Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000–2008
Introduction
Equity has been an overarching goal of public health policy in many countries for several decades. However, progress towards this goal has been disappointing. Poor-rich disparities in health financing, in access to health care and in health outcomes persist in many countries and even widen in some countries [1]. To address health inequities an equity-oriented approach to health and health sector policy is needed. A concerted effort must be made to ensure that health systems reach the poor more effectively [2]. Successful interventions aiming to reach the poor with health services exist in some countries [3]. However, replication of these interventions in developing countries where resources are scarce and health systems perform poorly is a big challenge and often requires context-specific experimentation through pilots [4].
The implementation of equitable health care financing mechanisms which could increase access for the poor and reduce poverty is critical to promoting health equity [5]. Yet, reliable knowledge on efficient and equitable health financing in different settings is sparse [6]. Moreover, the available knowledge is often not translated into policy. Closing the knowledge-policy gap is crucial to ensure health system strengthening and the achievement of health equity goals [7], [8], [9]. It requires a better understanding of interfaces between research and policy, in particular the factors affecting the uptake of research findings by policy. Despite a growing literature on policy analysis, knowledge in this field remains rather weak in developing countries [10], [11].
In Cambodia, despite considerable progress in the health sector, access to essential health services remains a problem, especially for the poor. To tackle this problem, multiple health financing innovations have been tested in recent years. Health Equity Fund (HEF) is one of these innovations aimed at promoting equity and reducing poverty through enhancing access to health services for the poor [12]. HEF pilots proved relatively successful and showed potential for improving equity and reducing poverty [13], [14], [15]. Supported by knowledge generated from the pilot schemes, HEFs went on to become part of national health policy. We analyse the HEF policy process to illustrate how knowledge was used to inform national health policy and draw lessons for translating knowledge into policies that promote equity (Box 1).
Section snippets
Materials and methods
This study is a retrospective analysis of the HEF policy process in Cambodia between 2000 and 2008, and was conducted under the guidance of a review team with members from the Cambodian Ministry of Health (MOH), the National Institute of Public Health and WHO's office in Phnom Penh. Document analysis and interviews are the most commonly used methods for policy analysis. They seem appropriate for retrospective analysis of a national and sub-national policy related to specific issues [21] and
Cambodian health policy and health sector reforms
As stated in policy documents that are reflected in article 72 of the National Constitution, health sector reforms in Cambodia are aimed at promoting equity and reducing poverty through enhancing access to and utilisation of quality services, especially for the poor, and protecting them from the impoverishing effects of ill-health. To reach these aims, the Cambodia health system has undergone a long series of reforms, including health financing reforms. Over the last decade, along with
Discussion
Pilot or experimental projects increase the likelihood of successful scaling-up by generating knowledge on how an innovation can be best implemented in a particular context, identifying potential problems and preventing unintended consequences of the introduction of an innovation prior to scaling-up [48]. While an increasing number of documented pilots is successfully scaled up, many successful small-scale pilots are ignored by policy makers or not scaled up to benefit larger populations
Conclusions
This paper illustrates how HEF pilots in Cambodia were successfully integrated in health policy and gradually scaled up nationwide. The study offers an example of how knowledge can be successfully translated into policy to promote health equity in low-income countries. Our findings suggest three important factors that can enhance the likelihood of uptake of a pilot project in health policy and its nationwide scaling-up. These include a policy context conducive to the creation, dissemination and
Acknowledgements
We thank Dr. Lo Veasna Kiry from the Ministry of Health, Dr. Saphorn Vonthanak from the National Institute of Public Health and Dr. Benjamin Lane from WHO for their contribution to the study. We are grateful to all the key informants for dedicating their valuable time for the interviews and to Dr. Steve Fabricant, Ms. Anjana Bhushan, Dr. Reijo Salmela, Kristof Decoster and Bart Jacobs for their comments on earlier drafts of this paper. This study was funded by the WHO and one co-author
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