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Mao S, Soputhy C, Lay S, Jacobs J, Ku GM, Chau D, Chhea C, Ir P. The barriers and facilitators of implementing a national laboratory-based AMR surveillance system in Cambodia: key informants' perspectives and assessments of microbiology laboratories. Front Public Health 2023; 11:1332423. [PMID: 38179556 PMCID: PMC10764616 DOI: 10.3389/fpubh.2023.1332423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024] Open
Abstract
Background Collecting data on antimicrobial resistance (AMR) is an essential approach for defining the scope of the AMR problem, developing evidence-based interventions and detecting new and emerging resistances. Our study aimed to identify key factors influencing the implementation of a laboratory-based AMR surveillance system in Cambodia. This will add additional insights to the development of a sustainable and effective national AMR surveillance system in Cambodia and other low- and middle-income countries. Methods Key informants with a role in governing or contributing data to the laboratory-based surveillance system were interviewed. Emerging themes were identified using the framework analysis method. Laboratories contributing to the AMR surveillance system were assessed on their capacity to conduct quality testing and report data. The laboratory assessment tool (LAT), developed by the World Health Organisation (WHO), was adapted for assessment of a diagnostic microbiology laboratory covering quality management, financial and human resources, data management, microbiology testing performance and surveillance capacity. Results Key informants identified inadequate access to laboratory supplies, an unsustainable financing system, limited capacity to collect representative data and a weak workforce to be the main barriers to implementing an effective surveillance system. Consistent engagement between microbiology staff and clinicians were reported to be a key factor in generating more representative data for the surveillance system. The laboratory assessments identified issues with quality assurance and data analysis which may reduce the quality of data being sent to the surveillance system and limit the facility-level utilisation of aggregated data. A weak surveillance network and poor guidance for outbreak response were also identified, which can reduce the laboratories' opportunities in detecting critical or emerging resistance occurring in the community or outside of the hospital's geographical coverage. Conclusion This study identified two primary concerns: ensuring a sustainable and quality functioning of microbiology services at public healthcare facilities and overcoming sampling bias at sentinel sites. These issues hinder Cambodia's national AMR surveillance system from generating reliable evidence to incorporate into public health measures or clinical interventions. These findings suggest that more investments need to be made into microbiology diagnostics and to reform current surveillance strategies for enhanced sampling of AMR cases at hospitals.
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Affiliation(s)
- Sovathiro Mao
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Sokreaksa Lay
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Jan Jacobs
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Grace Marie Ku
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Frailty in Ageing Research, Vrije Universiteit Brussel, Brussels, Belgium
| | - Darapheak Chau
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
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Te V, Chhim S, Buffel V, Van Damme W, van Olmen J, Ir P, Wouters E. Evaluation of Diabetes Care Performance in Cambodia Through the Cascade-of-Care Framework: Cross-Sectional Study. JMIR Public Health Surveill 2023; 9:e41902. [PMID: 37347529 DOI: 10.2196/41902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/28/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Cambodia has seen an increase in the prevalence of type 2 diabetes (T2D) over the last 10 years. Three main care initiatives for T2D are being scaled up in the public health care system across the country: hospital-based care, health center-based care, and community-based care. To date, no empirical study has systematically assessed the performance of these care initiatives across the T2D care continuum in Cambodia. OBJECTIVE This study aimed to assess the performance of the 3 care initiatives-individually or in coexistence-and determine the factors associated with the failure to diagnose T2D in Cambodia. METHODS We used a cascade-of-care framework to assess the T2D care continuum. The cascades were generated using primary data from a cross-sectional population-based survey conducted in 2020 with 5072 individuals aged ≥40 years. The survey was conducted in 5 operational districts (ODs) selected based on the availability of the care initiatives. Multiple logistic regression analysis was used to identify the factors associated with the failure to diagnose T2D. The significance level of P<.05 was used as a cutoff point. RESULTS Of the 5072 individuals, 560 (11.04%) met the definition of a T2D diagnosis (fasting blood glucose level ≥126 mg/dL and glycated hemoglobin level ≥6.5%). Using the 560 individuals as the fixed denominator, the cascade displayed substantial drops at the testing and control stages. Only 63% (353/560) of the participants had ever tested their blood glucose level in the last 3 years, and only 10.7% (60/560) achieved blood glucose level control with the cutoff point of glycated hemoglobin level <8%. The OD hosting the coexistence of care displayed the worst cascade across all bars, whereas the OD with hospital-based care had the best cascade among the 5 ODs. Being aged 40 to 49 years, male, and in the poorest category of the wealth quintile were factors associated with the undiagnosed status. CONCLUSIONS The unmet needs for T2D care in Cambodia were large, particularly in the testing and control stages, indicating the need to substantially improve early detection and management of T2D in the country. Rapid scale-up of T2D care components at public health facilities to increase the chances of the population with T2D of being tested, diagnosed, retained in care, and treated, as well as of achieving blood glucose level control, is vital in the health system. Specific population groups susceptible to being undiagnosed should be especially targeted for screening through active community outreach activities. Future research should incorporate digital health interventions to evaluate the effectiveness of the T2D care initiatives longitudinally with more diverse population groups from various settings based on routine data vital for integrated care. TRIAL REGISTRATION International Standard Randomized Controlled Trials Number (ISRCTN) ISRCTN41932064; https://www.isrctn.com/ISRCTN41932064. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/36747.
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Affiliation(s)
- Vannarath Te
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine (Antwerp), Antwerp, Belgium
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Srean Chhim
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
| | - Veerle Buffel
- Centre for Population, Family & Health, Department of Sociology, University of Antwerp, Antwerp, Belgium
| | - Wim Van Damme
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine (Antwerp), Antwerp, Belgium
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Por Ir
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
| | - Edwin Wouters
- Centre for Population, Family & Health, Department of Sociology, University of Antwerp, Antwerp, Belgium
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
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Chham S, Van Olmen J, Van Damme W, Chhim S, Buffel V, Wouters E, Ir P. Scaling-up integrated type-2 diabetes and hypertension care in Cambodia: what are the barriers to health system performance? Front Public Health 2023; 11:1136520. [PMID: 37333565 PMCID: PMC10272385 DOI: 10.3389/fpubh.2023.1136520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
Background Non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia. Methods Using qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis. Results Scaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making. Conclusion The health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes.
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Affiliation(s)
- Savina Chham
- National Institute of Public Health, Phnom Penh, Cambodia
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
| | - Josefien Van Olmen
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Gerontology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Srean Chhim
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Veerle Buffel
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
| | - Edwin Wouters
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
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Chhim S, Ku G, Mao S, Put WVD, Van Damme W, Ir P, Chhea C, Or V. Descriptive assessment of COVID-19 responses and lessons learnt in Cambodia, January 2020 to June 2022. BMJ Glob Health 2023; 8:bmjgh-2023-011885. [PMID: 37137538 PMCID: PMC10163327 DOI: 10.1136/bmjgh-2023-011885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/21/2023] [Indexed: 05/05/2023] Open
Abstract
As a member state of the International Health Regulations 2005, Cambodia is continuously strengthening its capacity to respond to health emergencies and prevent the international spread of diseases. Despite this, Cambodia's capacity to prevent, detect and rapidly respond to public health threats remained limited at the onset of the pandemic, as was the case in most countries. This paper describes epidemiological phases, response phases, strategy and lessons learnt in Cambodia between 27 January 2020 and 30 June 2022. We classified epidemiological phases in Cambodia into three phases, in which Cambodia responded using eight measures: (1) detect, isolate/quarantine; (2) face coverings, hand hygiene and physical distancing measures; (3) risk communication and community engagement; (4) school closures; (5) border closures; (6) public event and gathering cancellation; (7) vaccination; and (8) lockdown. The measures corresponded to six strategies: (1) setting up and managing a new response system, (2) containing the spread with early response, (3) strengthening the identification of cases and contacts, (4) strengthening care for patients with COVID-19, (5) boosting vaccination coverage and (6) supporting disadvantaged groups. Thirteen lessons were learnt for future health emergency responses. Findings suggest that Cambodia successfully contained the spread of SARS-CoV-2 in the first year and quickly attained high vaccine coverage by the second year of the response. The core of this success was the strong political will and high level of cooperation from the public. However, Cambodia needs to further improve its infrastructure for quarantining and isolating cases and close contacts and laboratory capacity for future health emergencies.
