Study setting and interventions
Kampong Cham is the biggest province in Cambodia with a total population of 1,680,000. The public health system in this province consists of ten operational health districts (ODs), each with a referral hospital and several health centres. The provincial hospital is the referral hospital of Kampong Cham OD, located in the provincial town. All the public health facilities receive free drugs and medical supplies, staff salaries, and a budget for running costs (which make up about 60-70% of the total recurrent costs) from the government. In addition, they charge fees from patients. Along with the public health system, there are numerous and often unregulated private practices. According to the Cambodia Demographic and Health Survey 2005, 12.3% of births in Kampong Cham province took place in a health facility and only 8.2% occurred in public facilities. About 53% of women delivered at home with traditional birth attendants [13].
The study was conducted in three of the ten ODs in Kampong Cham province, namely Cheung Prey, Chamkar Leu and Prey Chhor. There are three referral hospitals (without operation theatres for surgical interventions) and 42 health centres, serving a total population of approximately 538,000. Surgical cases, including caesarean sections, are referred to the provincial hospital. Since 2005, the Ministry of Health and the Belgian Technical Cooperation have implemented several health financing schemes, including Health Equity Fund (HEF), vouchers, and performance-based contracting (PBC) to improve access to basic health services for the population, especially the poor, in the three ODs. At the end of 2007, the government introduced a delivery incentive scheme nation-wide to boost deliveries in public health facilities. Through this scheme, midwives and other health personnel receive a government incentive of USD12.5 for each live birth attended in a referral hospital and USD15 in a health centre on top of the fees they charge from patients.
The HEF scheme (See Additional file 1) started in late 2005 in the three district hospitals in the study area to improve access for the poor to hospital care services. The management of the HEF scheme was entrusted to two non-governmental organisations (NGOs), acting as a third party purchaser. NGO staff interview potentially poor patients at the hospitals to determine their eligibility for HEF assistance, using a predefined questionnaire and eligibility criteria (See Additional file 1). On the basis of the total index scores, the interviewees are then classified into three categories of eligibility: very poor, poor and non-poor. The latter category is excluded from HEF assistance. According to the eligibility category, patients receive a full or partial benefit package, including payment for hospital user fees, payment for the cost of transportation to the health centre or hospital, food allowance during the hospitalization, and funeral cost in the event of death.
The voucher scheme was launched in Cheung Prey, Prey Chhor and Chamkar Leu operational health districts (ODs) in February, June and July 2007, respectively. The objective was to improve access to safe delivery for poor women, thereby contributing to the reduction of maternal and newborn mortality and morbidity. The management of the voucher scheme was sub-contracted to the NGOs operating HEF in the area, as voucher management agencies (VMA). The voucher recipients are poor pregnant women in the catchment area. Public health centres are selected to provide health services to the voucher recipients. To ensure sufficient quality for safe delivery, only 30 of the 42 health centres in the three ODs were selected on the basis of three criteria: they (1) can provide the minimum package of services (as recommended by the Ministry of Health for a health centre), (2) have at least one skilled midwife available in time of need, and (3) have a record of relatively high utilisation for antenatal care and delivery. Only these health centres were thus contracted to provide maternal services to voucher recipients in a timely and professional way.
Poor pregnant women are identified by local health volunteers and VMA staff at home, using the same pre-defined questionnaire and eligibility criteria as for HEF. Each eligible poor woman receives a voucher with five detachable coupons, which entitle her to free services at the health centre (for three antenatal care visits, delivery and one postnatal care visit) and transportation costs for five round trips between her home and the health centre, and for referrals from the health centre to the referral hospital in case of complications. User fees and other related costs at referral hospitals are paid for by the HEF. Voucher recipients are encouraged to use all five coupons for their pregnancy, but they are free to use only one or a few of them. The vouchers are only valid for the current pregnancy. At the end of each month, the VMA pay the contracted health centres on the basis of the number of coupons and the price of user fees (about USD7.5 for a normal delivery and USD0.25 for each antenatal and postnatal care visit). The VMA provide cash advances to the contracted health centres to pay for the transportation cost of voucher recipients using a pre-defined price-list. The list estimates the transportation cost for each village in the catchment area to the health centre, taking USD0.1 per kilometre, the estimated rate for moto-taxis, as the unit-based fare. For monitoring purposes, the VMA collected routine data on the number of poor pregnant women identified, the number of vouchers distributed, the utilisation of vouchers for ANC, delivery, postnatal care and referral services, the costs of services provided through the voucher schemes and the number of deliveries supported by HEF at hospitals.
The performance-based contracting (PBC) scheme started in late 2005 and was gradually expanded to all government health facilities and management bodies in the three ODs as a strategy to address the vicious cycle of underpaid health staff, and poorly performing and thus under-utilised health services. This strategy was inspired by the 'Cambodian New Deal' experiment in Sotnikum, which is described in detail elsewhere [28, 29]. In the PBC arrangements, contracted facilities receive financial incentives related to certain process and output indicators. In addition, they also receive support for staff capacity building, quality improvement and basic drug and medical supplies. As a result, the performance of the contracted facilities has improved considerably and a minimum quality (24 hour services and absence of informal fees) is now more or less ensured.
In two other ODs in Kampong Cham province, Memot and Ponheakrek, the Ministry of Health and its development partners implemented a special "contracting" scheme initially in Memot in 1999 as a first phase, and then in Ponheakrek in 2004 as a second phase. Several studies have described the first phase of this contracting model and demonstrated its effectiveness [30, 31]. In general, it is similar to the PBC in the three study ODs. The only difference is that the management of the ODs is completely outsourced to an international organization as contractor and that the performance-based part of staff income is much higher than in the PBC model. In four other rural ODs, there were no major interventions during the study period, apart from the delivery incentive scheme.
