- Email: [email protected]
Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000–2008
Health Policy 96 (2010) 200–209
Contents lists available at ScienceDirect
Health Policy journal homepage: www.elsevier.com/locate/healthpol
Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000–2008 Por Ir a,b,∗ , Maryam Bigdeli c , Bruno Meessen b , Wim Van Damme b a b c
Siem Reap Provincial Health Department, Ministry of Health, No. 221, Street 217, Phnom Penh, Cambodia Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, B-2000 Antwerp, Belgium Department of Health Systems, Cambodian Office of the World Health Organization, No. 177-179 Corner Streets Pasteur, Phnom Penh, Cambodia
a r t i c l e
i n f o
Keywords: Health Equity Fund Cambodia Health equity Health policy Knowledge Knowledge translation
a b s t r a c t Objectives: To understand how knowledge is used to inform policy on Health Equity Funds (HEFs) in Cambodia; and to draw lessons for translating knowledge into health policies that promote equity. Methods: We used a knowledge translation framework to analyse the HEF policy process between 2000 and 2008. The analysis was based on data from document analysis, key informant interviews and authors’ observations. Results: The HEF policy-making process in Cambodia was both innovative and incremental. Insights from pilot projects were gradually translated into national health policy. The uptake of HEF in health policy was determined by three important factors: a policy context conducive to the creation, dissemination and adoption of lessons gained in HEF pilots; the credibility and timeliness of HEF knowledge generated from pilot projects; and strong commitment, relationships and networks among actors. Conclusions: Knowledge locally generated through pilot projects is crucial for innovative health policy. It can help adapt blueprints and best practices to a local context and creates ownership. While international organisations and donors can take a leading role in innovative interventions in low-income countries, the involvement of government policy makers is necessary for their scaling-up. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Equity has been an overarching goal of public health policy in many countries for several decades. However, progress towards this goal has been disappointing. Poorrich disparities in health financing, in access to health care and in health outcomes persist in many coun-
∗ Corresponding author at: Siem Reap Provincial Health Department, Ministry of Health, No. 221, Street 217, Orussey 2, Khan 7 Makara, Phnom Penh, Cambodia. Tel.: +855 12 657 725. E-mail addresses: [email protected] (P. Ir), [email protected] (M. Bigdeli), [email protected] (B. Meessen), [email protected] (W. Van Damme). 0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2010.02.003
tries and even widen in some countries [1]. To address health inequities an equity-oriented approach to health and health sector policy is needed. A concerted effort must be made to ensure that health systems reach the poor more effectively [2]. Successful interventions aiming to reach the poor with health services exist in some countries [3]. However, replication of these interventions in developing countries where resources are scarce and health systems perform poorly is a big challenge and often requires context-specific experimentation through pilots [4]. The implementation of equitable health care financing mechanisms which could increase access for the poor and reduce poverty is critical to promoting health equity [5].
P. Ir et al. / Health Policy 96 (2010) 200–209
Box 1: Concepts and definitions • HEF is a demand-side financing mechanism to promote access to priority public health services for the poor in an environment where user fees are charged [16]. The management of the fund is entrusted to a third party, usually a local nongovernmental organisation. HEF beneficiaries are identified according to eligibility criteria, either at the community before health care demand (preidentification) or at the health facilities through interviews (post-identification). At the health facility, the eligible poor patients get full or partial support from HEF for the cost of user fees, transport cost and other costs during hospitalisation [12,15]. • Knowledge is the active linkage of information to a context and its integration into thinking and practice [17]. It results from a series of three successive transformations: from reality to data, from data to information (know-what), and from information to knowledge (know-how) [18]. Knowledge is a form of evidence and the meaning of knowledge and evidence is often used interchangeably [17,19]. • Policy is a broad statement of goals, objectives and means that creates a framework for activity. It often takes the form of explicit written documents, but may also be implicit or unwritten. Health policy covers courses of action (and inaction) that affect the set of institutions, organisations, services, and funding arrangements of the health care system [20].
Yet, reliable knowledge on efficient and equitable health financing in different settings is sparse [6]. Moreover, the available knowledge is often not translated into policy. Closing the knowledge-policy gap is crucial to ensure health system strengthening and the achievement of health equity goals [7–9]. It requires a better understanding of interfaces between research and policy, in particular the factors affecting the uptake of research findings by policy. Despite a growing literature on policy analysis, knowledge in this field remains rather weak in developing countries [10,11]. In Cambodia, despite considerable progress in the health sector, access to essential health services remains a problem, especially for the poor. To tackle this problem, multiple health financing innovations have been tested in recent years. Health Equity Fund (HEF) is one of these innovations aimed at promoting equity and reducing poverty through enhancing access to health services for the poor [12]. HEF pilots proved relatively successful and showed potential for improving equity and reducing poverty [13–15]. Supported by knowledge generated from the pilot schemes, HEFs went on to become part of national health policy. We analyse the HEF policy process to illustrate how knowledge was used to inform national health policy and draw lessons for translating knowledge into policies that promote equity (Box 1).
201
2. Materials and methods This study is a retrospective analysis of the HEF policy process in Cambodia between 2000 and 2008, and was conducted under the guidance of a review team with members from the Cambodian Ministry of Health (MOH), the National Institute of Public Health and WHO’s office in Phnom Penh. Document analysis and interviews are the most commonly used methods for policy analysis. They seem appropriate for retrospective analysis of a national and sub-national policy related to specific issues [21] and they are preferably used in combination [22]. In this case study, data were collected through document analysis, key informant interviews and direct observations of the authors who have been involved in the HEF policy process in Cambodia. We collected all documents on HEFs, policies related to HEFs and health financing reforms in Cambodia published between 1995 and 2008. These documents included journal articles, working papers, evaluation reports and policy documents of the MOH, government and different agencies. The electronically published papers were searched through PubMed and Google scholars using the following keywords: Health Equity Funds; access to health services for the poor; and Cambodia. Others were identified and gathered through the authors’ networks and key informants. The collected documents were analysed to gain insight into the HEF policy process; the position of related stakeholders and knowledge they had used to inspire the policy. The document analysis also guided our selection of key informants and the development of a questionnaire for interviews. On the basis of information collected through the document analysis, prior knowledge of the authors and guidance of the review team, 20 key informants were intentionally selected and invited for interviews. The interviewees were policy makers, researchers and managers from government line ministries, donor agencies, academic institutes, national and international NGOs who have been closely involved in the HEF policy development. The interviews were conducted by the first author (PI), using a semistructured questionnaire, and aimed at assessing the role of key stakeholders in the HEF policy process, their knowledge on HEFs and their position towards HEF policy. Each of the interviews took between 30 min and 1 h. We took extensive notes of the responses and processed them immediately after the interviews. The collected data were manually coded, thematically grouped and then analysed. The key information and insights gathered through key informant interviews were triangulated with those of document analysis and authors’ prior knowledge. Policy-making is rarely a linear process, an event or an explicit set of decisions; instead, it tends to evolve through an interactive process and usually involves a wide range of actors. Several frameworks for policy analysis have been proposed by scholars [19,21,23]. “Knowledge translation is the exchange, synthesis and effective communication of reliable and relevant research results. The focus is on promoting interaction among the producers and users of research, removing the barriers to research use, and tailoring information to different target audiences
202
P. Ir et al. / Health Policy 96 (2010) 200–209
Fig. 1. The 4-K framework.
so that effective interventions are used more widely” [7]. Drawing on these concepts and frameworks, we propose a knowledge translation framework to analyse the HEF policy process in Cambodia (Fig. 1). This 4-K framework describes four stages of getting knowledge into policy: K1—exploiting existing knowledge; K2—creating new knowledge or innovations; K3—transferring new knowledge; and K4—adopting and using new knowledge. In each stage, various actors interplay within a complex environment to generate new knowledge to feed the ‘stock of knowledge’ or make use of the available knowledge for action. Any action that makes use of the knowledge is considered ‘policy’, which is not depicted in this framework. This study obtained ethical approval from the Cambodian National Ethics Committee with reference number 002 NECHR. To ensure personal confidentiality, interviews were kept anonymous. Verbal consent was obtained from each key informant prior to the interview.
3. Results
Tax-based free of charge delivery of public health services between 1990 and 1995 was not very successful in providing access to basic health care for the population. User fees with exemptions for the poor were therefore introduced in 1997 and progressively expanded to all public health facilities. Several studies showed that user fees help improve the performance of public health facilities, but become a barrier for the poor to access health services, especially hospital services, in the absence of a viable exemption system [14,15,24–26]. Along with user fees, several contracting models were tested with the objective of improving public health services’ performance. Although relatively successful, these pilots did not really address the barrier of user fees and several other demand barriers to access for the poor [25,27–29]. Since 1999, an international NGO has also been experimented with community-based health insurance, but the result of the pilot was not persuasive enough to attract policy makers’ attention. Various surveys conducted in the late 1990s showed the low utilisation rate of public facilities and high health care costs that were mainly paid out-of-pocket, bringing about households’ debt and landlessness [30–32]. In this context, HEF pilots emerged as a possible remedy.
3.1. Cambodian health policy and health sector reforms As stated in policy documents that are reflected in article 72 of the National Constitution, health sector reforms in Cambodia are aimed at promoting equity and reducing poverty through enhancing access to and utilisation of quality services, especially for the poor, and protecting them from the impoverishing effects of ill-health. To reach these aims, the Cambodia health system has undergone a long series of reforms, including health financing reforms. Over the last decade, along with budgetary reform several health financing schemes have been developed and implemented (Fig. 2).
3.2. Knowledge translation: the path from HEF pilots to national health policy The first HEF pilots were initiated in 2000. They proved relatively successful and showed potential in improving health equity and reducing poverty [13,27,29,33]. Inspired by their success, several new HEF pilots were launched in other places and produced similar results [14,15,34–39]. Key characteristics of first and new HEF pilots are summarised in Table 1. HEF was therefore included in key MOH and government strategic documents in 2002 [40,41] and the first HEF policies were developed [16,42].
P. Ir et al. / Health Policy 96 (2010) 200–209
203
Fig. 2. Development of different health financing schemes in Cambodia.
