3 Country Presentation For Vientiane Conference

Conference Health and social protection: Meeting the needs of the poor Vientiane 2008 Cambodia, China and Lao PDR Initial thoughts from POVILL www.povill.com

Cambodia Chean Rithy Men Centre for Advanced Studies

We will report on… Different types of major illness affecting household livelihoods Health-seeking behaviors Coping strategies to finance health care expenditure Impact of HEF on hospital utilization

Three level health system with first level organized in health district (health centers and referral hospital) Public health services are highly subsidized Public health facilities adopt “flat fees” charging system Staff working in public health facilities have modest economic incentive Most staff earn their living by dual practices Private practices are loosely regulated Cambodian Health Care System

THE STUDY: DESIGN AND DATA COLLECTION

Research sample Sites Rapid Household Survey In-depth study Village HH Person HH Mongkol Borei 80 2,000 11,495 110 Sonikum 80 2,000 10,950 110 Kirivong 80 1,975 10,716 110 Total 240 5,975 33,161 330

Self-reported serious illness last year N= 33,161 Total number of individual in sample Percentage of reported serious illness Mongkol Borei 11,495 13.82% Sotr Nikum 10,950 14.94% Kirivong 10,716 16.48% Average over three ODs 15.05%

Major illness includes more than inpatient care N=4992 Total number of Individual in Sample (M.I.) Received Inpatient treatment Mongkol Borei 1589 29.64% Sotr Nikum 1637 30.05% Kirivong 1766 29.38% Average over three ODs 29.68%

Working days lost due to serious illness N= 4992 Frequency Percentage no working days lost 426 11.51% 1-5 workdays lost 343 9.26% 6-10 workdays lost 550 14.86% 11-15 workdays lost 421 11.37% 16-30 workdays lost 696 18.80% >30 workdays lost 1265 34.17% Children 1291 25.86%

A highly fragmented health system Distribution of health seeking behaviors over respective providers (30 days recall period), RHS Public sector: 18%

Different incentives for health professionals with dual practices in public and private settings (n=55)

An example of irrational practices

Coping strategies with major illness Frequency Percent Using saving 86 1.4 Reduce food expenditures 24 0.4 Remove children from school 19 0.3 Sell stored food 319 5.3 Sell household assets 99 1.7 Sell production tools 206 3.4 Sell livestock 317 5.3 Sell land 93 1.6 Borrow money from friends/relatives 911 15.2 Borrow money from informal money lender 1,594 26.7 Borrow money from credit institute 234 3.9 Seek additional work 615 10.3 Total of HH reported severe financial problem due serious illness 3,068 (51% total sample)

Redressing health seeking behaviors: HEF as part of the solution? HEF is a mechanism or fund that is operated by an independent organisation in the interest of poor people, purchases health care for those poor people (from a public health care provider), and also pays for all the associated costs (from non-medical providers). Independent = purchaser-provider split , the organisation does not belong to the Ministry of Health.

Functions of HEF -> Local NGOs are particularly suited to perform these various functions

HEF boosts utilization of public hospitals (Logistic regression (of likelihood to go to public hospitals (vs other option) for seriously ill people who got the advice from a qualified expert to seek inpatient care (N=1567) RHS) Odds for a HEF card holder to go to the public hospital are 2.4 higher than someone with a same profile without a HEF card!

Conclusion Illness is a major burden for rural households (suffering, health care expenditures, lost days…). Several factors have led to a fragmentation of the Cambodian health system. Many providers are loosely regulated; this leads to unsatisfactory quality of care, irrationnal prescription and unnecessary health care expenditure. Due to coping mechanisms adopted by households, households can be tipped into poverty. Health equity funds (and the civil society) can be part of the solution to this problem. Yet, other measures are needed: improve quality of service and care in public facilities to attract users, maintain a system of public hospitals close to the rural population and regulate private health care facilities, including informal providers.

More to come More analysis on RHS and In-depth data Further analysis or follow-up study on households with chronic diseases More analysis on informal health providers

China Professor Jin Institute of Social and Public Policy

Quantitative Research: Major Research questions and methods Research questions Dependent variables Independent variables Samples collected Impact of Major illness on household livelihood Household livelihood Major illness Coping strategies Rapid Household survey: 12000 HH In-depth Interview: 600HH NCMS ’ effect on the out-of-pocket inpatient care expenses. NCMS ’ effect on utilization of inpatient service among rural residents. Medical expenditure Out-of pocket payment Inpatient care schemes As above Unnecessary care and drug, and unnecessary cost to the poor Unnecessary drug, tests, services Poor/non-poor 3 tracer conditions 628 inpatient care Impact of scheme on unnecessary care, drug Unnecessary drug, test and services With/wo scheme As above

Major Preliminary Findings ---1. Household Survey

1 Diversity of Major Illness Concept/definition, Perception from different actors Complicated concept: economically, socially, medically Household perception in terms of inpatient care; large amount of money spent; long time drugs-taken; disabled; great amount of working days lost NCMS: not adequate response

