Conference on Health and Social Protection: Meeting the needs of the poor, 9-10 October 2008. www.povill.com

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

2. Cambodia Chean Rithy Men Centre for Advanced Studies

5. THE STUDY: DESIGN AND DATA COLLECTION

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

9. PRELIMINARY FINDINGS

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

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

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

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

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

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

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

19. Targeting for HEF

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

23. China Professor Jin Institute of Social and Public Policy

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

25. Major Preliminary Findings ---1. Household Survey

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

29. Major Preliminary Findings ---2. Impact of Schemes

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

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

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

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

38. Major Preliminary Findings ---4. Institutional Analysis

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

43. Lao PDR Anonh Xeuatvongsa Ministry of Health

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

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

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

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

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

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

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