Health Policy and Planning Advance Access originally published online on November 17, 2005
Health Policy and Planning 2006 21(1):27-39; doi:10.1093/heapol/czj001
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Original article |
Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia
1 Swiss Red Cross, Phnom Penh, Cambodia and 2 Centre for Development Studies, University of Wales Swansea, UK
Correspondence: Neil Price, Centre for Development Studies, University of Wales Swansea, SA2 8PP, UK. E-mail: n.l.price{at}swansea.ac.uk
This article presents research findings into the effectiveness of an innovative equity fund approach to improving access to public sector health services for the poor in Kirivong Operational Health District in Cambodia. The operational health district is the lowest organizational level in the Cambodian health system, providing services through health centres and a single referral hospital. An equity fund involves a third party identifying the poor and paying user fees on their behalf by reimbursing the service provider, thus relieving health staff of such responsibility.
We explore the appropriateness of utilizing community members to identify the poorest. The impact of newly introduced pagoda-managed equity funds on access to public health services for the poorest, and on their out-of-pocket expenditure during illness episodes, is then examined. We conclude with an evaluation of the contribution of the equity funds to community participation.
The research indicates that identification by community members of those eligible for equity funds is feasible, accrues minimal direct costs, and is effective. Households identified as eligible for equity fund benefits were poorer than those identified as non-beneficiaries. Direct costs associated with seeking care were considerably lower for equity fund beneficiaries than for non-beneficiaries, and fewer beneficiaries than non-beneficiaries initially consulted the private sector, providing evidence of the equity fund's ability to attract the poorest to the public sector. The level and nature of community participation was enhanced considerably following the introduction of the pagoda-managed equity funds.
In order to maximize and sustain the equity benefits of such funds, we recommend that external agencies (such as international non-governmental organizations) limit their role to the provision of technical support and advice, rather than taking the lead on implementation and administration. Facilitating the design, implementation, administration and management of equity funds by indigenous community-based organizations has the advantage of not only greatly reducing administrative costs, allowing a large proportion of the fund to be spent on services for the poor, but also of enhancing local ownership, thus increasing the likelihood of equity funds being sustained in the future.
Key Words: health care financing, access, equity, user fees, community, local ownership
1The Cham Muslim minority was invited to send two representatives per mosque (five in total for KOD) to join the respective HCCMCs (Jacobs and Price 2003).
2The use of lists, while simple and low cost, may be contentious for reasons of confidentiality. However, it should be noted that pagodas act in the interests of the poor (see Jacobs and Price 2003) and village chiefs are prominently involved in the poverty alleviation programme of the Cambodian government. Within the villages and neighbourhoods, households’ socioeconomic status is known to most people. It is only when people (occasionally) attend health facilities outside their neighbourhood that they may feel stigmatized; within their own community, this is not the case.
3As previously explained, the lists are updated regularly through the addition (or removal) of eligible households, and therefore no additional resources are required to repeat the whole exercise.
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