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Waterworth CJ, Marella M, Bhutta MF, Dowell R, Khim K, Annear PL. Access to ear and hearing care services in Cambodia: a qualitative enquiry into experiences of key informants. J Laryngol Otol 2024; 138:22-32. [PMID: 36154944 PMCID: PMC10772024 DOI: 10.1017/s0022215122002158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE In Cambodia, little is known about the state of ear and hearing care, or the roles providers or key stakeholders play in delivering services. METHOD This was an exploratory study using semi-structured qualitative interviews and a questionnaire addressed to key stakeholders to explore their perceptions and experiences in providing services to people suffering from ear disease or hearing loss in Cambodia. RESULTS Several challenges were described including a lack of hearing services to meet the demand, especially outside Phnom Penh in primary care and aural rehabilitation. Supply-side challenges include a shortage of trained professionals, facilities and resources, poor co-ordination between providers, unclear referral pathways, and long wait times. CONCLUSION Now is an opportune time to build on the positive trend in providing integrated care for non-communicable diseases in Cambodia, through the integration of effective ear and hearing care into primary care and strengthening the package of activities delivered at government facilities.
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Affiliation(s)
- C J Waterworth
- Department of Audiology and Speech Pathology, University of Melbourne, Australia
- Nossal Institute for Global Health, University of Melbourne, Australia
| | - M Marella
- Nossal Institute for Global Health, University of Melbourne, Australia
| | - M F Bhutta
- Clinical and Experimental Medicine, Brighton & Sussex Medical School, Brighton, UK
- Department of ENT, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - R Dowell
- Department of Audiology and Speech Pathology, University of Melbourne, Australia
| | - K Khim
- Monitoring, Evaluation and Learning, Access Program, Phnom Penh, Cambodia
| | - P L Annear
- Nossal Institute for Global Health, University of Melbourne, Australia
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2
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Teo AKJ, Morishita F, Islam T, Viney K, Ong CW, Kato S, Kim H, Liu Y, Oh KH, Yoshiyama T, Ohkado A, Rahevar K, Kawatsu L, Yanagawa M, Prem K, Yi S, Tran HTG, Marais BJ. Tuberculosis in older adults: challenges and best practices in the Western Pacific Region. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 36:100770. [PMID: 37547037 PMCID: PMC10398605 DOI: 10.1016/j.lanwpc.2023.100770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/18/2023] [Accepted: 04/02/2023] [Indexed: 08/08/2023]
Abstract
The Western Pacific has one of the fastest-growing older adult populations globally, and tuberculosis (TB) remains one of the foremost infectious causes of disease and death in the region. Older adults are at higher risk of TB due to immunosenescence, comorbidities, and increased institutionalisation. Atypical symptoms and reduced access to health services may delay care-seeking and TB diagnosis, while co-morbidity and increased risk of adverse drug reactions complicate TB treatment. Post-TB sequelae and socioeconomic challenges may decrease the quality of life after TB treatment completion. Despite their high disease burden and special challenges, there is a lack of regionally coordinated policies and guidelines to manage TB among older adults. Routine TB screening at aged-care facilities, age-friendly infrastructure and services, awareness of atypical TB features, integration of TB and non-communicable diseases services, and person-centred approaches to treatment support could improve TB management among older adults. Addressing these challenges and adopting the best practices identified should inform policy formulation and implementation. Funding This project was funded by 1) the World Health Organization Regional Office for the Western Pacific, with financial contributions from the Government of the Republic of Korea through the Korean Disease Control and Prevention Agency and the Government of Japan through the Ministry of Health, Labour and Welfare, and 2) NUS Start-up Grant. The funders had no role in the paper design, collection, analysis, and interpretation of data and in writing of the paper.
