Impact of health financing policies in Cambodia: A 20 year experience

Improving the technical efficiency of public health centers in Cambodia: a two-stage data envelopment analysis

BACKGROUND

Cambodia is undergoing a series of reforms with the objective of reaching universal health coverage. Information on the causes of inefficiencies in health facilities could pave the way for a better utilization of limited resources available to ensure the best possible health care for the population.

OBJECTIVES

The purpose of this study is to evaluate the technical efficiency of health centers and the determinants for inefficiencies.

METHODS

This cross-sectional study used secondary data from a costing study on 43 health centers in six Cambodian provinces (2016-2017). Firstly, the Data Envelopment Analysis method with output-orientation was applied to calculate efficiency scores by selecting multiple input and output variables. Secondly, a tobit regression was performed to analyze potential explanatory variables that could influence the inefficiency of health centers.

RESULTS

Study findings showed that 18 (43%) health centers were operating inefficiently with reference to the variable returns to scale efficiency frontier and had a mean pure technical efficiency score of 0.87. Overall, 22 (51%) revealed deficits in producing outputs at an optimal scale size. Distance to the next referral hospital, size and quality performance of the health centers were significantly correlated with health center inefficiencies.

CONCLUSION

Differences in efficiency exist among health centers in Cambodia. Inefficient health centers can improve their technical efficiency by increasing the utilization and quality of health services, even if it involves higher costs. Technical efficiency should be continuously monitored to observe changes in health center performance over time.

Assessing progress towards universal health coverage in Cambodia: Evidence using survey data from 2009 to 2019

Over the past decades, many low- and middle-income countries have implemented health financing and system reforms to progress towards universal health coverage (UHC). In the case of Cambodia, out-of-pocket expenditure (OOPE) remains the main source of current health expenditure after several decades of reform, exposing households to financial risks when accessing healthcare and violating UHC's key tenet of financial protection. We use pre-pandemic data from the nationally representative Cambodia Socio-Economic Surveys of 2009 to 2019 to assess progress in financial protection to evaluate the reforms and obtain internationally comparable estimates. We find that following strong improvements in financial protection between 2009 and 2017, there was a reversal in the trend thereafter. The OOPE budget share rose, and the incidence of catastrophic spending and impoverishment increased in nearly all geographical and socioeconomic strata. For example, 17.7% of households experienced catastrophic health expenditure in 2019 at the threshold of 10% of total household consumption expenditure, and 3.9% of households were pushed into poverty by OOPE. The distribution of all financial protection indicators varied strongly across socioeconomic and geographical strata in all years. Fundamentally, the demonstrated trend reversal may jeopardize Cambodia's ability to progress towards UHC. To improve financial protection in the short term, there is a need to address the burden created by OOPE through targeted interventions to household groups that are most affected. In the medium term, our findings emphasize the importance of expanding health pre-payment schemes to currently uncovered vulnerable groups, specifically the near-poor. The government also needs to consider extending the scope of services covered and the range of providers to include the private sector under these schemes to reduce reliance on OOPE.

A stakeholder group assessment of interactions between child health and the sustainable development goals in Cambodia

Background

With the implementation of the Sustainable Development Goals, a systematic assessment of how the goals influence child health and vice versa has been lacking. We aimed to contribute to such an assessment by investigating the interactions between child health and the Sustainable Development Goals in Cambodia.

Methods

Based on the SDG Synergies approach, 272 interactions between 16 Cambodian Sustainable Development Goals and child health were evaluated by an interdisciplinary Cambodian stakeholder group. From this a cross-impact matrix was derived and network analysis applied to determine first and second-order effects of the interactions with a focus on child health.

Results

We show that with the exception of Cambodian Sustainable Development Goal 15 (life on land) the interactions are perceived to be synergistic between the child health and the Cambodian Sustainable Development Goals, and progress on Cambodian Sustainable Development Goal 16 (peace, justice and strong institutions) could have the largest potential to contribute to the achievement of the Cambodian Sustainable Development Goals, both when it comes to first and second-order interactions.

Conclusions

In this stakeholder assessment, our findings provide novel insights on how complex relationships play out at the country level and highlight important synergies and trade-offs, vital for accelerating the work toward the betterment of child health and achieving the Sustainable Development Goals.