3.2.1. K1—exploiting existing knowledge: the birth of HEF pilots The first HEF pilots were initiated by an ‘interest group’ situated among international health partners, mainly NGOs, who advocated for complementing supply-side interventions. These interventions aimed to provide health services to the population, but faced a severe problem of access for the poor. According to key informants and the project evaluation report [33], the HEF in the Urban Health Project was created by relatively few key people in the
health sector reform working group because many clients of the health rooms who needed referral could not afford to pay hospital user fees and other related costs, forewent the treatment or fell into debt. Similarly in Thmar Pouk and Sotnikum, the HEF pilots were initiated by Médecins sans Frontières and UNICEF because the hospital user fees became a barrier to access for the poor. The HEF pilots in Thmar Pouk and Sotnikum were first labelled Mulnithi Sangkrus Chun Krey Krar (‘a fund to save the poor’), a term inspired by existing local concepts of
Table 1 Summary of Health Equity Fund pilots at their initial stage. Key features
First HEF pilots
New HEF pilots
Phnom Penh
Thmar Pouk and Sotnikum
Svay Rieng
Pursat
Pearang
Kirivong
Population
Two urban slums: approximately 20,000
Province: approximately 530,000
Province: approximately 410,000
Health district: approximately 200,000
Health district: approximately 205,000
Supply-side intervention
Urban Health Project
Health districts: approximately 110,000 and 220,000 New Deal—‘Contracting’
‘Contracting’
August 2000
‘Health Financing Scheme’ July 2002
‘Contracting’
HEF started in
‘Health Financing Scheme’ July 2002
July 2002
May 2003
Design, monitoring and evaluation Health service delivery
MoH and WHO
UNICEF
WHO
HNI
ED and local community
District referral hospital and health centres National NGO
District referral hospital and health centres Pagodas Committees
Pre- and postidentification Total of hospital user fees, free delivery at health centres & referrals to tertiary care External (HNI)
Exclusive preidentification Total of hospital and health centre user fees
May and September 2000 MSF and UNICEF
Municipal hospital
District referral hospitals
Provincial hospital
Provincial hospital
HEF operator
Local health authority
National NGOs
National NGO
Beneficiary identification Benefit package
Exclusive postidentification 70% of hospital user fees, transport and food
Exclusive postidentification Part/total of hospital user fees, transport, food and basic items
Equity Fund Support Committee Pre- and postidentification Part/total of hospital user fees, transport and food
Funding
External (DFID)
External (MSF and MSF with UNICEF for Sotnikum)
External (UNICEF)
Exclusive postidentification Part/total of hospital user fees, transport, food and basic items
External (WHO)
MSF: Médecins sans Frontières; HNI: HealthNet International; ED: Enfants et Développement.
Pagodas with complement from ED
204
P. Ir et al. / Health Policy 96 (2010) 200–209
solidarity and social assistance. One year later, the pilots were coined ‘Health Equity Funds’. According to key informants, local and international experts’ knowledge of social assistance was tapped to design, implement, monitor and evaluate the pilot schemes. The decision to entrust the management of the scheme to a third party NGO was inspired by the concept of purchaser–provider split. 3.2.2. K2—creating new knowledge or innovation: results from HEF pilots Evaluations of these HEF pilots showed persuasive results in terms of promoting access to hospital services for the poor and potential effect on protecting the poor from the impact of health care costs [13,27,29,33]. Table 2 summarises the new knowledge on institutional arrangements and the effectiveness of the first pilot schemes. According to key informants, this wealth of new knowledge came in timely, as new initiatives to address the failure of user fee exemptions were sought. The HEF model was soon replicated in other places with some design modifications that created further knowledge for policy. Evaluation reports and case studies [14,15,34,35,39] showed that these new pilots reinforced knowledge on HEF effectiveness in improving access to hospital care for the poor and produced new knowledge on institutional arrangements and conditions for replication (Box 2 ). 3.2.3. K3—transferring new knowledge: dissemination of results from HEF pilots Coordination of multiple health actors in post-conflict situation in Cambodia had been a challenge for years [43]. The adoption of the Sector-Wide Management (SWiM) strategy in 2000 allowed finally tackling this challenge. A common strategic framework, including a health sector strategic plan, medium-term expenditure framework and joint annual performance review, was developed, allowing all key health actors to work together under the MOH leadership to achieve clear goals and objectives. In addition, several coordination mechanisms were developed. The Technical Working Group-Health (TWG-H) at central
Box 2: Summary of new knowledge gathered from new HEF pilots • Village-based pre-identification is feasible and costeffective. • Pre-identification seems to be superior to postidentification in promoting utilisation by the poor through increased awareness of HEF and certainty of their entitlements. But pre-identification alone is not practical and needs to be complemented by postidentification. • A limited benefit package may undermine the effectiveness of HEF. In addition to the support for secondary level care, the cost of further referrals to tertiary care institutions should also be included in the benefit package. • A mixed committee composed of representatives from the community, pagodas, local health authority and NGOs in charge of HEF (or at least of monitoring and evaluating HEF) is both effective and inexpensive. • The management arrangement of a Provincial Health Department in charge of the fund and an NGO in charge of identifying the poor also worked well. • Participation by the local community in the design, implementation and monitoring and evaluation not only greatly reduced the administrative cost but also enhanced local ownership of the HEF, thus contributing to sustainability.
level and the Provincial-TWG-H at provincial level allow the MOH and its partners to discuss and share information. MEDICAM, an association of NGOs active in health, provides a forum for its members to meet, discuss and share information, and represents the NGOs at TWG-H. Many sub-working groups, committees and tasks forces gather knowledge to develop specific guidelines or policies and report to TWG-H. Ad hoc meetings, workshops and conferences are often organised. This created a network through which health information and knowledge are transferred to policy makers (Fig. 3). As stated in the SWiM progress
Table 2 Summary of new knowledge generated from the first HEF pilots. Evaluations and case studies of HEF pilot schemes
The first year evaluation report of the Urban Health Project
Generated new knowledge Knowledge on institutional arrangements
Effectiveness
HEF managed by the local health authority has high risk of mismanagement and favouritism Post-identification has its limits in addressing uncertainty
HEF improves access to referral services for the needy poor HEF may help prevent poverty by reducing time lost and avoiding selling assets or taking a loan HEF appears to be an efficient way to transfer resources to the poor: running cost of HEF is smaller than gain in poverty reduction
Partial support for user fees, transport and food still causes barrier for the poor
Evaluation reports and case studies of the New Deal and HEFs in Thmar Pouk and Sotnikum
HEF is effectively managed by an NGO in a context where the hospital is functioning well Post-identification leaves poor households uncertain about their entitlement to assistance Besides user fees, transport costs and food, there are many other barriers for the poor to accessing services, not addressed by HEF
HEF improves access to hospital services for the poor HEF may help prevent poverty, but needs further investigation HEF is a cost-effective strategy to transfer resources to the poor
P. Ir et al. / Health Policy 96 (2010) 200–209
205
Fig. 3. Knowledge-policy communication network in health care in Cambodia.
report, “SWiM, it is argued, was successful in building the foundation for effective sector coordination. . . Coordination mechanisms like the TWG-H and the joint annual performance reviews provide for important occasions to discuss and monitor the implementation of the shared sector strategy. . .” [44]. The number of HEF schemes and coverage of poor population by HEFs were among the monitoring indicators used in the joint annual performance reviews since 2005. Another example of the success of SWiM was the implementation of contracting, a major component of the Health Support Programme, in which the MOH and several major donors coordinated their financial inputs to the health sector [25,28]. The generated HEF knowledge was mainly passed on through this network. The HEF pilot in Sotnikum was part of the New Deal, a mini-SWiM introduced as a strategy to address the vicious circle of underpaid, poorly performing health staff and thus under-utilised health services [27,29]. To broaden the scope of actors involved in the decisionmaking process and increase chances for the New Deal to have an impact on national health policy, Médecins sans Frontières and UNICEF initiated a steering committee that included key policy makers from the government and partner agencies. The roles and responsibilities of members and stakeholders were clearly stipulated in a contract. The steering committee organised quarterly meetings to track the progress of the pilots and discuss related issues. In addition to the steering committee members, operational stakeholders were also invited to attend the meetings. Results from the HEF pilot in Sotnikum were disseminated through the steering committee’s quarterly meetings, two reports that were widely distributed locally [27,29], two workshops and several meetings with all partners in the health sector. In addition, many field visits of national and international stakeholders were organised to Sotnikum between 2000 and 2002. Results from the HEF pilot in the Phnom Penh Urban Health Project followed a similar pattern. A management committee composed of key health sector reform actors was also created to monitor the progress of this HEF pilot. Many key informants from the government and international agencies reported that they had learned about HEF results through their direct participation and field visits. All health financing innovations, including HEFs, were extensively discussed in the
first Joint Annual Performance Review, where the MOH and its partners assess progress in the health sector and define priorities [45]. These local dissemination activities were strongly supported by HEF implementing agencies that needed to prove their success and the efficient use of received funding. The HEF experience was later shared with a larger public at international conferences and in peerreviewed journals [13–15,37,46]. Some key informants considered this useful for transferring HEF knowledge to academic and international actors. However, the influence of this on HEF policy could not be documented. The majority of the key informants noted that the active dissemination of the first HEF pilots’ results was essential to draw attention of key policy makers and donors to HEF and to stimulate a policy debate at the national level. Although Médecins sans Frontières, UNICEF and WHO all played a leading role, the involvement of government policy makers was crucial at this stage. 3.2.4. K4—adopting and using new knowledge: scaling-up and harmonisation of HEFs The stakeholders who adopted knowledge from the first HEF pilots were those who replicated the pilots and tested new models to create new knowledge. They had a direct interest in implementing HEFs to address problems faced in their projects and thus increase the efficiency of their inputs to reach equity goals. For example, UNICEF’s advisor said that the main reason for introducing a HEF in Svay Rieng hospital was to overcome the low user fee exemption rate and to increase the efficiency of UNICEF’s inputs. This new approach allowed UNICEF to shift its direct financial support to the hospital towards a fund for the poor through which purchasing power could be created. Similarly, project managers of HealthNet International and Enfants et Dévelopment said that they had adopted the HEF concept because it was considered an effective way to pay user fees for the poor. To get HEF on the policy agenda, a HEF think tank with members from NGOs involved in HEF pilots was formed. Monthly meetings occurred under the coordination of Medicam, which strongly advocated the MOH to take up the HEF approach. “We encourage the MOH to establish HEFs to support the poor who do not have the means to pay the user fees. We do our best to facilitate the gathering of
206
P. Ir et al. / Health Policy 96 (2010) 200–209
Table 3 Summary of HEF policy elements and available knowledge. Policy elements
Ideas with consensus or supported by knowledge
Pending questions
Target population
The ‘poor’
HEF operator
Third party payer
Beneficiary identification method
Pre- and post-identification is feasible
Benefit package
Hospital user fees, transportation cost and food allowance
Monitoring and evaluation
National core indicators and monitoring system
Funding mechanism and sustainability
External sources
Impact
Improved access for the poor
Those below the national poverty line or the poorest of the poor? NGOs, government health institution or religious group or mixed? Exclusive pre- or post-identification or both in combination? Health centre user fees? Third level care? Specialized services for chronic diseases? Mechanism to check fraud and over-utilisation, to assess quality of care, to measure the impact? State budget? Community participation? Health insurance? Protect the poor from impoverishing effect of health care cost? Poverty reduction?
