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Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries

While World Health Organization member countries embraced the concept of universal coverage as early as 2005, few low-income countries have yet achieved the objective. This is mainly due to numerous barriers that hamper access to needed health services. In this paper we provide an overview of the various dimensions of barriers to access to health care in low-income countries (geographical access, availability, affordability and acceptability) and outline existing interventions designed to overcome these barriers. These barriers and consequent interventions are arranged in an analytical framework, which is then applied to two case studies from Cambodia. The aim is to illustrate the use of the framework in identifying the dimensions of access barriers that have been tackled by the interventions. The findings suggest that a combination of interventions is required to tackle specific access barriers but that their effectiveness can be influenced by contextual factors. It is also necessary to address demand-side and supply-side barriers concurrently. The framework can be used both to identify interventions that effectively address particular access barriers and to analyse why certain interventions fail to tackle specific barriers.

Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia

BackgroundIn many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up.MethodsData on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation.ResultsFacility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for self-paid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme.ConclusionsVouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.

Composition of pluralistic health systems: how much can we learn from household surveys? An exploration in Cambodia.

In spite of all efforts to build national health services, health systems of many low-income countries are today highly pluralistic. Households use a vast range of public and private health care providers, many of whom are not controlled by national health authorities. Experts have called on Ministries of Health to re-establish themselves as stewards of the entire health system. Modern stewardship will require national and decentralized health authorities to have an overall view of their pluralistic health system, especially of the components outside the public sector. Little guidance has been provided so far on how to develop such a view. In this paper, we explore whether household surveys could be a source of information. The study builds on secondary data analysis of a household survey carried out in three health districts in rural Cambodia and of two national surveys. Cambodia is indeed an interesting case, as massive efforts by donors in favour of the public sector go hand in hand with a dominant role of the private sector in the provision of health care services. The study confirms that the health care sector in Cambodia is now highly pluralistic, and that the great majority of health seeking behaviour takes place outside the public health system. Our analysis of the survey also shows that the disaffection of the population with public health facilities varies across places, socio-economic groups and health problems. We illustrate how such knowledge could allow stewards to better identify challenges for existing or future health policies. We argue that a whole research programme on the composition of pluralistic health systems still needs to be developed. We identify some challenges and opportunities.

Bridging community-based health insurance and social protection for health care - a step in the direction of universal coverage?

keywords health care, community-based health insurance, social protection, universal coverageAccess to affordable and effective health care is a majorproblem in low and middle income countries (LMIC) andout-of-pocket expenditure for health care a major cause ofimpoverishment (Meessen et al. 2003; Frenk et al. 2006;McIntyre et al. 2006; Van Doorslaer et al. 2006). Oneway to facilitate access and overcome catastrophic expen-diture is through a health insurance mechanism, wherebyrisks are shared and financial inputs pooled by way ofcontributions from salaries or taxation (Carrin et al.2005). In European history, social health insurance (SHI)initially covered salaried workers and their families. Theself-employed, unemployed and destitute were onlycovered at a later stage (Ba¨rnighausen & Sauerborn 2002).In LMIC today, the majority of people are either self-employed or work in the informal sector, which makesexpansion of formal health insurance, if any, much moredifficult. Taxation systems are generally insufficientlydeveloped and do not allow for adequate revenue collec-tion to ensure universal coverage (Carrin et al. 2005).One response to the difficulty of providing insurancecoverage for people in the informal sector is the develop-ment of community-based health insurance (CBHI). Suchan arrangement implies that the community plays animportant role in mobilizing, pooling, allocating, manag-ing and/or supervising health-care resources (Jakab K Jakab & Krishnan 2001;van Ginneken 2002; Carrin et al. 2005). CBHI schemesattempt to tap willingness and ability to pay for health careand try to build local risk-sharing arrangements based onsolidarity which requires time to mature. In practice,however, most CBHI schemes are small. A review of 258CBHI schemes found that 50% had less than 500 members[International Labour Organisation (ILO) 2002], whichundermines the CBHI’s potential (Criel & Waelkens 2003;Carrin et al. 2005).Small-scheme federations or networks can be establishedto increase membership and improve financial leverage ofCBHI (Waelkens & Criel 2004). Support organizations canbe set up to provide management assistance at the outset;scheme management can be subcontracted to an umbrellaorganization or schemes may even merge (Carrin et al.2005). Alternatively, a scheme with a larger membershipmay be started (Carrin et al. 2005), although this may onlybe possible if premiums are subsidized. In this respect,Bennett (2004) suggests that government subsidies toschemes should target the poor, more specifically thoseunabletopayapremium,toenableequitableaccesstohealthservices. The situation of CBHI in sub-Saharan Africa leadsto a similar analysis (Ndiaye et al. 2007): CBHI is not anoption for the poorest, and someone else therefore needs topay the insurance premium for them – in full or in part.Hence, the need for subsidies to cover the poorest house-holds–whileatthesametimeexercisinggreatcautionnottoundermine and jeopardize local solidarity dynamics andwillingness to pay by other than the poorest households.Rationale for bridging CBHI and social protectionprogrammes (SPP) for health careThe World Bank defines SPP as public interventions that:(i) assist households and communities to better manage