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Affiliation(s)
- Srean Chhim
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Grace Ku
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sovathiro Mao
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
| | - Willem Van De Put
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Por Ir
- Management team, National Institute of Public Health, Phnom Penh, Cambodia
| | - Chhorvann Chhea
- Management team, National Institute of Public Health, Phnom Penh, Cambodia
| | - Vandine Or
- Management team, Ministry of Health, Phnom Penh, Cambodia
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Chhim S, Vong WI, Pa K, Chhorn C, Housen T, Parry AE, Van Damme W, Ir P, Chhea C. A descriptive assessment of the National Institute of Public Health's contribution to the COVID-19 response in Cambodia,
2020-2021. Western Pac Surveill Response J 2023; 14:1-7. [PMID: 37064543 PMCID: PMC10090031 DOI: 10.5365/wpsar.2023.14.1.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Objective This paper examines the contributions made by the National Institute of Public Health to Cambodia's response to the coronavirus disease (COVID-19) pandemic during 2020-2021. Methods The activities conducted by the Institute were compared with adaptations of the nine pillars of the World Health Organization's 2020 COVID-19 strategic preparedness and response plan. To gather relevant evidence, we reviewed national COVID-19 testing data, information about COVID-19-related events documented by Institute staff, and financial and technical reports of the Institute's activities. Results The main contributions the Institute made were to the laboratory pillar and the incident management and planning pillar. The Institute tested more than 50% of the 2 575 391 samples for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and provided technical advice about establishing 18 new laboratories for SARS-CoV-2 testing in the capital city of Phnom Penh and 11 provinces. The Institute had representatives on many national committees and coauthored national guidelines for implementing rapid COVID-19 testing, preventing transmission in health-care facilities and providing treatment. The Institute contributed to six other pillars, but had no active role in risk communication and community engagement. Discussion The Institute's support was essential to the COVID-19 response in Cambodia, especially for laboratory services and incident management and planning. Based on the contributions made by the Institute during the COVID-19 pandemic, continued investment in it will be critical to allow it to support responses to future health emergencies in Cambodia.
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Affiliation(s)
- Srean Chhim
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Kimsorn Pa
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Tambri Housen
- University of Newcastle, Newcastle, New South Wales, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Amy Elizabeth Parry
- Australian National University, Canberra, Australian Capital Territory, Australia
| | | | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
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Martens M, Wouters E, van Olmen J, Klemenc Ketiš Z, Chhim S, Chham S, Buffel V, Danhieux K, Stojnić N, Zavrnik Č, Poplas Susič A, Van Damme W, Ir P, Remmen R, Ku GMV, Klipstein-Grobusch K, Boateng D. Process evaluation of the scale-up of integrated diabetes and hypertension care in Belgium, Cambodia and Slovenia (the SCUBY Project): a study protocol. BMJ Open 2022; 12:e062151. [PMID: 36581422 PMCID: PMC9806029 DOI: 10.1136/bmjopen-2022-062151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Integrated care interventions for type 2 diabetes (T2D) and hypertension (HT) are effective, yet challenges exist with regard to their implementation and scale-up. The 'SCale-Up diaBetes and hYpertension care' (SCUBY) Project aims to facilitate the scale-up of integrated care for T2D and HT through the co-creation and implementation of contextualised scale-up roadmaps in Belgium, Cambodia and Slovenia. We hereby describe the plan for the process and scale-up evaluation of the SCUBY Project. The specific goals of the process and scale-up evaluation are to (1) analyse how, and to what extent, the roadmap has been implemented, (2) assess how the differing contexts can influence the implementation process of the scale-up strategies and (3) assess the progress of the scale-up. METHODS AND ANALYSIS A comprehensive framework was developed to include process and scale-up evaluation embedded in implementation science theory. Key implementation outcomes include acceptability, feasibility, relevance, adaptation, adoption and cost of roadmap activities. A diverse range of predominantly qualitative tools-including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping-were developed to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. The role of context is considered relevant, and barriers and facilitators to scale-up will be continuously assessed. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Institutional Review Board (ref. 1323/19) at the Institute of Tropical Medicine (Antwerp, Belgium). The SCUBY Project presents a comprehensive framework to guide the process and scale-up evaluation of complex interventions in different health systems. We describe how implementation outcomes, mechanisms of impact and scale-up outcomes can be a basis to monitor adaptations through a co-creation process and to guide other scale-up interventions making use of knowledge translation and co-creation activities.
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Affiliation(s)
- Monika Martens
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Edwin Wouters
- Centre for Population, Family & Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
| | - Josefien van Olmen
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Zalika Klemenc Ketiš
- Community Health Center Ljubljana, Ljubljana, Slovenia
- Department of Family Medicine, Medical Faculty, University of Maribor, Maribor, Slovenia
- Department of Family Medicine, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Srean Chhim
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Savina Chham
- Centre for Population, Family & Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Veerle Buffel
- Centre for Population, Family & Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
| | - Katrien Danhieux
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Črt Zavrnik
- Community Health Center Ljubljana, Ljubljana, Slovenia
| | | | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Gerontology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Roy Remmen
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Grace Marie V Ku
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, Gauteng, South Africa
| | - Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
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Nalule Y, Pors P, Samol C, Ret S, Leang S, Ir P, Macintyre A, Dreibelbis R. A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia. Sci Rep 2022; 12:19646. [PMID: 36385113 PMCID: PMC9666993 DOI: 10.1038/s41598-022-23937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/08/2022] [Indexed: 11/17/2022] Open
Abstract
Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care.
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Affiliation(s)
- Yolisa Nalule
- grid.8991.90000 0004 0425 469XDisease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | | | | | | | - Supheap Leang
- grid.436334.5National Institute of Public Health, Phnom Penh, Cambodia
| | - Por Ir
- grid.436334.5National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Robert Dreibelbis
- grid.8991.90000 0004 0425 469XDisease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
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Kheang ST, Ridley R, Ngeth E, Ir P, Ngor P, Sovannaroth S, Lek D, Phon S, Kak N, Yeung S. G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study. PLoS One 2022; 17:e0275822. [PMID: 36264996 PMCID: PMC9584508 DOI: 10.1371/journal.pone.0275822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/25/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Cambodia aims to eliminate malaria by 2025, however tackling Plasmodium vivax (P.v) presents multiple challenges. The prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency has prevented the deployment of 8-aminoquinolones for “radical cure”, due to the risk of severe haemolysis. Patients with P. vivax have therefore continued to experience recurrent relapses leading to cumulative health and socioeconomic burden. The recent advent of point of care testing for G6PD deficiency has made radical cure a possibility, however at the time of the study lack of operational experience and guidance meant that they had not been introduced. This study therefore aimed to design, implement and evaluate a new care pathway for the radical cure of P.vivax. Methods This implementation study took place in Pursat province, Western Cambodia. The interventions were co-developed with key stakeholders at the national, district, and local level, through a continuous process of consultations as well as formal meetings. Mixed methods were used to evaluate the feasibility of the intervention including its uptake (G6PD testing rate and the initiation of primaquine treatment according to G6PD status); adherence (self-reported); and acceptability, using quantitative analysis of primary and secondary data as well as focus group discussions and key informant interviews. Results The co-development process resulted in the design of a new care pathway with supporting interventions, and a phased approach to their implementation. Patients diagnosed with P.v infection by Village Malaria Workers (VMWs) were referred to local health centres for point-of-care G6PD testing and initiation of radical cure treatment with 14-day or 8-week primaquine regimens depending on G6PD status. VMWs carried out follow-up in the community on days 3, 7 and 14. Supporting interventions included training, community sensitisation, and the development of a smartphone and tablet application to aid referral, follow-up and surveillance. The testing rate was low initially but increased rapidly over time, reflecting the deliberately cautious phased approach to implementation. In total 626 adults received G6PD testing, for a total of 675 episodes. Of these 555 occurred in patients with normal G6PD activity and nearly all (549/555, 98.8%) were initiated on PQ14. Of the 120 with deficient/intermediate G6PD activity 61 (50.8%) were initiated on PQ8W. Self-reported adherence was high (100% and 95.1% respectively). No severe adverse events were reported. The pathway was found to be highly acceptable by both staff and patients. The supporting interventions and gradual introduction were critical to success. Challenges included travel to remote areas and mobility of P.v patients. Conclusion The new care pathway with supporting interventions was highly feasible with high levels of uptake, adherence and acceptability in this setting where high prevalence of G6PD deficiency is high and there is a well-established network of VMWs. Scaling up of the P.v radical cure programme is currently underway in Cambodia and a decline in reduction in the burden of malaria is being seen, bringing Cambodia a step closer to elimination.