The Sustainable Development Goals (SDGs) are a set of 17 global goals set by the United Nations to guide the world toward development that meets the needs of the present without compromising the ability of future generations to meet their own needs. The efforts to achieve the different SDGs are interconnected. To better understand in what way, a group with different expertize and perspectives was assembled in Cambodia to score the linkages between the SDGs and child health. This identified that most goals promote better child health and that advancements in child health also help achieve the SDGs in Cambodia. Our study provides useful knowledge and a practical approach for policy makers trying to accelerate the work toward better child health in Cambodia.

Helldén et al. apply the Sustainable Development Goals (SDGs) Synergies approach to investigate interactions between SDGs and child health in Cambodia in an interdisciplinary Cambodian stakeholder group. They identify SDGs that positively influence child health and show that progress on child health also promotes the achievement of most other goals.

The Quality of Primary Care in Cambodia: An Assessment of Knowledge and Effort of Public Sector Maternal and Child Care Providers

Improving the quality of primary care is essential for achieving universal health coverage in low- and middle-income countries. This study examined the level and variation in primary care provider knowledge and effort in Cambodia, using cross-sectional data collected in 2014-2015 from public sector health centers in nine provinces. The data included clinical vignettes and direct observations of processes of antenatal care, postnatal care, and well-child visits and covered between 290-495 health centers and 370-847 individual providers for each service and type of data. The results indicate that provider knowledge and observed effort were generally low and varied across health centers and across individual providers. In addition, providers' effort scores were generally lower than their knowledge scores, indicating the presence of a "know-do gap." Although higher provider knowledge was correlated with higher levels of effort during patient encounters, knowledge only explained a limited fraction of the provider-level variation in effort. Due to low baseline performance and the know-do gap, improving provider adherence to clinical guidelines through training and practice standardization alone may have limited impact. Overall, the findings suggest that raising the low quality of care provided by Cambodia's public sector will require multidimensional interventions that involve training, strategies that increase provider motivation, and improved health center management. The authors reported there is no funding associated with the work presented in this article.

Role of User Benefit Awareness in Health Coverage Utilization among the Poor in Cambodia

The objective of this study was to understand the steps to health coverage benefit utilization in Cambodia toward improving access to health care and financial risk protection for the poor. We particularly examine the role of user awareness in the pathway to care seeking and benefit utilization with respect to the Health Equity Funds (HEF). Using 2016 survey data that were nationally representative of households with children under two years of age, we used a series of logistic regression models to evaluate associations between respondents' awareness of benefits, public health care seeking behaviors, coverage benefit claims, and out-of-pocket expenditures. Beneficiaries were generally aware of their entitlements, although their awareness of specific benefits, such as transport reimbursement, was relatively lower. Awareness of free services at public health centers was associated with twice the odds of having ever visited a public provider for outpatient care, while awareness of free services at public hospitals was associated with higher odds of always seeking inpatient care in the public sector. Study findings point to the decision of where to seek care as the critical point in the pathway to HEF utilization. If the decision had already been made to go to a public provider, it was likely that HEF benefits were claimed. Interventions that prompt appropriate care seeking in the public sector may do the most to improve HEF utilization and subsequently improve access to care through sufficient financial risk protection.

Strengthening Health Systems in Humanitarian Settings: Multi-Stakeholder Insights on Contraception and Postabortion Care Programs in the Democratic Republic of Congo and Somalia

Background: In humanitarian settings, strengthening health systems while responding to the health needs of crisis-affected populations is challenging and marked with evidence gaps. Drawing from a decade of family planning and postabortion care programming in humanitarian settings, this paper aims to identify strategic components that contribute to health system strengthening in such contexts. Materials and Methods: A diverse range of key informants from North Kivu (Democratic Republic of Congo, DRC) and Puntland (Somalia), including female and male community members, adolescents and adults, healthcare providers, government and community leaders, participated in qualitative interviews, which applied the World Health Organization health system building blocks framework. Data were thematically analyzed according to this framework. Results: Findings from the focus group discussions (11 in DRC, 7 in Somalia) and key informant interviews (seven in DRC, four in Somalia) involving in total 54 female and 72 male participants across both countries indicate that health programs in humanitarian settings, such as Save the Children's initiative on family planning and postabortion care, could contribute to strengthening health systems by positively influencing national policies and guidance, strengthening local coordination mechanisms, capacitating the healthcare workforce with competency-based training and supportive supervision (benefiting facilities supported by the project and beyond), developing the capacity of Ministry of Health staff in the effective management of the supply chain, actively and creatively mobilizing the community to raise awareness and create demand, and providing quality and affordable services. Financial sustainability is challenged by the chronically limited healthcare expenditure experienced in both humanitarian contexts. Conclusions: In humanitarian settings, carefully designed healthcare interventions, such as those that address the family planning and postabortion care needs of crisis-affected populations, have the potential not only to increase access to essential services but also contribute to strengthening several components of the health system while increasing the government capacity, ownership, and accountability.

Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia

In Cambodia, diabetes caused nearly 3% of the country’s mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.

User experiences and perceptions of health wearables: an exploratory study in Cambodia

BACKGROUND

In many low- and middle-income countries (LMICs), health system capacities to address the burden of non-communicable diseases (NCDs) are often inadequate. In these countries, wearable health technologies such as smartbands and smartwatches could be used as part of public health programmes to improve the monitoring, prevention, and control of NCDs. Considering this potential, the purpose of this study was to explore user experiences and perceptions of a health wearable in Cambodia.

METHODS

Data collection involved a survey, conducted between November 2019 and January 2020, among different categories of participants (including hypertensive participants, non-hypertensive participants, postgraduate students, and civil servants). All participants were given a sample of a watch-type wearable and advised to use it day and night. One month after product delivery, we conducted a survey to explore their views and experiences. Results were analysed by using descriptive statistics and Chi square or Fisher's exact test to compare responses from urban and rural participants.

RESULTS

A total of 156 adult participants completed the study. Technology acceptance was positive overall. 89.1% of the participants said they would continue using the watch and 76.9% of them would recommend it to either friends or relatives, while 94% said the device stimulated them to think more frequently about their health. However, challenges to technology adoption were also identified, including concerns with the accuracy and quality of the device and unfamiliarity with the concept of health self-monitoring, especially among the elderly. Short battery life and cost were also identified as potential barriers to continued use.

CONCLUSIONS

Health wearables are a promising new technology that could be used in Cambodia and in other LMICs to strengthen health sector responses to the challenges of NCDs. However, this technology should be carefully adapted to the local context and the needs of less resourced population groups. In addition, further studies should examine if adequate health sector support and infrastructure are in place to implement and sustain the technology.

Do Health Expenditures Converge Among ASEAN Countries?

This paper aims to determine the existence of convergence in health expenditures among Association for South East Asian Nations (ASEAN) countries. Based on the SPSM procedure and panel KSS unit root test results, the public health expenditures (PUHE) in Indonesia, Lao PDR, Cambodia, the Philippines, and Myanmar are converging, while that of Brunei Darussalam, Malaysia, Vietnam, Singapore, and Thailand are diverging. In addition, the sequences of private health expenditures (PRHE) in ASEAN member states are stationary, which implies convergence. This finding is in accordance with Wagner's law, that is, as nations develop, they are forced to expand public expenditure. Specifically, countries with low levels of PUHE tend to catch up with the high health spending countries. This research has policy implications with regard to the convergence of health expenditure across countries. The government in low- and lower-middle income countries should raise PUHE to provide access to health services for those who are unaffordable individuals.

Health equity funds as the pathway to universal coverage in Cambodia: care seeking and financial risk protection

Cambodia has developed the health equity fund (HEF) system to improve access to health services for the poor, and this strengthens the health system towards the universal health coverage goal. Given rising healthcare costs, Cambodia has introduced several innovations and accomplished considerable progress in improving access to health services and catastrophic health expenditures for the targeted population groups. Though this is improving in recent years, HEF households remain at the higher risk of catastrophic spending as measured by the higher share of HEF households with catastrophic health expenses being at 6.9% compared to the non-HEF households of 5.5% in 2017. Poverty targeting poses another challenge for the health system. Nevertheless, HEF appeared to be more significantly associated with decreased out-of-pocket expenditure per illness among those who sought care from public providers. Increasing population and cost coverages of the HEF and effectively attracting beneficiaries to the public sector will further enhance the financial protection and pave the pathway towards universal coverage. Our recommendations focus on leveraging the HEF experience for expanding coverage and increasing equitable access, as well as strengthening the quality of healthcare services.

Does contracting-out of primary health care services to non-state providers reduce child mortality in South Sudan? A synthetic control analysis

Contracting-out is increasingly utilized as a health system strengthening strategy in lower- and middle-income countries (LMICs), to expand access to health interventions known to reduce child mortality. Existing scholarship suggests its effect has been mixed, limiting a definitive conclusion on its magnitude and direction. There are few studies assessing the impact on under-five mortality rate (U5MR) and fewer evaluations to-date have focused on Sub-Saharan Africa. We test the hypothesis that the contracting-out approach implemented in South Sudan in 2012 led to an observable reduction in U5MR. We use a novel approach, the synthetic control method to construct a synthetic South Sudan from a panel of LMICs using data from the World Bank Developmental Indicators (WDI) database. The analysis shows on average, contracting-out had a limited effect on the rate of decline of U5MR; U5MR declined by 5.2% annually between 2000 and 2011, and by 2.58% between 2012 and 2014. Relative to its synthetic control, U5MR is 2% and 5% higher in 2012 and 2013, continuing to diverge during the observation period. These findings suggest limitations in the contracting approach, and we discuss the possible policy implications of these findings.

Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications

In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities exist between the standard of care in neighbouring countries. While awareness of South-South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regional trade liberalization to perceptions about the quality of care and the pressure of relatives and other advisers in local communities. Furthermore, there is a diversity of medical travels from Cambodia, ranging from first class travels to international hospitals in Bangkok and cross-border 'medical tourism' to perilous overland journeys of poor patients, who regularly resort to borrowing or liquidating assets to cover costs. The implications of the research findings for health sector development and equitable access to care for Cambodians deserve particular attention. To some extent, the increase in medical travels can stimulate improvements in the quality of local health services. However, concerns remain that these developments will mainly affect high-cost private services, widening disparities in access to care between population groups.

Can social accountability mechanisms using community scorecards improve quality of pediatric care in rural Cambodia?

Objective

To determine the effect of social accountability strategies on pediatric quality of care.

Design and Setting

A non-randomized quasi experimental study was conducted in four districts in Cambodia and all operational public health facilities were included.

Participants

Five patients under 5 years and their caretakers were randomly selected in each facility.

Interventions

To determine the effect of maternal and child health interventions integrating citizen voice and action using community scorecards on quality of pediatric care.

Outcome Measures

Patient observations were conducted to determine quality of screening and counseling, followed by exit interviews with caretakers.

Results

Results indicated significant differences between intervention and comparison facilities; screening by Integrated Management of Childhood Illness (IMCI) trained providers (100% vs 67%, P < 0.019), screening for danger signs; ability to drink/breastfeed (100% vs 86.7%, P < 0.041), lethargy (86.7% vs 40%, P < 0.004) and convulsions (83.3 vs 46.7%, P < 0.023). Screening was significantly higher for patients in the intervention facilities for edema (56.7% vs 6.7%, P < 0.000), immunization card (90% vs 40%, P < 0.002), child weight (100 vs 86.7, P < 0.041) and checking growth chart (96.7% vs 66.7%, P < 0.035). The IMCI index, constructed from key performance indicators, was significantly higher for patients in the intervention facilities than comparison facilities (screening index 8.8 vs 7.0, P < 0.018, counseling index 2.7 vs 1.5, P < 0.001). Predictors of screening quality were child age, screening by IMCI trained provider, wealthier quintiles and intervention facilities.

Conclusion

The institution of social accountability mechanisms to engage communities and facility providers showed some improvements in quality of care for common pediatric conditions, but socioeconomic disparities were evident.

Unintended effects of Janani Suraksha Yojana on maternal care in India

Background

The Janani Suraksha Yojana (JSY) is the largest ever conditional cash transfer programme worldwide. It primarily aimed to reduce the maternal and child mortality by increasing the facility based delivery in India. Besides, the JSY has resulted in reduction of out-of-pocket expenditure for delivery care and increased antenatal care. Though studies have examined the direct outcome of JSY, limited studies have attempted to understand the unintended effects (indirect) of the programme. The aim of this study is to examine the effect of JSY on contraceptive use, initiation of breast feeding and postnatal check-up in India.

Data & Methods

Data from the National Family Health Survey 4, 2015-16 was used in the analyses. A total of 148,746 institutional births in five years preceding the survey were analysed and the analyses were carried out for Low Performing States (LPS) and High Performing States (HPS). Descriptive statistics and the propensity score matching were used to understand the unintended effects of JSY.

Results

In India, the use of contraception, early initiation of breastfeeding and postnatal check up was consistently higher among JSY beneficiaries compared to non-JSY beneficiaries. Among JSY beneficiaries, about 45% of the mothers breastfed their child within one hour compared to 42% of the JSY non-beneficiaries. The pattern was almost similar for postnatal check-up. The variations in contraceptive use, breastfeeding practice and postnatal check-up among JSY beneficiaries were higher in LPS states compared to HPS. For instance, in LPS, among JSY beneficiaries, about 58% mothers breastfed their child within one hour of delivery compared to 46% in HPS. Controlling for socio-economic covariates, the JSY beneficiaries in LPS were 12% more likely to use contraception, 8% were more likely to initiate the breast feeding within one hour of child delivery and 6% were more likely to get their postnatal check-up than their counterparts in HPS.

