors
Why did it work? HEF does no go against interest of any actor Pragmatic concept reaching a dual objective: access for the poor and
income for facilities New way to channel donor funding and account for equity in donor
projects and programs Locally generated evidence, local success story
Au KunKop Chai
Thank You