User:Tapleyjordanwood/sandbox

Introduction
The Health Equity Fund (HEF) is Cambodia's social health protection system for the poor. It functions by purchasing services from public health facilities on behalf of the poor, covering the medical expenses of approximately 3 million people, or almost 20% of the population of Cambodia. The HEF has been shown to increase access to health services, support improvements in the quality of care, and provide a significant source of revenue for health centers and hospitals. Supporting the public health goals of the Royal Government of Cambodia the HEF is the vision of the Ministry of Health (MOH) and its Development Partners including USAID, the World Bank, the Australian Department of Foreign Affairs and Trade, the German Development Cooperation, and the Korean development agency KOICA.

Targeting the Poor
The targeting mechanism of the HEF relies on the identification of poor households. All members of a poor household are entitled to full HEF benefits. There are two methods by which poor households are identified. The first is through the national Identification of Poor Households Programme (IDPoor) within the Ministry of Planning. The second is by the HEF itself through an interview process at public hospitals that is conducted on demand with patients who are unable to pay the necessary service fees.

Pre-Identificaiton
Pre-identification is the process of identifying poor households before they seek social assistance from mechanisms such as the HEF. Funded by the Royal Government of Cambodia, the national Identification of Poor Households Program (IDPoor) of the Ministry of Planning conducts the pre-identification process in annual rounds that each cover one third of the country. Pre-Identified poor households are identified using standardized processes at the village and commune levels that result in the classification into two levels of poverty status that include Poor Level 1 (“very poor”) and Poor Level 2 households (“poor”).

Each poor household identified receives an “Equity Card” that includes a household number, a picture of household members, their address, and the name of the head of household. “Equity Cards” are valid for three years until the next round of pre-identification in a given area. The Ministry of Planning provides the MoH with a complete data set of all households identified during each annual round, covering a third of the country, of the IDPoor process that is incorporated into the MOH Patient Management and Registration System (PMRS) and available to public health facilities to check the validity of the “Equity Cards”.

Post-Identification
Post-identification interviews are conducted in public hospitals on demand for in-patients unable to pay the service fees. Interviews are conducted during working hours in the morning from 7: 30 – 11:30 am and afternoon from 2:00 – 5:30 pm on weekdays. The interview process takes about 15 minutes and based on the results, eligibility for HEF benefits can be provided immediately to the patient and includes all members of his/her entire household. Like the pre-identification process it classifies households into Poor Level 1 and Level 2 and provides them with a uniquely numbered “Priority Access Card” that is valid for 12 months.

Accessing Benefits
Identified poor patients can access their HEF benefits at public health center or hospitals by presenting either their "Equity Card" or "Priority Access Card" at the time that they seek service. At health centers, staff record the patients "Equity Card" or "Priority Access Card" number in the standard MOH utilization register books. At public hospitals, staff use the MOH Patient Management and Registration System (PMRS) to confirm eligibility of HEF eligible patients and record the details of the services and non-medical benefits (transportation reimbursements and caretaker food allowances) provided to each HEF supported patient. All HEF benefits are fully portable: they can be accessed at any public health facility in the country.

Categories of HEF Benefits
These include payment of service fees at public health facilities, transportation reimbursements, caretaker food allowances, and funeral support as detailed in the table below. HEF benefits are fully portable: eligible poor can seek health care at any contracted public health facility nation-wide. '' 1. Except in cases of delivery, attempted delivery, post-abortion care, permanent contraception or emergency. ''

In order for HEF supported patients to access transportation reimbursements at Referral Hospitals[1] they are required to have a referral letter from a Health Center or pre-arranged appointment in order to encourage patients to access the appropriate levels of care. Referrals to the Khmer-Soviet National Friendship Hospital are required to be pre-arranged and fully documented to ensure that the necessary services are available.

Public health facilities are paid by the HEF system on a case-based output payment system the details of which are provided in in the table below. Payments are made directly to facilities at the end of each month based on the documented utilization by HEF beneficiaries. 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.

HEF Provider Payment Mechanism
'' 2. Health Centers and Former District Hospitals are paid $0.50 per consultation if they have achieved a score of less than 75% on the MOH Level 1 Quality Assessment, or $1.00 if they have achieved 75% or higher. ''

'' 3. Referral Hospital facilities at the CPA 1-3 levels will receive a case-based payment for attempted deliveries that are referred to a higher level of care if there is a documented referral that clearly states a valid reason for the referral. This payment is to ensure that there are no financial considerations involved in the decision to refer a delivery to higher care. ''

'' 4. Major surgical cases are defined by the use of general or epidural anesthesia during the procedure. ''

HEF Complaint Mechanism
The HEF system has established a formalized complaint mechanism to allow for the reporting complaints from HEF supported patients. Complaints are registered into the MOH PMRS by representatives of the HEFP based on their daily ward visits, through client satisfaction surveys, by health providers, and by the HEFI/PCA during household visits, beside interviews, or key information interviews. In general complaints are recorded anonymously without disclosing the identity of the concerned beneficiary or aggrieved party unless they specifically agree to be identified and participate in subsequent discussions and potential solutions.