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Affiliation(s)
- Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW, Australia
| | - Fukushi Morishita
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Tauhid Islam
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Kerri Viney
- World Health Organization, Global Tuberculosis Programme, Geneva, Switzerland
| | - Catherine W.M. Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, National University of Singapore, Singapore, Singapore
- Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore, Singapore
- Institute of Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore
| | - Seiya Kato
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - HeeJin Kim
- Korean National Tuberculosis Association, Seoul, Republic of Korea
| | - Yuhong Liu
- Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Kyung Hyun Oh
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Takashi Yoshiyama
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Akihiro Ohkado
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Kalpeshsinh Rahevar
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Lisa Kawatsu
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Manami Yanagawa
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Kiesha Prem
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Center for Global Health Research, Public Health Program, Touro University California, Vallejo, CA, USA
| | - Huong Thi Giang Tran
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Ben J. Marais
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW, Australia
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3
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Kaiser AH, Okorafor O, Ekman B, Chhim S, Yem S, Sundewall J. Assessing progress towards universal health coverage in Cambodia: Evidence using survey data from 2009 to 2019. Soc Sci Med 2023; 321:115792. [PMID: 36842307 DOI: 10.1016/j.socscimed.2023.115792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/27/2022] [Accepted: 02/17/2023] [Indexed: 02/22/2023]
Abstract
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.
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Affiliation(s)
- Andrea Hannah Kaiser
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden; Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH Cambodia, Improving Social Protection and Health Project, Sayon Building, Samdach Pan Ave No. 41, 12211, Phnom Penh, Cambodia.
| | - Okore Okorafor
- Forte Metrix Consulting, 58 Sara Circle, Langeberg Heights, Durbanville, 7550, Western Cape, South Africa.
| | - Björn Ekman
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden.
| | - Srean Chhim
- National Institute of Public Health Cambodia, Lot 80, Street 566 & Corner with Street 289, Boeung Kak 2, Toul Kork, Phnom Penh, Cambodia.
| | - Sokunthea Yem
- National Institute of Public Health Cambodia, Lot 80, Street 566 & Corner with Street 289, Boeung Kak 2, Toul Kork, Phnom Penh, Cambodia.
| | - Jesper Sundewall
- Lund University, Department of Clinical Sciences, Malmö (IKVM), Division of Social Medicine and Global Health (SMGH), CRC, Jan Waldenströms Gata 35, Malmö, Sweden; HEARD, University of KwaZulu-Natal, South Africa.
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Koy S, Fuerst F, Tuot B, Starke M, Flessa S. The Flipped Break-Even: Re-Balancing Demand- and Supply-Side Financing of Health Centers in Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1228. [PMID: 36674006 PMCID: PMC9858853 DOI: 10.3390/ijerph20021228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Supply-side healthcare financing still dominates healthcare financing in many countries where the government provides line-item budgets for health facilities irrespective of the quantity or quality of services rendered. There is a risk that this approach will reduce the efficiency of services and the value of money for patients. This paper analyzes the situation of public health centers in Cambodia to determine the relevance of supply- and demand-side financing as well as lump sum and performance-based financing. Based on a sample of the provinces of Kampong Thom and Kampot in the year 2019, we determined the income and expenditure of each facility and computed the unit cost with comprehensive step-down costing. Furthermore, the National Quality Enhancement Monitoring Tool (NQEMT) provided us with a quality score for each facility. Finally, we calculated the efficiency as the quotient of quality and cost per service unit as well as correlations between the variables. The results show that the largest share of income was received from supply-side financing, i.e., the government supports the health centers with line-item budgets irrespective of the number of patients and the quality of care. This paper demonstrates that the efficiency of public health centers increases if the relevance of performance-based financing increases. Thus, the authors recommend increasing performance-based financing in Cambodia to improve value-based healthcare. There are several alternatives available to re-balance demand- and supply-side financing, and all of them must be thoroughly analyzed before they are implemented.
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Affiliation(s)
- Sokunthea Koy
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Franziska Fuerst
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Bunnareth Tuot
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Maurice Starke
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Steffen Flessa
- Department of Health Care Management, University of Greifswald, 17487 Greifswald, Germany
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5
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Han D, Nagpal S, Bauhoff S. The Quality of Primary Care in Cambodia: An Assessment of Knowledge and Effort of Public Sector Maternal and Child Care Providers. Health Syst Reform 2022; 8:2124903. [PMID: 36174665 DOI: 10.1080/23288604.2022.2124903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
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.
