Stata statistical software: release 17. Two additional service payment categories (i.e. A study of Portuguese public hospitals found that good clinical safety practices tend to be associated with low technical efficiency, concluding that there are trade-offs between efficiency and quality [74]. Figure4 shows the predicted marginal effects of private healthcare providers on public hospital and health center technical efficiency after controlling for population size and other covariates. Predicted marginal effects of provincial-municipal level private providers on public hospital and health center technical efficiency with 95% confidence intervals (2019 data). Although this approach is possible if the data is available our focus is on the provincial-municipal level where management responsibility has recently been delegated. 327 LV/PrK on Revision of Annex 1 of Inter-Ministerial Prakas No. 
Health Policy Plan. In addition, minor surgeries at hospitals are 7.3 times higher than for non-HEF beneficiaries. Additionally, the national Payment Certification Agency, which is responsible for monitoring, verifying and certifying HEF claims, is to play a key role in developing the social health protection system. For example, the project introduced an innovative voucher program targeting reproductive health services for women from vulnerable groups and the poor. Retrieved from Geneva. Health Operational Districts (ODs), responsible for health center oversight, are typically comprised of 1015 health centers covering about 100,000200,000 people and a district referral hospital. As private health services and health insurers can exacerbate health inequity, it is essential for countries to determine the appropriate level of privatization in their systems which necessitates transparent and responsible regulation alongside efforts to improve public system efficiency [77]. Socio Econ Plan Sci. However, costing exercises are resource intensive and can require significant expense and effort [13]. In 2019, Cambodia had a total of 117 CPA13 hospitals with a provincial-municipality average of 4.68 (Std dev. It will consolidate and institutionalize the ongoing successes of the project, while also taking further steps in health financing reform. US$ 105,203,311 for hospitals and US$102,028,845 for health centers) and the estimated cost assuming the GIZ service specific unit costs multiplied by total service outputs.Footnote 1 For the hospital model the total cost in the data only accounted for 67.2% of the projected (GIZ) costs (i.e. RJK: Conceptualization, Methodology, Data curation, Formal analysis, Writing-Original draft, review and editing, Project administration. 2019;9(3):e022155. Furthermore, reducing inequities in health outcomes, especially for marginalized groupsthe poor, remote rural population, ethnic minorities and womenwill be strongly emphasized. https://doi.org/10.1177/1010539520957841. 26. The wide variability (6% - 255%) of payments as a proportion of the estimated unit costs suggests that payment rates should be realigned. https://doi.org/10.1186/s13561-021-00354-8, DOI: https://doi.org/10.1186/s13561-021-00354-8. Health Equity Fund payments cover between 6% and 255% of the estimated unit costs, corresponding to health center maternity care and CPA3 hospital minor surgery respectively. Alterity or austerity: a review on the value of health equity in times of international economic crises. In addition, predictable financing to sub-national governments is imperative to improve health service performance (Gertler, Giovagnoli and Martinez 2014). Hence, we use the GIZ weights as a reference, but allow for deviations of the relative GIZ price 50% up and down. Freeman M, Savva N, Scholtes S. Economies of scale and scope in hospitals: an empirical study of volume spillovers. https://doi.org/10.1002/hec.1372. Likewise, GIZ data shows health center maternity service cost to be higher ($101.09) than CPA13 hospital maternity costs, $51.98, $44.93, and $39.18 respectively. INQUIRY J Health Care Organ Provision Financ. Health econometrics using Stata: Stata press; 2017. 2021a. The projected cost of additional user-fee payments to expand the Health Equity Fund to the uncovered 1st3rd wealth quintile people (approximately 3.5 million people) are modeled to range from US$ 23.0 (using current HEF payment rates) to 36.5 million (using NSSF payment rates), assuming the adoption of several complimentary policy options [17]. The second stage analysis identifies several factors which explain the variation in technical efficiency among the provinces. found HEF to be associated with higher public health facility efficiency [11]. https://doi.org/10.1016/j.ejor.2014.05.007. In 2019, 38.6% of the approved Ministry of Health budget (~USD $444 million) was allocated to the provincial-municipal level. This may be redressed by correcting the underlying causes and incentivizing health center referrals such as prioritizing service provision at hospitals for patients with a formal health center referral. Figure2 shows the total hospital and health center inpatient and outpatient to financing ratios for each province-municipality. 2020. Thmey T. Hun Sen announces up to 50 pct budget cut amid COVID-19. 2015;30(9):115261. Cambodias public health system consists of a network of 34 national and provincial-municipal level hospitals, 92 Operational District (OD) referral hospitals, 1222 health centers, and 128 health posts. Radojicic M, Jeremic V, Savic G. Going beyond health efficiency: what really matters? Free benefits under the HEF have been extended to some informal workers and selected populations (about 93,500 enrollees). Theory of cost and production functions: Princeton University press; 2015. https://doi.org/10.1515/9781400871087. This program focuses on four areas to improve: (1) budget credibility; (2) financial accountability; (3) budget policy linkages; and (4) performance accountability [34]. Eur J Oper Res. Annear, PGJ; Ir, P; Jacobs, B; Men C, Nachtnebel M, Oum S, Robins A, Ros CE. Such measures could increase budgetary space for health providing that they are well-defined and public financial management systems enable such gains to be repurposed toward prioritized health needs [58]. Jacobs et al. https://doi.org/10.1016/j.omega.2018.07.010. This could raise total population coverage of social health insurance to 60% while leveraging the unutilized service capacity of the public health system. Health provider payments can incentivize or de-incentivize particular services. Finally, we use RStudio 4.1.0 (R [54]) to estimate the unit cost for each of the major insurance reimbursement categories by using the DEA Aumann-Shapley applied cost allocation approach. 