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Affiliation(s)
- Soy Ty Kheang
- The Center for Health and Social Development (HSD), Phnom Penh, Cambodia
- National Institute of Public Health (NIPH), Phnom Penh, Cambodia
| | - Rosemarie Ridley
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Eng Ngeth
- The Center for Health and Social Development (HSD), Phnom Penh, Cambodia
| | - Por Ir
- The Center for Health and Social Development (HSD), Phnom Penh, Cambodia
- National Institute of Public Health (NIPH), Phnom Penh, Cambodia
| | - Pengby Ngor
- National Malaria Control Program, The National Center for Parasitology, Entomology and Malaria Control (CNM), Phnom Penh, Cambodia
| | - Siv Sovannaroth
- National Malaria Control Program, The National Center for Parasitology, Entomology and Malaria Control (CNM), Phnom Penh, Cambodia
| | - Dysoley Lek
- National Malaria Control Program, The National Center for Parasitology, Entomology and Malaria Control (CNM), Phnom Penh, Cambodia
| | - Somaly Phon
- The Center for Health and Social Development (HSD), Phnom Penh, Cambodia
| | - Neeraj Kak
- The Center for Health and Social Development (HSD), Phnom Penh, Cambodia
| | - Shunmay Yeung
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
- * E-mail:
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9
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Chham S, Buffel V, Van Olmen J, Chhim S, Ir P, Wouters E. The cascade of hypertension care in Cambodia: evidence from a cross-sectional population-based survey. BMC Health Serv Res 2022; 22:838. [PMID: 35768805 PMCID: PMC9241312 DOI: 10.1186/s12913-022-08232-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background Hypertension (HTN) is a leading cause of cardiovascular diseases and deaths globally. To respond to the high HTN prevalence (23.5% among adults aged 40–69 years in 2016) in Cambodia, the government (and donors) established innovative interventions to improve access to screening, care, and treatment at different public health system and community levels. We assessed the effectiveness of these interventions and resulting health outcomes through a cascade of HTN care and explored key determinants. Methods We performed a population-based survey among 5070 individuals aged ≥ 40 years to generate a cascade of HTN care in Cambodia. The cascade, built with conditional approach, shows the patients’ flow in the health system and where they are lost (dropped out) along the steps: (i) prevalence, (ii) screening, (iii) diagnosis, (iv) treatment in the last twelve months, (v) treatment in the last three months, and (vi) HTN being under control. The profile of people dropping out from each bar of the cascade was determined by multivariate logistic regression. Results The prevalence of HTN (i) among study participants was 35.2%, of which 81.91% had their blood pressure (BP) measured in the last three years (ii). Over 63.72% of those screened were diagnosed by healthcare professionals as hypertensive patients (iii). Among these, 56.19% received treatment in the last twelve months (iv) and 54.26% received follow-up treatment in the last three months (v). Only 35.8% of treated people had their BP under control (vi). Males, those aged ≥ 40 years, and from poorer households had lower odds to receive screening, diagnosis, and treatment. Lower odds to have their BP under-control were found in males, those from poor and rich quintiles, having HTN < five years, and receiving treatment at a private facility. Conclusions Overall, people with HTN are lost along the cascade, suggesting limited access to appropriate screening, diagnosis, and treatment and resulting poor health outcomes, especially among those who are male, aged 40–49 years, from poorer households, and visiting a private facility. Efforts to improve the quality of facility-based and community-based interventions are needed to prevent inequitable drops along the cascade of care.
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Affiliation(s)
- Savina Chham
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia. .,Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium.
| | - Veerle Buffel
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
| | - Josefien Van Olmen
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Srean Chhim
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia
| | - Por Ir
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia
| | - Edwin Wouters
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium.,Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
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10
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Horváth C, Hong K, Wheeler P, Ir P, Chhea C, Kinzer MH, Ly V, Willacy E. How Management and Leadership Training Can Impact a Health System: Evaluation Findings From a Public Health Management Training Program in Cambodia. Front Public Health 2022; 9:784198. [PMID: 35155346 PMCID: PMC8826233 DOI: 10.3389/fpubh.2021.784198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/24/2021] [Indexed: 11/21/2022] Open
Abstract
In 2017, the National Institute of Public Health in Cambodia collaborated with the U.S. Centers for Disease Control and Prevention to provide management and leadership training for 20 managers and senior staff from 10 health centers. We conducted a mixed methods evaluation of the program's outcomes and impact on the graduates and health centers. From June 2018 (baseline) to January 2019 (endpoint), we collected data from a competency assessment, observational visits, and interviews. From baseline to endpoint, all 20 participants reported increased competence in seven management areas. Comparing baseline and endpoint observational visits, we found improvements in leadership and governance, health workforce, water, sanitation, and hygiene, and health centers' use of medical products and technologies. When evaluating the improvements made by participants against the World Health Organization's key components of a well-functioning health system, the program positively contributed toward building four of the six components—leadership and governance, health information systems, human resources for health, and service delivery. While these findings are specific to the context of Cambodian health centers, we hope this evaluation adds to the growing body of research around the impact of skilled public health management on health systems.
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Affiliation(s)
- Chelsea Horváth
- Consultant to Training Programs in Epidemiology and Public Health Interventions Network, Boldogasszonyfa, Hungary
| | - Kimsear Hong
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Paulah Wheeler
- Division of Global HIV and TB, Center for Global Health, U.S. Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Michael H Kinzer
- Division of Global Health Protection, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Vanthy Ly
- Division of Global Health Protection, Center for Global Health, U.S. Centers for Disease Control and Prevention, Phnom Penh, Cambodia
| | - Erika Willacy
- Division of Global Health Protection, Center for Global Health, U.S. Centers for Disease Control and Prevention, Boston, MA, United States
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11
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Te V, Wouters E, Buffel V, Van Damme W, van Olmen J, Ir P. Generation of cascades of care for diabetes and hypertension care continuum in Cambodia: a population-based survey protocol (Preprint). JMIR Res Protoc 2022; 11:e36747. [PMID: 36053576 PMCID: PMC9482065 DOI: 10.2196/36747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vannarath Te
- Health Policy and Systems Research Unit, National Institute of Public Health, Phnom Penh, Cambodia
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine (Antwerp), Antwerp, Belgium
- Quality of Integrated Care, Spearhead Research Public Health & Primary Care, The University of Antwerp, Antwerp, Belgium
| | - Edwin Wouters
- Center for Longitudinal & Life Course Studies, Department of Sociology, The University of Antwerp, Antwerp, Belgium
| | - Veerle Buffel
- Center for Longitudinal & Life Course Studies, Department of Sociology, The University of Antwerp, Antwerp, Belgium
| | - Wim Van Damme
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine (Antwerp), Antwerp, Belgium
| | - Josefien van Olmen
- Quality of Integrated Care, Spearhead Research Public Health & Primary Care, The University of Antwerp, Antwerp, Belgium
| | - Por Ir
- Health Policy and Systems Research Unit, National Institute of Public Health, Phnom Penh, Cambodia
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12
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Liverani M, Ir P, Wiseman V, Perel P. User experiences and perceptions of health wearables: an exploratory study in Cambodia. Glob Health Res Policy 2021; 6:33. [PMID: 34556184 PMCID: PMC8459510 DOI: 10.1186/s41256-021-00221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/14/2021] [Indexed: 10/25/2022] Open
Abstract
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.
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Affiliation(s)
- Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. .,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan. .,Faculty of Public Health, Mahidol University, Bangkok, Thailand.
