FACT SHEET | 2019 HEALTH EQUITY AND QUALITY IMPROVEMENT PROJECT CONTEXT Cambodia has experienced remarkable growth and has made dramatic improvements in poverty reduction and health outcomes, since the early 2000s. Under-five Under-five mortality rate mortality rate is 83 reduces to 35 per 1,000 live births Halves poverty, Maternal mortality ratio Attains Achieves Millennium reduces to 170 lower-middle Maternal mortality Development Goal 1 income status ratio is 472 per Achieves Millennium 100,000 live births Development Goals 4 and 5 2005 2009 2014 2015 2019 Despite these significant OUR APPROACH Key shifts in H-EQIP design from improvements, many (HSSP2), its immediate predecessor, challenges remain. The Health Equity and Quality Improvement focus on sustainable financing and Project (H-EQIP) builds upon and scales up the implementating major health systems innovations supported by the Royal Government initiatives through : of Cambodia (RGC) and its pooled fund partners Mainstreaming the implementation ABOUT of payments for health over the past 15 years. H-EQIP aims to improve of project activities through RGC services are out-of-pocket... 60% access to quality health services for targeted structures and creating systemic this constitutes an population groups while protecting against platforms; important source of debt impoverishment due to the cost of health Increasing fund flows to the and impoverishment for services in Cambodia and to provide immediate subnational implementation level; the poor. and effective response in case of an eligible Building domestic capacity for crisis or emergency. project implementation support, 6.3% 8.6% 13.4% H-EQIP improves the resourcing and management information systems, and monitoring roles; of population of elderly of disabled of proven health sector innovations, Enhancing the use of output-based including Health Equity Funds (HEFs) and Service payments through HEF and Delivery Grants (SDGs), to ensure institutional performance-based financing and financial sustainability, according to the through SDGs and Disbursement incur catastrophic spending RGC’s Third Health Strategic Plan (2016-2020). Linked Indicators (DLIs).1 H-EQIP builds on the innovations and achievements supported in the Second Health approach to strengthen health systems, Access to health services Sector Support Program 2009-2016 (HSSP2) especially to support improvements in continue to pose a challenge. and a voucher program for health services. quality of care by focusing on enhancing HSSP2 supported SDGs to Referral Hospitals provider knowledge through pre-service Perceived poor quality of care (RHs) and Operational Districts (ODs), granting and in-ser vice training, improved in certain public facilities a degree of autonomy in the optimal use of availability of critical infrastructure, and human and financial resources to deliver quality strengthening public financial management. Gaps remain in health services. The Program also supported the SDGs and HEFs are now systemic platforms infrastructure, skills and expansion of the HEF for nationwide coverage to and Cambodia has become a leading competencies of health all of the estimated 3 million poor in Cambodia. example of their successful implementation. workforce The voucher program targeted reproductive A key strategic shift is to attain institutional National averages mask health services for women from vulnerable sustainability by transferring responsibility persistent geographical and groups and the poor. H-EQIP further supports for HEF monitoring, verification and socio-economic disparities in the integration of these services into the information systems from an internationally maternal and child health Cambodian health system. recruited firm to an independent government outcomes H-EQIP strengthens the results-based focus of agency. Since its establishment in late 2017, Non-communicable diseases health sector financing. Over 80 percent of the the Payment Certification Agency (PCA) has (NCDs) present a rising financing under the project use results-based steadily assumed its role as an independent disease burden modalities. The project uses a multipronged verification and purchasing agency. 1 Disbursement Linked Indicators (DLIs) disburse funds against targets achieved on health system strengthening measures. PROJECT ACTIVITIES Component 1: This component expands the SDGs as conceived under HSSP2 and Strengthening Health complements fixed and performance-based grants into a Service Delivery decentralized and flexible financing flow to different levels of the Cambodian primary and secondary health system. (US$ 74.2 million) SDGs CONSIST OF: SDGs ARE DELIVERED UNDER TO DATE: THREE SUB-COMPONENTS: A fixed element, 100% financed by Fixed and performance-based the RGC. Disbursed quarterly to SDGs for Health Centers (HCs) are grants are flowing to health facilities promote quality and equity. Fixed provided to help finance the Minimum on time. lump sum grants can be used only for Package of Activities. The amount operating costs at health facilities. and payment of the performance The National Quality Enhancement grants is based on the quality and Monitonring Tools have been A Performance-based element, utilization of services provided. developed and an ICT system for co-funded by the RGC and H-EQIP use in the quality improvement partners, to reward health facilities SDGs for Referral Hospitals (RHs) process has been rolled out for quality performance. The are provided as an incentive to nationwide as of July 2019. performance on pre-defined criteria improve the quality of care at the as measured through a set of secondar y level , improve Health facilities nationwide are standardized supervision checklists performance in capacity-building being assessed by OD and PHD and managerial performance scores activities and overall management of assessors as of August 2019, and underlies the National Quality health facilities, and promote the seven rounds of verification of Enhancement