Discussion

The unintended effects of JSY were strong and significant in the low performing states. The coverage of JSY should be further extended and the programme needs to be continued.

Can social accountability improve access to free public health care for the poor? Analysis of three Health Equity Fund configurations in Cambodia, 2015–17

Within the context of universal health coverage, community participation has been identified as instrumental to facilitate access to health services. Social accountability whereby citizens hold providers and policymakers accountable is one popular approach. This article describes one example, that of Community-Managed Health Equity Funds (CMHEFs), as an approach to community engagement in Cambodia to improve poor people’s use of their entitlement to fee-free health care at public health facilities. The objectives of this article are to describe the size of its operations and its ability to enable poor people continued access to health care. Using data collected routinely, we compare the uptake of curative health services by eligible poor people under three configurations of Health Equity Funds (HEFs) during a 24-month period (July 2015–June 2017): Standard HEF that operated without community engagement, Mature CMHEFs established years before the study period and New CMHEFs initiated just before the study period. One year within the study, non-governmental organizations (NGOs) stopped operating the HEF nationwide and only the community-participation aspects of New CMHEF continued receiving technical assistance from an NGO. Using utilization figures for curative services by non-poor people for comparison, following the cessation of HEF management by the NGOs, outpatient consultation figures declined for all three configurations in comparison with the year before but only significantly for Standard HEF. The three HEF configurations experienced a highly statistically significant reduction in monthly inpatient admissions following halting of NGO management of HEFs. This study shows that enhancing access to free health care through social accountability is optimized at health centres through engagement of a wide range of community representatives. Such effect at hospitals was only observed to a limited extent, suggesting the need for more engagement of hospital management authorities in social accountability mechanisms.

Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy

Cambodia’s healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012–14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of −0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.

Costing for universal health coverage: insight into essential economic data from three provinces in Cambodia

BACKGROUND

Knowledge of the costs of health services improves health facility management and aids in health financing for universal health coverage. Because of resource requirements that are often not present in low- and middle-income countries, costing exercises are rare and infrequent. Here we report findings from the initial phase of establishing a routine costing system for health services implemented in three provinces in Cambodia.

METHODS

Data was collected for the 2016 financial year from 20 health centres (including four with beds) and five hospitals (three district hospitals and two provincial hospitals). The costs to the providers for health centres were calculated using step-down allocations for selected costing units, including preventive and curative services, delivery, and patient contact, while for hospitals this was complemented with bed-day and inpatient day per department. Costs were compared by type of facility and between provinces.

RESULTS

All required information was not readily available at health facilities and had to be recovered from various sources. Costs per outpatient consultation at health centres varied between provinces (from US$2.33 to US$4.89), as well as within provinces. Generally, costs were inversely correlated with the quantity of service output. Costs per contact were higher at health centres with beds than health centres without beds (US$4.59, compared to US$3.00). Conversely, costs for delivery were lower in health centres with beds (US$128.7, compared to US$413.7), mainly because of low performing health centres without beds. Costs per inpatient-day varied from US$27.61 to US$55.87 and were most expensive at the lowest level hospital.

CONCLUSIONS

Establishing a routine health service costing system appears feasible if recording and accounting procedures are improved. Information on service costs by health facility level can provide useful information to optimise the use of available financial and human resources.

Enteric Fever in Cambodia: Community Perceptions and Practices Concerning Disease Transmission and Treatment

Enteric fever is a systemic bacterial infection in humans that is endemic in Cambodia and for which antibiotic resistance is increasingly reported. To guide public health programs, this qualitative study sought to explore community perceptions on transmission and treatment. Participant observation was carried out in hospital settings, pharmacies, and at a community level in Phnom Penh. In-depth interviews 39 and one focus group discussion were carried out with blood culture–confirmed enteric fever patients and purposively selected key informants. Informants were theoretically sampled based on initial themes identified using abductive analysis. Nvivo 11 was used for thematic coding. An urgent need to address health literacy concerning the transmission of enteric fever was identified, as lay informants did not link the disease and its symptoms to bacterial contamination of foods and drinks but rather to foods considered “bad” following humoral illness interpretations. As a result, lay informants considered recurrence of enteric fever preventable with appropriate dietary restrictions and Khmer traditional medicines. This study also reveals pluralistic health-care–seeking behavior. For initial and mild symptoms, patients preferred home treatment or traditional healing practices; limited household finances delayed treatment seeking. When symptoms persisted, patients first visited drug outlets or private practitioners, where they received a mix of nonessential medicines and one or more antibiotics often without prescription or confirmation of diagnosis. Inappropriate use of antibiotics was common and was related to diagnostic uncertainty and limited finances, factors which should be addressed during future efforts to improve the uptake of appropriate diagnostics and treatment of enteric fever.

