Moving towards universal health coverage in Cambodia

The USAID Social Health Protection (SHP) Project, managed by University Research Co., LLC (URC) and its partners, supports the Royal Government of Cambodia (RGC) in its ambitious goal of moving towards universal health coverage by the end of the project in 2018.  The SHP Project, building on the momentum of the Better Health Systems (BHS) Project (2009–2013), continues to provide innovation and technical support to the RGC to complete national coverage of the Health Equity Fund (HEF) system.  By the end of the SHP Project, this critical health safety net will be integrated into the overall national health system, under RGC oversight, and will be expanded to offer support to other vulnerable groups beyond the poor.

URC and its partners are working towards achieving the project’s four primary objectives: (1) increase capacity of RGC institutions; (2) reduce financial barriers; (3) increase demand for quality services; and (4) increase access to targeted health services for people living with HIV and most at risk populations.

To achieve these objectives the project is active in the following areas:

  • Institutional support to the RGC to build capacity for the long-term management of social health protection mechanisms;
  • Technical assistance to the existing HEF system, which is the largest current SHP mechanism in the country, to complete nation-wide expansion, ensure the purchase of quality services, and remain efficient and effective;
  • Technical assistance to the Ministry of Planning poverty identification program to advocate for improvements in rural pre-identification of the poor and inform development of urban pre-identification systems.
  • Development of web-based patient information systems that provide unique patient identification numbers and manage medical records, benefit eligibility, and expenditures;
  • Community mobilization to create local committees who collect donations and provide additional benefits to the vulnerable to complement the national HEF system

The Health Equity Fund system

USAID, through URC, has supported development of the HEF system since 2003.  Starting from a handful of pilots in the early 2000s, it has become a national system and a key component of public health financing providing health insurance to ~3.2 million poor people in Cambodia.  Currently, the HEF system operates nationally and totaled $14 million (US) in expenditures in 2014—60% of which came from bi- and multi-lateral donors, including the Australian aid agency (DFAT), the World Bank, the German Federal Ministry for Economic Cooperation (BMZ), the Korean International Cooperation Agency (KOICA), and UNICEF, with the other 40% from the Cambodian government.

Poor households are pre-identified through the national poverty identification program, known as IDPoor, under the Cambodian Ministry of Planning.  Additionally, patients who are unable to pay the fees at public hospitals are interviewed on-site (known as post-identification) and awarded coverage if they qualify.  The day-to-day access to services is managed by national non-governmental organizations, “HEF Operators,” who facilitate poor patients at hospitals when they seek care.

The HEF system provides a standard set of benefits to individuals who have been identified as poor.  These include payment of service fees at public health facilities, transportation reimbursements, caretaker food allowances, and funeral support as detailed in Table 1.  HEF benefits are fully portable: eligible poor can seek health care at any contracted public health facility nation-wide.

Public health facilities are paid by the HEF system on a case-based output payment system. Payments are made directly to facilities at the end of each month, based on HEF beneficiaries’ documented utilization. Transportation reimbursements are calculated for HEF beneficiaries based on the actual traveling distance from their village to the Referral Hospital.  The first half of the transportation reimbursement is paid at the time of admission and the second half at the time of authorized discharge.  A caretaker food allowance of $1.25 per day is paid for HEF beneficiaries who are admitted for in-patient care.

All HEF beneficiary personal details, including eligibility and utilization/benefit records, are managed using the MOH Patient Management and Registration System. The PMRS, a web-based application designed to manage all patient-level information nationwide, was developed under the stewardship of the Department of Planning and Health Information (DPHI) of the MOH.  The PMRS is one of the modules within the larger web-based Health Management and Information System (HMIS). 

Built into the PMRS are specific tools for the management of the HEF system. This includes pre-identification data imported from the IDPoor program, and post-identification data collected by all HEF Operators. The system automatically calculates transportation reimbursements; tracks distribution of caretaker food allowances; generates monthly invoices; and automatically reports aggregate monthly statistics into the Social Health Protection module of the HMIS.

URC serves as the “HEF implementer,” providing independent verification of the benefits delivered by the HEF system and technical assistance to the HEF Operators. The PMRS is used by URC in the independent verification process to sample households for interview, track verification results, and serves as the platform for the formal HEF Complaint System. To accomplish this task, URC currently fields a total of 35 field-based monitors, covering 62 Operational Districts, to conduct household and key informant interviews, bedside monitoring, and document reviews to verify HEF Operator activities.  Every month, each HEF Operator submits their monthly financial report and invoice for certification before to URC forwards it on to the MOH for payment.

In the second year of the project (2015), special partnerships are being formed to broaden the focus of the HEF to cover additional vulnerable groups, including people living with HIV, the homeless, and the landless, among others. These partnerships will advocate for better service delivery to most-at-risk populations, engage with local governance structures to make social health protection more flexible and locally appropriate, and continue to innovate using information technologies to build bridges between the various national vertical programs and broader health systems. The MOH aims to expand the HEF system to achieve 100% coverage nationally by the end of 2015.

A closeup of a health equity fund operator verifying information provided by a patient's HEF card.
A health equity fund operator verifies information provided by a patient’s HEF card, which can be used by the whole family to seek care.
Date 
February 17, 2015
Authors 
Tapley Jordanwood, Chief of Party, Social Health Protection Project
Regions/ Countries