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
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13
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Siyam A, Ir P, York D, Antwi J, Amponsah F, Rambique O, Funzamo C, Azeez A, Mboera L, Kumalija CJ, Rumisha SF, Mremi I, Boerma T, O'Neill K. The burden of recording and reporting health data in primary health care facilities in five low- and lower-middle income countries. BMC Health Serv Res 2021; 21:691. [PMID: 34511083 PMCID: PMC8436492 DOI: 10.1186/s12913-021-06652-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/05/2022] Open
Abstract
Background Recording and reporting health data in facilities is the backbone of routine health information systems which provide data collected by health facility workers during service provision. Data is firstly collected in a register, to record patient health data and care process, and tallied into nationally designed reporting forms. While there is anecdotal evidence of large numbers of registers and reporting forms for primary health care (PHC) facilities, there are few systematic studies to document this potential burden on health workers. This multi-country study aimed to document the numbers of registers and reporting forms use at the PHC level and to estimate the time it requires for health workers to meet data demands. Methods In Cambodia, Ghana, Mozambique, Nigeria and Tanzania, a desk review was conducted to document registers and reporting forms mandated at the PHC level. In each country, visits to 16 randomly selected public PHC facilities followed to assess the time spent on paper-based recording and reporting. Information was collected through self-reports of estimated time use by health workers, and observation of 1360 provider-patient interactions. Data was primarily collected in outpatient care (OPD), antenatal care (ANC), immunization (EPI), family planning (FP), HIV and Tuberculosis (TB) services. Result Cross-countries, the average number of registers was 34 (ranging between 16 and 48). Of those, 77% were verified in use and each register line had at least 20 cells to be completed per patient. The mean time spent on recording was about one-third the total consultation time for OPD, FP, ANC and EPI services combined. Cross-countries, the average number of monthly reporting forms was 35 (ranging between 19 and 52) of which 78% were verified in use. The estimated time to complete monthly reporting forms was 9 h (ranging between 4 to 15 h) per month per health worker. Conclusions PHC facilities are mandated to use many registers and reporting forms pausing a considerable burden to health workers. Service delivery systems are expected to vary, however an imperative need remains to invest in international standards of facility-based registers and reporting forms, to ensure regular, comparable, quality-driven facility data collection and use. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06652-5.
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Affiliation(s)
- Amani Siyam
- Health Workforce Department, World Health Organization, Avenue Appia 20, CH-1211, Geneva, Switzerland.
| | - Por Ir
- National Institute of Public Health, No. 80, Samdach Penn Nouth Blvd (289), Sangkat Boeungkak 2, Tuol Kork District, Phnom Penh, Cambodia
| | - Dararith York
- Department of Planning and Health Information, Ministry of Health, No. 80, Samdach Penn Nouth Blvd (289), Sangkat Boeungkak 2, Tuol Kork District, Phnom Penh, Cambodia
| | - James Antwi
- Centre for Health and Social Policy Research, West End University College, Ngleshie Amanfro, Accra, Ghana
| | - Freddie Amponsah
- Ghana Health Service, Private Mail Bag, Ministries, Accra, Ghana
| | - Ofelia Rambique
- National Institute of Health, Vila de Marracuene, National Road, 3943, Maputo, Mozambique
| | - Carlos Funzamo
- World Health Organization Country Office, Rua Joseph Ki-zerbo 227, P.O. Box 377, Maputo, Mozambique
| | - Aderemi Azeez
- Federal Ministry of Health, Federal Secretariat, Phase III, Shehu Shagari Way, Central Business District, Abuja, FCT, Nigeria
| | - Leonard Mboera
- SACIDS Foundation for One Health (SACIDS), Sokoine University of Agriculture (SUA), P.O. Box 3297, Chuo Kikuu, SUA, Morogoro, Tanzania
| | - Claud John Kumalija
- Health Management Information System (HMIS), Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Susan Fred Rumisha
- The National Institute for Medical Research, 3 Barack Obama Drive, P.O.Box 9653, 11101, Dar es Salaam, Tanzania
| | - Irene Mremi
- The National Institute for Medical Research, 3 Barack Obama Drive, P.O.Box 9653, 11101, Dar es Salaam, Tanzania
| | - Ties Boerma
- Department of Community Health Sciences, Max Rady College of Medicine-University of Manitoba, Room S113 - 750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada
| | - Kathryn O'Neill
- Integrated Health Services Department, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland
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14
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Liverani M, Ir P, Jacobs B, Asante A, Jan S, Leang S, Man N, Hayen A, Wiseman V. Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications. Health Policy Plan 2021; 35:1011-1020. [PMID: 33049780 DOI: 10.1093/heapol/czaa061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Bart Jacobs
- Social Health Protection Project, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289 Khan Toul Kork P.O. Box 1238 Phnom Penh, Cambodia
| | - Augustine Asante
- School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia
| | - Stephen Jan
- The George Institute for Global Health, 1 King St, Newtown NSW 2042, Australia.,University of New South Wales, Sydney NSW 2052, Australia
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Nicola Man
- School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia
| | - Andrew Hayen
- University of Technology Sydney (UTS), 15 Broadway, Ultimo NSW 2007, Australia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,The Kirby Institute, UNSW, Sydney NSW 2052, Australia
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15
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Nalule Y, Buxton H, Ir P, Leang S, Macintyre A, Pors P, Samol C, Dreibelbis R. Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study. BMC Pregnancy Childbirth 2021; 21:429. [PMID: 34139995 PMCID: PMC8212449 DOI: 10.1186/s12884-021-03901-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/26/2021] [Indexed: 12/14/2022] Open
Abstract
Background Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility –based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants. Methods This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours. Results Birth attendants’ compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants’ qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives’ hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception. Conclusion The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants’ hand hygiene compliance in our study settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03901-7.
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Affiliation(s)
- Yolisa Nalule
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
| | - Helen Buxton
- Division of Psychiatry, University College London, London, W1T 7BN, UK
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | | | | | - Robert Dreibelbis
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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16
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Chham S, Radovich E, Buffel V, Ir P, Wouters E. Determinants of the continuum of maternal health care in Cambodia: an analysis of the Cambodia demographic health survey 2014. BMC Pregnancy Childbirth 2021; 21:410. [PMID: 34078318 PMCID: PMC8170811 DOI: 10.1186/s12884-021-03890-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Cambodia has achieved significant progress in maternal health, yet remains in the group of countries with the highest maternal mortality ratio in South-East Asia. Extra efforts are needed to improve maternal health through assessing the coverage of maternal health services as a continuum of care (CoC) and identifying the gaps. Our study aims to explore the coverage level of the Optimal CoC by (1) measuring the continuity of optimal antenatal care (ANC), skilled birth attendance (SBA) and optimal post-natal care (PNC), (2) identifying the determinants of dropping out from one service to another and (3) of not achieving the complete CoC. Method The study employed data from the Cambodia Demographic Health Survey 2014. We restricted our analysis to married women who had a live birth in the five years preceding the survey (n = 5678). Bi-variate and multivariate logistic regression were performed using STATA version 14. Results Almost 50% of women had achieved the complete optimal CoC, while the remaining have used only one or two of the services. The result shows that the level of women’s education was positively associated with the use of optimal ANC, the continuation to using optimal PNC and achieving the complete CoC. More power of women in household decision making was also positively associated with receiving the complete CoC. The birth order was negatively associated with achieving the complete CoC, while exposure to the mass media and having health insurance increased the odds of achieving the complete CoC. Household wealth consequently emerged as an influential predictor of dropping out and not achieving the complete CoC. Receiving all different elements of ANC care improved the continuity of care from optimal ANC to SBA and from SBA to optimal ANC. Conclusion The findings urge policy makers to approach maternal health care as a continuum of care with different determinants at each step. Household wealth was found to be the most influential factor, yet the study discovered also other barriers to optimal maternal health care which need to be addressed: future intervention should thus not only aim to increase wealth or health insurance coverage but also stimulate the education of women and empower women to claim power in household decision-making.
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Affiliation(s)
- Savina Chham
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia.
| | - Emma Radovich
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Por Ir
- National Institute of Public Health, Lot 80, Street 566 & Corner with 289, St 566, Phnom Penh, Cambodia
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17
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van Olmen J, Menon S, Poplas Susič A, Ir P, Klipstein-Grobusch K, Wouters E, Peñalvo JL, Zavrnik Č, Te V, Martens M, Danhieux K, Chham S, Stojnić N, Buffel V, Yem S, White G, Boateng D, Klemenc-Ketis Z, Prevolnik VR, Remmen R, Van Damme W. Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study. Glob Health Action 2021; 13:1824382. [PMID: 33373278 PMCID: PMC7594757 DOI: 10.1080/16549716.2020.1824382] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.
