Cambodia Health Researchers Forum 11 Nov 2015 combined presentations

Health Researchers’ Forum
“Mapping and Planning Health Systems Research in Cambodia:
Building the evidence base for policy and practice”
Phnom Penh, 11 November 2015

Objectives:
• Bring together health researchers and research institutes in
Cambodia to share areas of common work and interest in
health systems research.
• Share information on and insight into the connection
between the research process, the evaluation of health
intervention and activities, and the formation of new health
policies, and how these connections could be strengthened.
Cambodia Health Researchers’ Forum November 2015

Morning programme
08:00-08:15 Welcome to Participants and Introduction of the Workshop
08:15-08:30
Opening Remarks
National research priorities and activities
08:30-08:45 Update from Policy Dialogue
08:45-09:45
ReBUILD RPC presentation and report
Contributions from research institutes
9:45-10:15 Break and Refreshments
10:15-11:15
NIPH presentation – research activities and future plans
11:15-12:15
Nossal/DFAT research report
12:15-12.30 Launch of the Cambodia Health in Transition study

Afternoon programme
13:30-14:30 Researchers’ forum
- Small group discussion of the major research plans and priorities
14:30-15:00 Report back by small groups
15:00-15:30 Break and Refreshments
15:30-16:30 Panel discussion
Alignment of research and health policy (HSP3) and its challenges
16:30-17:00 Closing Remark
Next steps and future collaboration

HEALTH RESEARCHERS’
FORUM
Phnom Penh
11 November 2015
Peter Annear

Health Policy Dialogue
Ministry of Health, Asia Pacific Observatory, World Health
Organization, Nossal Institute, German Cooperation
• The Cambodia Health In Transition study
• THEME: Equity in Access and Quality of Service
• ATTENDANCE: Dr Eng Huot, Dr Lo Veasnakiry, MOH, NIPH,
UHS, MOEF, the Councils (Medical, Nursing, Midwifery,
Pharmacy), Toomas Palu (APO/WB), Paul Keogh (DFAT),
URC, UNFPA, UNICEF, UNAIDS

H.E. Dr Eng Huot
• Aim is to inform the development of HSP3
• Policy Brief is consistent with health priorities
• Phase of demographic transition and health transition
• Build on gains in financial risk protection (HEFs)
• Further improve the quality of care
• More equitable distribution of health outcomes
• More effective in-service and pre-service training
• Enforce stronger regulatory mechanisms

Policy and strategy
Draft Policy Brief (APO)
• Economic and demographic change
• A mixed health system – public and private
• Equity as a central health system goal
• Inequities remain – rural/urban, rich/poor
• The need to improve quality of care
• The need to coordinate the private sector

Issues discussed
• SDGs and UHC
• Reduce the share of external funding
• Utilization remains low despite increased demand
• Supply side constraint on access to services
• Focus on the new Health Strategic Plan (HSP3)
• Quality of care and patient trust
• National health budget
• Motivated workforce
• Further strengthen the public sector
• Health research priorities (HSP3)
• Ensure policy is sustainable and feasible

Issues and challenges
• Development of the Health Strategic Plan 2016-2020
• Consolidation of the HEFs
• Unification with the NSSF and NSSF/CS
• Strengthening of pre-service education
• Regulating the mixed health system

The ReBuild consortium: Overview of
its work globally and in Cambodia
Barbara McPake
Nossal Institute for Global Health,
University of Melbourne and
Institute for International Health,
Queen Margaret University
On behalf of ReBUILD consortium
www.rebuildconsortium.com
Funded by

REsearch for BUILDing pro-poor health
systems in the aftermath of conflict
6 year DFID funded research programme
consortium
Partner countries: Cambodia, Sierra
Leone, Uganda, Zimbabwe
Objectives to grow understanding of the
factors affecting health system
development in the aftermath of conflict

What do we mean by ‘conflict
affected’?
Need to define conflict and conflict
affected in terms of nature, space and
time
We are all conflict affected
The program is trying to look at the long
and short term influences of particular
conflicts on health system development in
affected countries

Sierra
Leone and
Cambodia
Zimbabwe
and
Northern
Uganda
Key starting points
Post conflict is a
neglected area
of HS research
Opportunity to
set HS in a pro-
poor direction
Useful to think
about what policy
space there is in
the immediate
post conflict
period
Useful to think
about the long
term implications
of the policy
decisions in that
period
Decisions made early post-conflict can steer the long term
development of the health system

Existing literature
Focus on immediate aftermath of conflict and role
of humanitarian actors
Focus on national level decision making and
challenges of state capacity to manage multiple
humanitarian actors
Interested in connections between peace process
and health system building
Much to say about aid effectiveness
Little to say about long term implications of conflict
and decisions made immediately after
Weak methodology and many neglected topics