29; 2001. Omega. For example, one simple measure would be to link all social health insurance provider payments to both service provision and health facility quality scores [50]. BK to delegate health management functions and service provision to the 25 provincial-municipal administrations. Health financing should focus on smart investments discussed above such as increasing social health insurance payments. 2015. Ensor T, So S, Witter S. Exploring the influence of context and policy on health district productivity in Cambodia. This study aims to quantify the extent to which current health financing can accommodate the expansion of social health protection coverage in Cambodia. Manage cookies/Do not sell my data we use in the preference centre. Crit Public Health. https://doi.org/10.1590/1413-812320182412.23202019. Many countries have committed to achieving universal health coverage, however pandemic-related decreases in revenue constrain increases to domestic health financing. https://doi.org/10.1016/0377-2217(92)90294-J. In addition, cost data can inform budget planning and efficient resource allocation. Google Scholar. 2016;254(2):66778. SD=Standard Deviation, US$=United States dollars, SHI=Social Health Insurance. Improved efficiency is a central tenant of Cambodias high-level policy and strategy documents. USAID continues to support Cambodias efforts to reduce the burden of infectious diseases; reduce infant mortality, under-5 mortality, and maternal mortality; and increase access to quality health services. The A-S price of product j is the average marginal cost as shown in eq. BMC Health Serv Res. This may be attributable to negative spillover effects whereas increased volume in one service area may be associated with increased cost in another area [73]. Phnom Penh: Phase IV; 2018. Scatterplot of inpatient days and outpatient services to total financing ratios by province-municipality, circle size weighted by population size (2019 data). During its current first phase of implementation, between 2016 and 2021, the Cambodian Ministry of Health (MOH) has introduced several health financing innovations designed to provide fair and equitable access to health care. To tackle these issues, Cambodia is renewing its commitment to carry out the next implementation phase of the Health Equity and Quality Improvement Project (H-EQIP). 2021. 2007;136(1):3164. and to improve poor beneficiaries access to health services. PLoS One. Cochrane Database Syst Rev. Increasing health sector expenditure may not significantly affect health outcomes when efficiency is low [4]. From double shock to double recoveryimplications and options for health financing in the time of COVID-19; 2021. https://doi.org/10.1596/35298. This study estimates the potential supply-side service space for 4.69 million additional social health protection beneficiaries in a fully efficient public health system.
Washington, DC: World Bank Group; 2019. IMA J Manag Math. Retrieved from https://cambodianess.com/article/hun-sen-announces-up-to-50-pct-budget-cut-amid-covid-19. Technical efficiency measures are overly optimistic under standard underlying DEA assumptions [46]. Asante AD, Ir P, Jacobs B, Supon L, Liverani M, Hayen A, et al. In particular, the higher than cost reimbursements for hospital surgeries is notable. https://doi.org/10.1093/imaman/14.1.49. 1999;87(2):275312. ffhal-03437399f. Regularly updated costing data for each facility level can be used to strengthen strategic purchasing and cost containment [19]. We would also like to acknowledge Souy Lart who facilitated the administrative requests and initial compilation of publicly available data. This study employs Data Envelopment Analysis (DEA), truncated regression, and pioneers the application of DEA Aumann-Shapley applied cost allocation to the health sector, enabling unit cost estimation for the major social health insurance payment categories. RGC. Aboubacar I, Essono M, Barroy H, Mailfert M. Health financing and budgeting reforms in Gabon: Progress and challenges on the road to universal health coverage. PubMed Central
Ozcan YA. Given minor surgeries at the hospital level are 7.3 times higher among HEF beneficiaries compared with the rest of the population, the overpayment may be creating a perverse incentive and service overutilization. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Therefore, we use bootstrapping (2000 times of repeated sampling, with =.05) to estimate bias-corrected technical efficiency scores. Economic impact of COVID-19. Economic crisis, health systems and health in Europe: impact and implications for policy: Open University press; 2015. Kolesar, R.J., Bogetoft, P., Chea, V. et al. The study focuses on 2019 as 2020 data is not likely to fairly represent the efficiency of the public health system due to pandemic-related changes in health care-seeking behavior. 6. It will consolidate and institutionalize the ongoing successes of the project, while also taking further steps in health financing reform, Planned for the period between 2022 and 2027, the next phase, aims to increase the equitable usage of health, To enhance access to health services, HEF will be used to both maintain the current, National Social Health Protection Framework. 2020;1010539520957841(8):4269. Exploring healthcare provision in Cambodia. Emrouznejad A. Evans D, Tandon A, Murray C, Lauer J. The National Strategic Development Plan 20192023 aims to strengthen the implementation of the Decentralization and De-concentration (D&D) Reform Program by delegating power and transfer of functions, resources and technology to administrative units to obtain appropriate autonomy, including decision-making, management and resource allocation [15]. However, provider remuneration is complex and there is also evidence that the risk of overprovision is contextual ([64, 65]. Service costs at CPA1 hospitals are higher compared to CPA2 hospitals and to a lesser degree CPA3 hospitals. Kolesar RJ, Pheakdey S, Jacobs B, Chan N, Yok S, Audibert M. Expanding social health protection in Cambodia: an assessment of the current coverage potential and gaps, and social equity considerations. 