Monitoring, Claims Processing, and Invoice Certification
The HEF system includes an independent monitoring process that verifies that services are delivered and accurately reported by health facilities. This process is currently undertaken by an international organization which serves in the role of the HEF Implementer (HEFI). There is currently an agreed plan by the Royal Government of Cambodia to create a new Cambodian institution known as the Payment Certification Agency (PCA) which will be established in 2016 and fully assume the current roles of the HEF Implementer by June 2018. Based on field monitoring that includes household and bedside interviews with patients, key informant interviews with local authorities and public health staff, and review of patient documentation, the HEFI/PCA provides a written certification of the invoices submitted by public health facilities to the MOH as a requirement before reimbursements are made to facilities through bank-to-bank transfers.

Key Institutions
A series of institutions are involved with the management and operations of the HEF at all administrative levels. These including the following with corresponding responsibilities provided below: 2.1 Department of Budget and Finance
 * 1) Ministry of Economy and Finance
 * 2) Ministry of Health

2.2 Department of Planning and Health Information

2.3 Health System Managers (Provincial Health Departments and Operational District Offices)

2.4 Health Care Providers
 * 1) National Hospitals
 * 2) Referral Hospitals
 * 3) Former District Hospitals
 * 4) Health Centers


 * 1) Payment Certification Agency and Health Equity Fund Implementer
 * 2) Health Equity Fund Promoters
 * 3) Health Financing Steering Committees at the Provincial and District Levels

Context
Following UN-sponsored elections in 1993, Cambodia entered a period of relative stability which allowed the country to begin to recover from the atrocities under the Khmer Rouge (1975-79) and the Vietnamese Occupation which left the country internationally isolated. This period saw a complete destruction of the health system that included demolition of health infrastructure and left only a few surviving health professionals. Initial reconstruction was initiated under the Vietnamese occupation and more conscious health planning with local ownership began with the 1995 Health Coverage Plan (HCP) (Grundy et al. 2009). The HCP focused on a rapid increase in the quantity of mostly rural health facilities and staff. The HCP created health operational districts (ODs) based on population coverage and geographic access criteria to respective public health facilities. Each OD was to cover 100,000- 200,000 people with a network of primary care facilities (health centers) linked to referral hospitals for higher levels of care. In addition, the HCP further prescribed roles and responsibilities to each level of health administrative structure.

Alongside the HCP, the MOH also introduced the Health Financing Charter in 1996, which led to the introduction of user-fees at public health facilities. Under the Charter’s rules, each facility is required to have consultations with local authorities and community members to set the fees that are then approved by the MOH. It also required that each facility publicly post their user fees and that a system of exemptions for the poor be put in place. This has led to a wide variety of user fee schedules and rates that are currently used by the vast majority of public health facilities. The charter further stipulated that 99% of revenues from user-fees would remain at the facility and could be used to ‘a maximum of 49% for direct staff supplementation’ (Barber et al. 2004) with 50% for running costs and 1% remitted back to the national treasury. The charter was later amended to increase the amount for staff salary supplementation to 60% and facility running costs were reduced to 39%.

Despite the intention to increase staff incentives and improve the quality of services, public provider salaries, and quality, remained low. Exemptions for the poor from user-fees proved to be ineffective as health staff who were given the latitude to award an exemption did so through a reduction of their own income. In response, the British Department for International Development (DfID), Médecins Sans Frontières (MSF) and the United Nations Children’s Fund (UNICEF) began to experiment with new approaches to health financing that addressed the barriers created by the new user fees, which were initially termed ‘Equity Funds’. In 1999 an initiative known as the ‘New Deal’ was introduced in a few ODs with the rationale of ‘better payment for better services’ (Van Damme et al. 2001). [null It was expected that at a later stage cost recovery would mostly be achieved by increased government expenditure.] [TJ1] As part of the ‘New Deal’ Equity Funds were created to reimburse user-fees incurred by the poor at public hospitals to support the poor to overcome barriers presented by user fees and boost provider incomes on a performance basis. First implemented in three ODs, HEFs introduced a third-party purchaser function that could negotiate price and quality on behalf of identified poor beneficiaries (Van Damme et al. 2001).