Conceptual framework
Poor people may encounter numerous barriers to accessing health care [32, 33]. User fees are one of the main barriers to accessing government health services in low-income countries [34]. In Cambodia, previous studies have identified several access barriers related to distance, costs, quality of care, knowledge of users, and socio-cultural practices [25, 26, 35]. In addition to costs, low staff income (which often induces attitude problems or even absence of the midwife at the health facility) has been found to be one of the main causes of the low percentage of deliveries in public health facilities [14]. Figure 1 shows how different interventions in the three study ODs address the above barriers.
The hospital-based HEF that identifies poor patients and pays user fees and other access-related costs on their behalf improves financial access for the poor to hospital care, including delivery [25–27]. Although in general health centre user fees are not a big barrier to access in Cambodia [36], the fee for delivery could nevertheless constitute a major financial barrier for the poor, especially when combined with transport cost [14]. The voucher scheme, which is designed as a health centre-based HEF for maternal services, improves financial access for poor women to maternal care, including delivery, at the health centre.
The PBC and the delivery incentive scheme address the issue of low staff income through performance and output-based cash incentives. The PBC helps improve the general performance of providers whereas the delivery incentive scheme focuses on the midwife and delivery. More generally, these interventions can also improve quality of care and partly address financial barriers by preventing informal payments [31, 37].
Data collection
In this case study, we used a combination of methods to collect quantitative and qualitative data. We collected data on the number of vouchers distributed and the number of voucher and HEF beneficiaries between 2006 and 2008 from the database and reports of the VMA and HEF agents.
Data on deliveries in public health facilities (facility deliveries) in the three study ODs were extracted from the routine health information system. For comparison, similar data were also gathered for other ODs in Kampong Cham province. In the routine health information system, data on deliveries in the facilities are collected every month by the health facilities in consultation with community representatives who gather information on deliveries during the previous month in all villages in the catchment area of the health centre.
To calculate denominators for the assessed indicator, facility deliveries as percentage of the expected number of births, we used the population figure estimated by the recent census and the crude birth rate of 25.9‰ for rural areas as estimated by the Cambodia Demographic and Health Survey 2005 [13]. This crude birth rate seems to hold true for 2006, 2007 and 2008, as the trend in contraceptive prevalence rate indicated by the health information system remained relatively stable throughout this period. If this trend had changed, the magnitude of the change would not have been very large. However, the fertility rate among poor women was estimated to be higher than among the general population. Therefore, we estimated the crude birth rate among poor women, the target group of voucher and HEF schemes, at 27‰. The recent identification of poor households in the study area found 26% of the households to be poor and eligible for HEF and vouchers.
Qualitative data were collected through focus group discussions and key informant interviews. We conducted nine focus group discussions in late 2007 with a total of 87 voucher recipients. Five groups included 51 voucher recipients who did not use their vouchers for delivery (non-user group) whereas the four other groups included 36 voucher recipients who used their vouchers (user group). Participants were randomly selected from the list of voucher recipients and beneficiaries at health centres, the non-user group from health centres with low utilisation rates of vouchers for delivery and the user group from health centres with high utilisation rates of vouchers. The aim of the focus group discussions was to understand reasons for use and non-use of vouchers. For similar purposes, the first author conducted in-depth interviews with 20 voucher recipients, both voucher users and non-users, in early 2009. He also interviewed 18 key informants, including village health volunteers, traditional birth attendants, health centre midwives, health centre chiefs, district and provincial chiefs of maternal and child health programmes, managers of the two VMA and HEF implementing NGOs and key staff of the Belgian Technical Cooperation to gain insight in the implementation process and the effectiveness of voucher and HEF schemes.
Data analysis
WHO defines a skilled attendant as "an accredited health professional - such as a midwife, doctor or nurse - who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns" [38]. In the study area, deliveries in public health facilities (facility deliveries) were attended by trained midwives and other health personnel, who are considered skilled birth attendants.
In order to assess the effectiveness of vouchers and HEFs in improving access to skilled birth attendants, an indicator on deliveries in public health facilities as percentage of the expected number of births was computed in MS excel. This indicator was calculated for the nine rural ODs in Kampong Cham province operating under the management umbrella of the Provincial Health Department. We first assessed the trend of this indicator between 2006 and 2008 in the three study ODs and then compared it to the situation in two other groups of ODs without voucher and HEF schemes: respectively, a group of two ODs with special contracting and the delivery incentive scheme, and a group of four ODs with only the delivery incentive scheme. To avoid bias, we excluded Kampong Cham OD from the comparison, as this OD covers the provincial town and the urban area, and the provincial hospital providing referral services for the whole province is also based there.
The operational analysis of the voucher scheme focused on three main stages: health centre selection, voucher distribution and voucher utilisation. The last-named was analysed among voucher recipients in 2007, as some of the voucher recipients in 2008 had not yet delivered at the time of the study.
The qualitative data from the focus group discussions and in-depth interviews were manually coded, grouped and analysed.
Ethical consideration
This study is part of the EC-funded Poverty and Illness research project, which received ethical approval from the Cambodian National Ethics Committee for Health Research on 10 August 2007 with reference number 063 NECHR. Verbal consent was obtained from each participant and respondent prior to the focus group discussion and interview.