evidence on the success of HEF and forward it to policy makers through all means, in particular TWG-H”, said the Medicam director during the interview. However, the real policy uptake of this new knowledge took place only in 2002 when HEFs became an integral part of the Health Sector Strategic Plan [40] and in the Poverty Reduction Strategy [41]. Many key informants considered this a breakthrough for the country-wide scaling-up of HEFs. They reported three main reasons for the adoption of HEF knowledge and its translation into these two strategic documents: HEF turned out to be an effective solution to the failure of the user fees exemption policy; by its very nature HEF promoted equity, it therefore fitted nicely into the MOH pro-poor policy; and finally HEF mobilised additional resources for government health facilities. One key informant emphasized that “HEF is a pragmatic concept that allows reaching the dual objective of ensuring access for poor patients to government health facilities, while at the same time helping these facilities to generate income. HEF does not seem to harm anybody’s interest”. Despite this set of possible advantages of HEF for all stakeholders [27], from the very beginning, donor agencies did not refrain from debating HEF. Some of their high level personnel, who were pro‘contracting’ and health insurance models, opposed the idea of HEF and argued that HEF was just charity and would probably not be efficient or sustainable. Only in 2003 a consensus was obtained and donors started earmarking funds for HEF. To guide further development of HEFs, the MOH developed a Strategic Framework for Equity Funds and a National Equity Fund Implementation and Monitoring Framework after a thorough consultation process. Experiences from pilots were carefully examined and incorporated [42]. In order to create an environment in which old HEFs could continue and new HEFs could be created under various funding arrangements, the framework did refrain from stipulating strict standardisation rules. Three HEF management models were proposed: model 1 with an NGO as implementer; model 2 with the district health office as implementer; and model 3 without an implementer but with the particular hospital in charge of management.
Models 2 and 3 have not been supported by knowledge from HEF pilots. This broad policy guidance and the historical development of context-specific HEF pilots by different actors with different sources of funding created variations in implementation arrangements. Therefore, from 2005 on several initiatives were taken to harmonise the schemes: e.g. the Ministry of Planning’s approach to systematic national poverty identification and the MOH’s Forum on HEF. The forum reached a consensus on the positive impact of HEFs in terms of access to public health services for the poor, but concluded that the knowledge on mitigating the impoverishing effect of illness on the poor was ambiguous. Furthermore, key policy aspects of HEF remained partly unresolved, like the beneficiary identification method, organisation and management model, benefit package, reliable funding source, and monitoring and evaluation (Table 3). During the interviews, none of the 20 key informants expressed their disagreement with the existence of HEF, but many questioned the impact and sustainability of HEF and insisted on some HEF designs and institutional arrangements. Some favoured post-identification, while others recommended pre-identification. Key informants from NGOs and some donor agencies preferred HEF to be managed by a third party independent from the MOH, whereas government key informants argued that it would be more efficient and sustainable if HEF was managed and monitored within the existing MOH structures. In late 2006, the MOH and Ministry of Economy and Finance jointly issued a Prakas (directive) to allocate part of the State budget to subsidise health care costs for the poor through reimbursement of the cost of user fees for exempted poor patients. This Prakas can be seen as a commitment of the government to allocate funds for the care of the poor. It embodies the first regulatory application of the National Framework and applies models 2 and 3 for HEF management. However, the effectiveness of this model needs further assessment. As of 2008, there were 50 HEF schemes, including 15 government subsidy schemes, based in 51 hospitals and 120 health centres in Cambodia, providing cover-
P. Ir et al. / Health Policy 96 (2010) 200–209
age for over 50% of the total population in Cambodia [47]. 4. Discussion Pilot or experimental projects increase the likelihood of successful scaling-up by generating knowledge on how an innovation can be best implemented in a particular context, identifying potential problems and preventing unintended consequences of the introduction of an innovation prior to scaling-up [48]. While an increasing number of documented pilots is successfully scaled up, many successful small-scale pilots are ignored by policy makers or not scaled up to benefit larger populations because policy makers lack essential knowledge on the determinants of successful scaling-up [4,49,50]. In this study, we used a 4-K framework to analyse the process in which HEF pilots successfully went on to become part of national health policy and were gradually scaled up nationwide. The application of the framework illustrates how a successful pilot project can inspire national health policy and helps identify factors determining successful scaling-up. A number of health policy-making models have been proposed by scholars. These include problemsolving, interactive, political, tactical, knowledge-driven and enlightenment models [19]. Our findings show that HEF policy development followed the knowledge-driven and enlightenment models. The HEF policy-making process was complex and incremental. When a few pioneering HEF pilots proved relatively successful, HEFs were gradually scaled up and became part of national health policy aimed at promoting equity and reducing poverty. The HEF policy development was supported by three types of locally generated knowledge: knowledge on the failure of user fee exemptions and its consequences, knowledge on the effectiveness of HEF pilots in addressing this problem, and knowledge on institutional arrangements and conditions for replication of the pilot schemes. These types of knowledge are among the key attributes that enhance the potential for scaling-up innovations [48]. A number of policy analyses have identified three common factors that determine the influence of evidence on policy: the policy context; the credibility and timeliness of evidence; and actors and the interaction between them [20,21,23,51]. This study shows that the uptake of HEF in health policy was also equally determined by three important factors: a policy context conducive to the creation, dissemination and adoption of HEF pilot experiences; the credibility and timeliness of HEF knowledge generated from the HEF pilots; and last but not least, the commitment of key actors and good relationships among them. The context is the environment in which the policy is being developed and implemented. It is a fundamental but often neglected factor influencing the utilisation of evidence [52]. The Cambodian context in the late 1990s and early 2000s was very favourable to HEF pilots, as Cambodian health policy has adopted a pro-poor approach and explicitly set equity as a goal. Successive efforts to achieve this goal, particularly through health financing reforms, were not entirely satisfactory. There was conclusive knowledge that user fees constituted a financial barrier to access
207
for the poor and knowledge on poverty induced by low access to health services by the poor also began to emerge. The government was therefore supportive of innovations. The development of the Health Sector Strategic Plan and Poverty Reduction Strategy in 2002 created a window of opportunity for the uptake of HEF in policy. Credibility and timeliness of evidence are important for policy uptake. Credibility of evidence does not only depend on its topical relevance, but also on its operational usefulness, and more importantly, on whether the evidence provides a solution to a problem [23]. HEF related knowledge was gathered over time through evaluations and case studies. Although one can raise methodological concerns about those studies, on the whole the evidence base proved strong enough to convince policy makers and donors to adopt the HEF idea. HEF proved effective in addressing financial barriers to accessing public health services for the poor and showed potential in improving health equity and reducing poverty—a goal that has been strongly emphasized since the arrival of poverty reduction strategic papers. HEF was not only a response to the user fee exemption failure, but also an efficient way to transfer donor funds to the poor in donor projects and programmes. The new knowledge came in timely as people were trying to a solution to address problems they were facing. Kaufman and colleagues found that the main reason for successful scaling-up of a Quality of Care Pilot Project in China was the fact that it was home-grown [49]. Similarly, HEF is locally generated, creating ownership by the Cambodian health leaders, also the approach is easy to understand, adopt and implement. All key informants showed strong support for HEF, at least in the short- and medium-term. They considered HEF a pragmatic concept that allows reaching the double objective of ensuring access for poor patients while at the same time helping public health facilities to generate income. Actors and the interaction between them are also a central factor influencing health policy [20,23]. Direct interaction between policy makers and researchers is the most influential facilitator of research uptake for policy [22]. In Cambodia, there are many national and international NGOs and donor agencies active in health sector development. They work within a SWiM framework under the guidance of the MOH [44]. Several networks and forums have been created to gather all key health stakeholders and facilitate policy dialogue. Getting an innovation like HEF on the policy agenda and scaling it up successfully were huge challenges in this complex and crowded field. Disagreements between stakeholders were unavoidable. Although none of the key informants challenged the existence of HEF during the interviews, in the beginning, there had been some opponents to HEF, mainly the high level personnel of donor agencies who doubted the efficiency and sustainability of HEF. They tended to favour contracting and health insurance models. Moreover, HEF proponents also disagreed on many key policy aspects of HEF. Tantivess and Walt [53] showed in a study on the scaling-up of antiretroviral therapy in Thailand that networks of non-state actors can play a crucial role in the policy process. In Cambodia, HEF pilots were initiated by an ‘interest group’ of international health partners, mainly
208
P. Ir et al. / Health Policy 96 (2010) 200–209
