Utilization of vouchers and HEF
A total of 2,725 vouchers were distributed in the three health districts within less than two years of operation. During this period, 2,062 vouchers were used by poor pregnant women for ANC1, 1,498 for ANC2, 1,140 for ANC3, 1,280 for delivery and 684 for postnatal care. Of the 1,280 voucher users for delivery, 215 delivered in referral hospitals; 63 of them were referred by health centres whereas 152 others went straight to the hospitals possibly after advice given by the health centres during ANC visits.
Figure presents the total number of vouchers distributed and used in 2007 and 2008. The comparison of the figures shows a significant increase in the number of vouchers distributed and used for all recommended services, especially delivery. However, in both years the difference between the number of distributed and used vouchers remains large, indicating that many distributed vouchers were not used.
Vouchers distributed and used in 2007 and 2008.
In 2006, HEF supported 132 poor pregnant women who delivered at the three district hospitals. The respective figures for 2007 and 2008 were 346 and 549; these included the voucher holders.
Facility deliveries in the three study ODs
Among the total of 5,611 facility deliveries in the three study ODs in 2008, 4,391 (78.3%) happened in health centres and 1,220 (21.7%) in referral hospitals. Vouchers supported 876 (19.9%) of the total health centre deliveries while HEF supported 549 (45%) of the total hospital deliveries. In total, 1,425 poor pregnant women benefited from the voucher and HEF schemes, which accounts for 25.4% of the total number of facility deliveries. Vouchers and HEFs financed 11.4% of the expected number of births in the three study ODs (estimated at 12,485) and 40.6% of the expected number of births among poor women (3,509) in 2008.
Figure shows that facility deliveries as percentage of the expected number of births in the three ODs increased sharply from 16.3% in 2006 to 24.9% in 2007 and 44.9% in 2008, and this increase was not only for voucher and HEF beneficiaries, but also for self-paid deliveries. Facility deliveries of voucher beneficiaries increased by 195.9% within two years, from 2.4% in 2007 to 7% in 2008, while the figures for HEF beneficiaries and self-paid deliveries increased by 58.1% and 69.8% respectively within the same period. The highest increase in facility deliveries was observed in 2008 when all three interventions were put in place.
Facility deliveries by type of beneficiary in the three ODs between 2006 and 2008.
Comparison of facility delivery trends in the three study ODs and two other groups of ODs
Figure compares the facility deliveries in the three study ODs to those in two other groups of ODs between 2006 and 2008. The figure shows that the facility deliveries increased in the three groups of ODs over this period. The absolute increases between 2006 and 2008 were 28.6%, 14.5% and 8.6% of the expected number of deliveries, respectively, for the group of study ODs, the group of two ODs with special contracting, and the group of four ODs with the delivery incentive scheme only. In the last group, the percentage of facility deliveries also increased substantially in 2008, but the increase was less pronounced than in the other two groups.
Comparison of facility deliveries in three groups of ODs in Kampong Cham between 2006 and 2008.
Operational analysis of the voucher scheme
The operational process of the voucher scheme can be divided into three stages: (1) health centre selection, (2) voucher distribution and (3) voucher utilisation.
(1) Health centre selection. By 2008, only 30 (71.4%) of the 42 health centres in the three ODs had been selected and included in the voucher scheme. Twelve health centres and their catchment villages were not covered because they did not meet the selection criteria (six health centres lacked proper infrastructures). Pregnant women living in the catchment areas of these twelve health centres were thus automatically excluded from the voucher scheme.
(2) Voucher distribution. Voucher distribution started with the pre-selection of potentially poor pregnant women in the target villages by village health volunteers. These women were later interviewed by VMA staff. On the basis of the schedule set for 2007, the VMA staff was supposed to make a total of 894 visits to the 329 villages in the catchment areas of the 30 contracted health centres. In reality, only 545 (60.9%) of the scheduled visits took place.
(3) Voucher utilisation. Analysis of the 1,093 poor pregnant women who received vouchers in 2007 shows that 855 (78.2%) of them had used their vouchers for ANC1, 665 (60.8%) for ANC2, 501 (45.8%) for ANC3 and 487 (44.6%) for delivery. Therefore, more than half of the voucher recipients did not make use of their voucher for delivery.
Results from focus group discussions
None of the 87 women participating in the focus group discussions had delivered in the health centre prior to the introduction of the voucher scheme, although about half of them had previously sought ANC at the health centre. Almost all the women had used vouchers to seek ANC at the contracted health centres at least once, even those who had not used their voucher for delivery (the non-user group).
All the women participating in the user group were in general satisfied with the services provided at the health centres. They reported three main reasons for using their vouchers for delivery at health centres. First, with a voucher they could get free care and some money to pay for transportation costs. Second, they felt safer when delivering at the health centre (compared to home deliveries with traditional birth attendants). Third, they could immediately get their child vaccinated after the delivery at the health centre.
Women participating in the non-user group reported several reasons for the non-use of their vouchers for delivery at health centres. Transportation and intra-household constraints were mentioned as the two main reasons. First, some women lived in remote areas far away from the health centres. Although they knew that transportation costs would be paid for by the voucher scheme, they could seldom find appropriate means of transport when the deliveries happened in the middle of the night. If they did manage to find transport, they anticipated that the price would be much higher than the day time price approved by the voucher scheme. They therefore feared that such higher costs would not be fully covered by the voucher scheme. Second, several intra-household constraints made it difficult for some poor pregnant women to leave their home. Many women claimed that if they came to deliver at health centres, nobody would look after their house and take care of their children or that nobody could accompany them to health centres. In addition, many of them expressed dissatisfaction with health centre services and staff. Some women reported poor staff attitudes and extra payments hinted by midwives. Some doubted the midwife's availability at night for delivery.
Results from key informant interviews
All the key informants observed a significant improvement in facility deliveries in the study area. Many of the village health volunteers and traditional birth attendants interviewed claimed that there were almost no home deliveries any more in their villages. The traditional birth attendants referred all pregnant women to health centres for delivery. Other key informants also confirmed this. They reported several reasons for this improvement. First, poor pregnant women who received a voucher could now go to the health centre without having to overcome financial barriers. Second, thanks to the cash incentives from the PBC and delivery incentive scheme, midwives and health centre personnel had become more committed to ensuring 24-hour services at health centres and to providing more health education to promote facility deliveries during outreach activities. Third, village health volunteers and traditional birth attendants also received cash incentives from the health centre for referrals of pregnant women for delivery at the health centre. Fourth, the district and provincial health management teams applied stronger monitoring and stricter rules for 24-hour services. Informal payments were no longer allowed.