Within Asia, Cambodia has some of the poorest maternal health indicators. Following years of war, genocide, and occupation, the country has struggled to rebuild its health care system. The maternal mortality ratio is estimated at 266 deaths per 100,000 live births -- the second highest in the region [1
]. The low prevalence of contraception use for spacing and limiting births, the low use of skilled attendance at birth, and the lack of emergency obstetric care when complications arise are seen as the leading contributors to these high rates of death [2
]. Another contributing factor pertains to women’s roles in the society. According to a 2004 population survey, about 40% of rural women in Cambodia are illiterate [3
]. The total fertility rate in rural communities is approximately 4 children per women, approximately one child more per woman than in the urban areas of Cambodia [4
]. The total fertility rate of the poorest wealth quintile is 4.9 [4
In Cambodia, the population relies upon a mixture of public facilities, private providers, private drug sellers and traditional healers. The quality of the public system has suffered from a lack of resources; complaints of long waits and staff shortages reflect the funding constraints within the public system. But the poorest continue to rely on public services because they have been priced out of most private healthcare options.
User fees were introduced in public health facilities in Cambodia in 1997 with the goal of injecting funds into the health system, which in turn, would be expected to enhance the quality of services. Because of government subsidies and donor support, user fees were set lower than private healthcare fees. But studies from around the world have shown that user fees have a strong negative effect on the use of healthcare services by the poorest [5
]. Ten years later, more than two thirds of total health expenditures were derived from direct out-of-pocket payments (USD 35 per capita, 2007), contributing to unmanageable healthcare-related debt, hitting the poor the hardest [7
]. The increasing need for developing fiscal safety nets for the poor and vulnerable was clear.
In an effort to extend the reach of public health care coverage to the poor, especially in the domain of child and maternal health, the Cambodian government developed a National Social Protection Strategy for the Poor and Vulnerable in 2000. Part of this strategy includes the Health Equity Fund, which is designed to reduce financial barriers to accessing health services at the provincial hospital level. Evidence from several studies suggests that these funds have successfully reduced out-of-pocket payments and health care-related debts [8
]. In 2007, the government set out to work with various foreign donors to find a complementary strategy to the existing Health Equity Fund that would extend to the primary care level. Several pilot programs were launched to ascertain if voucher schemes might be the answer. Evidence from one pilot program that was tested in 2008 suggested that a voucher scheme contributed to increasing the number of deliveries in public health facilities [8
In 2011, the German Development Bank, Kreditanstalt für Wiederaufbau, partnered with the Cambodian Ministry of Health to roll out a larger scale reproductive and maternal health voucher program. With a voucher, poor women can overcome some of the barriers to accessing family planning and safe delivery services including out-of-pocket and transportation costs. The Cambodia Vouchers for Reproductive Health Project is managed by Action for Health, a Cambodia-based organization, and is being evaluated by the Population Council. The program gives poor women a voucher to access quality services from pre-approved providers who are reimbursed for providing services to the voucher client. This is one of two health care subsidy programs that have been implemented in the area; Marie Stopes International launched a voucher program for reproductive health services in 2010.
Within this system, subsidized vouchers are distributed to poor households for a specific health good or service, such as maternal care or family planning, along with information about the benefits of birth spacing and limiting as well as how and where they might obtain the services, thus, eliminating traditional barriers to care. These services are targeted explicitly because they are know to be evidence-based and cost-effective.
Patients redeem these vouchers at accredited facilities, which have undergone a quality assessment in order to demonstrate their ability to provide the types of standards of care required, and have signed a contract with a third party agency, often known as voucher management agencies (VMA). A third party VMA (i.e., a non-governmental organization or private company) processes claims from facilities for each voucher patient visit and delivers reimbursement funds provided by donors to either government ministries or directly to the third party agency.
In return for steady, reliable income for the increased utilization of services by clientele, clinics are incentivized to maintain high quality services in order to satisfy patient demand, because otherwise, these same patients would be eligible to receive care through other settings. In sum, by targeting specific populations, increasing access and utilization, and enhancing quality and efficiency, it is anticipated that voucher programs will significantly improve the health of populations.
Cambodia program design
The Vouchers for Reproductive Health Project was launched in partnership with the Ministry of Health in early 2011 in three provinces in Cambodia: Kampong Thom, Prey Veng and Kampot. Within this system, subsidized vouchers are distributed to poor households. Patients receive vouchers for maternity care, family planning and abortion, along with counseling about the types of services offered. As is true of other voucher programs, the facilities are accredited and have signed up with a VMA, led by EPOS Consulting and implemented by Action for Health. Action for Health processes claims from facilities for each voucher patient visit and reimburses the Ministry of Health’s government clinics, as well as several non-profit Marie Stopes International clinics.
All providers at participating clinics were officially salaried employees, although, as will be explained in more detail later, unofficial payments to public health providers is a common practice. Apart from accrediting public clinics, the VMA was charged with hiring and training distributors and overseeing voucher distribution. Voucher distributors were trained and supervised by a voucher agent at each operational district and by an overall provincial coordinator. The Ministry of Health provided education sessions for distributors and supplied them with leaflets and other educational materials. Vouchers are offered for family planning counseling and services, prenatal care up to 4 visits, delivery services, postnatal care up to 6 weeks postpartum, abortion services. In addition, a transportation stipend based on kilometers travelled is provided in cash to women at facilities.
Distributors were positioned throughout 9 operational districts within the 3 provinces: Kampong Thom (Stung, Kampong Thom and Baray Santuk); Prey Veng (Preasdach, Peareang and Kampong Trabek); Kampot (Angkor Chey, Kampong Trach and Chhouk). These three provinces are geographically diverse and represent one southern, coastal province (Kampot), one province just outside the capital city (Prey Veng), and one in the northern part of the country (Kampong Thom). Most clinics enrolled in the program in the three provinces were public health facilities. The private Marie Stopes clinics were only accessible to those participants from the Kampong Thom region.
Program eligibility for the voucher and, in turn, this evaluation, was pre-determined by the Ministry of Planning using a poverty grading scale to determine if a family falls under a pre-determined poverty line. If they were determined to be poor, they were given a numbered poor identification card with a photo of the family. This card gives households access to the Health Equity Fund, which covers all care at the district hospital. The voucher program, then, acts to extend the fund’s reach to the local health clinics. The poverty grading scale measured physical household characteristics, such as the type of roofing or flooring and family assets, such as ownership of a bicycle or amount of land. Distributors approached households that were identified as poor households. The total number of vouchers distributed by February 2012 was 3,523 for safe motherhood services and 15,631 for family planning [9
The purpose of this study was to gather early information about women’s experiences with vouchers. Information gathered prior to the start of the program using hypothetical scenarios or behavioral intention questions have proven to produce inaccurate results [10
]. Thus, this study aims to collect information about experiences early in the implementation of the initiative in order to ascertain whether program modifications are needed.
This study will explore women’s experiences with and perceptions about: 1) accessing health care services prior to the voucher program, and 2) redeeming their reproductive health vouchers for services at accredited facilities since the program started.