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Affiliation(s)
- Josefien van Olmen
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium.,Department of Sociology, University of Antwerp , Antwerp, Belgium
| | - Sonia Menon
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Antonija Poplas Susič
- Community Health Center Ljubljana , Slovenia.,Department of Family Medicine, Faculty of Medicine, University of Ljubljana , Ljubljana, Slovenia
| | - Por Ir
- National Institute of Public Health , Ljubljana, Cambodia
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University , Utrecht, The Netherlands.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - Edwin Wouters
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
| | - José L Peñalvo
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Črt Zavrnik
- Community Health Center Ljubljana , Slovenia
| | - Vannarath Te
- National Institute of Public Health , Ljubljana, Cambodia
| | - Monika Martens
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Katrien Danhieux
- Department of Sociology, University of Antwerp , Antwerp, Belgium
| | - Savina Chham
- National Institute of Public Health , Ljubljana, Cambodia
| | | | - Veerle Buffel
- Department of Sociology, University of Antwerp , Antwerp, Belgium
| | - Sokunthea Yem
- National Institute of Public Health , Ljubljana, Cambodia
| | - Gareth White
- Department of Public Health, Institute of Tropical Medicine Antwerp , Antwerp, Belgium
| | - Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University , Utrecht, The Netherlands
| | - Zalika Klemenc-Ketis
- Community Health Center Ljubljana , Slovenia.,Department of Family Medicine, Faculty of Medicine, University of Ljubljana , Ljubljana, Slovenia.,Department of Family Medicine, Faculty of Medicine, University of Maribor , Maribor, Slovenia
| | | | - Roy Remmen
- Community Health Center Ljubljana , Slovenia
| | - Wim Van Damme
- National Institute of Public Health , Ljubljana, Cambodia
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Nalule Y, Buxton H, Macintyre A, Ir P, Pors P, Samol C, Leang S, Dreibelbis R. Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia. Int J Environ Res Public Health 2021; 18:4416. [PMID: 33919264 PMCID: PMC8122667 DOI: 10.3390/ijerph18094416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum. METHODS Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours. RESULTS Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge. CONCLUSIONS Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.
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Affiliation(s)
- Yolisa Nalule
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Helen Buxton
- Division of Psychiatry, University College London, London W1T 7BN, UK;
| | - Alison Macintyre
- Policy and Programs Division, WaterAid Australia, Melbourne 3002, Australia;
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia; (P.I.); (S.L.)
| | - Ponnary Pors
- WASH and Health Division, WaterAid Cambodia, Phnom Penh, Cambodia; (P.P.); (C.S.)
| | - Channa Samol
- WASH and Health Division, WaterAid Cambodia, Phnom Penh, Cambodia; (P.P.); (C.S.)
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia; (P.I.); (S.L.)
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
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Asante AD, Ir P, Jacobs B, Supon L, Liverani M, Hayen A, Jan S, Wiseman V. Erratum: Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy. Health Policy Plan 2020; 35:888. [PMID: 32494814 PMCID: PMC7487329 DOI: 10.1093/heapol/czaa037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Van Damme W, Dahake R, Delamou A, Ingelbeen B, Wouters E, Vanham G, van de Pas R, Dossou JP, Ir P, Abimbola S, Van der Borght S, Narayanan D, Bloom G, Van Engelgem I, Ag Ahmed MA, Kiendrébéogo JA, Verdonck K, De Brouwere V, Bello K, Kloos H, Aaby P, Kalk A, Al-Awlaqi S, Prashanth NS, Muyembe-Tamfum JJ, Mbala P, Ahuka-Mundeke S, Assefa Y. The COVID-19 pandemic: diverse contexts; different epidemics-how and why? BMJ Glob Health 2020; 5:e003098. [PMID: 32718950 PMCID: PMC7392634 DOI: 10.1136/bmjgh-2020-003098] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/02/2020] [Accepted: 07/04/2020] [Indexed: 02/06/2023] Open
Abstract
It is very exceptional that a new disease becomes a true pandemic. Since its emergence in Wuhan, China, in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has spread to nearly all countries of the world in only a few months. However, in different countries, the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now, the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe and the USA. But this variety of global trajectories is little described, analysed or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain (unknowns). Learning from the variety of ways the COVID-19 epidemic is unfolding across the globe can potentially contribute to solving the COVID-19 puzzle. This paper tries to make sense of this variability-by exploring the important role that context plays in these different COVID-19 epidemics; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. These unknowns and uncertainties require a deeper understanding of the variable trajectories of COVID-19. Unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by COVID-19 and for future waves elsewhere.
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Affiliation(s)
- Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | | | - Alexandre Delamou
- Africa Centre of Excellence for Prevention and Control of Transmissible Diseases, Gamal Abdel Nasser University of Conakry, Conakry, Guinea
| | - Brecht Ingelbeen
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Edwin Wouters
- Department of Sociology and Centre for Population, University of Antwerp, Antwerpen, Belgium
- Centre for Health Systems Research and Development, University of the Free State-Bloemfontein Campus, Bloemfontein, Free State, South Africa
| | - Guido Vanham
- Biomedical Department, Institute of Tropical Medicine, Antwerpen, Belgium
- Biomedical Department, University of Antwerp, Antwerpen, Belgium
| | - Remco van de Pas
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Jean-Paul Dossou
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
- Public Health, Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Seye Abimbola
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | | | | | - Gerald Bloom
- Health and Nutrition Cluster, Institute of Development Studies, Brighton, UK
| | - Ian Van Engelgem
- European Commission Directorate General for Civil Protection and Humanitarian Aid Operations, Kinshasa, Democratic Republic of Congo
| | | | - Joël Arthur Kiendrébéogo
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
- Public Health, University of Ouagadougou Health Sciences Training and Research Unit, Ouagadougou, Burkina Faso
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Vincent De Brouwere
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Kéfilath Bello
- Public Health, Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Helmut Kloos
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Peter Aaby
- INDEPTH Network, Bandim Health Project, Bissau, Guinea-Bissau
| | - Andreas Kalk
- Bureau GIZ à Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Sameh Al-Awlaqi
- Center for International Health Protection, Robert Koch Institute, Berlin, Germany
| | - N S Prashanth
- Health Equity Cluster, Institute of Public Health, Bengaluru, India
| | | | - Placide Mbala
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
| | - Steve Ahuka-Mundeke
- Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Annear PL, Tayu Lee J, Khim K, Ir P, Moscoe E, Jordanwood T, Bossert T, Nachtnebel M, Lo V. Protecting the poor? Impact of the national health equity fund on utilization of government health services in Cambodia, 2006-2013. BMJ Glob Health 2019; 4:e001679. [PMID: 31798986 PMCID: PMC6861123 DOI: 10.1136/bmjgh-2019-001679] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 09/25/2019] [Accepted: 10/12/2019] [Indexed: 11/03/2022] Open
Abstract
Introduction Cambodia's health equity fund (HEF) is the country's most significant social security scheme, covering the poorest one-fifth of the national population. During the last two decades, the HEF system was scaled up from an initial two health districts to national coverage of public health facilities. This is the first national study to examine the impact of the HEF on the utilisation of public health facilities. Methods We first investigated the level of national HEF population coverage and health service use made by HEF eligible members using an administrative HEF operational dataset. Second, through multilevel interrupted time series analysis of routine monthly utilisation statistics during 2006-2013, we evaluated the impact of the HEF on hospital and health centre utilisation. Results The proportion of HEF beneficiaries using hospital services in a given year (4.6%) appeared to exceed rates in the general population (3.3%). The introduction of the HEF was associated with: a significant level change in the monthly number of consultations at HCs followed by a gradual slope increase in time trend and a significant level change in the monthly number of deliveries. Overall, this was equivalent to a 15.6% net increase in number of consultations and 5.3% in deliveries in the first year. At RHs: a significant level change in the number of RH inpatient cases, followed by a sustained slope increase; a significant slope increase in the number of outpatient consultations and in the overall number of newborn deliveries. Overall, this was equivalent to a 47.9% net increase in inpatient cases, 24.1% in outpatient cases and 31.4% in deliveries in the first year. Conclusion The implementation of the HEF scheme was associated with increased utilisation of primary and secondary care services by the poor.