Outpatient and inpatient use for selected serious illness groups Type of serious illness Percent using inpatient treatment Percent using only outpatient services Percent other Circulatory 13.5 60.5 25.9 Respiratory 16.6 62.6 20.9 Digestive 16.5 57.8 25.7 Urinogenital 15.2 65.2 19.6

2 Demographic changes and its implication for healthcare intervention Household composition and out migration Changing patterns of household composition: Unit of analysis Migrant labor and their health seeking behavior: Scheme: population targeted Impact of changing demographic pattern on household health seeking behavior and their livelihoods Preliminary findings from household study in China

Major Preliminary Findings ---2. Impact of Schemes

The distribution of the social economic situation of households by NCMS ● The poorest were less inclined to be covered by NCMS

Method Multiple Linear regression Result The effect of NCMS participation on out-of-pocket expenses of hospitalization of households with major illness is not statistically significant ( P >0.05).

Method Two-level logistic regression Result The effect of NCMS on utilization of hospital service of households with major illness is not statistically significant ( P >0.05)

Different household social economic status of MFA targets 0.66% of the poorest households were covered by MFA The overall coverage rate(0.31%) is low

Major Preliminary Findings ---3. Provider’s performance, Unnecessary Care and Unnecessary cost

Regression of log transformed total cost of pneumonia +: P <0.1; *: P <0.05; **: P <0.01; ***: P <0.001 NCMS: New Cooperative Medical Scheme Model 1 Model 2 Model 3 Model 4 Economic status (Ref.: Low) Middle 0.240* 0.230* 0.176+ 0.195* High 0.386** 0.375** 0.279* 0.312* Facility level (Ref.: County hospital) Township Health centre -0.801** -0.701* -0.652* Health insurance (Ref.: No insurance) NCMS -0.299* -0.273* Other insurance -0.234+ -0.166 Doctor education level (Ref.: <3) 3 -0.080 >=5 0.000 Age of the patient -0.114* Squared age 0.015* _cons 6.491** 6.533** 6.782** 6.777** N 207.000 207.000 199.000 201.000

Median unnecessary cost of drug treating pneumonia by economic status (RMB Yuan)

Major Preliminary Findings ---4. Institutional Analysis

Qualitative research Major Research questions and methods Research Questions Methods Policy process of the NCMS and MFA at national level; Impact of the policy context and the interplay of relevant stakeholders on policy process - Literature and record review: documents/published paper/gray report/ news; Key informants interview : officials from MOH, MOCA, MOF; hospital managers; Focus group discussion: rural residents - Participatory observation: policy seminar by MOCA, workshops

Qualitative research --Main findings Rural health policy process: response to the transitional context of China - unequal share of the resources distributed; - unequal access to essential health care; - political priority shift to harmonious development; - rising concern on rural health development; - more revenues to support Stakeholder analysis: - political elites & academic elites: significant role - the media: active in shaping public opinion - rural residents: passive recipients of policies Formal/informal mechanisms: not sufficiently to voice out the interest of rural residents

“ Its not the end, its just the end of beginning” ----Churchill With the unique datasets, More findings are coming 6000 household survey 600 household In-depth interview

Next steps To Provide the evidence by Dealing with selection bias Dealing with confounding factors To Influence evidence-based policy making process to Improve better targeting of scheme Improve design and implementation of schemes Improve provider’s performance for cost-effective services

Lao PDR Anonh Xeuatvongsa Ministry of Health

Topics to be covered in the presentation Country profile Enforcement of medical law Findings from the research into the level and causes of household poverty and health seeking behaviour Analysis of the way in which the Health Equity Fund is working Some findings related to provider performance Further issues to be explored

Country Profile & Health Indicators Population: 5.82 millions (2007) GDP 701US$ per capita (2007) GDP annual growth rate: 7.9% (2007) 30% of the population under poverty line (2005) Life expectancy 61 years (female 62, male 59) (2005) IMR 70 per 1000 live births (2005) U5MR 98 per 1000 live births (2005) MMR 405 per 100.000 live births (2005) Data source: National report 2006-07 and National census 2005.

National Health Expenditure 3.6% of GDP in 2005 17.5 USD per capita in 2005 - Out of pocket: 79.8 % of THE - Donor: 11.3 % of THE - Domestic Gov. : 8.9% of THE GGE on Health as % of GGE: 4.6% Social security fund as % of GGHE: 11.2% Data source: NHA unit, EIP/HSF/CEP, WHO, Geneva 2007

Transform of Medical Law into practice Lao has a strong legal framework to protect poor people from catastrophic illness. However, Law dissemination is yet saturated in public and whose responsibility is not clear, Institutional arrangement to enforce the Law’s implementation is yet sufficient, Fee exemption for poor is not standardized, Inconsistent in identifying poverty level in different sectors.