NGOs, who were looking for ways to address the problem of access for the poor. This group also took a leading role in the generation and transfer of new knowledge to policy makers. However, this was only possible thanks to the openness and support from the MOH. Hyder et al. [11] emphasized that the engagement of decision makers is crucial to promoting the use of evidence for policy development. In Cambodia, from the beginning several decision makers from government ministries and donor agencies had been involved in the two first HEF pilots as members of the steering and management committees. Their role became more prominent at the stage of scaling-up and harmonisation. Although HEF pilots successfully went on to become part of national health policy and were gradually scaled up nationwide, the HEF policy development is still a workin-progress. Many policy issues, including government funding for HEFs, remain and hence need to be carefully addressed to effectively scale up HEFs nationwide to achieve equity goals. Moreover, the overall impact of HEF policy on health equity requires further assessment. We acknowledge some limitations in this policy analysis. First, we do not have explicit criteria for appreciating the extent to which each of the above-mentioned factors contributed to the translation of knowledge into policy. Second, heavy involvement of the authors in the HEF policy process, which is a strength of the study, could lead to information interpretation bias. However, the combination of document analysis and key informant interviews – the two most common methods for policy analysis [21] – with guidance from a review team, should minimize this bias. Finally, the development of HEF policy might have been rather unique in terms of content, setting and timing. As described in the results section, a number of pilot projects in health financing have been set up in Cambodia over the last decades. Unlike HEF pilots, other pilots such as contracting and community-based health insurance were not (or at least less) successfully scaled up. It appears that within the same setting and time frame, different pilots can achieve different levels of success in scaling-up. 5. Conclusions This paper illustrates how HEF pilots in Cambodia were successfully integrated in health policy and gradually scaled up nationwide. The study offers an example of how knowledge can be successfully translated into policy to promote health equity in low-income countries. Our findings suggest three important factors that can enhance the likelihood of uptake of a pilot project in health policy and its nationwide scaling-up. These include a policy context conducive to the creation, dissemination and adoption of the pilot experience; the credibility and timeliness of knowledge generated by the pilot; and strong commitment and a good relationship between actors involved in the pilot. Knowledge locally generated through pilots is crucial for innovative health policy. This knowledge can help avoid a one-size-fits-all approach and adapt blueprints to a local context. Most importantly, it also creates ownership among policy makers. In low-income countries with scarce resources and limited research capacity, interna-
tional organisations and donors can take a leading role in innovative interventions, as they often have a broader scientific network and resources and are perhaps more willing to take risks. However, involvement of government policy makers in the innovations is necessary for their scaling-up. Acknowledgements We thank Dr. Lo Veasna Kiry from the Ministry of Health, Dr. Saphorn Vonthanak from the National Institute of Public Health and Dr. Benjamin Lane from WHO for their contribution to the study. We are grateful to all the key informants for dedicating their valuable time for the interviews and to Dr. Steve Fabricant, Ms. Anjana Bhushan, Dr. Reijo Salmela, Kristof Decoster and Bart Jacobs for their comments on earlier drafts of this paper. This study was funded by the WHO and one co-author benefited from the support of the POVILL project funded by the Sixth Framework Programme of the European Commission (http://www.povill.com/en index.aspx). References [1] Gwatkin DR, Rutstein S, Johnson K, Suliman E, Wagstaff A, Amouzou A. Socio-economic differences in health, nutrition, and population within developing countries: an overview. Washington, DC: Health, Nutrition and Population, World Bank; 2007. [2] Gwatkin DR, Bhuiya A, Victora CG. Making health systems more equitable. Lancet 2004;364:1273–80. [3] Reaching the poor with health services. Washington, DC: Development Outreach, World Bank; 2005. [4] Scaling up health service delivery: from pilot innovations to policies and programmes. Geneva: World Health Organization; 2007. [5] Braveman P, Gruskin S. Poverty, equity, human rights and health. Bulletin of the World Health Organization 2003;81:539–45. [6] Palmer N, Mueller DH, Gilson L, Mills A, Haines A. Health financing to promote access in low income settings-how much do we know? Lancet 2004;364:1365–70. [7] World report on knowledge for better health: strengthening health systems. Geneva: World Health Organization; 2004. [8] Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization 2004;82:724–31. [9] Thamlikitkul V. Bridging the gap between knowledge and action for health: case studies. Bulletin of the World Health Organization 2006;84:603–7. [10] Gilson L, Raphaely N. The terrain of health policy analysis in low and middle income countries: a review of published literature 1994–2007. Health Policy and Planning 2008;23:294–307. [11] Hyder AA, Bloom G, Leach M, Syed SB, Peters DH. Exploring health systems research and its influence on policy processes in low income countries. BMC Public Health 2007;7:309. [12] Bigdeli M, Annear PL. Barriers to access and the purchasing function of health equity funds: lessons from Cambodia. Bulletin of the World Health Organization 2009;87:560–4. [13] Hardeman W, Van Damme W, Van Pelt M, Por I, Kimvan H, Meessen B. Access to health care for all? User fees plus a Health Equity Fund in Sotnikum, Cambodia. Health Policy and Planning 2004;19:22–32. [14] Jacobs B, Price N. Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia. Health Policy and Planning 2006;21:27–39. [15] Noirhomme M, Meessen B, Griffiths F, Ir P, Jacobs B, Thor R, et al. Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia. Health Policy and Planning 2007;22:246–62. [16] Strategic framework for equity funds: promoting access to priority health services among the poor. Phnom Penh: Ministry of Health, Government of Cambodia; 2003. [17] Evidence Policy for the WHO Regional Office for Europe. Geneva: World Health Organization; 2004. [18] Landry R, Amara N, Pablos-Mendes A, Shademani R, Gold I. The knowledge-value chain: a conceptual framework for knowledge
P. Ir et al. / Health Policy 96 (2010) 200–209
[19] [20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30] [31]
[32] [33]
[34] [35]
translation in health. Bulletin of the World Health Organization 2006;84:597–602. Bowen S, Zwi AB. Pathways to “evidence-informed” policy and practice: a framework for action. PLoS Medicine 2005;2:e166. Buse K, Mays N, Walt G. Making health policy. 1st ed. London: Open University Press, London School of Hygiene and Tropical Medicine; 2005. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Research Policy and Systems 2003;1:2. Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers’ perceptions of their use of evidence: a systematic review. Journal of Health Services Research and Policy 2002;7:239–44. Young J, Court J, Bridging Research and Policy in International Development: An Analytical and Practical Framework. RAPID Briefing Paper 1; 2004. Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T. User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Social Science and Medicine 2004;58:553–64. Barber S, Bonnet F, Bekedam H. Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia. Health Policy Planning 2004;19:199–208. Wilkinson D, Holloway J, Fallavier P. The impact of user fees on access, equity and health provider practices in Cambodia. Phnom Penh, Cambodia: Ministry of Health; 2001. Meessen B, Van Damme W, Ir P, Van Leemput L, Hardeman W. The New Deal in Cambodia: the second year. Confirmed results; confirmed challenges. Phnom Penh, Cambodia: MSF Cambodia; 2002. Soeters R, Griffiths F. Improving government health services through contract management: a case from Cambodia. Health Policy Planning 2003;18:74–83. Van Damme W, Meessen B, von Schreeb J, Thayly H, Thomé JM, Overtoom R, et al. Sotnikum New Deal: the first year. Better income for health staff; better service to the population. Phnon Penh, Cambodia: MSF Cambodia; 2001. Health care demand survey. Phnom Penh, Cambodia: National Institute of Public Health; 1998. Cambodia Poverty Assessment. Poverty reduction and economic management sector unit and human development sector unit for East Asia and Pacific Region. World Bank; 1999. Oxfam: health and landlessness. Phnom Penh, Cambodia: Oxfam; 2000. Knowles J. An economic evaluation of the health care for the poor component of the Phnom Penh urban health project. Phnom Penh, Cambodia: MOH and WHO; 2001. Health Equity Fund in Pursat provincial hospital: 6-month evaluation report. Phnom Penh, Cambodia: WHO Cambodia; 2003. Annear PL, Wilkinson D, Chean RM, Van Pelt M. Study of financial access to health services for the poor in Cambodia. Phase 1. Scope, design and data analysis. Phnom Penh, Cambodia: MOH, WHO, RMIT University; 2006.
209
[36] Jacobs B, Price N. The impact of the introduction of user fees at a district hospital in Cambodia. Health Policy Planning 2004;19: 310–21. [37] Jacobs B, Price N, Sam SO. A sustainability assessment of a health equity fund initiative in Cambodia. International Journal of Health Planning and Management 2007;22:183–203. [38] Jacobs B, Price NL, Oeun S. Do exemptions from user fees mean free access to health services? A case study from a rural Cambodian hospital. Tropical Medicine and International Health 2007;12: 1391–401. [39] Nguyen A. The Svay Rieng Health Equity Funds. A project evaluation. Phnom Penh, Cambodia: UNICEF Cambodia; 2004. [40] Health Sector Strategic Plan 2003–2007. Phnom Penh, Cambodia: Ministry of Health; 2002. [41] National Poverty Reduction Strategy 2003–2005. Phnom Penh, Cambodia: Council for Social Development, Ministry of Planning; 2002. [42] National Equity Fund Implementation and Monitoring Framework. Phnom Penh, Cambodia: MOH; 2005. [43] Lanjouw S, Macrae J, Zwi AB. Rehabilitating health services in Cambodia: the challenge of coordination in chronic political emergencies 1. Health Policy Planning 1999;14:229–42. [44] An assessment of progress under sector-wide management and recommendations to the MOH and health partners for improving harmonization and alignment in the health sector: consolidated report phase 1 and 2. Phnom Penh, Cambodia: Ministry of Health, Royal Government of Cambodia; 2007. [45] Joint Health Sector Review Report. Phnom Penh, Cambodia: MOH; 2001. [46] Meessen B, Van Damme W, Tashobya CK, Tibouti A. Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia. Lancet 2006;368:2253–7. [47] Annual Health Financing Report 2008. Phnom Penh, Cambodia: Bureau of Health Economics and Financing, Department of Planning and Health Information, Ministry of Health; 2009. [48] Practical guidance for scaling up health service innovations. Geneva: ExpandNet, World Health Organisation; 2009. [49] Kaufman J, Erli Z, Zhenming X. Quality of care in China: scaling up a pilot project into a national reform program 55. Studies in Family Planning 2006;37:17–28. [50] Phillips JF. Translating pilot project success into national policy development: two projects in Bangladesh 18. Asia Pacific Population Journal 1987;2:3–28. [51] Gilson L, McIntyre D. The interface between research and policy: experience from South Africa. Social Science and Medicine 2008;67:748–59. [52] Dobrow MJ, Goel V, Upshur RE. Evidence-based health policy: context and utilisation. Social Science and Medicine 2004;58:207–17. [53] Tantivess S, Walt G. The role of state and non-state actors in the policy process: the contribution of policy networks to the scaleup of antiretroviral therapy in Thailand 1. Health Policy Planning 2008;23:328–38.