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Affiliation(s)
| | - John Tayu Lee
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Keovathanak Khim
- Public Health Department, University of Health Sciences, Phnom Penh, Cambodia
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Ellen Moscoe
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | | | - Thomas Bossert
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | | | - Veasnakiry Lo
- Department of Planning and Health Information, Ministry of Health, Cambodia, Cambodia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Chhea C, Ir P, Sopheab H. Low birth weight of institutional births in Cambodia: Analysis of the Demographic and Health Surveys 2010-2014. PLoS One 2018; 13:e0207021. [PMID: 30408102 PMCID: PMC6224106 DOI: 10.1371/journal.pone.0207021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/22/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Low birth weight (LBW), an important risk factor for early childhood mortality and morbidity, is a major public health concern in developing countries including Cambodia. This study examined the prevalence of LBW across provinces in Cambodia and changes over time, and identified the factors associated with such condition. METHODS We used children datasets from Cambodia Demographic and Health Survey (CDHS) 2010 and 2014. There were 3,522 children and 4,991 children in both surveys. Maps illustrating provincial variation in LBW prevalence were constructed. Then, multivariate analyses were conducted to assess factors independently associated with LBW in CDHS 2014. RESULTS LBW prevalence remained stable between 2010 and 2014, at around 7.0% 95% CI: 5.8-8.1). all institutional births, but within significant variation across provinces. Factors independently associated with LBW included mother's no education compared with those whose mothers had secondary or higher education (AOR = 1.6, 95% CI: 1.0-2.6), babies born to mothers with < 4 antenatal care (ANC) visits during the pregnancy compared with those whose mothers had at least 4 ANC visits (AOR = 2.0, 95% CI: 1.5-2.8). Also, first-born babies were at greater risk of LBW compared with second-born babies (AOR = 1.4, 95% CI: 1.0-2.0). CONCLUSION The study points to key sub-populations at greater risk and regions where LBW is particularly prevalent. Programs should target provinces where LBW prevalence remains high. Illiterate women, especially those pregnant for the first time should be the program priority. The current national program policy, which recommends that pregnant women have ≥ 4 ANC visits during pregnancy should be further reinforced and implemented. Program design should consider ways to communicate the importance of making the recommended number of ANC visits among women with no formal education.
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Affiliation(s)
- Chhorvann Chhea
- School of Public Health at the National Institute of Public Health, Tuol Kork District, Phnom Penh, Cambodia
| | - Por Ir
- School of Public Health at the National Institute of Public Health, Tuol Kork District, Phnom Penh, Cambodia
| | - Heng Sopheab
- School of Public Health at the National Institute of Public Health, Tuol Kork District, Phnom Penh, Cambodia
- * E-mail:
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Ozawa S, Villar-Uribe M, Evans DR, Kulkarni V, Ir P. Building informed trust: developing an educational tool for injection practices and health insurance in Cambodia. Health Policy Plan 2018; 33:1009-1017. [DOI: 10.1093/heapol/czy080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Manuela Villar-Uribe
- Health Nutrition and Population Global Practice, World Bank Group, Washington, DC, USA
| | | | - Vivek Kulkarni
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
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Meessen B, Shroff ZC, Ir P, Bigdeli M. From Scheme to System (Part 1): Notes on Conceptual and Methodological Innovations in the Multicountry Research Program on Scaling Up Results-Based Financing in Health Systems. Health Syst Reform 2017; 3:129-136. [PMID: 31514678 DOI: 10.1080/23288604.2017.1303561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract-This article presents conceptual and methodological developments made in analyzing the scale up of results-based financing (RBF) as part of a multicountry research program supported by the Alliance for Health Policy and Systems Research. Following a brief overview of the research process, the article proposes a new five-dimensional conceptualization of scale-up (population coverage, service coverage, health system integration, cross-sectoral diffusion, and knowledge expansion) to capture various facets of RBF scale-up. It also presents how Walt and Gilson's health policy triangle framework was modified to identify the enablers and barriers to scale-up in the country case studies included in this research program. The article then puts forth a four-phase model of scale-up, including phases of generation, adoption, institutionalization, and expansion, developed for the purpose of this research program. The article concludes by providing some lessons learned on the use of the methods and theoretical frameworks developed for this multicountry research program.
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Affiliation(s)
- Bruno Meessen
- Department of Public Health , Institute of Tropical Medicine , Antwerp , Belgium
| | | | - Por Ir
- National Institute of Public Health , Phnom Penh , Cambodia
| | - Maryam Bigdeli
- Health System Governance, Policy and Aid Effectiveness, World Health Organization , Geneva , Switzerland
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Khim K, Ir P, Annear PL. Factors Driving Changes in the Design, Implementation, and Scaling-Up of the Contracting of Health Services in Rural Cambodia, 1997–2015. Health Syst Reform 2017; 3:105-116. [DOI: 10.1080/23288604.2017.1291217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Keovathanak Khim
- Public Health, University of Health Sciences, Khan Daun Penh, Phnom Penh, Cambodia
| | - Por Ir
- Health System Strengthening, National Institute of Public Health, Khan Tuol Kork, Phnom Penh, Cambodia
| | - Peter Leslie Annear
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Wiseman V, Asante A, Ir P, Limwattananon S, Jacobs B, Liverani M, Hayen A, Jan S. System-wide analysis of health financing equity in Cambodia: a study protocol. BMJ Glob Health 2017; 2:e000153. [PMID: 28589000 PMCID: PMC5321386 DOI: 10.1136/bmjgh-2016-000153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/17/2016] [Accepted: 11/22/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To assess progress towards universal health coverage, countries like Cambodia require evidence on equity in the financing and distribution of healthcare benefits. This evidence must be based on a system-wide perspective that recognises the complex roles played by the public and private sectors in many contemporary healthcare systems. OBJECTIVE To undertake a system-wide assessment of who pays and who benefits from healthcare in Cambodia and to understand the factors influencing this. METHODS Financing and benefit incidence analysis will be used to calculate the financing burden and distribution of healthcare benefits across socioeconomic groups. Data on healthcare usage, living standards and self-assessed health status will be derived from a cross-sectional household survey designed for this study involving a random sample of 5000 households. This will be supplemented by secondary data from the Cambodian National Health Accounts 2014 and the Cambodian Socioeconomic Survey (CSES) 2014. We will also collect qualitative data through focus group discussions and in-depth interviews to inform the interpretation of the quantitative analyses. POTENTIAL IMPACT This study will produce previously unavailable information on who pays for, and who benefits from, health services across the entire health system of Cambodia. This evidence comes at a critical juncture in healthcare reform in South-East Asia with so many countries seeking guidance on the equity impact of their current financing arrangements that include a complex mix of public and private providers.
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Affiliation(s)
- Virginia Wiseman
- Department of Public Health & Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Augustine Asante
- Department of Public Health & Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Supon Limwattananon
- Khon Kaen University, Khon Kaen, Thailand
- Ministry of Public Health International Health Policy Program (IHPP), Thailand
| | - Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney Sydney, New South Wales, Australia
| | - Stephen Jan
- George Institute for Global Health, Sydney, New South Wales, Australia
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Ir P, Korachais C, Chheng K, Horemans D, Van Damme W, Meessen B. Boosting facility deliveries with results-based financing: a mixed-methods evaluation of the government midwifery incentive scheme in Cambodia. BMC Pregnancy Childbirth 2015; 15:170. [PMID: 26276138 PMCID: PMC4537578 DOI: 10.1186/s12884-015-0589-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing the coverage of skilled attendance at births in a health facility (facility delivery) is crucial for saving the lives of mothers and achieving Millennium Development Goal five. Cambodia has significantly increased the coverage of facility deliveries and reduced the maternal mortality ratio in the last decade. The introduction of a nationwide government implemented and funded results-based financing initiative, known as the Government Midwifery Incentive Scheme (GMIS), is considered one of the most important contributors to this. We evaluated GMIS to explore its effects on facility deliveries and the health system. METHODS We used a mixed-methods design. An interrupted time series model was applied, using routine longitudinal data on reported deliveries between 2006 and 2011 that were extracted from the health information system. In addition, we interviewed 56 key informants and performed 12 focus group discussions with 124 women who had given birth (once or more) since 2006. Findings from the quantitative data were carefully interpreted and triangulated with those from qualitative data. RESULTS We found that facility deliveries have tripled from 19% of the estimated number of births in 2006 to 57% in 2011 and this increase was more substantial at health centres as compared to hospitals. Segmented linear regressions showed that the introduction of GMIS in October 2007 made the increase in facility deliveries and deliveries with skilled attendants significantly jump by 18 and 10% respectively. Results from qualitative data also suggest that the introduction of GMIS together with other interventions that aimed to improve access to essential maternal health services led to considerable improvements in public health facilities and a steep increase in facility deliveries. Home deliveries attended by traditional birth attendants decreased concomitantly. We also outline several operational issues and limitations of GMIS. CONCLUSIONS The available evidence strongly suggests that GMIS is an effective mechanism to complement other interventions to improve health system performance and boost facility deliveries as well as skilled birth attendance; thereby contributing to the reduction of maternal mortality. Our findings provide useful lessons for Cambodia to further improve GMIS and for other low-income countries to implement similar results-based financing mechanisms.