Monitoring Process utilization of services by HEF results have been completed as of (NQEMP). Scores are verified beneficiaries. June 2019; with the eighth round through a third party mechanism.2 ongoing. Performance-based grants can be SDGs for Provincial Health spent on operations at health Depar tments (PHDs) and facilities and staff incentives. Quality Operational Districts (ODs) help to improvement plans based on the strengthen the management of ODs assessment performance, and and PHDs to monitor quality subsequent coaching activities for improvement at health facilities. the health facilities have been the Performance of ODs and PHDs is mainstay in the National Quality measured on a regular basis against Enhancement Process. self-reported activities on a scorecard, measuring key supervisory processes and health system outputs. PHASE: 1 2 3 ROUNDS OF EX-ANTE ASSESSMENT As of August 2019 9 4 1 HC 462 347 394 PRH/RH 43 34 35 ODs 34 33 33 PROVINCES 14 8 3 Phase 3 commenced in July 2019. 2 Results obtained through the quality assessments are verified by an independent government agency using a mix of random and risk-based sampling to assess the quality and authenticity of the assessments. PROJECT ACTIVITIES Component 2: This component continues to support and expand the scale and Improving Financial scope of the HEF system, co-financing with the government to Protection and Equity cover the cost of health care service fees and other associated costs for the poor. (US$ 70 million) From July 2016 - Dec 2018 HEF FINANCED 6.3 million outpatient visits The Health Equity Fund system has The component also finances HEF TO DATE: enabled improved access for Cambodia’s Promoters, which are contracted non- poor by paying for costs of healthcare as governmental or community-based HEFs were expanded to five more well as transport  and incidental costs organizations with patient advocacy roles. national hospitals in April 2018. associated with hospitalization. Building HEF Promoters’ main functions are to: on the success of the HEF system, the RGC currently finances at least 50% project aims to increase utilization by the • Conduct post-identification of the poor of direct benefit costs and this is poor and ensure sustainability by for those missed during the Ministry of expected to increase with envisaged transferring implementation and payment Planning’s pre-identifcation process; government expansion of HEF cer tification responsibility from • Measure and report on consumer international NGOs to the RGC. This has beneficiary groups and benefit satisfaction; been achieved through a newly created packages. • Raise awareness and promote HEF PCA which is an autonomous public utilization among the very poor; PCA assumed the HEF monitoring administrative entity and through the transfer of various roles previously • Promote the utilization of HEFs and role starting in January 2018, with a performed by HEF Operators to the wider health services among identified complete transfer of the role in July hospitals themselves. remote and difficult-to-access 2018. communities, where relevant. With the MOH and MEF as its technical and HEF Promoters are now on board, financial guardians, the PCA has a mandate have received training, and staff have to independently verify the benefits been placed in all referral hospitals. provided to HEF patients, which was formerly performed by the Health Equity Funds Implementer. It also undertakes verification of  the SDG assessments of health facilities and their supervisory levels. The PCA is also ensuring continuity of the HEF monitoring system by using field monitoring as well as taking over the management of the Patient Management and Registration System (PMRS) for recording and monitoring HEF claims. The PMRS is a fully Cambodian IT solution that has helped enhance the transparency and efficiency of the HEF system. With domestic management and ownership, the PCA has ensured a cost-efficient and sustainable mechanism for managing the HEF system, and is well placed to a play a central role in the evolving context as Cambodia progresses towards Universal Health Coverage. PROJECT ACTIVITIES Component 3: This component supports the attainment of supply-side readiness, Ensuring Sustainable health infrastructure improvements, and strengthening project and Responsive Health management and monitoring and evaluation (M&E) that are critical Systems for the key reforms in RGC’s health sector. (US$ 36 million) Sub-component 3.1: Sub-component 3.2: Sub-component 3.3: Health System Strengthening Health Infrastructure Improvement Project Management, Monitoring, (US$ 21 million) (US$ 13 million) and Evaluation (US$ 2 million) The project supports a program of This sub-component finances prioritized This sub-component supports provision of activities to strengthen service delivery at civil works. technical assistance to integrate project health facilities and strengthen management into national systems and government institutions. The civil works are identified in the strengthen Monitoring and Evaluation ministry’s civil works plan for 2016–2020, (M&E) of health sector performance. This includes suppor t for the with a priority placed on issues of access, implementation of comprehensive pre- attention to remote areas, concerns around Technical support is provided on day-to- service and in-service training programs patient safety and improving maternal and day coordination, administration, for health workers, equipment for health neonatal survival. The investment plan procurement, financial management, facilities to meet minimum standards for covers 45 HCs, 15 maternity and neonatal environmental and social safeguards the provision of obstetric and neonatal units at RHs, and 2 PRHs. management. A technical assistance grant care, carrying out enhanced health service from the Japan Policy and Human quality monitoring, improving timeliness of Resources Development (PHRD) Trust SDG and HEF payments, the establishment Fund also contributes to