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Cambodia’s Integrated Social Health Protection Scheme

Assessing its impact on poor Cambodians’ access to free health care at public health facilities

A Cambodian hospital during a dengue outbreak

In Cambodia a recent study shows that the integrated Social Health Protection Scheme (iSHPH) has enhanced HEF beneficiaries’ utilisation of public health services and reduced their out-of-pocket payments by opening Health Equity Fund (HEF) membership to the near-poor and by complementing it with other interventions that reduce access barriers.

Cambodia introduced user fees in the public health sector in the late 1990s. Contrary to experiences in other countries this led to an increase in the population’s utilisation of curative public health services due to various factors, including staff members’ improved interpersonal skills.

With this move from free health care to client paid care, however, poor people saw their financial access decrease. The exemption mechanisms which had been put in place for them failed, firstly, due to reluctance of staff members to forego potential revenue and, secondly, because of vague regulations concerning whom to exempt.

The large majority of poor Cambodians entitled to HEF still seek healthcare from private providers

Cambodian hospital during a dengue outbreak

Despite their entitlement to free health care at the point of delivery at public health facilities, up to 70% of the poor who are entitled to HEF still initiate healthcare seeking at private health providers, thereby incurring considerable out-of-pocket expenses and further depleting their already scarce resources. To pay off medical bills many of them borrow money at exorbitant interest rates and/or sell the productive assets they need for their livelihood.

Poor Cambodians’ use of private health services can in part be explained by the fact that they are available everywhere: over the past 20 years, the private health sector has expanded disproportionally. Its providers range from traditional healers and market vendors to well-qualified practitioners who often working both in the public and private sector (dual practice) and serve their patients both at health facilities and at their homes. In brief: private sector providers are geographically very accessible.

To enable access to health care at minimal costs for poor Cambodians who are eligible for HEF, it is important to have them initiate care seeking at public health facilities. As per HEF’s procedures, they should initially consult the nearest primary-level public health care facility, the health centre, and should only go to the hospital upon referral by health centre staff. If they do not follow this referral system their transport costs to the hospital are not reimbursed. Prior to nationwide rollout of the HEF in 2015, many geographical areas had HEF arrangements that only covered hospital services without effective referral procedures from the health centre to the hospital level.


The integrated Social Health Protection Scheme aims to enhance its beneficiaries’ use of public health services

In the rural province of Kampong Thom, in central Cambodia, the Ministry of Health with support of the Cambodian-German Social Health Protection Programme, commissioned by the German Federal Ministry for Economic Cooperation and Development (BMZ), piloted the integrated Social Health Protection Scheme (iSHPS). The iSHPS commenced in 2011 and opened the HEF program to voluntary enrolment of non-HEF community members. Opening the HEF for voluntary enrolment of non-HEF eligible people aimed at providing the near poor population a degree of social health protection whilst at the same time reducing the stigma that would have been attached to HEF membership if it was only open to the poor.

In addition, Health Equity Fund services were complemented by a range of other measures aimed at reducing barriers to access. These included firstly, vouchers to promote uptake of a selected set of underutilised maternal and child health services. Secondly, health centres were reimbursed for services delivered under the iSHPS on a pay-for-performance basis that combined output payments adjusted by objective quality and client satisfaction scores. These scores were based on annual targets set in consultation with the facilities, and evolved over time. Thirdly, the iSHPS area benefited from interventions aimed at increasing health providers’ degree of accountability and responsiveness. As a fourth component, investments were made in the technical and structural quality of health services.


Investigating iSHPS’ effects on health seeking behaviour and out-of-pocket expenditure

This working paper reports on a) the iSHPS’s effectiveness in attracting HEF beneficiaries to initiate care seeking at public health facilities and on b) the degree to which it provides financial risk protection to its beneficiaries.

These effects are assessed by comparing HEF beneficiaries’ care seeking and out-of-pocket expenditures with the care seeking and out-of-pocket expenditures of HEF beneficiaries from other provinces where the HEF covered only hospital services or where HEF covered health centre and hospital services. For this assessment, data were collected between October 2013 and February 2014 from 1,636 matched households of HEF beneficiaries in two other health districts with iSHPS and two other health districts without iSHPS.

In the two latter districts, some health centres were not covered by the HEF while other health centres were included, allowing additional comparison to assess the effect of health centre inclusion on care seeking by HEF beneficiaries. Apart from HEF, these districts did not have any notable interventions aimed at enabling financial access to public health care services for HEF beneficiaries.

Only illness episodes during the month preceding interview were considered. Costs involved direct medical and non-medical out-of-pocket expenses related to care seeking for the concerned illness episode.


In iSHPS districts more HEF beneficiaries consult public health providers and they incur lower costs

The findings indicated that the proportion of HEF beneficiaries who first consulted public health providers was highest in iSHPS districts (55.7%), followed by areas where health centres and hospitals were covered by HEF (39.5%), and lowest in by areas where only hospital services were covered by HEF (13.4%).

The overall costs (out-of-pocket expenses and transport) associated with the illness episode were lowest for HEF beneficiaries residing in the iSHPS districts (US$ 10.3), significantly lower than for those residing in control areas were health centre services were covered by HEF (US$18.6) or control areas where only hospital services were covered by HEF (US$ 20.7).

The findings suggest that the iSHPS scheme which complements HEF with additional interventions is significantly more effective in attracting HEF beneficiaries to public health facilities and in lowering their direct costs associated with health care seeking than the HEF scheme on its own. The findings also show that the inclusion of health centres in HEF arrangements, as compared to HEF coverage of hospital services only, improves HEF beneficiaries’ care seeking at all levels of public health facilities.

The working paper as download

Attracting poor people to public health facilities to access free health care: an assessment of the Integrated Social Health Protection Scheme (GIZ, 2017)

Bart Jacobs, Ashish Bajracharya, Jyotirmoy Saha,
Chhorvann Chhea, Ben Bellows, Adelio Fernandes Antunes

April 2017


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