2011;11(1):115. This study did find a small, but highly significant positive relationship between health center utilization and technical efficiency. 2019;86:21836. Estimating the technical efficiency of health care systems: A cross-country comparison using the directional distance function. J Policy Model. Health Econ. In addition, the analysis shows that a 1% increase in hospital non-discretionary resources decreases hospital technical efficiency by 0.241 points (p-value<0.08). Moreover, health service utilization rates in Cambodia are considered low compared with other Asian countries [66]. Kolesar, RJ, Erreygers, G, Van Damme, W, Chea, V, Choeurng, T, Leng, S. Hardship Financing, Productivity Loss, and the Economic Cost of Illness and Injury in Cambodia. The Rectangular Strategy Phase IV sets out to deepen reforms to achieve good governance, particularly public administration reform, public financial management reform, decentralization and de-concentration reform [14]. Retrieved from https://www.thestar.com.my/aseanplus/aseanplus-news/2021/05/06/cambodia039s-economy-projected-to-return-to-positive-growth-in-2021-as-covid-19-new-cases-continues-to-soar-total-now-above-17500. aggregated hospital services are compared with other aggregated hospital outputs and aggregated health center services with other aggregated health center services). 2015. Calculations are proportionally weighted and restricted (+/50%) from updated Deutsche Gesellschaft fr Internationale Zusammenarbeit (GIZ) Social Health Protection Programme costing data that was compiled using a standard step-down micro-costing methodology for public health centers and referral hospitals CPA13 [13, 31]. This site uses cookies to optimize functionality and give you the best possible experience. Asia Pac J Public Health. The World Bank in Cambodia. 2020. https://doi.org/10.1596/34572. H-EQIP is co-financed by the Cambodian government, the World Bank, and several partner agencies including: the Australian Department of Foreign Affairs and Trade, the German Development Bank, the Korean International Cooperation Agency, and Japans Population and Human Resources Development program. Tangcharoensathien V, Limwattananon S, Patcharanarumol W, Thammatacharee J, Jongudomsuk P, Sirilak S. Achieving universal health coverage goals in Thailand: the vital role of strategic purchasing. Each PHD operated the provincial hospital and governed the Health Operational Districts [30]. Who benefits from healthcare spending in Cambodia? In fact, there is evidence of both public and private healthcare facilities providing surgeries for commercial interest [79]. World Bank. A crisis like no other, an uncertain recovery: World Economic Outlook Update. Cambodia has achieved significant economic growth and secured key health indicators since 1980when it was left with only 50 doctors. 2007;41(1):121. Enhancing equal access to health services. Health at a glance: Asia/Pacific 2018: measuring Progress towards universal health coverage. Article https://doi.org/10.1093/heapol/czaa151. Notwithstanding, it is important to note that utilization data does not capture effectiveness or quality of the service provided [59]. (version 4.1.0). The theoretical literature has shown this method (and A-S prices) possesses a number of desirable properties, and it has essentially been the unanimous recommendation of economists for decades when sharing the costs of joint production [56]. Int Bus Econ Re J. Outputs focus on the major social health insurance payment categories (i.e. Goryakin Y, Revill P, Mirelman AJ, Sweeney R, Ochalek J, Suhrcke M. Public financial management and health service delivery: a literature review: Global Health Economics: Shaping Health Policy in Low-and Middle-Income Countries; 2020. p. 191215. Public sector health expenditure is 47% of Cambodias total health expenditure [9]; however, only about 20% of people with an illness or injury first seek care in the public sector [10]. Due to the COVID-19 pandemic, this protection plan might also be expanded. Outpatient cases are 1.63 and 1.37 times higher compared to the rest of the population, at hospitals and health centers, respectively. The MPA focuses on preventative and basic curative services; each health center serves approximately 10,00020,000 people. Equation 3 expresses the assumption of the ratio of the dual weights for k outputs. 2017;187:30611. Finally, the hospital utilization rate has a highly statistically significant (p<0.001) negative effect on health center technical efficiency. Health financing and access to effective interventions. GE: Writing- Review & editing. 2000;3. https://doi.org/10.1002/14651858.CD002215. J Econ. Moreover, shifting financial resources to smart investments, especially demand-side financing including increasing the payment/reimbursement rates would likely further incentivize increased service provision and improve technical efficiency. For health centers, there is a non-linear effect with small (0.001), but statistically significant (p<0.05) positive effect on technical efficiency when the number of small-scale private providers is limited up to about 750. (Photo: Dominic Chavez/Global Financing Facility). Given the Royal Government of Cambodias (RGC) current D&D reform program discussed above, the unit of analysis or DMU is the provincial-municipal administration. Quadratic and logarithmic transformations for each variable were also tested; these variables (along with hospital and health center utilization rates in the hospital model) were excluded from the final regression models as they did not add explanatory power nor improve the fit as evaluated using the log ratio test [53]. SP: Conceptualization, Writing- Review & editing. In addition, 2019 provides a baseline to enable the future performance evaluations of the impact of the D&D policy change. Inter-Ministrial Prakas No. Sub-Decree on delegating of health management functions and service provision to municiple-provincial administrations. Distributed over 37,000 insecticide-treated nets in target areas and educated over 59,000 people through malaria screening and testing. Special attention will also be placed on providing a package of services, with an increased focus on non-communicable diseases. And, countries with higher levels of inequity in income, education, and health are the least efficient in relation to health outcomes [3]. US$48,828,997) indicating that the GIZ costs can only explain about half of the actual costs. Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary health financing, and incentivizing a referral system. 2020. Eur J Oper Res. The marginal negative effect of supply-side resources/financing on technical efficiency suggests that increased financial autonomy and demand-side financing may yield better value for money. 2014;9(5):e97874. 1992;56(1):8097. Most government ministries and institutions, exempting the Ministry of Health, are required to reduce their expenditures by at least 50% of the approved national budget figures for the current year [1]. The corresponding adjusted rates are $211.23 for maternity care at health centers and $34.92, $30.18, and $26.32 at hospitals CPA13 respectively. Article In 2020, the Cambodian economy registered negative growth of 3.1% [24]. The comparative efficiency of National Health Systems in producing health: an analysis of 191 countries, GPE discussion paper, vol. PubMed Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary financing, and incentivizing a referral system to improve gatekeeping. From 2015 to 2018, the number of out-patient visits per HEF beneficiary per year increased by 40 percent. Building on this successful fast track to UHC, the Cambodian MOH is now designing the next phase of H-EQIP. Eur J Oper Res. In 2001, the Cambodian central government began introducing decentralization reforms [33] with the Public Financial Management Reform Program following in 2004.
The result shows that provinces with the lowest and highest quality scores have higher technical efficiency. Star. Another factor is limited service availability, particularly for non-communicable diseases [10]. Aumann-Shapley health center maternity service costs are substantially higher ($344.00) compared to GIZ costing data. Manag Sci. The quality score is a facility-level index based on the three healthcare quality dimensions of structure, process, and outcome; scores are collected every 3 months through a national monitoring system [50]. US$156,608,043). Jacobs B, Hui K, Lo V, Thiede M, Appelt B, Flessa S. Costing for universal health coverage: insight into essential economic data from three provinces in Cambodia. Simar L, Wilson PW. Beiter D. Technical efficiency of public health centers. 2018;22(1):384403. https://doi.org/10.1186/s12889-021-10395-7. Cooper W, Huang Z, Li SX, Parker BR, Pastor JT. 4. There is evidence of an increase in the use of public health services among HEF beneficiaries. Schenkman S, Bousquat A. However, the Ministry of Health does not separate these services in the provincial-municipal aggregated data and the assumptions required to model utilization for these services among the general population yielded inconsistent results. Finally, efficiency gains need to be reinvested to provide an incentive for continuous health system performance improvement [58]. Improving Health System Efficiency: Reforms for improving the efficiency of health systems: lessons from 10 country cases. Another study concluded that increasing health service utilization and quality could improve public health center efficiency [12]. Health Equity and Quality Improvement Project (H-EQIP), Australian Department of Foreign Affairs and Trade, Japans Population and Human Resources Development. with restrictions on the dual weight. The 2010 World Health Report asserts that all countries can achieve more with the same resources, conservatively estimating that 2040% of all healthcare expenditure is wasted [7]. Health centers provide a minimum package of activities (MPA) and operate health posts which extend services to hard-to-reach areas. A recent costing study found that most health facilities make a minor surplus suggesting that they could increase the number of patients without running a loss [31]. The authors would like to express our appreciation to various departments of the Cambodian Ministry of Health and the National Social Security Fund for sharing administrative statistics disaggregated by province. The pandemics disproportionate impacts on poor and vulnerable communities present opportunities for policy makers to tackle deep-rooted system performance issues with long-term implications for health financing and health systems performance [17]. 22. https://doi.org/10.1371/journal.pone.0195179. The approach is not without limitations however. 2003;14(1):4963.
https://doi.org/10.1002/hpm.2914. In the next phase, H-EQIP will further support the MOHs countrywide implementation of the National Quality Enhancement Monitoring Program, an internal quality improvement process to help hospitals reach higher national quality standards. Health Policy Plan. In addition, there is very limited data available that measure such outcomes at the provincial-municipal level. RGC. The same effect is observed for health centers: a 1% increase in non-discretionary resources decreases technical efficiency by 0.241 points (p-value<0.05). the difference expressed as a ratio of the GIZ costing data estimates.
Cambodia has had no malaria fatalities since 2018. Moreover, the dominance of the largely unregulated, pro-rich private sector accounts for a significant proportion (57.5%) of out-of-pocket spending [75, 76]. RGC. 2020;35(1):31838. Figure5 shows the current coverage of the four social health insurance schemes in relation to the expansion potential and national target. Robert John Kolesar. Testing the myth of fee-for-service and overprovision in health care. Vienna: R Foundation for Statistical Computing; 2021. Finally, a recent healthcare costing study found considerable differences in workload which was inversely correlated with total and unit costs within each facility level which suggests that cost-efficiency could be improved by increasing service volume [13]. Cookies policy. Saleh K, Couttolenc BF, Barroy H. Health financing in the Republic of Gabon: The World Bank; 2014. note that service volume along with contextual factors such as poverty incidence, population density and accessibility affect unit costs [13].
