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

Provincial Health Department, Ministry of Health, Siem Reap, Cambodia.
BMC Pregnancy and Childbirth (Impact Factor: 2.19). 01/2010; 10(1):1. DOI: 10.1186/1471-2393-10-1
Source: PubMed


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.
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.
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.
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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    • "Notwithstanding Cambodia ' s recent history of genocide under the Khmer Rouge ( 1975 – 1979 ) and internal conflict until the 1997 coup , this study confirms the noteworthy national reduction in under - five and neonatal mortality since 2000 [ 9 ] . These improve - ments are consistent with improvements in the maternal mortality ratio which decreased from 472 per 100 , 000 live births in 2000 – 2005 to 206 in 2006 – 2010 [ 9 ] . While it is not possible to make causal inferences from the available data , improvements are likely to be due to more than a decade of relative political and macroeconomic stability and high economic growth , increased female participation in the waged workforce and improved access to communications , transport infrastructure , education and potable water and sanitation [ 17 , 32 , 33 ] . "
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    ABSTRACT: Background: Cambodia has made considerable improvements in mortality rates for children under the age of five and neonates. These improvements may, however, mask considerable disparities between subnational populations. In this paper, we examine the extent of the country's child mortality inequalities. Methods: Mortality rates for children under-five and neonates were directly estimated using the 2000, 2005 and 2010 waves of the Cambodian Demographic Health Survey. Disparities were measured on both absolute and relative scales using rate differences and ratios, and where applicable, slope and relative indices of inequality by levels of rural/urban location, regions and household wealth. Findings: Since 2000, considerable reductions in under-five and to a lesser extent in neonatal mortality rates have been observed. This mortality decline has, however, been accompanied by an increase in relative inequality in both rates of child mortality for geography-related stratifying markers. For absolute inequality amongst regions, most trends are increasing, particularly for neonatal mortality, but are not statistically significant. The only exception to this general pattern is the statistically significant positive trend in absolute inequality for under-five mortality in the Coastal region. For wealth, some evidence for increases in both relative and absolute inequality for neonates is observed. Conclusion: Despite considerable gains in reducing under-five and neonatal mortality at a national level, entrenched and increased geographical and wealth-based inequality in mortality, at least on a relative scale, remain. As expected, national progress seems to be associated with the period of political and macroeconomic stability that started in the early 2000s. However, issues of quality of care and potential non-inclusive economic growth might explain remaining disparities, particularly across wealth and geography markers. A focus on further addressing key supply and demand side barriers to accessing maternal and child health care and on the social determinants of health will be essential in narrowing inequalities.
    PLoS ONE 10/2014; 9(10):e109044. DOI:10.1371/journal.pone.0109044 · 3.23 Impact Factor
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    • "Many studies argued for community-based agents, either to encourage women to visit health facilities and claim cash payments as in Progam Keluarga Harapan in Indonesia [34] and Janani Suraksha Yojana in India [39-41,43-47,50-57] or to distribute vouchers for maternity services [6,8,74]. However, social barriers such as women’s household responsibilities can still delay uptake or cause early self-discharge from hospital, and need to be addressed with wider social interventions [12,56,72,81]. "
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    ABSTRACT: Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system. The protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis. Thirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems. Demand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.
    BMC Pregnancy and Childbirth 01/2014; 14(1):30. DOI:10.1186/1471-2393-14-30 · 2.19 Impact Factor
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    • "Inadequate financial and human resources, lack of capital investment and poor management have affected the ability of the public sector to fulfill its mandate of providing quality healthcare services to all those in need resulting in greater reliance on the private sector (MoH 2010a). Perceived low quality of care in facilities, distance to health facilities, transportation challenges, costs of services including informal charges or expenses, opportunity costs from time lost while seeking care, provider attitudes, power dynamics including ineffective decision making at the household level and sociocultural norms are among client-level factors that affect the uptake of services in the country and similar settings (Thaddeus and Maine 1994; Ammoti-Kaguna and Nuwaha 2000; Afsana and Rashid 2001; Musoke 2002; Kyomuhendo 2003; Amone et al. 2005; UBOS and Macro International Inc. 2007; Essendi et al. 2010; Ir et al. 2010; Gabrysch et al. 2011; Njuki et al. 2012). "
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    ABSTRACT: There has been increased interest in and experimentation with demand-side mechanisms such as the use of vouchers that place purchasing power in the hands of targeted consumers to improve the uptake of healthcare services in low-income settings. A key measure of the success of such interventions is the extent to which the programmes have succeeded in reaching the target populations. This article estimates the coverage of facility deliveries by a maternal health voucher programme in South-western Uganda and examines whether such coverage is correlated with district-level characteristics such as poverty density and the number of contracted facilities. Analysis entails estimating the voucher coverage of health facility deliveries among the general population and poor population (PP) using programme data for 2010, which was the most complete calendar year of implementation of the Uganda safe motherhood (SM) voucher programme. The results show that: (1) the programme paid for 38% of estimated deliveries among the PP in the targeted districts, (2) there was a significant negative correlation between the poverty density in a district and proportions of births to poor women that were covered by the programme and (3) improving coverage of health facility deliveries for poor women is dependent upon increasing the sales and redemption rates. The findings suggest that to the extent that the programme stimulated demand for SM services by new users, it has the potential of increasing facility-based births among poor women in the region. In addition, the significant negative correlation between the poverty density and the proportions of facility-based births to poor women that are covered by the voucher programme suggests that there is need to increase both voucher sales and the rate of redemption to improve coverage in districts with high levels of poverty.
    Health Policy and Planning 10/2013; 29(Suppl 1). DOI:10.1093/heapol/czt079 · 3.47 Impact Factor
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