Contents lists available at ScienceDirect
Health Policy journal homepage: www.elsevier.com/locate/healthpol
Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000–2008 Por Ir a,b,∗ , Maryam Bigdeli c , Bruno Meessen b , Wim Van Damme b a b c
Siem Reap Provincial Health Department, Ministry of Health, No. 221, Street 217, Phnom Penh, Cambodia Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, B-2000 Antwerp, Belgium Department of Health Systems, Cambodian Office of the World Health Organization, No. 177-179 Corner Streets Pasteur, Phnom Penh, Cambodia
a r t i c l e
i n f o
Keywords: Health Equity Fund Cambodia Health equity Health policy Knowledge Knowledge translation
a b s t r a c t Objectives: To understand how knowledge is used to inform policy on Health Equity Funds (HEFs) in Cambodia; and to draw lessons for translating knowledge into health policies that promote equity. Methods: We used a knowledge translation framework to analyse the HEF policy process between 2000 and 2008. The analysis was based on data from document analysis, key informant interviews and authors’ observations. Results: The HEF policy-making process in Cambodia was both innovative and incremental. Insights from pilot projects were gradually translated into national health policy. The uptake of HEF in health policy was determined by three important factors: a policy context conducive to the creation, dissemination and adoption of lessons gained in HEF pilots; the credibility and timeliness of HEF knowledge generated from pilot projects; and strong commitment, relationships and networks among actors. Conclusions: Knowledge locally generated through pilot projects is crucial for innovative health policy. It can help adapt blueprints and best practices to a local context and creates ownership. While international organisations and donors can take a leading role in innovative interventions in low-income countries, the involvement of government policy makers is necessary for their scaling-up. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Equity has been an overarching goal of public health policy in many countries for several decades. However, progress towards this goal has been disappointing. Poorrich disparities in health financing, in access to health care and in health outcomes persist in many coun-
∗ Corresponding author at: Siem Reap Provincial Health Department, Ministry of Health, No. 221, Street 217, Orussey 2, Khan 7 Makara, Phnom Penh, Cambodia. Tel.: +855 12 657 725. E-mail addresses: [email protected] (P. Ir), [email protected] (M. Bigdeli), [email protected] (B. Meessen), [email protected] (W. Van Damme). 0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2010.02.003
tries and even widen in some countries [1]. To address health inequities an equity-oriented approach to health and health sector policy is needed. A concerted effort must be made to ensure that health systems reach the poor more effectively [2]. Successful interventions aiming to reach the poor with health services exist in some countries [3]. However, replication of these interventions in developing countries where resources are scarce and health systems perform poorly is a big challenge and often requires context-specific experimentation through pilots [4]. The implementation of equitable health care financing mechanisms which could increase access for the poor and reduce poverty is critical to promoting health equity [5].
P. Ir et al. / Health Policy 96 (2010) 200–209
Box 1: Concepts and definitions • HEF is a demand-side financing mechanism to promote access to priority public health services for the poor in an environment where user fees are charged [16]. The management of the fund is entrusted to a third party, usually a local nongovernmental organisation. HEF beneficiaries are identified according to eligibility criteria, either at the community before health care demand (preidentification) or at the health facilities through interviews (post-identification). At the health facility, the eligible poor patients get full or partial support from HEF for the cost of user fees, transport cost and other costs during hospitalisation [12,15]. • Knowledge is the active linkage of information to a context and its integration into thinking and practice [17]. It results from a series of three successive transformations: from reality to data, from data to information (know-what), and from information to knowledge (know-how) [18]. Knowledge is a form of evidence and the meaning of knowledge and evidence is often used interchangeably [17,19]. • Policy is a broad statement of goals, objectives and means that creates a framework for activity. It often takes the form of explicit written documents, but may also be implicit or unwritten. Health policy covers courses of action (and inaction) that affect the set of institutions, organisations, services, and funding arrangements of the health care system [20].
Yet, reliable knowledge on efficient and equitable health financing in different settings is sparse [6]. Moreover, the available knowledge is often not translated into policy. Closing the knowledge-policy gap is crucial to ensure health system strengthening and the achievement of health equity goals [7–9]. It requires a better understanding of interfaces between research and policy, in particular the factors affecting the uptake of research findings by policy. Despite a growing literature on policy analysis, knowledge in this field remains rather weak in developing countries [10,11]. In Cambodia, despite considerable progress in the health sector, access to essential health services remains a problem, especially for the poor. To tackle this problem, multiple health financing innovations have been tested in recent years. Health Equity Fund (HEF) is one of these innovations aimed at promoting equity and reducing poverty through enhancing access to health services for the poor [12]. HEF pilots proved relatively successful and showed potential for improving equity and reducing poverty [13–15]. Supported by knowledge generated from the pilot schemes, HEFs went on to become part of national health policy. We analyse the HEF policy process to illustrate how knowledge was used to inform national health policy and draw lessons for translating knowledge into policies that promote equity (Box 1).
201
2. Materials and methods This study is a retrospective analysis of the HEF policy process in Cambodia between 2000 and 2008, and was conducted under the guidance of a review team with members from the Cambodian Ministry of Health (MOH), the National Institute of Public Health and WHO’s office in Phnom Penh. Document analysis and interviews are the most commonly used methods for policy analysis. They seem appropriate for retrospective analysis of a national and sub-national policy related to specific issues [21] and they are preferably used in combination [22]. In this case study, data were collected through document analysis, key informant interviews and direct observations of the authors who have been involved in the HEF policy process in Cambodia. We collected all documents on HEFs, policies related to HEFs and health financing reforms in Cambodia published between 1995 and 2008. These documents included journal articles, working papers, evaluation reports and policy documents of the MOH, government and different agencies. The electronically published papers were searched through PubMed and Google scholars using the following keywords: Health Equity Funds; access to health services for the poor; and Cambodia. Others were identified and gathered through the authors’ networks and key informants. The collected documents were analysed to gain insight into the HEF policy process; the position of related stakeholders and knowledge they had used to inspire the policy. The document analysis also guided our selection of key informants and the development of a questionnaire for interviews. On the basis of information collected through the document analysis, prior knowledge of the authors and guidance of the review team, 20 key informants were intentionally selected and invited for interviews. The interviewees were policy makers, researchers and managers from government line ministries, donor agencies, academic institutes, national and international NGOs who have been closely involved in the HEF policy development. The interviews were conducted by the first author (PI), using a semistructured questionnaire, and aimed at assessing the role of key stakeholders in the HEF policy process, their knowledge on HEFs and their position towards HEF policy. Each of the interviews took between 30 min and 1 h. We took extensive notes of the responses and processed them immediately after the interviews. The collected data were manually coded, thematically grouped and then analysed. The key information and insights gathered through key informant interviews were triangulated with those of document analysis and authors’ prior knowledge. Policy-making is rarely a linear process, an event or an explicit set of decisions; instead, it tends to evolve through an interactive process and usually involves a wide range of actors. Several frameworks for policy analysis have been proposed by scholars [19,21,23]. “Knowledge translation is the exchange, synthesis and effective communication of reliable and relevant research results. The focus is on promoting interaction among the producers and users of research, removing the barriers to research use, and tailoring information to different target audiences
202
P. Ir et al. / Health Policy 96 (2010) 200–209
Fig. 1. The 4-K framework.
so that effective interventions are used more widely” [7]. Drawing on these concepts and frameworks, we propose a knowledge translation framework to analyse the HEF policy process in Cambodia (Fig. 1). This 4-K framework describes four stages of getting knowledge into policy: K1—exploiting existing knowledge; K2—creating new knowledge or innovations; K3—transferring new knowledge; and K4—adopting and using new knowledge. In each stage, various actors interplay within a complex environment to generate new knowledge to feed the ‘stock of knowledge’ or make use of the available knowledge for action. Any action that makes use of the knowledge is considered ‘policy’, which is not depicted in this framework. This study obtained ethical approval from the Cambodian National Ethics Committee with reference number 002 NECHR. To ensure personal confidentiality, interviews were kept anonymous. Verbal consent was obtained from each key informant prior to the interview.
3. Results
Tax-based free of charge delivery of public health services between 1990 and 1995 was not very successful in providing access to basic health care for the population. User fees with exemptions for the poor were therefore introduced in 1997 and progressively expanded to all public health facilities. Several studies showed that user fees help improve the performance of public health facilities, but become a barrier for the poor to access health services, especially hospital services, in the absence of a viable exemption system [14,15,24–26]. Along with user fees, several contracting models were tested with the objective of improving public health services’ performance. Although relatively successful, these pilots did not really address the barrier of user fees and several other demand barriers to access for the poor [25,27–29]. Since 1999, an international NGO has also been experimented with community-based health insurance, but the result of the pilot was not persuasive enough to attract policy makers’ attention. Various surveys conducted in the late 1990s showed the low utilisation rate of public facilities and high health care costs that were mainly paid out-of-pocket, bringing about households’ debt and landlessness [30–32]. In this context, HEF pilots emerged as a possible remedy.
3.1. Cambodian health policy and health sector reforms As stated in policy documents that are reflected in article 72 of the National Constitution, health sector reforms in Cambodia are aimed at promoting equity and reducing poverty through enhancing access to and utilisation of quality services, especially for the poor, and protecting them from the impoverishing effects of ill-health. To reach these aims, the Cambodia health system has undergone a long series of reforms, including health financing reforms. Over the last decade, along with budgetary reform several health financing schemes have been developed and implemented (Fig. 2).
3.2. Knowledge translation: the path from HEF pilots to national health policy The first HEF pilots were initiated in 2000. They proved relatively successful and showed potential in improving health equity and reducing poverty [13,27,29,33]. Inspired by their success, several new HEF pilots were launched in other places and produced similar results [14,15,34–39]. Key characteristics of first and new HEF pilots are summarised in Table 1. HEF was therefore included in key MOH and government strategic documents in 2002 [40,41] and the first HEF policies were developed [16,42].
P. Ir et al. / Health Policy 96 (2010) 200–209
203
Fig. 2. Development of different health financing schemes in Cambodia.