Health Policy Plan. In addition, minor surgeries at hospitals are 7.3 times higher than for non-HEF beneficiaries. Additionally, the national Payment Certification Agency, which is responsible for monitoring, verifying and certifying HEF claims, is to play a key role in developing the social health protection system. For example, the project introduced an innovative voucher program targeting reproductive health services for women from vulnerable groups and the poor. Retrieved from Geneva. Health Operational Districts (ODs), responsible for health center oversight, are typically comprised of 1015 health centers covering about 100,000200,000 people and a district referral hospital. As private health services and health insurers can exacerbate health inequity, it is essential for countries to determine the appropriate level of privatization in their systems which necessitates transparent and responsible regulation alongside efforts to improve public system efficiency [77]. Socio Econ Plan Sci. However, costing exercises are resource intensive and can require significant expense and effort [13]. In 2019, Cambodia had a total of 117 CPA13 hospitals with a provincial-municipality average of 4.68 (Std dev. It will consolidate and institutionalize the ongoing successes of the project, while also taking further steps in health financing reform. US$ 105,203,311 for hospitals and US$102,028,845 for health centers) and the estimated cost assuming the GIZ service specific unit costs multiplied by total service outputs.Footnote 1 For the hospital model the total cost in the data only accounted for 67.2% of the projected (GIZ) costs (i.e. RJK: Conceptualization, Methodology, Data curation, Formal analysis, Writing-Original draft, review and editing, Project administration. 2019;9(3):e022155. Furthermore, reducing inequities in health outcomes, especially for marginalized groupsthe poor, remote rural population, ethnic minorities and womenwill be strongly emphasized. https://doi.org/10.1177/1010539520957841. 26. The wide variability (6% - 255%) of payments as a proportion of the estimated unit costs suggests that payment rates should be realigned. https://doi.org/10.1186/s13561-021-00354-8, DOI: https://doi.org/10.1186/s13561-021-00354-8. Health Equity Fund payments cover between 6% and 255% of the estimated unit costs, corresponding to health center maternity care and CPA3 hospital minor surgery respectively. Alterity or austerity: a review on the value of health equity in times of international economic crises. In addition, predictable financing to sub-national governments is imperative to improve health service performance (Gertler, Giovagnoli and Martinez 2014). Hence, we use the GIZ weights as a reference, but allow for deviations of the relative GIZ price 50% up and down. Freeman M, Savva N, Scholtes S. Economies of scale and scope in hospitals: an empirical study of volume spillovers. https://doi.org/10.1002/hec.1372. Likewise, GIZ data shows health center maternity service cost to be higher ($101.09) than CPA13 hospital maternity costs, $51.98, $44.93, and $39.18 respectively. INQUIRY J Health Care Organ Provision Financ. Health econometrics using Stata: Stata press; 2017. 2021a. The projected cost of additional user-fee payments to expand the Health Equity Fund to the uncovered 1st3rd wealth quintile people (approximately 3.5 million people) are modeled to range from US$ 23.0 (using current HEF payment rates) to 36.5 million (using NSSF payment rates), assuming the adoption of several complimentary policy options [17]. The second stage analysis identifies several factors which explain the variation in technical efficiency among the provinces. found HEF to be associated with higher public health facility efficiency [11]. https://doi.org/10.1016/j.ejor.2014.05.007. In 2019, 38.6% of the approved Ministry of Health budget (~USD $444 million) was allocated to the provincial-municipal level. This may be redressed by correcting the underlying causes and incentivizing health center referrals such as prioritizing service provision at hospitals for patients with a formal health center referral. Figure2 shows the total hospital and health center inpatient and outpatient to financing ratios for each province-municipality. 2020. Thmey T. Hun Sen announces up to 50 pct budget cut amid COVID-19. 2015;30(9):115261. Cambodias public health system consists of a network of 34 national and provincial-municipal level hospitals, 92 Operational District (OD) referral hospitals, 1222 health centers, and 128 health posts. Radojicic M, Jeremic V, Savic G. Going beyond health efficiency: what really matters? Free benefits under the HEF have been extended to some informal workers and selected populations (about 93,500 enrollees). Theory of cost and production functions: Princeton University press; 2015. https://doi.org/10.1515/9781400871087. This program focuses on four areas to improve: (1) budget credibility; (2) financial accountability; (3) budget policy linkages; and (4) performance accountability [34]. Eur J Oper Res. Annear, PGJ; Ir, P; Jacobs, B; Men C, Nachtnebel M, Oum S, Robins A, Ros CE. Such measures could increase budgetary space for health providing that they are well-defined and public financial management systems enable such gains to be repurposed toward prioritized health needs [58]. Jacobs et al. https://doi.org/10.1016/j.omega.2018.07.010. This could raise total population coverage of social health insurance to 60% while leveraging the unutilized service capacity of the public health system. Health provider payments can incentivize or de-incentivize particular services. Finally, we use RStudio 4.1.0 (R [54]) to estimate the unit cost for each of the major insurance reimbursement categories by using the DEA Aumann-Shapley applied cost allocation approach. 29; 2001. Omega. For example, one simple measure would be to link all social health insurance provider payments to both service provision and health facility quality scores [50]. BK to delegate health management functions and service provision to the 25 provincial-municipal administrations. Health financing should focus on smart investments discussed above such as increasing social health insurance payments. 2015. Ensor T, So S, Witter S. Exploring the influence of context and policy on health district productivity in Cambodia. This study aims to quantify the extent to which current health financing can accommodate the expansion of social health protection coverage in Cambodia. Manage cookies/Do not sell my data we use in the preference centre. Crit Public Health. https://doi.org/10.1590/1413-812320182412.23202019. Many countries have committed to achieving universal health coverage, however pandemic-related decreases in revenue constrain increases to domestic health financing. https://doi.org/10.1016/0377-2217(92)90294-J. In addition, cost data can inform budget planning and efficient resource allocation. Google Scholar. 