Methodologies for considering long
term impacts
Life histories of older people’s
engagement with the health system
Reanalysis of multiple iterations of the
Cambodia Socio-Economic Survey

Series of health financing reforms
User fees 1996
CBHI 1998
Contracting 1999
Government subsidy scheme 2008
Health Equity Funds 2000
Vouchers 2007

Research progress update
Sreytouch Vong
Health Researcher’s Forum, Phnom Penh, November 2015
Funded by

Introduction to ReBUILD
• ReBUILD aims to deliver new
knowledge to inform the
development and implementation of
pro-poor health system in countries
recovering from political and social
conflict on health financing, human
resource and interrelated field.
• Focus on 4 countries: Sierra Leone,
Uganda, Zimbabwe and Cambodia
• Key research areas of ReBUILD: 5
main themes, affiliate “responsive
fund” projects and gender
mainstreaming across all themes
Rural posting
Contracting
Health
financing
Aid
architecture
Incentives
Responsive
fund
22

Project 1: Health Financing (Quantitative)
 Objective: To measure the impact of health
financing policies i.e. user fees, health equity funds,
the government health subsidy scheme, vouchers
and various combination of these policies on
household health spending
 Method: Using Cambodia Socio-Economic Survey
2004 and 2009, and employs a difference-in-
difference method and two part models to estimate
the effects of health financing policies on out-of-
pocket spending

Project 1: Health Seeking Behavior
(Qualitative)
 Objective:
 To explore the behaviour pathways followed by
Cambodians in accessing healthcare from 1950s to
the present and analyse the factors that influenced
their decisions
 To identify whether pro-poor health financing policy
such as CBHI and HEF contributed to household
financial protection for the poor and near poor
following their introduction in 2000

Project 1: Health Seeking Behavior
 Method:
 Life History approach was used for 24 in depth
interview, to collect information on episodes of
illnesses, deaths and births and on health spending
history
 The sampled population had to reflect the mix of
single or mixed scheme users of UF, HEF, CBHI and
private healthcare and they were selected on the
basis of an assessment that they were poor and aged
40 or older.

Project 2: HRH and Incentive
 Objective:
 To analyse HRH policies, focusing on policy drivers in
relation to health workers incentives for attracting and
retaining health workers in underserved areas
 Method:
 Qualitative data collection was conducted in 9 ODs in
six provinces between. 19 KIIs with health mangers and
senior official of MoH; and 18 IDIs with health workers.
 Quantitative: routine data were used for the analysis of
HW supply and distribution and performance outputs.

Project 3: Contracting Health Service
 Objective:
 To understand how contracting arrangement evolve since its
introduction
 To explore the challenges of current contracting arrangement-
Special Operating Agency (SOA)
 To explore the implications how services are delivered
 Method:
 Analysis existing data
 27 in depth interview with managers and health providers at
provincial and district level
 12 key informant interview with donors and MOH officials at
national level

Responsive Fund: Obstetric Referral in the
Cambodian Health System
 Research Question
 How is the OD functioning to enable access to
obstetric care for pregnant women in one rural
province?
 Method
 Using Appreciative Inquiry method
 30 interviews were conducted with pregnant
women, their husbands, mothers, midwives and
doctors at different system levels, VHSG and village
leaders.

The career pathway for health workers in
Cambodia: the role of gender
 Research Objective
 To understand career path development of female
and male health workers
 To identify barriers and enabling factors for career
advancement of female and male health workers
 Method
 Life history will be used for the interview with 20
managers and health workers at provincial and
district level

ReBUILD Cambodia
 Project 1: Health financing
and health seeking
behavoir
 Project2: Policies to Attract
and Retain Health Workers
in Rural Areas
 Project 3: The Change
Process of Contracting
Arrangement in Cambodia
Health Sector

Output Progress update
Status Detail
Project 1 Completed •Complete report of quantitative
•Working paper published in September
•Complete report of qualitative
•Expected report available online by December 2015
Project 2 In progress •Complete quantitative data analysis report
•Complete report from key informant interviews
•Making progress in report from in depth interviews
•Expected reports available in January 2016
Project 3 Completed •Complete report of quantitative analysis
•Complete report from key informant interviews
•Complete report from in depth interviews
•Expected reports available in December 2015
Responsive Fund Completed •Complete overall report
•In progress of journal article preparation
Gender and
Health Workforce
In progress •Report will be available in mid 2016

Thank you
Sreytouch Vong
vongsreytouch@gmail.com
On behalf of ReBUILD
consortium
Funded by

STRENGTHENING HEALTH RESEARCH
SYSTEM IN CAMBODIA: THE CURRENT
STATUS AND
FUTURE PROSPECTS
Por Ir, MD, MPH, PhD
National Institute of Pubic Health
November 11, 2015