3.2.1. K1—exploiting existing knowledge: the birth of HEF pilots The first HEF pilots were initiated by an ‘interest group’ situated among international health partners, mainly NGOs, who advocated for complementing supply-side interventions. These interventions aimed to provide health services to the population, but faced a severe problem of access for the poor. According to key informants and the project evaluation report [33], the HEF in the Urban Health Project was created by relatively few key people in the
health sector reform working group because many clients of the health rooms who needed referral could not afford to pay hospital user fees and other related costs, forewent the treatment or fell into debt. Similarly in Thmar Pouk and Sotnikum, the HEF pilots were initiated by Médecins sans Frontières and UNICEF because the hospital user fees became a barrier to access for the poor. The HEF pilots in Thmar Pouk and Sotnikum were first labelled Mulnithi Sangkrus Chun Krey Krar (‘a fund to save the poor’), a term inspired by existing local concepts of
Table 1 Summary of Health Equity Fund pilots at their initial stage. Key features
First HEF pilots
New HEF pilots
Phnom Penh
Thmar Pouk and Sotnikum
Svay Rieng
Pursat
Pearang
Kirivong
Population
Two urban slums: approximately 20,000
Province: approximately 530,000
Province: approximately 410,000
Health district: approximately 200,000
Health district: approximately 205,000
Supply-side intervention
Urban Health Project
Health districts: approximately 110,000 and 220,000 New Deal—‘Contracting’
‘Contracting’
August 2000
‘Health Financing Scheme’ July 2002
‘Contracting’
HEF started in
‘Health Financing Scheme’ July 2002
July 2002
May 2003
Design, monitoring and evaluation Health service delivery
MoH and WHO
UNICEF
WHO
HNI
ED and local community
District referral hospital and health centres National NGO
District referral hospital and health centres Pagodas Committees
Pre- and postidentification Total of hospital user fees, free delivery at health centres & referrals to tertiary care External (HNI)
Exclusive preidentification Total of hospital and health centre user fees
May and September 2000 MSF and UNICEF
Municipal hospital
District referral hospitals
Provincial hospital
Provincial hospital
HEF operator
Local health authority
National NGOs
National NGO
Beneficiary identification Benefit package
Exclusive postidentification 70% of hospital user fees, transport and food
Exclusive postidentification Part/total of hospital user fees, transport, food and basic items
Equity Fund Support Committee Pre- and postidentification Part/total of hospital user fees, transport and food
Funding
External (DFID)
External (MSF and MSF with UNICEF for Sotnikum)
External (UNICEF)
Exclusive postidentification Part/total of hospital user fees, transport, food and basic items
External (WHO)
MSF: Médecins sans Frontières; HNI: HealthNet International; ED: Enfants et Développement.
Pagodas with complement from ED
204
P. Ir et al. / Health Policy 96 (2010) 200–209
solidarity and social assistance. One year later, the pilots were coined ‘Health Equity Funds’. According to key informants, local and international experts’ knowledge of social assistance was tapped to design, implement, monitor and evaluate the pilot schemes. The decision to entrust the management of the scheme to a third party NGO was inspired by the concept of purchaser–provider split. 3.2.2. K2—creating new knowledge or innovation: results from HEF pilots Evaluations of these HEF pilots showed persuasive results in terms of promoting access to hospital services for the poor and potential effect on protecting the poor from the impact of health care costs [13,27,29,33]. Table 2 summarises the new knowledge on institutional arrangements and the effectiveness of the first pilot schemes. According to key informants, this wealth of new knowledge came in timely, as new initiatives to address the failure of user fee exemptions were sought. The HEF model was soon replicated in other places with some design modifications that created further knowledge for policy. Evaluation reports and case studies [14,15,34,35,39] showed that these new pilots reinforced knowledge on HEF effectiveness in improving access to hospital care for the poor and produced new knowledge on institutional arrangements and conditions for replication (Box 2 ). 3.2.3. K3—transferring new knowledge: dissemination of results from HEF pilots Coordination of multiple health actors in post-conflict situation in Cambodia had been a challenge for years [43]. The adoption of the Sector-Wide Management (SWiM) strategy in 2000 allowed finally tackling this challenge. A common strategic framework, including a health sector strategic plan, medium-term expenditure framework and joint annual performance review, was developed, allowing all key health actors to work together under the MOH leadership to achieve clear goals and objectives. In addition, several coordination mechanisms were developed. The Technical Working Group-Health (TWG-H) at central
Box 2: Summary of new knowledge gathered from new HEF pilots • Village-based pre-identification is feasible and costeffective. • Pre-identification seems to be superior to postidentification in promoting utilisation by the poor through increased awareness of HEF and certainty of their entitlements. But pre-identification alone is not practical and needs to be complemented by postidentification. • A limited benefit package may undermine the effectiveness of HEF. In addition to the support for secondary level care, the cost of further referrals to tertiary care institutions should also be included in the benefit package. • A mixed committee composed of representatives from the community, pagodas, local health authority and NGOs in charge of HEF (or at least of monitoring and evaluating HEF) is both effective and inexpensive. • The management arrangement of a Provincial Health Department in charge of the fund and an NGO in charge of identifying the poor also worked well. • Participation by the local community in the design, implementation and monitoring and evaluation not only greatly reduced the administrative cost but also enhanced local ownership of the HEF, thus contributing to sustainability.
level and the Provincial-TWG-H at provincial level allow the MOH and its partners to discuss and share information. MEDICAM, an association of NGOs active in health, provides a forum for its members to meet, discuss and share information, and represents the NGOs at TWG-H. Many sub-working groups, committees and tasks forces gather knowledge to develop specific guidelines or policies and report to TWG-H. Ad hoc meetings, workshops and conferences are often organised. This created a network through which health information and knowledge are transferred to policy makers (Fig. 3). As stated in the SWiM progress
Table 2 Summary of new knowledge generated from the first HEF pilots. Evaluations and case studies of HEF pilot schemes
The first year evaluation report of the Urban Health Project
Generated new knowledge Knowledge on institutional arrangements
Effectiveness
HEF managed by the local health authority has high risk of mismanagement and favouritism Post-identification has its limits in addressing uncertainty
HEF improves access to referral services for the needy poor HEF may help prevent poverty by reducing time lost and avoiding selling assets or taking a loan HEF appears to be an efficient way to transfer resources to the poor: running cost of HEF is smaller than gain in poverty reduction
Partial support for user fees, transport and food still causes barrier for the poor
Evaluation reports and case studies of the New Deal and HEFs in Thmar Pouk and Sotnikum
HEF is effectively managed by an NGO in a context where the hospital is functioning well Post-identification leaves poor households uncertain about their entitlement to assistance Besides user fees, transport costs and food, there are many other barriers for the poor to accessing services, not addressed by HEF
HEF improves access to hospital services for the poor HEF may help prevent poverty, but needs further investigation HEF is a cost-effective strategy to transfer resources to the poor
P. Ir et al. / Health Policy 96 (2010) 200–209
205
Fig. 3. Knowledge-policy communication network in health care in Cambodia.
report, “SWiM, it is argued, was successful in building the foundation for effective sector coordination. . . Coordination mechanisms like the TWG-H and the joint annual performance reviews provide for important occasions to discuss and monitor the implementation of the shared sector strategy. . .” [44]. The number of HEF schemes and coverage of poor population by HEFs were among the monitoring indicators used in the joint annual performance reviews since 2005. Another example of the success of SWiM was the implementation of contracting, a major component of the Health Support Programme, in which the MOH and several major donors coordinated their financial inputs to the health sector [25,28]. The generated HEF knowledge was mainly passed on through this network. The HEF pilot in Sotnikum was part of the New Deal, a mini-SWiM introduced as a strategy to address the vicious circle of underpaid, poorly performing health staff and thus under-utilised health services [27,29]. To broaden the scope of actors involved in the decisionmaking process and increase chances for the New Deal to have an impact on national health policy, Médecins sans Frontières and UNICEF initiated a steering committee that included key policy makers from the government and partner agencies. The roles and responsibilities of members and stakeholders were clearly stipulated in a contract. The steering committee organised quarterly meetings to track the progress of the pilots and discuss related issues. In addition to the steering committee members, operational stakeholders were also invited to attend the meetings. Results from the HEF pilot in Sotnikum were disseminated through the steering committee’s quarterly meetings, two reports that were widely distributed locally [27,29], two workshops and several meetings with all partners in the health sector. In addition, many field visits of national and international stakeholders were organised to Sotnikum between 2000 and 2002. Results from the HEF pilot in the Phnom Penh Urban Health Project followed a similar pattern. A management committee composed of key health sector reform actors was also created to monitor the progress of this HEF pilot. Many key informants from the government and international agencies reported that they had learned about HEF results through their direct participation and field visits. All health financing innovations, including HEFs, were extensively discussed in the
first Joint Annual Performance Review, where the MOH and its partners assess progress in the health sector and define priorities [45]. These local dissemination activities were strongly supported by HEF implementing agencies that needed to prove their success and the efficient use of received funding. The HEF experience was later shared with a larger public at international conferences and in peerreviewed journals [13–15,37,46]. Some key informants considered this useful for transferring HEF knowledge to academic and international actors. However, the influence of this on HEF policy could not be documented. The majority of the key informants noted that the active dissemination of the first HEF pilots’ results was essential to draw attention of key policy makers and donors to HEF and to stimulate a policy debate at the national level. Although Médecins sans Frontières, UNICEF and WHO all played a leading role, the involvement of government policy makers was crucial at this stage. 3.2.4. K4—adopting and using new knowledge: scaling-up and harmonisation of HEFs The stakeholders who adopted knowledge from the first HEF pilots were those who replicated the pilots and tested new models to create new knowledge. They had a direct interest in implementing HEFs to address problems faced in their projects and thus increase the efficiency of their inputs to reach equity goals. For example, UNICEF’s advisor said that the main reason for introducing a HEF in Svay Rieng hospital was to overcome the low user fee exemption rate and to increase the efficiency of UNICEF’s inputs. This new approach allowed UNICEF to shift its direct financial support to the hospital towards a fund for the poor through which purchasing power could be created. Similarly, project managers of HealthNet International and Enfants et Dévelopment said that they had adopted the HEF concept because it was considered an effective way to pay user fees for the poor. To get HEF on the policy agenda, a HEF think tank with members from NGOs involved in HEF pilots was formed. Monthly meetings occurred under the coordination of Medicam, which strongly advocated the MOH to take up the HEF approach. “We encourage the MOH to establish HEFs to support the poor who do not have the means to pay the user fees. We do our best to facilitate the gathering of
206
P. Ir et al. / Health Policy 96 (2010) 200–209
Table 3 Summary of HEF policy elements and available knowledge. Policy elements
Ideas with consensus or supported by knowledge
Pending questions
Target population
The ‘poor’
HEF operator
Third party payer
Beneficiary identification method
Pre- and post-identification is feasible
Benefit package
Hospital user fees, transportation cost and food allowance
Monitoring and evaluation
National core indicators and monitoring system
Funding mechanism and sustainability
External sources
Impact
Improved access for the poor
Those below the national poverty line or the poorest of the poor? NGOs, government health institution or religious group or mixed? Exclusive pre- or post-identification or both in combination? Health centre user fees? Third level care? Specialized services for chronic diseases? Mechanism to check fraud and over-utilisation, to assess quality of care, to measure the impact? State budget? Community participation? Health insurance? Protect the poor from impoverishing effect of health care cost? Poverty reduction?