Equality in financial access to healthcare in Cambodia from 2004 to 2014

Since the end of its internal conflict in 1998, Cambodia has experienced tremendous developments in the social, economic and health sectors, with the government embarking on substantial reforms in health financing. Health equity funds that have improved access to public health services for poor people have gradually been extended to the entire country. Using the World Health Organization's methods for the analysis of healthcare expenditure and household survey data from the 2004, 2009 and 2014 Cambodian Socio-Economic Survey, we assessed trends in reported illness, utilization of healthcare services and associated financial burden on households. The impact of out-of-pocket expenditures for health on catastrophic health expenditures, poverty headcount and depth over the same 10-year period are presented, disaggregated by consumption quintile and place of residence (rural, urban and capital). At the aggregated national level, evolution of these indicators was very positive and correlates with a substantial increase in the capacity-to-pay of households, which reduced the average financial burden on households. However, over time inequalities grew between rural and urban areas. By 2014, the national incidence of catastrophic health expenditure was 4.9%, but four times more likely among rural households than their peers in the capital. For rural households with members seeking medical care, catastrophic health expenditure incidence was 12.3%. The impoverishment rate due to health spending among the lowest consumption quintile was 15.3%; the highest rate in this analysis. These findings suggest that economic and health sector developments have indeed benefited many Cambodian people. However, these gains mainly benefited urban residents; especially those in the capital city. We argue that more resources should be allocated to rural health services to address inequalities and healthcare-related financial hardship, which traps vulnerable people into poverty.

IDPoor: a poverty identification programme that enables collaboration across sectors for maternal and child health in Cambodia

Mary White Kaba and colleagues describe how Cambodia’s national poverty identification system, IDPoor, has provided a nexus for different sectors’ contributions to maternal and child health among the poor

Health insurance and social capital in Ghana: a cluster randomised controlled trial

BACKGROUND

The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003, enrolment is still far from the desired target of universal coverage. Low community engagement in the design and management of the system was identified as one of the main barriers. The aim of the current study was to explore the role of social capital in NHIS enrolment in two regions of Ghana, Western and Greater Accra.

METHODS

The study involved a cluster-randomised controlled trial of 3246 clients of 64 healthcare facilities who completed both a baseline and a follow-up survey. Thirty-two facilities were randomly selected to receive two types of intervention. The remaining facilities served as control. The interventions were co-designed with stakeholders. Baseline and follow up surveys included measures of different types of social capital, as well as enrolment in the health insurance scheme.

RESULTS

The study found that the interventions encouraged NHIS enrolment (from 40.29 to 49.39% (intervention group) versus 36.49 to 36.75% (control group)). Secondly, certain types of social capital are associated with increased enrolment (log-odds ratios (p-values) of three types of vertical social capital are 0.127 (< 0.01), 0.0952 (< 0.1) and 0.15 (< 0.01)). Effectiveness of the interventions was found dependent on initial levels of social capital: respondents with lowest measured level of interpersonal trust in the intervention group were about 25% more likely to be insured than similar respondents in the control group. Among highly trusting respondents this difference was insignificant. There was however no evidence that the interventions effect social capital. Limitations of the study are discussed.

CONCLUSION

We showed that the interventions helped to increase enrolment but that the positive effect was not realized by changes in social capital that we hypothesised based on result of the first phase of our study. Future research should aim to identify other community factors that are part of the enrolment process, whether other interventions to improve the quality of services could help to increase enrolment and, as a result, could provide community benefits in terms of social capital.Our findings can guide the NHIS in Ghana and other health organizations to enhance enrolment.

TRIAL REGISTRATION

Ethical Clearance by Ghana Health Service Ethical Committee No. GHS-ERC 08.5.11.

Out-of-Pocket Household Expenditures on Medical Injections in Cambodia

BACKGROUND

Cambodia has one of the highest rates of overall medical injection usage worldwide. Therapeutic injections, which are often unnecessary, contribute to the spread of blood-borne diseases.

OBJECTIVE

This study describes injection practices and associated household expenditures in rural northwest Cambodia.