Graph 1: Percentage of number of poor households officially recognized ( N= 3000 HHs )

Graph 2 : Comparison of Percentage of main reasons of being poor among 9% of poor (n = 270 recognized as poor households) a = Poor environment (e.g. unfertile soil, no land, natural disaster, crops damage by wild animals e.g. insects and mice…) b = Labor shortage c = Many dependents d = Illness / disability e = Other

Rapid HH Survey [ in general ] (n=3000hh) : In-Dept Studies [ serious illness ] (n=150hh) . Self Treatm. Out Patient In Patient . Type of facility No ( n=809) (%) No (n=70hh) (%) No(n=99hh) (%) No(n=99hh) (%) 1. Govt. hospital : 353 43.64 15 21.5 65 65.6 65 65.6 a. Provincial Hospital : 138 17.1 9 12.9 44 44.4 44 44.4 b. District Hospital ] : 215 26.6 6 8.6 21 21.2 21 21.2 2. Govt. primary facility: 101 12.5 3 4.3 11 11.1 11 11.1 [ Health center ] 3. Private facility : 30 3.7 7 10 2 2 2 4. Pharmacy: 182 22.5 33 47.1 3 3 3 5.. TBA/VHW : 19 2.3 1 1.4 3 3 3 3 6. Drugstore/shop/trader : 4 0.5 0 0 0 0 0 0 7. Traditional healer : 14 1.7 9 12.9 4 4.04 4 4.04 8. Religious faith healer : 4 0.5 1 1.4 2 2 2 2 9. Other : 94 11.6 1 1.4 9 9.1 9 9.1 10. Did not seek care: 8 0.9 0 0 0 0 0 0 Total 809 100 70 100 99 100 99 100 Remarks : 1. Poor households : 9% ( out of 3000 hh ) 2. Death: n = 90 persons =>0.53% out of 17 093 persons 3. Serious health problem no treated because of cost: n = 102hh =>47.67 (out of 214 hh get serious health problem [ n = 219 persons] ) Health seeking behavior of people in the last month before the survey

Health seeking behavior of people with severe illnesses Type of facilities Number of Households (n = 3000 ) Percent ( %) 1. Central hospital : 51 1.7 2. Provincial hospital : 712 23.7 3. District Hospital : 1545 51.5 4. Health Centre : 440 14.67 5. Private clinic : 75 2.5 6. Outside country : 10 0.3 7. Other ** : 167 5.63 Total 3000 100 . Remark : Specified places ** : 1. Military hospital : 81 HH => 48.51% out of 167 HH 2. Traditional medicine : 40 HH => 23.96 % ; 3. Pharmacy : 12 HH => 7.19% .

Coverage of Health Equity Fund General poverty level: Three different situation from Sepone (very poor but changing very fast) to average rural situation (Nambak) and low poverty rate (in Vientiane Province but ranging from 1 to 15% across districts) HEF coverage: Lower rate of HEF pre-identification in Nambak and Vientiane Province versus general poverty level defined by government (30% in 2005) Decrease HEF in Nambak, and stable in Vientiane and Sepone * NGPES = National Growth and Poverty Eradication Strategy

HEF by Wealth index. Study sites: Nambak, Vangvieng and Sepone HEF Bénéficiaires (n=88) HEF Non Bénéficiaires (n=1412) Source: RHS

Utilization of HEF OPD: Visible positive impact of HEFB in Nambak and Vientiane Province IPD: Visible positive impact of HEFB in the 3 HEF Schemes

Costs Yearly data (Nambak, Vientiane province: 2007, Sepone: 2007/08) Nambak district Vientiane Province (11 districts) Sepone district Total benefits/year $19,717 $54,896 $19,108 total benefits/HEFB capita HEF Pre-id: $2,3; HEF Post-id: $1,9 HEF Pre-id: $2,8; HEF Post-id: $2,2 HEF Pre-id: $1,7 % OPD-IPD 12% vs 88% 19% vs 81% 18% vs 82% % medical fees-transport-others 82% vs 16% vs 2% 74% vs 13% vs 13% 82% vs 11% vs 7%

Knowledge on types of services for free with the HEF members Knowledge on benefits of HEF HEF Beneficiaries NEF NB N % N % Free medical services 78 98.7 470 98.5 Free food and soap while hospitalized 24 30.4 213 44.7 Free ambulance transportation to upper level 36 45.6 188 39.4 Free transportation back home of a relative’s body dead while hospitalized 34 43.0 147 30.8 Other (Room) 1 2.6 3 0.6

Provider performance No significant differences in treating poor and non poor patients Use of Essential Medicines is high in treating pneumonia 95% in poor patient (T1), 94% in near poor (T2) and 100% in non poor (T3) Unnecessary cost may not be high since many Essential Medicines prescribed

Provider performance continued However informal payment was 32% considered as unnecessary cost Access to health care for the poor may be a problem as expressed by one villager: “ having no money for the care cost I would prefer dying at home rather than going to hospital”

Issues for further exploration How do we increase knowledge amongst potential users of the benefits of the Health Equity Fund beyond free medical care? Should we extend the Health Equity Fund to the 15% of the population classed as very poor who are not currently covered? How? How can we encourage patients to utilise health centres? What is the optimum strategy for preventing the misuse of the Health Equity Fund? What institutional arrangement should be seriously made to enforce the medical law?

3 Country Presentation For Vientiane Conference

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3 Country Presentation For Vientiane Conference