OUTLINE
1. What is a Health Research System (HRS)?
2. Why strengthening HRS?
3. How to strengthen HRS?
4. The current status of HRS in Cambodia
5. Some future prospects
34

36
Definition
 A Health Research System (HRS): the
people, institutions, and activities whose
primary purpose (in relation to research)
is to generate high-quality knowledge
that can be used to promote, restore,
and/or maintain the health status of
populations
(Pang e al. 2003)

37
Key functions of a HRS
1. Governance:
 Defining health research questions and priorities:
A National Health Research Agenda
 Establishing norms and standards, including
ethical standards for research practices
2. Financing: Secure research funds and
allocate them transparently and accountably
3. Resources: Create and sustain human and
physical resources to conduct and utilize
health research
4. Generate and translate research findings into
policy, practice and productAdapted from (WHO, 2013 & Pang et al. 2003)

2 – WHY STRENGTHENING
HRS?
38

Health system and HRS are closely
linked?
39
Adapted from (Pang et al. 2003)

HRS is key to health system
strengthening and improving health &
health equity
Level and distribution (equity)
Context: political, economic, demographic and social determinants of
Inputs
Leadership &
governance
Health
financing
Health
workforce
Infrastructure
& supplies
Health
information &
research
Outputs
Increased
service
access and
readiness
Increased
service
quality and
safety
Improved
service
integration
Improved
information
and
knowledge
Outcome
s
Increased
coverage of
key
intervention
s
Increased
coverage of
financial risk
protection
Mitigation of
risk factors
Impact
Improved
survival and
health
Improved
household
financial
wellbeing
Increased
responsivene
ss
40
U
H
C

3 – HOW TO STRENGTHEN
HRS?
41

42
Strengthening the 4 key functions
1. Improve research governance through
defining health research questions and
priorities (NHRA) & establishing norms and
standards, including ethical standards for
research practices
2. Mobilize and secure research funds and
allocate them transparently and accountably
3. Create and sustain human and physical
resources to conduct and utilize health
research
4. Generate and translate research findings into

43
A holistic research capacity
For the whole research cycle:
 understanding the health problems and its
causes;
 identifying solutions;
 implementing the solutions; and
 measuring the effectiveness after
implementation

45
Health research governance in
Cambodia
Remains poor:
 No national health research agenda/plan: HSP2
highlights a few strategic interventions, but no
concrete implementation and M&E framework
 No national norms or standards to guide
research practices
 No specific institution(s) responsible for health
research governance
 National Ethics Committee for Health Research:
ethical review of proposals for research on
human subjects, using traditional approach –
direct submission with hard copies

46
Health research financing
Remains dependent on external funding sources;
issues with alignment with national priorities and
sustainability
 28 million US$ budget for over 200 health
research projects submitted to the NECHR in
2012, but mostly (if not all) are from external
funding sources
 No national budget for health research. In
2015, it is informed that national budget of
about 0.5 million US$ is allocated for health
research, but so far it is unknown what is going
on with this money

Individual and institutional capacity
building
 Limited opportunities for individual &
institutional capacity building on health
research
 It is mainly through two main ways:
 On the job training through national-international
institutional collaboration or research consortium
 Formal (short-term and long-term) national and
international training
 Many institutions doing research, but only 2
public institutions (NIPH & UHS) providing formal
training on health research through short
courses, graduate and undergraduate programs
47

48
Increasing no. of national researchers as PI, but
major research projects are still technically led by
international researchers
0
20
40
60
80
100
120
140
160
180
200
220
Year
2005
Year
2006
Year
2007
Year
2008
Year
2009
Year
2010
Year
2011
Year
2012
Numberofresearchprojects
National PI
International PI
~ 15% are
MPH students

49
0
10
20
30
40
50
60
70
2005 2006 2007 2008 2009 2010 2011 2012
Numberofarticles
International
first author
Cambodian
first author
Limited capacity of national health
researchers for reporting and communicating
research findings
Mainly by PhD students!