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Affiliation(s)
- Por Ir
- National Institute of Public Health, Ministry of Health, PO BOX 1300, Phnom Penh, Cambodia.
| | - Catherine Korachais
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Nationalestraat 155, B-2000, Antwerp, Belgium.
| | - Kannarath Chheng
- National Institute of Public Health, Ministry of Health, PO BOX 1300, Phnom Penh, Cambodia.
| | - Dirk Horemans
- Health Sector Support Programme, Belgian Technical Cooperation, Phnom Penh, Cambodia.
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Nationalestraat 155, B-2000, Antwerp, Belgium.
| | - Bruno Meessen
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Nationalestraat 155, B-2000, Antwerp, Belgium.
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Goyet S, Touch S, Ir P, SamAn S, Fassier T, Frutos R, Tarantola A, Barennes H. Gaps between research and public health priorities in low income countries: evidence from a systematic literature review focused on Cambodia. Implement Sci 2015; 10:32. [PMID: 25889672 PMCID: PMC4357145 DOI: 10.1186/s13012-015-0217-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 02/05/2015] [Indexed: 01/20/2023] Open
Abstract
Background Evidence-based public health requires that research provides policymakers with reliable and accessible information reflecting the disease threats. We described the scientific production of research in Cambodia and assessed to what extent it provides appropriate insights and implications for practice to guide health policymakers and managers and knowledge relevant for translation. Methods We conducted a systematic review of scientific articles published on biomedical research in Cambodia. Regression analysis assessed the trends over time and factors associated with actionable messages in the articles’ abstracts. Results From 2000 to 2012, 628 articles were published in 237 journals with a significant increase over time (from 0.6/million population to 5.9/million population, slope coefficient 7.6, 95% CI 6.5–8.7, p < 0.001). Most publications on diseases addressed communicable diseases (n = 410, 65.3%). Non-communicable diseases (NCD) were under-addressed (7.7% of all publications) considering their burden (34.5% of the disease burden). Of all articles, 67.8% reported descriptive studies and 4.3% reported studies with a high level of evidence; 27.4% of studies were led by an institution based in Cambodia. Factors associated with an actionable message (n = 73, 26.6%) were maternal health (OR 3.08, 95% CI 1.55–6.13, p = 0.001), the first author’s institution being Cambodian (OR 1.78, 95% CI 1.06–2.98, p = 0.02) and a free access to full article (OR 3.07, 95% CI 1.08–8.70, p = 0.03). Of all articles, 87% (n = 546) were accessible in full text from Cambodia. Conclusions Scientific publications do not fully match with health priorities. Gaps remain regarding NCD, implementation studies, and health system research. A health research agenda would help align research with health priorities. We recommend 1) that the health authorities create an online repository of research findings with abstracts in the local language; 2) that academics emphasize the importance of research in their university teaching; and 3) that the researcher teams involve local researchers and that they systematically provide a translation of their abstracts upon submission to a journal. We conclude that building the bridge between research and public health requires a willful, comprehensive strategy rather than relying solely only publications. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0217-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sophie Goyet
- Epidemiology and Public Health Unit, Institut Pasteur, Phnom Penh, Cambodia.
| | - Socheat Touch
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia.
| | - Por Ir
- Health System Research and Policy Support Unit, National Institute of Public Health, Phnom Penh, Cambodia.
| | - Sovannchhorvin SamAn
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia.
| | - Thomas Fassier
- University of Health Sciences of Cambodia, Phnom Penh, Cambodia.
| | - Roger Frutos
- UM2, CPBS, UMR 5236, CNRS-UM1-UM2, 1919 route de Mende, 34293, Montpellier, Cedex 5, France. .,Intertryp, UMR 17, IRD-Cirad, Campus International de Baillarguet, 34398, Montpellier, Cedex 5, France.
| | - Arnaud Tarantola
- Epidemiology and Public Health Unit, Institut Pasteur, Phnom Penh, Cambodia.
| | - Hubert Barennes
- Epidemiology and Public Health Unit, Institut Pasteur, Phnom Penh, Cambodia. .,INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Université de Bordeaux, F-33000, Bordeaux, France. .,Agence Nationale de Recherche sur le VIH et Hépatite, ANRS, Phnom Penh, Cambodia.
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Van de Poel E, Flores G, Ir P, O'Donnell O, Van Doorslaer E. Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia. Bull World Health Organ 2014; 92:331-9. [PMID: 24839322 DOI: 10.2471/blt.13.129122] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/05/2013] [Accepted: 11/28/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia. METHODS The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health-care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them. FINDINGS Overall, voucher schemes were associated with an increase of 10.1 percentage points (pp) in the probability of delivery in a public health-care facility; among women from the poorest 40% of households, the increase was 15.6 pp. Vouchers were responsible for about one fifth of the increase observed in institutional deliveries in districts with schemes. Universal voucher schemes had a larger effect on the probability of delivery in a public facility than schemes targeting the poorest women. Both types of schemes increased the probability of receiving postnatal care, but the increase was significant only for non-poor women. Universal, but not targeted, voucher schemes significantly increased the probability of receiving antenatal care. CONCLUSION Voucher schemes increased deliveries in health centres and, to a lesser extent, improved antenatal and postnatal care. However, schemes that targeted poorer women did not appear to be efficient since these women were more likely than less poor women to be encouraged to give birth in a public health-care facility, even with universal voucher schemes.
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Affiliation(s)
- Ellen Van de Poel
- Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands
| | - Gabriela Flores
- Institute of Health Economics and Management, University of Lausanne, Lausanne, Switzerland
| | - Por Ir
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Eddy Van Doorslaer
- Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands
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Flores G, Ir P, Men CR, O'Donnell O, van Doorslaer E. Financial protection of patients through compensation of providers: the impact of Health Equity Funds in Cambodia. J Health Econ 2013; 32:1180-1193. [PMID: 24189447 DOI: 10.1016/j.jhealeco.2013.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 01/07/2013] [Accepted: 09/16/2013] [Indexed: 06/02/2023]
Abstract
Public providers have no financial incentive to respect their legal obligation to exempt the poor from user fees. Health Equity Funds (HEFs) aim to make exemptions effective by giving NGOs responsibility for assessing eligibility and compensating providers for lost revenue. We use the geographic spread of HEFs over time in Cambodia to identify their impact on out-of-pocket (OOP) payments. Among households with some OOP payment, HEFs reduce the amount paid by 35%, on average. The effect is larger for households that are poorer and mainly use public health care. Reimbursement of providers through a government operated scheme also reduces household OOP payments but the effect is not as well targeted on the poor. Both compensation models raise household non-medical consumption but have no impact on health-related debt. HEFs reduce the probability of primarily seeking care in the private sector.
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Affiliation(s)
- Gabriela Flores
- Institute of Health Economics and Management, University of Lausanne, Switzerland; Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
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Annear PL, Ahmed S, Ros CE, Ir P. Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: A study of policy barriers and opportunities in Cambodia. Soc Sci Med 2013; 96:223-31. [DOI: 10.1016/j.socscimed.2013.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 12/17/2012] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
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Ir P, Jacobs B, Meessen B, Van Damme W. Toward a typology of health-related informal credit: an exploration of borrowing practices for paying for health care by the poor in Cambodia. BMC Health Serv Res 2012; 12:383. [PMID: 23134845 PMCID: PMC3507708 DOI: 10.1186/1472-6963-12-383] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Accepted: 10/30/2012] [Indexed: 11/22/2022] Open
Abstract
Background Borrowing money is a common strategy to cope with health care costs. The impact of borrowing on households can be severe, leading to indebtedness and further impoverishment. However, the available literature on borrowing practices for health is limited. We explore borrowing practices for paying for health care by the poor in Cambodia and provide a typology, associated conditions, and the extent of the phenomenon. Methods In addition to a semi-structured literature review, in-depth interviews were conducted with representatives of 47 households with health-related debt and 19 managers of formal or informal credit schemes. Results A large proportion of Cambodians, especially the poor, resort to borrowing to meet the cost of health care. Because of limited cash flow and access to formal creditors, the majority take out loans with high interest rates from informal money lenders. The most common type of informal credit is locally known as Changkar and consists of five kinds of loans: short-term loans, medium-term loans, seasonal loans, loans for an unspecified period, and loans with repayment in labour, each with different lending and repayment conditions and interest rates. Conclusion This study suggests the importance of informal credit for coping with the cost of treatment and its potentially negative impact on the livelihood of Cambodian people. We provide directions for further studies on financial protection interventions to mitigate harmful borrowing practices to pay for health care in Cambodia.