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.

Self-reported serious illnesses in rural Cambodia: a cross-sectional survey.

Background There is substantial evidence that ill-health is a major cause of impoverishment in developing countries. Major illnesses can have a serious economic impact on poor households through treatment costs and income loss. However, available methods for measuring the impact of ill-health on household welfare display several shortcomings and new methods are thus needed. To understand the potential complex impact of major illnesses on household livelihoods, a study on poverty and illness was conducted in rural Cambodia, as part of an international comparative research project. A cross-sectional survey was performed to identify households affected by major illness for further in-depth interviews. Methodology and Principal Findings 5,975 households in three rural health districts were randomly selected through a two-stage cluster sampling and interviewed. 27% of the households reported at least one member with a serious illness in the year preceding the survey and 15% of the household members reported suffering from at least one serious illness. The most reported conditions include common tropical infectious diseases, chronic diseases (notably hypertension and heart diseases) and road traffic accidents. Such conditions were particularly concentrated among the poor, children under five, women, and the elderly. Poor women often reported complications related to pregnancy and delivery as serious illnesses. Conclusions and Significance Despite some methodological limitations, this study provides new information on the frequency of self-reported serious illnesses among the rural Cambodias population, which serves as a basis for further in-depth investigation on ‘major illnesses’ and their economic consequences on poor households. This can in turn help policy makers to formulate appropriate interventions to protect the poor from the financial burden associated with ill-health. Our findings suggest that every year a considerable proportion of rural population in Cambodia, especially the poor and vulnerable, are affected by serious illnesses, both communicable and non-communicable diseases.

Factors Driving Changes in the Design, Implementation, and Scaling-Up of the Contracting of Health Services in Rural Cambodia, 1997–2015

Abstract—Contracting approaches have been used in various forms to improve the delivery of public health services in low- and middle-income countries. Cambodia has embarked on a public-sector reform that includes a model of internal contracting of health care through the Ministry of Health, supported by incentive payments for staff and facilities. Contracting for health care in Cambodia has evolved through three phases during 1997–2015, each with particular design features, arrangements, and structures; different levels of involvement of local and international stakeholders; and modifications based on evidence from operational research. Based on a review of published and gray literature and interviews with 29 local and international key informants, we identify national ownership, financial sustainability, and the need to strengthen service delivery institutions as the major forces that have shaped contracting in Cambodia, culminating in the move to internal contracting arrangements for public health care delivery. There remains a need to strengthen contracting governance arrangements.

Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: a study of policy barriers and opportunities in Cambodia.

Reaching out to the poor and the informal sector is a major challenge for achieving universal coverage in lesser-developed countries. In Cambodia, extensive coverage by health equity funds for the poor has created the opportunity to consolidate various non-government health financing schemes under the governments proposed social health protection structure. This paper identifies the main policy and operational challenges to strengthening existing arrangements for the poor and the informal sector, and considers policy options to address these barriers. Conducted in conjunction with the Cambodian Ministry of Health in 2011-12, the study reviewed policy documents and collected qualitative data through 18 semi-structured key informant interviews with government, non-government and donor officials. Data were analysed using the Organizational Assessment for Improving and Strengthening Health Financing conceptual framework. We found that a significant shortfall related to institutional, organisational and health financing issues resulted in fragmentation and constrained the implementation of social health protection schemes, including health equity funds, community-based health insurance, vouchers and others. Key documents proposed the establishment of a national structure for the unification of the informal-sector schemes but left unresolved issues related to structure, institutional capacity and the third-party status of the national agency. This study adds to the evidence base on appropriate and effective institutional and organizational arrangements for social health protection in the informal sector in developing countries. Among the key lessons are: the need to expand the fiscal space for health care; a commitment to equity; specific measures to protect the poor; building national capacity for administration of universal coverage; and working within the specific national context.