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Affiliation(s)
- Dan Han
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore
| | - Somil Nagpal
- Global Practice on Health, Nutrition and Population, Jakarta, Indonesia
| | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
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6
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Feldhaus I, Nagpal S, Bauhoff S. Role of User Benefit Awareness in Health Coverage Utilization among the Poor in Cambodia. Health Syst Reform 2022; 8:e2058336. [PMID: 35583478 DOI: 10.1080/23288604.2022.2058336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
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.
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Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Somil Nagpal
- Global Practice on Health, Nutrition, and Population, World Bank Group, Washington, DC, USA
| | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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7
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Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia. PLoS One 2021; 16:e0259628. [PMID: 34739523 PMCID: PMC8570764 DOI: 10.1371/journal.pone.0259628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022] Open
Abstract
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.
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8
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Jithitikulchai T, Feldhaus I, Bauhoff S, Nagpal S. Health equity funds as the pathway to universal coverage in Cambodia: care seeking and financial risk protection. Health Policy Plan 2021; 36:26-34. [PMID: 33332527 DOI: 10.1093/heapol/czaa151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Theepakorn Jithitikulchai
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.,World Bank Group, 1818 H Street, Washington, DC 20433, USA
| | - Isabelle Feldhaus
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Sebastian Bauhoff
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Somil Nagpal
- World Bank Group, 1818 H Street, Washington, DC 20433, USA
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Suzuki A, Matsui M, Tung R, Iwamoto A. "Why did our baby die soon after birth?"-Lessons on neonatal death in rural Cambodia from the perspective of caregivers. PLoS One 2021; 16:e0252663. [PMID: 34097710 PMCID: PMC8183999 DOI: 10.1371/journal.pone.0252663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/19/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Neonatal deaths represent around half the deaths of children less than five-years old in Cambodia. The process from live birth to neonatal death has not been well described. This study aimed to identify problems in health care service which hamper the reduction of preventable neonatal deaths in rural Cambodia. METHODS This study adopted a method of qualitative case study design using narrative data from the verbal autopsy standard. Eighty and forty villages were randomly selected from Kampong Cham and Svay Rieng provinces, respectively. All households in the target villages were visited between January and February 2017. Family caregivers were asked to describe their experiences on births and neonatal deaths between 2015 and 2016. Information on the process from birth to death was extracted with open coding, categorized, and summarized into several groups which represent potential problems in health services. RESULTS Among a total of 4,142 children born in 2015 and 2016, 35 neonatal deaths were identified. Of these deaths, 74% occurred within one week of birth, and 57% were due to low-birth weight. Narrative data showed that three factors should be improved, 1) the unavailability of a health-care professional, 2) barriers in the referral system, and 3) lack of knowledge and skill to manage major causes of neonatal deaths. CONCLUSION The current health system has limitations to achieve further reduction of neonatal deaths in rural Cambodia. The mere deployment of midwives at fixed service points such as health centers could not solve the problems occurring in rural communities. Community engagement revisiting the principle of primary health care, as well as health system transformation, is the key to the solution and potential breakthrough for the future.
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Affiliation(s)
- Ayako Suzuki
- Project for Improving Continuum of Care with focus on Intrapartum and Neonatal Care in Cambodia, Japan International Cooperation Agency, Phnom Penh, Cambodia
| | - Mitsuaki Matsui
- Project for Improving Continuum of Care with focus on Intrapartum and Neonatal Care in Cambodia, Japan International Cooperation Agency, Phnom Penh, Cambodia
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Nagasaki, Japan
| | - Rathavy Tung
- Project for Improving Continuum of Care with focus on Intrapartum and Neonatal Care in Cambodia, Japan International Cooperation Agency, Phnom Penh, Cambodia
- National Maternal and Child Health Center, Phnom Penh, Cambodia
| | - Azusa Iwamoto
- Project for Improving Continuum of Care with focus on Intrapartum and Neonatal Care in Cambodia, Japan International Cooperation Agency, Phnom Penh, Cambodia
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