2016;254(2):66778. SD=Standard Deviation, US$=United States dollars, SHI=Social Health Insurance. Improved efficiency is a central tenant of Cambodias high-level policy and strategy documents. USAID continues to support Cambodias efforts to reduce the burden of infectious diseases; reduce infant mortality, under-5 mortality, and maternal mortality; and increase access to quality health services. The A-S price of product j is the average marginal cost as shown in eq. BMC Health Serv Res. This may be attributable to negative spillover effects whereas increased volume in one service area may be associated with increased cost in another area [73]. Phnom Penh: Phase IV; 2018. Scatterplot of inpatient days and outpatient services to total financing ratios by province-municipality, circle size weighted by population size (2019 data). During its current first phase of implementation, between 2016 and 2021, the Cambodian Ministry of Health (MOH) has introduced several health financing innovations designed to provide fair and equitable access to health care. To tackle these issues, Cambodia is renewing its commitment to carry out the next implementation phase of the Health Equity and Quality Improvement Project (H-EQIP). 2021. 2007;136(1):3164. and to improve poor beneficiaries access to health services. PLoS One. Cochrane Database Syst Rev. Increasing health sector expenditure may not significantly affect health outcomes when efficiency is low [4]. From double shock to double recoveryimplications and options for health financing in the time of COVID-19; 2021. https://doi.org/10.1596/35298. This study estimates the potential supply-side service space for 4.69 million additional social health protection beneficiaries in a fully efficient public health system. Washington, DC: World Bank Group; 2019. IMA J Manag Math. Retrieved from https://cambodianess.com/article/hun-sen-announces-up-to-50-pct-budget-cut-amid-covid-19. Technical efficiency measures are overly optimistic under standard underlying DEA assumptions [46]. Asante AD, Ir P, Jacobs B, Supon L, Liverani M, Hayen A, et al. In particular, the higher than cost reimbursements for hospital surgeries is notable. https://doi.org/10.1093/imaman/14.1.49. 1999;87(2):275312. ffhal-03437399f. Regularly updated costing data for each facility level can be used to strengthen strategic purchasing and cost containment [19]. We would also like to acknowledge Souy Lart who facilitated the administrative requests and initial compilation of publicly available data. This study employs Data Envelopment Analysis (DEA), truncated regression, and pioneers the application of DEA Aumann-Shapley applied cost allocation to the health sector, enabling unit cost estimation for the major social health insurance payment categories. RGC. Aboubacar I, Essono M, Barroy H, Mailfert M. Health financing and budgeting reforms in Gabon: Progress and challenges on the road to universal health coverage. PubMed Central
Ozcan YA. Given minor surgeries at the hospital level are 7.3 times higher among HEF beneficiaries compared with the rest of the population, the overpayment may be creating a perverse incentive and service overutilization. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Therefore, we use bootstrapping (2000 times of repeated sampling, with =.05) to estimate bias-corrected technical efficiency scores. Economic impact of COVID-19. Economic crisis, health systems and health in Europe: impact and implications for policy: Open University press; 2015. Kolesar, R.J., Bogetoft, P., Chea, V. et al. The study focuses on 2019 as 2020 data is not likely to fairly represent the efficiency of the public health system due to pandemic-related changes in health care-seeking behavior. 6. It will consolidate and institutionalize the ongoing successes of the project, while also taking further steps in health financing reform, Planned for the period between 2022 and 2027, the next phase, aims to increase the equitable usage of health, To enhance access to health services, HEF will be used to both maintain the current, National Social Health Protection Framework. 2020;1010539520957841(8):4269. Exploring healthcare provision in Cambodia. Emrouznejad A. Evans D, Tandon A, Murray C, Lauer J. The National Strategic Development Plan 20192023 aims to strengthen the implementation of the Decentralization and De-concentration (D&D) Reform Program by delegating power and transfer of functions, resources and technology to administrative units to obtain appropriate autonomy, including decision-making, management and resource allocation [15]. However, provider remuneration is complex and there is also evidence that the risk of overprovision is contextual ([64, 65]. Service costs at CPA1 hospitals are higher compared to CPA2 hospitals and to a lesser degree CPA3 hospitals. Kolesar RJ, Pheakdey S, Jacobs B, Chan N, Yok S, Audibert M. Expanding social health protection in Cambodia: an assessment of the current coverage potential and gaps, and social equity considerations. 2011;11(1):115. This study did find a small, but highly significant positive relationship between health center utilization and technical efficiency. 2019;86:21836. Estimating the technical efficiency of health care systems: A cross-country comparison using the directional distance function. J Policy Model. Health Econ. In addition, the analysis shows that a 1% increase in hospital non-discretionary resources decreases hospital technical efficiency by 0.241 points (p-value<0.08). Moreover, health service utilization rates in Cambodia are considered low compared with other Asian countries [66]. Kolesar, RJ, Erreygers, G, Van Damme, W, Chea, V, Choeurng, T, Leng, S. Hardship Financing, Productivity Loss, and the Economic Cost of Illness and Injury in Cambodia. The Rectangular Strategy Phase IV sets out to deepen reforms to achieve good governance, particularly public administration reform, public financial management reform, decentralization and de-concentration reform [14]. Retrieved from https://www.thestar.com.my/aseanplus/aseanplus-news/2021/05/06/cambodia039s-economy-projected-to-return-to-positive-growth-in-2021-as-covid-19-new-cases-continues-to-soar-total-now-above-17500. aggregated hospital services are compared with other aggregated hospital outputs and aggregated health center services with other aggregated health center services). 