METHODS

We assessed care-seeking patterns of surveyed adult family members who sought healthcare in the previous 30 days, including location of care, medical injection use, and out-of-pocket household expenditures for treatment. A regression model was used to explore the impact of injection use on out-of-pocket household expenditures.

RESULTS

Among 480 households sampled, 298 included members who had been sick within the previous 30 days; a total of 342 episodes of care had been sought. Private providers accounted for over 66% (n = 226) of all episodes of care, with public and informal providers accounting for 20% (n = 69) and 14% (n = 47), respectively. Injections were administered in over 120 (35%) episodes of care, with 81% of injections administered by private providers. Patients who received injections incurred total out-of-pocket household expenditures that were, on average, 126,590 Cambodian Riel (KHR) (US$31.65) higher than those who did not receive injections (p < 0.01), equivalent to nearly half of the country's total annual health expenditure per capita. Receiving injections and perceived severity of illness were significantly associated with higher out-of-pocket household expenditures.

CONCLUSION

This study found high levels of medical injection use, particularly among private healthcare providers, which was significantly associated with high healthcare expenditures. Reducing the number of medical injections would not only reduce disease transmission risk but also contribute to reduced healthcare costs and greater financial protection.

Methods to improve quality performance at scale in lower- and middle-income countries

Universal Health Coverage is one of the Sustainable Development Goal targets. But coverage without quality health services limits benefits to populations. Performance-based financing programs (PBF) use strategic purchasing of services to expand coverage and promote quality by measuring quality and rewarding good performance. The widespread presence of PBF programs in lower and middle-income countries provide an opportunity to introduce and test new approaches for measuring and improving quality at scale. This article describes four approaches to improve quality of health services at scale in PBF programs. These approaches looked at structural and process measures of quality as well as outcome measures like patient satisfaction. Three types of tools were used in these approaches: clinical vignettes, competency tests and patient satisfaction surveys. Specific tools within each of the approaches are used in Kyrgyzstan, Cambodia, Democratic Republic of Congo and the Republic of Congo.

How much do conditional cash transfers increase the utilization of maternal and child health care services? New evidence from Janani Suraksha Yojana in India

Janani Suraksha Yojana (safe motherhood scheme, or JSY) provides cash incentives to marginal pregnant women in India conditional on having mainly institutional delivery. Using the fourth round of district level household survey (DLHS-4), we have estimated its effects on both intended and unintended outcomes. Our estimates of average treatment effect on the treated (ATT) from propensity score matching are remarkably higher than those found in previous prominent studies using the second and third rounds of the survey (DLHS-2 and DLHS-3). When we apply fuzzy regression discontinuity design exploiting the second birth order, our estimates of local average treatment effect (LATE) are much higher than that of ATT. For example, due to JSY, institutional delivery increases by around 16 percentage points according to ATT estimate but about 23 percentage points according to LATE estimate.

The effect of costs on Kenyan households' demand for medical care: why time and distance matter

In an environment of constrained resources, policymakers must identify solutions for financing and delivering health services that are efficient and sustainable. However, such solutions require that policymakers understand the complex interaction between household utilization patterns, factors influencing household medical decisions, and provider performance. This study examined whether and under what conditions out-of-pocket, transportation, and time costs influenced Kenyan households' choice of medical provider for childhood diarrhoeal illnesses. It compared these decisions with the actual cost and quality of those providers to assess strategies for increasing the utilization of high quality, low-cost primary care. This study analyzed nationally-representative survey data through several multinomial nested logit models. On average, time costs accounted for the greatest share of total costs. Households spent the most time and transportation costs utilizing public care, yet were more likely to incur catastrophic time and out-of-pocket costs seeking private care for their child's diarrhoeal illness. Out-of-pocket, transportation, and time costs influenced households' choice of provider, though demand was cost inelastic and households were most responsive to transportation costs. Poorer households were the most responsive to changes in all cost types and most likely to self-treat or utilize informal care. Many households utilized informal care that, relative to formal care, cost the same but was of worse quality-suggesting that such households were making poor medical decisions for their children. To achieve public policy objectives, such as financial risk protection for childhood illnesses and equitable access to primary care, policymakers could focus on three areas: (1) refine financing strategies for further reducing household out-of-pocket costs; (2) reduce or subsidize time and transportation costs for households seeking public and private care; and (3) increase transparency of costs and quality to improve household decisions.

Management towards financial sustainability for private health companies

Purpose

The purpose of this study was to identify a set of management practices towards financial sustainability for Brazilian private health insurance and plans companies.