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Teo AKJ, Ork C, Eng S, Sok N, Tuot S, Hsu LY, Yi S. Determinants of delayed diagnosis and treatment of tuberculosis in Cambodia: a mixed-methods study. Infect Dis Poverty 2020; 9:49. [PMID: 32381122 PMCID: PMC7203857 DOI: 10.1186/s40249-020-00665-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background Cambodia is among the 30 countries in the world with the highest burden of tuberculosis (TB), and it is estimated that 40% of people with TB remain undiagnosed. In this study, we aimed to investigate the determinants of delayed diagnosis and treatment of TB in Cambodia. Methods This mixed-method explanatory sequential study was conducted between February and September 2019 in 12 operational districts in Cambodia. It comprised of a retrospective cohort study of 721 people with TB, followed by a series of in-depth interviews. We assessed factors associated with time to TB diagnosis and treatment initiation using Cox proportional hazards model. Subsequently, we conducted in-depth interviews with 31 people with TB purposively selected based on the time taken to reach TB diagnosis, sex, and residence. Transcripts were coded, and thematic analyses were performed. Results The median time from the onset of symptoms to TB diagnosis was 49 days (Interquartile range [IQR]: 21–112). We found that longer time to diagnosis was significantly associated with living in rural area (Adjusted hazards ratio [aHR] = 1.25; 95% confidence interval [CI]: 1.06–1.48); TB symptoms—cough (aHR: 1.52; 95% CI: 1.18–1.94), hemoptysis (aHR 1.32; 95% CI: 1.07–1.63), and night sweats (aHR: 1.24; 95% CI: 1.05–1.46); seeking private health care/self-medication (aHR: 1.23; 95% CI: 1.04–1.45); and higher self-stigma (aHR: 1.02; 95% CI: 1.01–1.03). Participants who received education level above the primary level were inversely associated with longer time to diagnosis (aHR: 0.78; 95% CI: 0.62–0.97). The median time from TB diagnosis to the initiation of treatment was two days (IQR: 1–3). The use of smear microscopy for TB diagnosis (aHR: 1.50; 95% CI: 1.16–1.95) was associated with longer time to treatment initiation. Seeking private health care and self-medication before TB diagnosis, lack of perceived risk, threat, susceptibility, and stigma derived qualitatively further explained the quantitative findings. Conclusions TB diagnostic delay was substantial. Increasing public awareness about TB and consciousness regarding stigma, engaging the private healthcare providers, and tailoring approaches targeting the rural areas could further improve early detection of TB and narrowing the gap of missing cases in Cambodia.
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Affiliation(s)
- Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore.
| | - Chetra Ork
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Sothearith Eng
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Ngovlyly Sok
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Sovannary Tuot
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore.,KHANA Center for Population Health Research, Phnom Penh, Cambodia.,Center for Global Health Research, Touro University California, Vallejo, USA.,School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
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11
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Jacobs B, Sam Oeun S, Ir P, Rifkin S, Van Damme W. Can social accountability improve access to free public health care for the poor? Analysis of three Health Equity Fund configurations in Cambodia, 2015–17. Health Policy Plan 2020; 35:635-645. [DOI: 10.1093/heapol/czaa019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/31/2022] Open
Abstract
AbstractWithin 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.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Project, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
- Social Health Protection Network P4H, Phnom Penh, Cambodia
| | - Sam Sam Oeun
- Buddhism for Health, National Road 1, Borey Peng Huoth, #64, St. P-10E Khan Chbar Ampov, Phnom Penh, Cambodia
| | - Por Ir
- Technical Bureau, National Institute of Public Health, lot no. 80, Samdach Penn Nouth Blvd (St. 289), Phnom Penh, Cambodia
| | - Susan Rifkin
- Distance Learning, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Wim Van Damme
- Public Health Department, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
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12
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Saulnier DD, Hean H, Thol D, Ir P, Hanson C, Von Schreeb J, Mölsted Alvesson H. Staying afloat: community perspectives on health system resilience in the management of pregnancy and childbirth care during floods in Cambodia. BMJ Glob Health 2020; 5:e002272. [PMID: 32332036 PMCID: PMC7204936 DOI: 10.1136/bmjgh-2019-002272] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/27/2020] [Accepted: 03/30/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Resilient health systems have the capacity to continue providing health services to meet the community's diverse health needs following floods. This capacity is related to how the community manages its own health needs and the community and health system's joined capacities for resilience. Yet little is known about how community participation influences health systems resilience. The purpose of this study was to understand how community management of pregnancy and childbirth care during floods is contributing to the system's capacity to absorb, adapt or transform as viewed through a framework on health systems resilience. METHODS Eight focus group discussions and 17 semi-structured interviews were conducted with community members and leaders who experienced pregnancy or childbirth during recent flooding in rural Cambodia. The data were analysed by thematic analysis and discussed in relation to the resilience framework. RESULTS The theme 'Responsible for the status quo' reflected the community's responsibility to find ways to manage pregnancy and childbirth care, when neither the expectations of the health system nor the available benefits changed during floods. The theme was informed by notions on: i) developmental changes, the unpredictable nature of floods and limited support for managing care, ii) how information promoted by the public health system led to a limited decision-making space for pregnancy and childbirth care, iii) a desire for security during floods that outweighed mistrust in the public health system and iv) the limits to the coping strategies that the community prepared in case of flooding. CONCLUSIONS The community mainly employed absorptive strategies to manage their care during floods, relieving the burden on the health system, yet restricted support and decision-making may risk their capacity. Further involvement in decision-making for care could help improve the health system's resilience by creating room for the community to adapt and transform when experiencing floods.
