Cambodia Health Researchers Forum 11 Nov 2015 combined presentations
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Transcript of 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
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