Targeting the Poor
In the first Equity Fund efforts, poor individuals were identified using various interview tools that recorded household assets and average daily income that were scored to determine poverty status. Interviews were conducted in referral hospitals after patients had sought care and were often prompted by their in ability to pay the required user-fees. This process of interviewing patients after they have sought care is now defined as “post-identification” of the poor. In 2001 and 2002, MSF and UNICEF began experimenting with “pre-identification” of the poor through interviews at the village level with suspected poor households.

Propelled by positive outcomes from these first pilots (Meessen et al. 2002; Van Damme et al. 2001) individually financed HEF schemes were introduced into additional ODs through a variety of NGOs and funding sources. The first multilateral Health Sector Support Project identified the HEF mechanism as a strategy for scaling up and prompted the first national level policy documents which included the initial definition of the “HEF Operator” as a national NGO that functions at the Operational District level and the “HEF Implementer” which manages a cluster of HEF Operators. Starting in 2003, the USAID funded Health Systems Strengthening in Cambodia project implemented by University Research Co., LLC [TJ1] began funding HEFs as a mechanism to leverage quality improvements while at the same time providing social health protection.

Based on analysis of the lessons learned to date, URC with funding from USAID continued to expand the HEF mechanism to new ODs as well as support widespread application of pre-identification by HEF Operators. It has been very clearly documented that the combination of the identification with a HEF resulted in dramatic increases in utilization as illustrated by the graph below.

[graph]

The graph above demonstrates the dramatic increase in IPD use by pre-identified poor. The Y axis in this graph is the average number of total inpatient discharges per HEF hospital per month.[1]  The X axis tick marks represent months, for the green line they represent the 36 months prior to the poor population of a hospital catchment area being pre-identified and provided with HEF ID cards, for the red line they represent the 36 months following the distribution of ID cards. It is clear that the distribution of HEF ID cards to the pre-identified poor results in an immediate and sustained increase in the overall use of the IPD services of the associated hospital, by a factor of between 1.5 and 1.75. Since the HEF-eligible population represents only about 1/3 of the total population, and, given the timing, it must be assumed that the increase in IPD utilization comes from this population, the slightly less than doubling of IPD discharges for the hospitals as a whole corresponds almost exactly with the previous graph’s demonstration of about a three-fold increase in the use of IPD by HEF pre-identified poor compared to non-poor in the same catchment area.

Expansion of the HEF System
Despite HEFs being originally designed to address the core problem of catastrophic health expenditures at the referral hospital level, several efforts were made to expand the health system to cover benefits at the health center. These efforts were prompted by observations of health seeking behavior distortions among HEF beneficiaries who were bypassing the primary level of care altogether in favor of hospital services covered by the half as well as transport reimbursements and caretaker food allowances. The relative cost of supporting health center level services is minor compared to referral hospital services and provides the opportunity to establish referral mechanisms that encourage health Center use and prevent unnecessary admissions at the hospital. With relatively few Heatlh Centers covered until 2007, the idea took hold in 2008 and with a total of 547 Health Centers (out of X Total, X%) covered as of mid-2014.

[graph]

Development of the HEF Information Systems
In 2004 URC began development of a patient level database known as the “HEF Operational Database” or the “Reto Database” (after the systems architect) to manage beneficiary information generated by pre-identification exercises, their corresponding utilization of public health services supported by the HEFs, and the required financial management tools. This database was programmed in Microsoft FoxPro, which facilitated easy replication of the database as a standalone application used by HEF operators at covered referral hospitals. Utilization of referral hospital services by HEF beneficiaries was entered in real time starting at the moment patients arrived and completed upon discharge. Utilization at the health center level was initially recorded by access facilitators who were employed by the HEF operator and posted at each health Center to manage patient access and record utilization details in a paper-based register system. These paper registers were sent to the HEF operator main office at the referral hospital on a weekly basis for data entry.

In early 2012 it became clear that the data entry burden for the ever-expanding number of health centers was becoming very difficult for HEF operators to manage. In many ODs to full time staff were dedicated to only data entry tasks. After removing the requirement to enter all Health Center visits by HEF beneficiaries into the HEF Operational Database in order to receive reimbursement from the MOH/HSSP2 pooled fund, many HEF Operators continued data entry of Health Center utilzation given the advantages it provides in financial management and reporting.

As part of the larger USAID Better Health Systems project, URC also worked with the MOH/DPHI to develop a web-based patient level medical record system known as the “Patient Management and Registration System” (PMRS). This software was originally designed to manage patient flow at the facility level providing each patient with the national unique identification number that provided an easy tool to manage the hard copy patient medical dossiers within each facility. Following the retirement of Dr. Reto Gass, the architect of the HEF operational database, a decision was taken to integrate the required functions to manage the half into the PMRS. Starting in January 2013 individual HEFs operators began exclusive use of the PMRS for HEF management. By July 2013 all have operators were using the PMRS and had stopped using the HEF Operational Database.

