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 programme08:00-08:15 Welcome to Participants and Introduction of the Workshop

08:15-08:30Opening Remarks

National research priorities and activities

08:30-08:45 Update from Policy Dialogue

08:45-09:45ReBUILD RPC presentation and report

Contributions from research institutes

9:45-10:15 Break and Refreshments

10:15-11:15NIPH presentation – research activities and future plans

Contributions from research institutes

11:15-12:15Nossal/DFAT research report

Contributions from research institutes

12:15-12.30 Launch of the Cambodia Health in Transition study

Cambodia Health Researchers’ Forum November 2015

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

Cambodia Health Researchers’ Forum November 2015

HEALTH RESEARCHERS’

FORUMPhnom 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 CambodiaBarbara 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

Key idea: path dependency

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

19

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

www.rebuildconsortium.com

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

ContractingHealth

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 youSreytouch Vong

vongsreytouch@gmail.com

On behalf of ReBUILD consortium

www.rebuildconsortium.com

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

1 - WHAT IS HRS?35

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

health

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

policy, practice and product

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

THE CURRENT STATUS44

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

Year2005

Year2006

Year2007

Year2008

Year2009

Year2010

Year2011

Year2012

Nu

mb

er

of

researc

h p

roje

cts

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

Num

ber

of a

rtic

les

Internationalfirst author

Cambodianfirst author

Limited capacity of national health

researchers for reporting and communicating

research findings

Mainly by PhD students!

Trend in health research production in

Cambodia, 2000-201150

Publications led by Cambodian institutions:

slope 1.9; p<0.001

Source: Goyet et al., 2015

Mismatch between research publications and

burden of diseases51

Source: Goyet et al., 2015

FUTURE PROSPECTS52

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

Developing policy briefs

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

social health protection schemes

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 FUNDSNATIONAL MEMBERSHIP AND

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

Visits by facility type

Distance travelled to facility

HEF reimbursements by facility type

Average total IPD and HEF IPD1

00

200

300

400

500

600

Ave

rag

e IP

D c

ase

s

0 20 40 60 80 100ordinal 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

100

01

50

02

00

0

Ave

rag

e O

PD

case

s

0 20 40 60 80 100ordinal number of month

Ever had HEF (n = 46) Never had HEF (n = 16)

HEF-supported cases (n = 46)

Average total deliveries and HEF:RH0

50

100

150

Ave

rag

e #

de

livery

case

s p

er

mo

nth

0 20 40 60 80 100ordinal number of month

(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

900Ja

n

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

Mon

thly

num

ber

of n

ew c

ase

cons

ulta

tions

HCs with HEF atone point oftime in thestudy period -intervention

HCs with no HEFthroughout thestudy period -control

Average total deliveries/month at HC

0

2

4

6

8

10

12

14

16

18

20Ja

n

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

Mon

thly

num

ber

of d

eliv

erie

s

HCs with HEF atone point of timein the studyperiod -intervention

HCs with no HEFthroughout thestudy 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

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

Cambodia Health Researchers’ Forum November 2015

Researchers’ forumKey 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?

Cambodia Health Researchers’ Forum November 2015

Researchers’ forumDiscuss 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 November 2015