evidence on the success of HEF and forward it to policy makers through all means, in particular TWG-H”, said the Medicam director during the interview. However, the real policy uptake of this new knowledge took place only in 2002 when HEFs became an integral part of the Health Sector Strategic Plan [40] and in the Poverty Reduction Strategy [41]. Many key informants considered this a breakthrough for the country-wide scaling-up of HEFs. They reported three main reasons for the adoption of HEF knowledge and its translation into these two strategic documents: HEF turned out to be an effective solution to the failure of the user fees exemption policy; by its very nature HEF promoted equity, it therefore fitted nicely into the MOH pro-poor policy; and finally HEF mobilised additional resources for government health facilities. One key informant emphasized that “HEF is a pragmatic concept that allows reaching the dual objective of ensuring access for poor patients to government health facilities, while at the same time helping these facilities to generate income. HEF does not seem to harm anybody’s interest”. Despite this set of possible advantages of HEF for all stakeholders [27], from the very beginning, donor agencies did not refrain from debating HEF. Some of their high level personnel, who were pro‘contracting’ and health insurance models, opposed the idea of HEF and argued that HEF was just charity and would probably not be efficient or sustainable. Only in 2003 a consensus was obtained and donors started earmarking funds for HEF. To guide further development of HEFs, the MOH developed a Strategic Framework for Equity Funds and a National Equity Fund Implementation and Monitoring Framework after a thorough consultation process. Experiences from pilots were carefully examined and incorporated [42]. In order to create an environment in which old HEFs could continue and new HEFs could be created under various funding arrangements, the framework did refrain from stipulating strict standardisation rules. Three HEF management models were proposed: model 1 with an NGO as implementer; model 2 with the district health office as implementer; and model 3 without an implementer but with the particular hospital in charge of management.
Models 2 and 3 have not been supported by knowledge from HEF pilots. This broad policy guidance and the historical development of context-specific HEF pilots by different actors with different sources of funding created variations in implementation arrangements. Therefore, from 2005 on several initiatives were taken to harmonise the schemes: e.g. the Ministry of Planning’s approach to systematic national poverty identification and the MOH’s Forum on HEF. The forum reached a consensus on the positive impact of HEFs in terms of access to public health services for the poor, but concluded that the knowledge on mitigating the impoverishing effect of illness on the poor was ambiguous. Furthermore, key policy aspects of HEF remained partly unresolved, like the beneficiary identification method, organisation and management model, benefit package, reliable funding source, and monitoring and evaluation (Table 3). During the interviews, none of the 20 key informants expressed their disagreement with the existence of HEF, but many questioned the impact and sustainability of HEF and insisted on some HEF designs and institutional arrangements. Some favoured post-identification, while others recommended pre-identification. Key informants from NGOs and some donor agencies preferred HEF to be managed by a third party independent from the MOH, whereas government key informants argued that it would be more efficient and sustainable if HEF was managed and monitored within the existing MOH structures. In late 2006, the MOH and Ministry of Economy and Finance jointly issued a Prakas (directive) to allocate part of the State budget to subsidise health care costs for the poor through reimbursement of the cost of user fees for exempted poor patients. This Prakas can be seen as a commitment of the government to allocate funds for the care of the poor. It embodies the first regulatory application of the National Framework and applies models 2 and 3 for HEF management. However, the effectiveness of this model needs further assessment. As of 2008, there were 50 HEF schemes, including 15 government subsidy schemes, based in 51 hospitals and 120 health centres in Cambodia, providing cover-
P. Ir et al. / Health Policy 96 (2010) 200–209
age for over 50% of the total population in Cambodia [47]. 4. Discussion Pilot or experimental projects increase the likelihood of successful scaling-up by generating knowledge on how an innovation can be best implemented in a particular context, identifying potential problems and preventing unintended consequences of the introduction of an innovation prior to scaling-up [48]. While an increasing number of documented pilots is successfully scaled up, many successful small-scale pilots are ignored by policy makers or not scaled up to benefit larger populations because policy makers lack essential knowledge on the determinants of successful scaling-up [4,49,50]. In this study, we used a 4-K framework to analyse the process in which HEF pilots successfully went on to become part of national health policy and were gradually scaled up nationwide. The application of the framework illustrates how a successful pilot project can inspire national health policy and helps identify factors determining successful scaling-up. A number of health policy-making models have been proposed by scholars. These include problemsolving, interactive, political, tactical, knowledge-driven and enlightenment models [19]. Our findings show that HEF policy development followed the knowledge-driven and enlightenment models. The HEF policy-making process was complex and incremental. When a few pioneering HEF pilots proved relatively successful, HEFs were gradually scaled up and became part of national health policy aimed at promoting equity and reducing poverty. The HEF policy development was supported by three types of locally generated knowledge: knowledge on the failure of user fee exemptions and its consequences, knowledge on the effectiveness of HEF pilots in addressing this problem, and knowledge on institutional arrangements and conditions for replication of the pilot schemes. These types of knowledge are among the key attributes that enhance the potential for scaling-up innovations [48]. A number of policy analyses have identified three common factors that determine the influence of evidence on policy: the policy context; the credibility and timeliness of evidence; and actors and the interaction between them [20,21,23,51]. This study shows that the uptake of HEF in health policy was also equally determined by three important factors: a policy context conducive to the creation, dissemination and adoption of HEF pilot experiences; the credibility and timeliness of HEF knowledge generated from the HEF pilots; and last but not least, the commitment of key actors and good relationships among them. The context is the environment in which the policy is being developed and implemented. It is a fundamental but often neglected factor influencing the utilisation of evidence [52]. The Cambodian context in the late 1990s and early 2000s was very favourable to HEF pilots, as Cambodian health policy has adopted a pro-poor approach and explicitly set equity as a goal. Successive efforts to achieve this goal, particularly through health financing reforms, were not entirely satisfactory. There was conclusive knowledge that user fees constituted a financial barrier to access
207
for the poor and knowledge on poverty induced by low access to health services by the poor also began to emerge. The government was therefore supportive of innovations. The development of the Health Sector Strategic Plan and Poverty Reduction Strategy in 2002 created a window of opportunity for the uptake of HEF in policy. Credibility and timeliness of evidence are important for policy uptake. Credibility of evidence does not only depend on its topical relevance, but also on its operational usefulness, and more importantly, on whether the evidence provides a solution to a problem [23]. HEF related knowledge was gathered over time through evaluations and case studies. Although one can raise methodological concerns about those studies, on the whole the evidence base proved strong enough to convince policy makers and donors to adopt the HEF idea. HEF proved effective in addressing financial barriers to accessing public health services for the poor and showed potential in improving health equity and reducing poverty—a goal that has been strongly emphasized since the arrival of poverty reduction strategic papers. HEF was not only a response to the user fee exemption failure, but also an efficient way to transfer donor funds to the poor in donor projects and programmes. The new knowledge came in timely as people were trying to a solution to address problems they were facing. Kaufman and colleagues found that the main reason for successful scaling-up of a Quality of Care Pilot Project in China was the fact that it was home-grown [49]. Similarly, HEF is locally generated, creating ownership by the Cambodian health leaders, also the approach is easy to understand, adopt and implement. All key informants showed strong support for HEF, at least in the short- and medium-term. They considered HEF a pragmatic concept that allows reaching the double objective of ensuring access for poor patients while at the same time helping public health facilities to generate income. Actors and the interaction between them are also a central factor influencing health policy [20,23]. Direct interaction between policy makers and researchers is the most influential facilitator of research uptake for policy [22]. In Cambodia, there are many national and international NGOs and donor agencies active in health sector development. They work within a SWiM framework under the guidance of the MOH [44]. Several networks and forums have been created to gather all key health stakeholders and facilitate policy dialogue. Getting an innovation like HEF on the policy agenda and scaling it up successfully were huge challenges in this complex and crowded field. Disagreements between stakeholders were unavoidable. Although none of the key informants challenged the existence of HEF during the interviews, in the beginning, there had been some opponents to HEF, mainly the high level personnel of donor agencies who doubted the efficiency and sustainability of HEF. They tended to favour contracting and health insurance models. Moreover, HEF proponents also disagreed on many key policy aspects of HEF. Tantivess and Walt [53] showed in a study on the scaling-up of antiretroviral therapy in Thailand that networks of non-state actors can play a crucial role in the policy process. In Cambodia, HEF pilots were initiated by an ‘interest group’ of international health partners, mainly
208
P. Ir et al. / Health Policy 96 (2010) 200–209