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Affiliation(s)
- Por Ir
- National Institute of Public Health, Ministry of Health, PO BOX 1300, Phnom Penh, Cambodia.
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Meessen B, Bigdeli M, Chheng K, Decoster K, Ir P, Men C, Van Damme W. Composition of pluralistic health systems: how much can we learn from household surveys? An exploration in Cambodia. Health Policy Plan 2011; 26 Suppl 1:i30-44. [PMID: 21729915 DOI: 10.1093/heapol/czr026] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In spite of all efforts to build national health services, health systems of many low-income countries are today highly pluralistic. Households use a vast range of public and private health care providers, many of whom are not controlled by national health authorities. Experts have called on Ministries of Health to re-establish themselves as stewards of the entire health system. Modern stewardship will require national and decentralized health authorities to have an overall view of their pluralistic health system, especially of the components outside the public sector. Little guidance has been provided so far on how to develop such a view. In this paper, we explore whether household surveys could be a source of information. The study builds on secondary data analysis of a household survey carried out in three health districts in rural Cambodia and of two national surveys. Cambodia is indeed an interesting case, as massive efforts by donors in favour of the public sector go hand in hand with a dominant role of the private sector in the provision of health care services. The study confirms that the health care sector in Cambodia is now highly pluralistic, and that the great majority of health seeking behaviour takes place outside the public health system. Our analysis of the survey also shows that the disaffection of the population with public health facilities varies across places, socio-economic groups and health problems. We illustrate how such knowledge could allow stewards to better identify challenges for existing or future health policies. We argue that a whole research programme on the composition of pluralistic health systems still needs to be developed. We identify some challenges and opportunities.
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Jacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan 2011; 27:288-300. [PMID: 21565939 DOI: 10.1093/heapol/czr038] [Citation(s) in RCA: 304] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
While World Health Organization member countries embraced the concept of universal coverage as early as 2005, few low-income countries have yet achieved the objective. This is mainly due to numerous barriers that hamper access to needed health services. In this paper we provide an overview of the various dimensions of barriers to access to health care in low-income countries (geographical access, availability, affordability and acceptability) and outline existing interventions designed to overcome these barriers. These barriers and consequent interventions are arranged in an analytical framework, which is then applied to two case studies from Cambodia. The aim is to illustrate the use of the framework in identifying the dimensions of access barriers that have been tackled by the interventions. The findings suggest that a combination of interventions is required to tackle specific access barriers but that their effectiveness can be influenced by contextual factors. It is also necessary to address demand-side and supply-side barriers concurrently. The framework can be used both to identify interventions that effectively address particular access barriers and to analyse why certain interventions fail to tackle specific barriers.
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Affiliation(s)
- Bart Jacobs
- Health Sector Support Programme, Luxembourg Development, Ministry of Health, PO BOX 7084, Vientiane, Lao PDR.
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Tangcharoensathien V, Patcharanarumol W, Ir P, Aljunid SM, Mukti AG, Akkhavong K, Banzon E, Huong DB, Thabrany H, Mills A. Health-financing reforms in southeast Asia: challenges in achieving universal coverage. Lancet 2011; 377:863-73. [PMID: 21269682 DOI: 10.1016/s0140-6736(10)61890-9] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this sixth paper of the Series, we review health-financing reforms in seven countries in southeast Asia that have sought to reduce dependence on out-of-pocket payments, increase pooled health finance, and expand service use as steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor-supported health equity funds to reach the poor, and reliable funding and appropriate identification of the eligible poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam, social health insurance financed by payroll tax is commonly used for formal sector employees (excluding Malaysia), with varying outcomes in terms of financial protection. Alternative payment methods have different implications for provider behaviour and financial protection. Two alternative approaches for financial protection of the non-poor outside the formal sector have emerged-contributory arrangements and tax-financed schemes-with different abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both important in accelerating financial protection. Expanding coverage of good-quality services and ensuring adequate human resources are also important to achieve universal coverage. As health-financing reform is complex, institutional capacity to generate evidence and inform policy is essential and should be strengthened.
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Ir P, Men C, Lucas H, Meessen B, Decoster K, Bloom G, Van Damme W. Self-reported serious illnesses in rural Cambodia: a cross-sectional survey. PLoS One 2010; 5:e10930. [PMID: 20532180 PMCID: PMC2880606 DOI: 10.1371/journal.pone.0010930] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 05/07/2010] [Indexed: 11/18/2022] Open
Abstract
Background There is substantial evidence that ill-health is a major cause of impoverishment in developing countries. Major illnesses can have a serious economic impact on poor households through treatment costs and income loss. However, available methods for measuring the impact of ill-health on household welfare display several shortcomings and new methods are thus needed. To understand the potential complex impact of major illnesses on household livelihoods, a study on poverty and illness was conducted in rural Cambodia, as part of an international comparative research project. A cross-sectional survey was performed to identify households affected by major illness for further in-depth interviews. Methodology and Principal Findings 5,975 households in three rural health districts were randomly selected through a two-stage cluster sampling and interviewed. 27% of the households reported at least one member with a serious illness in the year preceding the survey and 15% of the household members reported suffering from at least one serious illness. The most reported conditions include common tropical infectious diseases, chronic diseases (notably hypertension and heart diseases) and road traffic accidents. Such conditions were particularly concentrated among the poor, children under five, women, and the elderly. Poor women often reported complications related to pregnancy and delivery as serious illnesses. Conclusions and Significance Despite some methodological limitations, this study provides new information on the frequency of self-reported serious illnesses among the rural Cambodia's population, which serves as a basis for further in-depth investigation on ‘major illnesses’ and their economic consequences on poor households. This can in turn help policy makers to formulate appropriate interventions to protect the poor from the financial burden associated with ill-health. Our findings suggest that every year a considerable proportion of rural population in Cambodia, especially the poor and vulnerable, are affected by serious illnesses, both communicable and non-communicable diseases.
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Affiliation(s)
- Por Ir
- Provincial Health Department, Ministry of Health, Siem Reap, Cambodia.
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Ir P, Horemans D, Souk N, Van Damme W. Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia. BMC Pregnancy Childbirth 2010; 10:1. [PMID: 20059767 PMCID: PMC2820432 DOI: 10.1186/1471-2393-10-1] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Accepted: 01/07/2010] [Indexed: 11/10/2022] Open
Abstract
Background In many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up. Methods Data on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation. Results Facility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for self-paid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme. Conclusions Vouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.
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Affiliation(s)
- Por Ir
- Provincial Health Department, Ministry of Health, Siem Reap, Cambodia.
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Jacobs B, Bigdeli M, Pelt MV, Ir P, Salze C, Criel B. Bridging community-based health insurance and social protection for health care - a step in the direction of universal coverage? Trop Med Int Health 2008; 13:140-3. [DOI: 10.1111/j.1365-3156.2007.01983.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Noirhomme M, Meessen B, Griffiths F, Ir P, Jacobs B, Thor R, Criel B, Van Damme W. Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia. Health Policy Plan 2007; 22:246-62. [PMID: 17526640 DOI: 10.1093/heapol/czm015] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is a large body of evidence that user fees in the health sector create exclusion. Health equity funds attempt to improve access to health care services for the poorest by paying the provider on their behalf. This paper reviews four hospital-based health equity funds in Cambodia and draws lessons for future operations. It investigates the practical questions of 'who should do what and how'. It presents, in a comparative framework, similarities and differences in objectives, the actors involved, design aspects and functional modalities between the health equity funds. The results of this review are presented along the lines of identification, hospitalization rates and relative costs. The four schemes had a positive impact on the volume of utilization of hospital services by the poorest patients. They now account for 7 to 52% of total hospital use. The utilization of hospitals by paying patients has remained constant in the same period. The comparative review shows that a range of operational arrangements may be adopted to achieve the health equity fund objectives. Our study identifies essential design aspects, and leaves different options open for others.
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