2015. Calculations are proportionally weighted and restricted (+/50%) from updated Deutsche Gesellschaft fr Internationale Zusammenarbeit (GIZ) Social Health Protection Programme costing data that was compiled using a standard step-down micro-costing methodology for public health centers and referral hospitals CPA13 [13, 31]. This site uses cookies to optimize functionality and give you the best possible experience. Asia Pac J Public Health. The World Bank in Cambodia. 2020. https://doi.org/10.1596/34572. H-EQIP is co-financed by the Cambodian government, the World Bank, and several partner agencies including: the Australian Department of Foreign Affairs and Trade, the German Development Bank, the Korean International Cooperation Agency, and Japans Population and Human Resources Development program. Tangcharoensathien V, Limwattananon S, Patcharanarumol W, Thammatacharee J, Jongudomsuk P, Sirilak S. Achieving universal health coverage goals in Thailand: the vital role of strategic purchasing. Each PHD operated the provincial hospital and governed the Health Operational Districts [30]. Who benefits from healthcare spending in Cambodia? In fact, there is evidence of both public and private healthcare facilities providing surgeries for commercial interest [79]. World Bank. A crisis like no other, an uncertain recovery: World Economic Outlook Update. Cambodia has achieved significant economic growth and secured key health indicators since 1980when it was left with only 50 doctors. 2007;41(1):121. Enhancing equal access to health services. Health at a glance: Asia/Pacific 2018: measuring Progress towards universal health coverage. Article https://doi.org/10.1093/heapol/czaa151. Notwithstanding, it is important to note that utilization data does not capture effectiveness or quality of the service provided [59]. (version 4.1.0). The theoretical literature has shown this method (and A-S prices) possesses a number of desirable properties, and it has essentially been the unanimous recommendation of economists for decades when sharing the costs of joint production [56]. Int Bus Econ Re J. Outputs focus on the major social health insurance payment categories (i.e. Goryakin Y, Revill P, Mirelman AJ, Sweeney R, Ochalek J, Suhrcke M. Public financial management and health service delivery: a literature review: Global Health Economics: Shaping Health Policy in Low-and Middle-Income Countries; 2020. p. 191215. Public sector health expenditure is 47% of Cambodias total health expenditure [9]; however, only about 20% of people with an illness or injury first seek care in the public sector [10]. Due to the COVID-19 pandemic, this protection plan might also be expanded. Outpatient cases are 1.63 and 1.37 times higher compared to the rest of the population, at hospitals and health centers, respectively. The MPA focuses on preventative and basic curative services; each health center serves approximately 10,00020,000 people. Equation 3 expresses the assumption of the ratio of the dual weights for k outputs. 2017;187:30611. Finally, the hospital utilization rate has a highly statistically significant (p<0.001) negative effect on health center technical efficiency. Health financing and access to effective interventions. GE: Writing- Review & editing. 2000;3. https://doi.org/10.1002/14651858.CD002215. J Econ. Moreover, shifting financial resources to smart investments, especially demand-side financing including increasing the payment/reimbursement rates would likely further incentivize increased service provision and improve technical efficiency. For health centers, there is a non-linear effect with small (0.001), but statistically significant (p<0.05) positive effect on technical efficiency when the number of small-scale private providers is limited up to about 750. (Photo: Dominic Chavez/Global Financing Facility). Given the Royal Government of Cambodias (RGC) current D&D reform program discussed above, the unit of analysis or DMU is the provincial-municipal administration. Quadratic and logarithmic transformations for each variable were also tested; these variables (along with hospital and health center utilization rates in the hospital model) were excluded from the final regression models as they did not add explanatory power nor improve the fit as evaluated using the log ratio test [53]. SP: Conceptualization, Writing- Review & editing. In addition, 2019 provides a baseline to enable the future performance evaluations of the impact of the D&D policy change. Inter-Ministrial Prakas No. Sub-Decree on delegating of health management functions and service provision to municiple-provincial administrations. Distributed over 37,000 insecticide-treated nets in target areas and educated over 59,000 people through malaria screening and testing. Special attention will also be placed on providing a package of services, with an increased focus on non-communicable diseases. And, countries with higher levels of inequity in income, education, and health are the least efficient in relation to health outcomes [3]. US$48,828,997) indicating that the GIZ costs can only explain about half of the actual costs. Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary health financing, and incentivizing a referral system. 2020. Eur J Oper Res. The marginal negative effect of supply-side resources/financing on technical efficiency suggests that increased financial autonomy and demand-side financing may yield better value for money. 2014;9(5):e97874. 1992;56(1):8097. Most government ministries and institutions, exempting the Ministry of Health, are required to reduce their expenditures by at least 50% of the approved national budget figures for the current year [1]. The corresponding adjusted rates are $211.23 for maternity care at health centers and $34.92, $30.18, and $26.32 at hospitals CPA13 respectively. Article In 2020, the Cambodian economy registered negative growth of 3.1% [24]. The comparative efficiency of National Health Systems in producing health: an analysis of 191 countries, GPE discussion paper, vol. PubMed Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary financing, and incentivizing a referral system to improve gatekeeping. From 2015 to 2018, the number of out-patient visits per HEF beneficiary per year increased by 40 percent. Building on this successful fast track to UHC, the Cambodian MOH is now designing the next phase of H-EQIP. Eur J Oper Res. In 2001, the Cambodian central government began introducing decentralization reforms [33] with the Public Financial Management Reform Program following in 2004.