Trend in health research production in
Cambodia, 2000-2011
50
Publications led by Cambodian institutions:
slope 1.9; p<0.001
Source: Goyet et al., 2015

Mismatch between research publications and
burden of diseases
51
Source: Goyet et al., 2015

Improve health research
governance
 Development and implementation of a
National Health Research Agenda
(NIPH under MOH leadership)
 Development and implementation of
national strategies for health/health
system research (in HSP3)
 Strengthening role of the NECHR
(NIPH as a secretariat)
53

Research capacity building (1)
 Human capacity (national health researchers
and health research users):
 Formal and informal training on necessary health
research and data management skills
 Increasing opportunities for informative
evaluations & research practices
(projects/consultancies)
 Networking with other research institutions
 Organizing researchers’ forum/workshops
 Creating an online Cambodian Public Health
Journal
54

Research capacity building (2)
 Financial capacity:
Access to government budget for health
research (expected to come in 2016
onward)
Mobilize donors’ support and apply for
various external grants for health
research
55

Priority health system research
 Mobilize technical and financial support to
conduct health system research on specific
health program and health system cross-
cutting areas of high priorities through:
 operational research on quality of care
 implementation research on NCDs, mainly
chronic NCDs, e.g. diabetes, hypertension,
cervical cancer…
 implementation research on nutrition and food
safety?
 Impact evaluations of major health financing and
56

Some key references
 Pang et al. (2003): Knowledge for better health –a
conceptual framework and foundation for health
research systems. Bulletin of WHO, 81 (11): 815-
820.
 WHO (2013): The World Health Report 2013 –
Research for Universal Health Coverage. WHO,
Geneva.
 Goyet et al. (2015): Gaps between research and
public health in low-income countries: evidence from
a systematic literature review focused n Cambodia
57

HEALTH EQUITY FUNDS
NATIONALMEMBERSHIPAND
UTILIZATION OF HEALTH SERVICES
Australian Aid
ADRA Research Project
Nossal Institute, NIPH, URC, Harvard University
Peter Annear
11 November 2015

ADRA HEF membership analysis
• Research carried out during 2013-2015
• The first comprehensive national assessment of HEF
membership and utilization
• Household level data (including HMIS)
• Consistent with the Health Strategic Plan
• The research team:
• Peter Annear and Matthias Nachtnebel (Nossal Institute)
• Khim Keo Vathanak (now UHS)
• Ir Por (NIPH)
• Tapley Jordanwood (URC)
• Ellen Moscoe, Till Barnighausen and Tom Bossert (Harvard)

Research questions
We began the research with questions about:
• Household benefits derived from HEFs
• Population coverage of HEFs
• Utilization of health services resulting from HEFs
• National cost of operating the HEFs
Data sources:
• HEF membership database
• CSES (recent surveys)
• HMIS (time series data)

Research outputs
• National membership and utilization
• National HEF coverage
• National HC utilization
• National RH utilization
• Current and up-to-date review of the literature (evidence)
• A history of the HEFs (evolution, policy, outcomes)

National membership
National population coverage of 2,990,988 in 62 ODs as of
December 2014:
• Now approaching national coverage (expanded population
coverage)
• Extended to every referral hospital and every health centre

Distribution by age at admission

Distance travelled to facility

HEF reimbursements by facility type

Average total IPD and HEF IPD
100200300400500600
0 20 40 60 80 100
ordinal number of month
Ever had HEF (n = 46) Never had HEF (n = 16)
HEF-supported cases (n = 46)

Average total OPD and HEF OPD:RH
0
500
100015002000
AverageOPDcases
0 20 40 60 80 100
Ever had HEF (n = 46) Never had HEF (n = 16)
HEF-supported cases (n = 46)

Average total deliveries and HEF:RH
0
50
100150
0 20 40 60 80 100
(mean) del_his Fitted values
(mean) hef_del Fitted values

Average total OPD/month at HC
0
100
200
300
400
500
600
700
800
900
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
2006 2007 2008 2009 2010 2011 2012 2013
Monthlynumberofnewcaseconsultations
HCs with HEF at
one point of
time in the
study period -
intervention
HCs with no HEF
throughout the
study period -
control

Average total deliveries/month at HC
0
2
4
6
8
10
12
14
16
18
20
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
2006 2007 2008 2009 2010 2011 2012 2013
Monthlynumberofdeliveries
HCs with HEF at
one point of time
in the study
period -
intervention
HCs with no HEF
throughout the
study period -
control

Conclusions
• HEF meets the design expectation by increasing
utilization by both HEF members and fee-paying users
• Significant impact on hospital IPD
• HEF contributes to increased hospital revenue
• Effect of HEF on OPD is positive but not strong (RH)
• Delayed benefits for OPD
• Implementing HEF at HC thus diverting users to HCs
• Significant positive effect of HEF at HCs through
increased OPD and deliveries

Researchers’ forum
Key questions to address in the small group discussions:
1. How well aligned is the current and planned research to health
service needs in Cambodia?
2. What are the priorities for HS research and what are the current
gaps in the evidence?
3. How could HS research be better managed, coordinated and
funded, to provide evidence for HS policy and practice?

Researchers’ forum
Discuss amongst table groups – all 3 questions.
Output from groups:
1. Decide TWO key bullet points on each of these questions
2. Out of all these, what is the ONE priority action

Cambodia Health Researchers Forum 11 Nov 2015 combined presentations

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