Gabriela Flores

Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia

OBJECTIVE To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia. METHODS The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health-care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them. FINDINGS Overall, voucher schemes were associated with an increase of 10.1 percentage points (pp) in the probability of delivery in a public health-care facility; among women from the poorest 40% of households, the increase was 15.6 pp. Vouchers were responsible for about one fifth of the increase observed in institutional deliveries in districts with schemes. Universal voucher schemes had a larger effect on the probability of delivery in a public facility than schemes targeting the poorest women. Both types of schemes increased the probability of receiving postnatal care, but the increase was significant only for non-poor women. Universal, but not targeted, voucher schemes significantly increased the probability of receiving antenatal care. CONCLUSION Voucher schemes increased deliveries in health centres and, to a lesser extent, improved antenatal and postnatal care. However, schemes that targeted poorer women did not appear to be efficient since these women were more likely than less poor women to be encouraged to give birth in a public health-care facility, even with universal voucher schemes.

Impact of Performance‐Based Financing in a Low‐Resource Setting: A Decade of Experience in Cambodia

This paper exploits the geographic expansion of performance-based financing (PBF) in Cambodia over a decade to estimate its effect on the utilization of maternal and child health services. PBF is estimated to raise the proportion of births occurring in incentivized public health facilities by 7.5 percentage points (25%). A substantial part of this effect arises from switching the location of institutional births from private to public facilities; there is no significant impact on deliveries supervised by a skilled birth attendant, nor is there any significant effect on neonatal mortality, antenatal care and vaccination rates. The impact on births in public facilities is much greater if PBF is accompanied by maternity vouchers that cover user fees, but there is no significant effect among the poorest women. Heterogeneous effects across schemes differing in design suggest that maintaining management authority within a health district while giving explicit service targets to facilities is more effective in raising utilization than contracting management to a non-governmental organization while denying it full autonomy and leaving financial penalties vague. Copyright

Financial Protection of Patients Through Compensation of Providers: The Impact of Health Equity Funds in Cambodia

Public providers have no financial incentive to respect their legal obligation to exempt the poor from user fees. Health Equity Funds (HEFs) aim to make exemptions effective by giving NGOs responsibility for assessing eligibility and compensating providers for lost revenue. We use the geographic spread of HEFs over time in Cambodia to identify their impact on out-of-pocket (OOP) payments. Among households with some OOP payment, HEFs reduce the amount paid by 35%, on average. The effect is larger for households that are poorer and mainly use public health care. Reimbursement of providers through a government operated scheme also reduces household OOP payments but the effect is not as well targeted on the poor. Both compensation models raise household non-medical consumption but have no impact on health-related debt. HEFs reduce the probability of primarily seeking care in the private sector.

Catastrophic Medical Expenditure Risk

We propose a measure of household exposure to particularly onerous medical expenses. The measure can be decomposed into the probability that medical expenditure exceeds a threshold, the loss due to predictably low consumption of other goods if it does and the further loss arising from the volatility of medical expenses above the threshold. Depending on the choice of threshold, the measure is consistent with a model of reference-dependent utility with loss aversion. Unlike the risk premium, the measure is only sensitive to particularly high expenses, and can identify households that expect to incur such expenses and would benefit from subsidised, but not actuarially fair, insurance. An empirical illustration using data from seven Asian countries demonstrates the importance of taking account of informal insurance and reveals clear differences in catastrophic medical expenditure risk across and within countries. In general, risk is higher among poorer, rural and chronically ill populations.

Catastrophic medical expenditure risk

Abstract Background WHO (2000, 2010) maintains that financial protection against medical expenditure risk should be a central objective of health systems. We claim that identification of the welfare losses to households and behavioural consequences of exposure to risk necessarily requires adoption of an ex-ante perspective, which is not taken by current measures of financial protection. Methods In this cross-sectional study, we first derive measures of catastrophic medical expenditures risks at the household level from models of reference-dependent utility with loss aversion: there is a feeling of loss when medical expenditures rise so high that some aspired level of consumption is not realised. These measures can be decomposed into the risk of experiencing a low level of consumption due to high medical expenditures and the variability of consumption below the aspired threshold due to uncertain medical expenditures. Second, we propose a method of estimating risk exposure from cross-section data using quantile regressions. It exploits information on the means of financing health payments to identify the distribution of medical expenditures that threaten non-medical consumption. Finally, we apply this to World Health Survey data from seven Asian countries. Findings Exposure to medical expenditure risk is generally higher for households that have less recourse to self-insurance, lower incomes and wealth, chronic illness, and lower education. Risk is highest in Laos and China, and is lowest in Malaysia among the countries examined. At plausible levels of risk aversion, the variability in consumption by medical expenses in excess of 20% income is the largest component of the loss arising from exposure to medical expenditure risk, exceeding 80% of the loss in all countries except Malaysia. The probability that medical expenditures exceed 20% of income is highest in India, China, and Laos (15–17%). Interpretation We have proposed measures of downside risk arising from uninsured medical expenditures. Unlike the risk premium, these measures focus on exposure to the risk of unusually high expenses. Coverage of these risks is arguably the priority in countries with insufficient resources to provide comprehensive coverage. The main limitations of the measures proposed are that they do not reflect the risk of being unable to afford essential health care and take no account of the long-term consequences of paying for health care by borrowing or selling assets. Notwithstanding these limitations, the method offers new insights revealing, for example, that catastrophic medical expenditure risk is not necessarily highest in the countries with the highest mean level of out-of-pocket medical expenditure. Funding This study is funded by the European Commission 7th Framework Program (grant number 223166).