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Affiliation(s)
- Dell D Saulnier
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Hom Hean
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Dawin Thol
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Department of Preventive Medicine, Phnom Penh, Cambodia
| | - Por Ir
- Technical Bureau, National Institute of Public Health, Phnom Penh, Cambodia
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Johan Von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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13
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Ir P, Jacobs B, Asante AD, Liverani M, Jan S, Chhim S, Wiseman V. Exploring the determinants of distress health financing in Cambodia. Health Policy Plan 2020; 34:i26-i37. [PMID: 31644799 PMCID: PMC6807511 DOI: 10.1093/heapol/czz006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2019] [Indexed: 11/14/2022] Open
Abstract
Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty-the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt-even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.
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Affiliation(s)
- Por Ir
- National Institute of Public Health, Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Augustine D Asante
- School of Public Health & Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, UK
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, 1 King St Newtown, New South Wales, Australia
| | - Srean Chhim
- National Institute of Public Health, Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, UK.,Kirby Institute, University of New South Wales, Wallace Wurth Building, High St, Kensington NSW, Australia
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14
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Asante AD, Ir P, Jacobs B, Supon L, Liverani M, Hayen A, Jan S, Wiseman V. Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy. Health Policy Plan 2020; 34:i4-i13. [PMID: 31644800 PMCID: PMC6807515 DOI: 10.1093/heapol/czz011] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Augustine D Asante
- School of Public Health & Community Medicine, University of New South Wales (UNSW) Sydney, Kensington NSW, Australia
| | - Por Ir
- National Institute of Public Health, Lot no 80, Street 289, Phnom Penh, Cambodia
| | - Bart Jacobs
- National Institute of Public Health, Lot no 80, Street 289, Phnom Penh, Cambodia
| | | | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, Kings Cross, London, UK.,Faculty of Public Health, Mahidol University, Bangkok, Thailand.,School of Tropical Medicine and Global Health, Nagasaki University, Japan
| | - Andrew Hayen
- University of Technology Sydney (UTS), 15 Broadway, Ultimo NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, Newtown, Australia.,University of New South Wales (UNSW Sydney), Kensington NSW, Australia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, Kings Cross, London, UK.,Kirby Institute for Infections and Immunity, University of New South Wales (UNSW Sydney), Level 6, Wallace Wurth Building, High Street, Kensington NSW, Australia
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15
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Treleaven E. Migration and investments in the health of children left behind: the role of remittances in children's healthcare utilization in Cambodia. Health Policy Plan 2019; 34:684-693. [PMID: 31539036 DOI: 10.1093/heapol/czz076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2019] [Indexed: 01/05/2023] Open
Abstract
Remittances, financial support from family members who have migrated for work, are an increasingly important source of income for households left behind in many lower- and middle-income countries. While remittances have been shown to affect the health status of children left behind, evidence is very limited as to whether and how they affect children's healthcare utilization. Yet, this is an important consideration for policymakers seeking to improve equitable access to quality care in settings where migration is common. I examine whether children under age five whose household receives remittances are more likely to utilize higher quality healthcare providers than those without remittances in Cambodia, a country with high rates of migration and a pluralistic health system. The analysis includes 2230 children reporting recent illness in three waves of the Cambodia Socio-Economic Survey with data on migration, remittances and children's health expenditures. I use mixed-effects and fixed-effects regression analysis to estimate the effect of remittances on children's likelihood of entering care with a formally trained provider, and among those attending a formally trained provider, likelihood of using a public-sector facility. Treatment expenditures are lower among households with remittances, while transportation expenditures do not vary significantly by remittance status. In mixed-effects and fixed-effect regression models, children who receive remittances have a lower likelihood of utilizing qualified providers (adjusted OR = 0.66, 95% confidence interval 0.44-0.98), though this effect is attenuated in fixed-effects models, and there is no association between remittances and attending a public-sector facility. These findings underscore that remittances alone are not sufficient to increase children's utilization of qualified providers in migrant-sending areas, and suggest that policymakers should to address barriers to care beyond cost to promote utilization and equity of access to higher quality care where remittances are a common source of income.