the strengthening of sustainable health service purchasing of Cambodia’s M&E system. arrangements, and delivery of NCDs and long-term family planning (LTFP) services. TO DATE: Financing to the RGC is provided based on externally verified results which are In February 2019, an additional tracked by DLIs and aimed at measuring financing to the project was made performance against health system effective with US$ 6 million from the strengthening actions. Multi-Donor Trust Fund to expand the scope of the project and its Disbursement Linked Indicators (DLIs) development impact, with a focus on Supply Side Institutional NCD Service Readiness supporting enhanced services for Readiness Strengthening & Improvement cervical cancer screening and treatment, hyper tension and DLI 1: Comprehensive pre- DLI 4: Health service DLI 7: ODs enabled to diabetes screening and treatment, service training program in quality monitoring by provide quality cervical and LTFP services. Three additional foundational courses for MOH enhanced cancer screening and medical and nursing treatment services DLIs were added on the set-up and professionals implemented by DLI 5: Sustainable health roll-out of these services, and to University of Health Sciences purchasing DLI 8: ODs enabled to incentivize delivery of services. arrangements provide quality DLI 2: Comprehensive in- established by the hypertension and Construction of HCs has begun and service training program on recipient diabetes screening and procurement of construction and Minimum Package of treatment services Activities for health workers DLI 6: Timeliness of HEF design firms for RHs and PRHs is implemented by MOH and SDG payments DLI 9: ODs providing under way. improved quality long-term family DLI 3: C2 hospitals fully planning services equipped to provide emergency obstetric care and neonatal care PROJECT OUTCOMES PROJECT OUTCOMES INTERMEDIATE Number of women screened for 8. cervical cancer using visual inspection RESULTS INDICATORS with acetic acid method H-EQIP contributes to RGC’s broader development agenda, as defined by the 9. Number of ODs reporting an increase of 1. Proportion of HCs with functioning HC over 10 percent in current LTFP service Third Health Strategic Plan (2016- management committees users over the last 12 months 2020), the National Strategic Development 2. Percentage of HC, CPA-1, and CPA-3 10. People who have received essential Plan (2014-2018) and the Rectangular facilities that receive payments based health, nutrition, and population Strategy 3 with its focus on strengthening on performance that includes quality services, disaggregated by gender quality and affordability of health services, scores within 90 days of the end of the 10 as well as expanding coverage and quarter increasing equitable access to effective 3. Reduction in the variance in score on HC and efficient health systems. quality assessment Intermediate 4. Percentage of CPA-1, CPA-2, and CPA-3 The project also accelerates progress Results indicators facilities having a 60% quality score in toward Universal Health Coverage in focus on: the previous quality assessments Cambodia, whereby all people receive the 5. OPD consultations (new cases only) per health care they need without suffering • Measuring improvements in the quality person per year financial hardship. Universal Health of service delivery at health facilities Number of UHS courses that adopt 6. Coverage is a focus of the new global • Increased utilization of health services competency-based curricula with Sustainable Development Goals. Cambodia • Improved pre-service training for trained faculty and use of skills is committed to achieving the Sustainable laboratory health staff Development Goals, which are viewed as 7. Percentage of HCs, hospitals, and OD/ • Greater efficiency in the management long-term goals and is proceeding steadily PHD receiving HEF and SDG payments and dministration of the public health and as quickly as fiscally possible. within the specified timelines system. 4 PROJECT FINANCING Project PROJECT COST IDA MDTF RGC PHRD Components (COMPLEMENTARY FINANCING) 1. Strengthening Health Service Delivery 74.2 7.5 12.5 54.2 0 Project Development Objective 2. Improving Financial Protection and Equity 70.0 11.25 18.75 40.0 0 indicators include: 3. Ensuring Sustainable & Responsive Health System 36.0 11.25 24.75 0 1.0 Increase in the number of HCs 4. Contingent Emergency Response 0 0 0 0 0 exceeding 60% score on the quality assessment of health facilities TOTAL 181.2 30 56.0 94.2 1.0 Reduction in out-of-pocket health expenditure as percentage of the total health expenditure Reduction in the share of households that experienced impoverishing health spending during the year Increase in the number of outpatient services (episodes) covered by HEF FACT SHEET | 2019 HEALTH EQUITY AND QUALITY IMPROVEMENT PROJECT The project has made PROJECT NAME remarkable progress in Cambodia Health Equity and Quality the past two and a half years. Improvement Project (H-EQIP) IMPLEMENTING AGENCY The percentage of health facilities receiving timely payments is... 100% Ministry of Health (MoH) Royal Government of Cambodia TARGET GROUP 40% The number of outpatient visits per HEF beneficiary per year increased by over...from 0.72 in 2015 to 1.02 in 2018. The population of Cambodia, particularly the poor and vulnerable, and public health care 639 providers Among 805 HCs assessed, the number of HCs scoring more than 60% went up to... REGION Nationwide DURATION July, 2016- June, 2021 OVERALL AVERAGE SCORE INCREASE FINANCIAL  US$ 181.2 million From round 1 to 9 of the assessment SCOPE PARTNERS DFAT Australia HEALTH CENTERS KfW Germany KOICA Korea Round 1 45% World Bank Group Round 9 65% REFERRAL HOSPITALS Round 1 44% Round 9 58% Referral Hospitals Round 1 27% Round 9 74% Provincial Referral Hospitals Progress against other indicators is on track and is reported in semi-annual Implementation Status and Results reports, which are publically available on the World Bank website.