The result shows that provinces with the lowest and highest quality scores have higher technical efficiency. Star. Another factor is limited service availability, particularly for non-communicable diseases [10]. Aumann-Shapley health center maternity service costs are substantially higher ($344.00) compared to GIZ costing data. Manag Sci. The quality score is a facility-level index based on the three healthcare quality dimensions of structure, process, and outcome; scores are collected every 3 months through a national monitoring system [50]. US$156,608,043). Jacobs B, Hui K, Lo V, Thiede M, Appelt B, Flessa S. Costing for universal health coverage: insight into essential economic data from three provinces in Cambodia. Simar L, Wilson PW. Beiter D. Technical efficiency of public health centers. 2018;22(1):384403. https://doi.org/10.1186/s12889-021-10395-7. Cooper W, Huang Z, Li SX, Parker BR, Pastor JT. 4. There is evidence of an increase in the use of public health services among HEF beneficiaries. Schenkman S, Bousquat A. However, the Ministry of Health does not separate these services in the provincial-municipal aggregated data and the assumptions required to model utilization for these services among the general population yielded inconsistent results. Finally, efficiency gains need to be reinvested to provide an incentive for continuous health system performance improvement [58]. Improving Health System Efficiency: Reforms for improving the efficiency of health systems: lessons from 10 country cases. Another study concluded that increasing health service utilization and quality could improve public health center efficiency [12]. Health Equity and Quality Improvement Project (H-EQIP), Australian Department of Foreign Affairs and Trade, Japans Population and Human Resources Development. with restrictions on the dual weight. The 2010 World Health Report asserts that all countries can achieve more with the same resources, conservatively estimating that 2040% of all healthcare expenditure is wasted [7]. Health centers provide a minimum package of activities (MPA) and operate health posts which extend services to hard-to-reach areas. A recent costing study found that most health facilities make a minor surplus suggesting that they could increase the number of patients without running a loss [31]. The authors would like to express our appreciation to various departments of the Cambodian Ministry of Health and the National Social Security Fund for sharing administrative statistics disaggregated by province. The pandemics disproportionate impacts on poor and vulnerable communities present opportunities for policy makers to tackle deep-rooted system performance issues with long-term implications for health financing and health systems performance [17]. 22. https://doi.org/10.1371/journal.pone.0195179. The approach is not without limitations however. 2003;14(1):4963.
https://doi.org/10.1002/hpm.2914. In the next phase, H-EQIP will further support the MOHs countrywide implementation of the National Quality Enhancement Monitoring Program, an internal quality improvement process to help hospitals reach higher national quality standards. Health Policy Plan. In addition, there is very limited data available that measure such outcomes at the provincial-municipal level. RGC. The same effect is observed for health centers: a 1% increase in non-discretionary resources decreases technical efficiency by 0.241 points (p-value<0.05). the difference expressed as a ratio of the GIZ costing data estimates.
Cambodia has had no malaria fatalities since 2018. Moreover, the dominance of the largely unregulated, pro-rich private sector accounts for a significant proportion (57.5%) of out-of-pocket spending [75, 76]. RGC. 2020;35(1):31838. Figure5 shows the current coverage of the four social health insurance schemes in relation to the expansion potential and national target. Robert John Kolesar. Testing the myth of fee-for-service and overprovision in health care. Vienna: R Foundation for Statistical Computing; 2021. Finally, a recent healthcare costing study found considerable differences in workload which was inversely correlated with total and unit costs within each facility level which suggests that cost-efficiency could be improved by increasing service volume [13]. Cookies policy. Saleh K, Couttolenc BF, Barroy H. Health financing in the Republic of Gabon: The World Bank; 2014. note that service volume along with contextual factors such as poverty incidence, population density and accessibility affect unit costs [13].