NGOs, who were looking for ways to address the problem of access for the poor. This group also took a leading role in the generation and transfer of new knowledge to policy makers. However, this was only possible thanks to the openness and support from the MOH. Hyder et al. [11] emphasized that the engagement of decision makers is crucial to promoting the use of evidence for policy development. In Cambodia, from the beginning several decision makers from government ministries and donor agencies had been involved in the two first HEF pilots as members of the steering and management committees. Their role became more prominent at the stage of scaling-up and harmonisation. Although HEF pilots successfully went on to become part of national health policy and were gradually scaled up nationwide, the HEF policy development is still a workin-progress. Many policy issues, including government funding for HEFs, remain and hence need to be carefully addressed to effectively scale up HEFs nationwide to achieve equity goals. Moreover, the overall impact of HEF policy on health equity requires further assessment. We acknowledge some limitations in this policy analysis. First, we do not have explicit criteria for appreciating the extent to which each of the above-mentioned factors contributed to the translation of knowledge into policy. Second, heavy involvement of the authors in the HEF policy process, which is a strength of the study, could lead to information interpretation bias. However, the combination of document analysis and key informant interviews – the two most common methods for policy analysis [21] – with guidance from a review team, should minimize this bias. Finally, the development of HEF policy might have been rather unique in terms of content, setting and timing. As described in the results section, a number of pilot projects in health financing have been set up in Cambodia over the last decades. Unlike HEF pilots, other pilots such as contracting and community-based health insurance were not (or at least less) successfully scaled up. It appears that within the same setting and time frame, different pilots can achieve different levels of success in scaling-up. 5. Conclusions This paper illustrates how HEF pilots in Cambodia were successfully integrated in health policy and gradually scaled up nationwide. The study offers an example of how knowledge can be successfully translated into policy to promote health equity in low-income countries. Our findings suggest three important factors that can enhance the likelihood of uptake of a pilot project in health policy and its nationwide scaling-up. These include a policy context conducive to the creation, dissemination and adoption of the pilot experience; the credibility and timeliness of knowledge generated by the pilot; and strong commitment and a good relationship between actors involved in the pilot. Knowledge locally generated through pilots is crucial for innovative health policy. This knowledge can help avoid a one-size-fits-all approach and adapt blueprints to a local context. Most importantly, it also creates ownership among policy makers. In low-income countries with scarce resources and limited research capacity, interna-
tional organisations and donors can take a leading role in innovative interventions, as they often have a broader scientific network and resources and are perhaps more willing to take risks. However, involvement of government policy makers in the innovations is necessary for their scaling-up. Acknowledgements We thank Dr. Lo Veasna Kiry from the Ministry of Health, Dr. Saphorn Vonthanak from the National Institute of Public Health and Dr. Benjamin Lane from WHO for their contribution to the study. We are grateful to all the key informants for dedicating their valuable time for the interviews and to Dr. Steve Fabricant, Ms. Anjana Bhushan, Dr. Reijo Salmela, Kristof Decoster and Bart Jacobs for their comments on earlier drafts of this paper. This study was funded by the WHO and one co-author benefited from the support of the POVILL project funded by the Sixth Framework Programme of the European Commission (http://www.povill.com/en index.aspx). References [1] Gwatkin DR, Rutstein S, Johnson K, Suliman E, Wagstaff A, Amouzou A. Socio-economic differences in health, nutrition, and population within developing countries: an overview. Washington, DC: Health, Nutrition and Population, World Bank; 2007. [2] Gwatkin DR, Bhuiya A, Victora CG. Making health systems more equitable. Lancet 2004;364:1273–80. [3] Reaching the poor with health services. Washington, DC: Development Outreach, World Bank; 2005. [4] Scaling up health service delivery: from pilot innovations to policies and programmes. Geneva: World Health Organization; 2007. [5] Braveman P, Gruskin S. Poverty, equity, human rights and health. Bulletin of the World Health Organization 2003;81:539–45. [6] Palmer N, Mueller DH, Gilson L, Mills A, Haines A. Health financing to promote access in low income settings-how much do we know? Lancet 2004;364:1365–70. [7] World report on knowledge for better health: strengthening health systems. Geneva: World Health Organization; 2004. [8] Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization 2004;82:724–31. [9] Thamlikitkul V. Bridging the gap between knowledge and action for health: case studies. Bulletin of the World Health Organization 2006;84:603–7. [10] Gilson L, Raphaely N. The terrain of health policy analysis in low and middle income countries: a review of published literature 1994–2007. Health Policy and Planning 2008;23:294–307. [11] Hyder AA, Bloom G, Leach M, Syed SB, Peters DH. Exploring health systems research and its influence on policy processes in low income countries. BMC Public Health 2007;7:309. [12] Bigdeli M, Annear PL. Barriers to access and the purchasing function of health equity funds: lessons from Cambodia. Bulletin of the World Health Organization 2009;87:560–4. [13] Hardeman W, Van Damme W, Van Pelt M, Por I, Kimvan H, Meessen B. Access to health care for all? User fees plus a Health Equity Fund in Sotnikum, Cambodia. Health Policy and Planning 2004;19:22–32. [14] Jacobs B, Price N. Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia. Health Policy and Planning 2006;21:27–39. [15] Noirhomme M, Meessen B, Griffiths F, Ir P, Jacobs B, Thor R, et al. Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia. Health Policy and Planning 2007;22:246–62. [16] Strategic framework for equity funds: promoting access to priority health services among the poor. Phnom Penh: Ministry of Health, Government of Cambodia; 2003. [17] Evidence Policy for the WHO Regional Office for Europe. Geneva: World Health Organization; 2004. [18] Landry R, Amara N, Pablos-Mendes A, Shademani R, Gold I. The knowledge-value chain: a conceptual framework for knowledge
P. Ir et al. / Health Policy 96 (2010) 200–209
[19] [20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30] [31]
[32] [33]
[34] [35]
translation in health. Bulletin of the World Health Organization 2006;84:597–602. Bowen S, Zwi AB. Pathways to “evidence-informed” policy and practice: a framework for action. PLoS Medicine 2005;2:e166. Buse K, Mays N, Walt G. Making health policy. 1st ed. London: Open University Press, London School of Hygiene and Tropical Medicine; 2005. Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M. The utilisation of health research in policy-making: concepts, examples and methods of assessment. Health Research Policy and Systems 2003;1:2. Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers’ perceptions of their use of evidence: a systematic review. Journal of Health Services Research and Policy 2002;7:239–44. Young J, Court J, Bridging Research and Policy in International Development: An Analytical and Practical Framework. RAPID Briefing Paper 1; 2004. Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T. User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Social Science and Medicine 2004;58:553–64. Barber S, Bonnet F, Bekedam H. Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia. Health Policy Planning 2004;19:199–208. Wilkinson D, Holloway J, Fallavier P. The impact of user fees on access, equity and health provider practices in Cambodia. Phnom Penh, Cambodia: Ministry of Health; 2001. Meessen B, Van Damme W, Ir P, Van Leemput L, Hardeman W. The New Deal in Cambodia: the second year. Confirmed results; confirmed challenges. Phnom Penh, Cambodia: MSF Cambodia; 2002. Soeters R, Griffiths F. Improving government health services through contract management: a case from Cambodia. Health Policy Planning 2003;18:74–83. Van Damme W, Meessen B, von Schreeb J, Thayly H, Thomé JM, Overtoom R, et al. Sotnikum New Deal: the first year. Better income for health staff; better service to the population. Phnon Penh, Cambodia: MSF Cambodia; 2001. Health care demand survey. Phnom Penh, Cambodia: National Institute of Public Health; 1998. Cambodia Poverty Assessment. Poverty reduction and economic management sector unit and human development sector unit for East Asia and Pacific Region. World Bank; 1999. Oxfam: health and landlessness. Phnom Penh, Cambodia: Oxfam; 2000. Knowles J. An economic evaluation of the health care for the poor component of the Phnom Penh urban health project. Phnom Penh, Cambodia: MOH and WHO; 2001. Health Equity Fund in Pursat provincial hospital: 6-month evaluation report. Phnom Penh, Cambodia: WHO Cambodia; 2003. Annear PL, Wilkinson D, Chean RM, Van Pelt M. Study of financial access to health services for the poor in Cambodia. Phase 1. Scope, design and data analysis. Phnom Penh, Cambodia: MOH, WHO, RMIT University; 2006.
209
[36] Jacobs B, Price N. The impact of the introduction of user fees at a district hospital in Cambodia. Health Policy Planning 2004;19: 310–21. [37] Jacobs B, Price N, Sam SO. A sustainability assessment of a health equity fund initiative in Cambodia. International Journal of Health Planning and Management 2007;22:183–203. [38] Jacobs B, Price NL, Oeun S. Do exemptions from user fees mean free access to health services? A case study from a rural Cambodian hospital. Tropical Medicine and International Health 2007;12: 1391–401. [39] Nguyen A. The Svay Rieng Health Equity Funds. A project evaluation. Phnom Penh, Cambodia: UNICEF Cambodia; 2004. [40] Health Sector Strategic Plan 2003–2007. Phnom Penh, Cambodia: Ministry of Health; 2002. [41] National Poverty Reduction Strategy 2003–2005. Phnom Penh, Cambodia: Council for Social Development, Ministry of Planning; 2002. [42] National Equity Fund Implementation and Monitoring Framework. Phnom Penh, Cambodia: MOH; 2005. [43] Lanjouw S, Macrae J, Zwi AB. Rehabilitating health services in Cambodia: the challenge of coordination in chronic political emergencies 1. Health Policy Planning 1999;14:229–42. [44] An assessment of progress under sector-wide management and recommendations to the MOH and health partners for improving harmonization and alignment in the health sector: consolidated report phase 1 and 2. Phnom Penh, Cambodia: Ministry of Health, Royal Government of Cambodia; 2007. [45] Joint Health Sector Review Report. Phnom Penh, Cambodia: MOH; 2001. [46] Meessen B, Van Damme W, Tashobya CK, Tibouti A. Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia. Lancet 2006;368:2253–7. [47] Annual Health Financing Report 2008. Phnom Penh, Cambodia: Bureau of Health Economics and Financing, Department of Planning and Health Information, Ministry of Health; 2009. [48] Practical guidance for scaling up health service innovations. Geneva: ExpandNet, World Health Organisation; 2009. [49] Kaufman J, Erli Z, Zhenming X. Quality of care in China: scaling up a pilot project into a national reform program 55. Studies in Family Planning 2006;37:17–28. [50] Phillips JF. Translating pilot project success into national policy development: two projects in Bangladesh 18. Asia Pacific Population Journal 1987;2:3–28. [51] Gilson L, McIntyre D. The interface between research and policy: experience from South Africa. Social Science and Medicine 2008;67:748–59. [52] Dobrow MJ, Goel V, Upshur RE. Evidence-based health policy: context and utilisation. Social Science and Medicine 2004;58:207–17. [53] Tantivess S, Walt G. The role of state and non-state actors in the policy process: the contribution of policy networks to the scaleup of antiretroviral therapy in Thailand 1. Health Policy Planning 2008;23:328–38.