Linkages to Quality of Care
As part of URC's broader mission to improve quality, they found the providers were significantly more interested in quality improvement when it was linked with HEF eligibility and provision of additional funding for incentives and facility improvements. In collaboration with the Quality Assurance Office of the MOH and provincial health departments URC began piloting a dynamic pricing model of HEF payments tied to the results of annual quality assessments conducted by the MOH/QAO using the Level 1 Quality Assessment Tool which measured the structural quality of care. Initially, it was required that all public health facilities contracted by the HEF system first achieve a 65% or greater score on the MOH level I quality assessment tool. Following qualification, each facility must improve their score to 75% or greater after one year, and 85% or greater after two years. In general this linkage worked well with most facilities qualifying to provide services to have beneficiaries and improving their scores in subsequent years. No facilities were ever shut down because they failed to meet these minimum requirements.

There were however many facilities who were never able to meet the minimum 65% threshold score required to establish a contract with the HEF system. The PHD Director in Banteay Meanchey, Dr. Chum Vannarith advocated that this was essentially unfair to the poor regions of his province leaving underfunded health centers in a cycle of low funding, low utilization, and inability to meet the 65% required minimum. Based on his suggestion, the linkage between the purchase of services by the half and quality of care was changed according to the table below.

This new linkage provided both incentives for health facilities to improve their score with a price adjustment factor which resulted in either a deduction of the standard prices or a bonus to the standard prices normally paid by the HEF system. Additionally, the annual quality assessment process was changed to a quarterly assessment process under the responsibility of the PhD and OD responsible staff reducing reliance on central MOH resources and scheduling of quality assessments and in proving the feedback loop to encourage faster quality improvement. This new quality linkage, under approval from H.E. Professor Eng Huot, was introduced in Banteay Meanchey, Battambang, Pursat, Phnom Penh, and Siem Reap. A similar linkage between the prices paid to public health facilities by the HEF system, quality of care measures, and performance was created by GIZ and implemented in Kampong Thom and Kampot provinces.

Benefit Package and Provider Payment Mechanism
In the early years of establishing the HEF in individual ODs, negotiations with individual public health facilities were done on the one by one basis to establish the services which would be covered, the provider payment mechanism to be used, and the prices to be paid for services. This was usually done based on the existing user fee schedule established by the public health facility under the 1996 health financing charter. Most HEFs started off by paying facilities based on these existing user fee schedules however it soon became common for public health facilities to revise their user fee schedules to increase prices and maximize revenue from the HEF. In 2006 (?), URC began a process of introducing case-based payments in the hospitals where the half was purchasing services under USAID funding. This moved to a case-based payments disconnected the provider payment mechanism and price from the user fee schedule, discouraged over servicing of patients and put the HEF operators (and URC) in a better position to monitor and prevent unnecessary medical charges. Under a fee-for-service system questioning the services provided to an individual patient often prompted the response from a provider that they are "very concerned about this patient" or "doing everything they can to make sure this patient gets better" which were hard to dismiss due to the seniority position of the doctor. Under the case based payment mechanism the hospital received one payment for each patient irrespective of disease, length of stay, or services provided. This reduced the level of judgment required to assemble determination of whether the patient needed to be in hospital or not.

With the ongoing expansion of the HEFs system to additional ODs and continued pressure from public health facilities to revision of their existing user fee schedules and subsequent request to renegotiate their contract with the HEF, URC worked with MOH/DPHI to convene the key stakeholders in the HEF system in order to establish a standard benefit package and provider payment mechanism for the whole system. The prices were determined based on the existing rates that HEFs are paying for public health facilities nationwide and reset at slightly above the average in order to increase the number of facilities that would see more HEF revenue and decrease the number that would see less revenue.

The Standard Benefit Package and Provider Payment Mechanism for Health Equity Funds was officially approved by the MOH on January 18, 2012, effective from January 1. Following three months of operations under the new standardized benefit package and provider payment mechanism, the HEF operators provided extensive feedback and requests for clarification to the document to facilitate clear understanding and provision of benefits under the HEF system. As a result, a revised document was developed and the MOH subsequently approved the new version in June 2012.

Additional feedback was generated by development partners engaged in material, child, and family planning services who noted that long-term family planning, permanent contraceptive methods, and many maternal/child health services were not adequately addressed in the standard benefit package. Following extensive consultation and written request to the MOH a revised benefit package was released effective September 1, 2014 that address these issues. [1] Discharge data is used because it is the basis on which HEF payments to the hospitals are made.

[TJ1]Key innovations:

Widespread pre-identification

Expansion to Health Centers

Standardization of the benefit package/PPM

Database systems

Linkage of quality to purchase [TJ1]I don’t understand that statement