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Affiliation(s)
- Emily Treleaven
- Institute for Social Research, Population Studies Center, University of Michigan, 426 Thompson St, Ann Arbor, MI, USA
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16
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Jacobs B, Hui K, Lo V, Thiede M, Appelt B, Flessa S. Costing for universal health coverage: insight into essential economic data from three provinces in Cambodia. HEALTH ECONOMICS REVIEW 2019; 9:29. [PMID: 31667671 PMCID: PMC6822335 DOI: 10.1186/s13561-019-0246-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/04/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
- Social Health Protection Network P4H, Phnom Penh, Cambodia
| | - Kelvin Hui
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
| | - Veasnakiry Lo
- Department of Planning and Health Information, Ministry of Health, Phnom Penh, Cambodia
| | | | - Bernd Appelt
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
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17
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Korachais C, Ir P, Macouillard E, Meessen B. The impact of reimbursed user fee exemption of health centre outpatient consultations for the poor in pluralistic health systems: lessons from a quasi-experiment in two rural health districts in Cambodia. Health Policy Plan 2019; 34:740-751. [DOI: 10.1093/heapol/czz095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Fees charged at the point of use are a barrier to the health services’ users, especially for the poorest. Two decades ago, Cambodia introduced the so-called health equity fund (HEF) strategy, a waiver scheme which enhances access to public health services for the poor without undermining the economic situation of facilities. Evidence suggests that hospital-based HEF effectively removed financial barriers and reduced out-of-pocket expenditures. There is less evidence on the effectiveness of the HEF when assistance is extended to the primary level of healthcare. This research explores the impact of a HEF extended to health centres in two rural health districts. Two household surveys and 16-month diary data allowed to assess the impact of the intervention on health-seeking behaviours and expenditure of poor households. Though HEF effectively removed user fees at public health facilities, health centre utilization of sick and poor people did not budge much in the intervention district; self-medication and private provider consultations remained the preferred health-seeking behaviours, by far, even if more expensive. Difference-in-difference estimates confirmed that HEF had a slight impact on health-seeking behaviours, but only for the subgroups of HEF beneficiaries living close to the health centre and ready to test their new entitlement. This research reminds on the importance of the context for the effectiveness of any policy: in a highly pluralistic health sector, waiving already low-user fees in public health centres may be insufficient to increase rapidly the use of those facilities and reduce catastrophic spending. In such context, apart from distance to health centres, perceived quality of services at the health centres, which was relatively low compared with other providers, also matters. Although the HEF scheme plays a role in improving perceived and objective quality of care, complementary means are to be deployed.
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Affiliation(s)
- Catherine Korachais
- Department of Public Health, Institute of Tropical Medicine of Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium
| | - Por Ir
- Department of Public Health, Institute of Tropical Medicine of Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium and Technical Bureau, National Institute of Public Health, lot no. 80, Samdach Penn Nouth Blvd (St. 289), Phnom Penh, Cambodia
| | - Elodie Macouillard
- Department of Public Health, Institute of Tropical Medicine of Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium and GRET, Campus du jardin d'agronomie tropicale, 45 bis avenue de la Belle Gabrielle, 94052 Nogent sur Marne, France
| | - Bruno Meessen
- Department of Public Health, Institute of Tropical Medicine of Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium
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