Design/methodology/approach

The present paper uses a bimodal two-step approach. The first step was quantitative, with the data envelopment analysis (DEA) technique in 521 Brazilian private health companies (PHCs). At this stage, the objective was to obtain scores to rank the PHCs regarding their financial performance and services in 2013. From the quantitative analysis, two PHCs displaying contrasting performances were selected and interviewed to identify differentiating management practices.

Findings

The Group Medicine PHCs displayed a higher performance in the financial approach. Following the qualitative comparative analysis, the financially sustainable PHC presented the following differentials: a high level of financial management professionalization, a deliberate policy for the control and prevention of claims and a larger share of revenues from health plans over service revenues.

Research limitations/implications

However, a limitation of the study lies in the fact that by not using any cash flow or financial result variables, the financial efficiency model used in the study does not evaluate the generation capacity of long-term results. It is noteworthy that, because it is a multiple case study, the results found cannot be generalized and should be understood only as characteristics of the studied PHCs in here.

Practical implications

The present paper can contribute to managers of Brazilian PCHs towards the implementation of management tools aimed at the sustainability of those organizations.

Originality/value

Despite the importance of the Supplemental Health Insurance System for public health in Brazil, PHCs have received a high volume of complaints and struggled with constant financial problems.

Changes in catastrophic health expenditure in post-conflict Sierra Leone: an Oaxaca-blinder decomposition analysis

Background

At the end of the eleven-year conflict in Sierra Leone, a wide range of policies were implemented to address both demand- and supply-side constraints within the healthcare system, which had collapsed during the conflict. This study examines the extent to which households’ exposure to financial risks associated with seeking healthcare evolved in post-conflict Sierra Leone.

Method

This study uses the 2003 and 2011 cross-sections of the Sierra Leone Integrated Household Survey to examine changes in catastrophic health expenditure between 2003 and 2011. An Oaxaca-Blinder decomposition approach is used to quantify the extent to which changes in catastrophic health expenditure are attributable to changes in the distribution of determinants (distributional effect) and to changes in the impact of these determinants on the probability of incurring catastrophic health expenditure (coefficient effect).

Results

The incidence of catastrophic health expenditure decreased significantly by 18% from approximately 50% in 2003 t0 32% in 2011. The decomposition analysis shows that this decrease represents net effects attributable to the distributional and coefficient effects of three determinants of catastrophic health expenditure – ill-health, the region in which households reside and the type of health facility used. A decrease in the incidence of ill-health and changes in the regional location of households contributed to a decrease in catastrophic health expenditure. The distributional effect of health facility types observed as an increase in the use of public health facilities, and a decrease in the use of services in facilities owned by non-governmental organizations (NGOs) also contributed to a decrease in the incidence of catastrophic health expenditure. However, the coefficient effect of public health facilities and NGO-owned facilities suggests that substantial exposure to financial risk remained for households utilizing both types of health facilities in 2011.

Conclusion

The findings support the need to continue expanding current demand-side policies in Sierra Leone to reduce the financial risk of exposure to ill health.

Leaving no one behind: lessons on rebuilding health systems in conflict- and crisis-affected states

Conflict and fragility are increasing in many areas of the world. This context has been referred to as the 'new normal' and affects a billion people. Fragile and conflict-affected states have the worst health indicators and the weakest health systems. This presents a major challenge to achieving universal health coverage. The evidence base for strengthening health systems in these contexts is very weak and hampered by limited research capacity, challenges relating to insecurity and apparent low prioritisation of this area of research by funders. This article reports on findings from a multicountry consortium examining health systems rebuilding post conflict/crisis in Sierra Leone, Zimbabwe, northern Uganda and Cambodia. Across the ReBUILD consortium's interdisciplinary research programme, three cross-cutting themes have emerged through our analytic process: communities, human resources for health and institutions. Understanding the impact of conflict/crisis on the intersecting inequalities faced by households and communities is essential for developing responsive health policies. Health workers demonstrate resilience in conflict/crisis, yet need to be supported post conflict/crisis with appropriate policies related to deployment and incentives that ensure a fair balance across sectors and geographical distribution. Postconflict/crisis contexts are characterised by an influx of multiple players and efforts to support coordination and build strong responsive national and local institutions are critical. The ReBUILD evidence base is starting to fill important knowledge gaps, but further research is needed to support policy makers and practitioners to develop sustainable health systems, without which disadvantaged communities in postconflict and postcrisis contexts will be left behind in efforts to promote universal health coverage.