Scaling-up integrated type-2 diabetes and hypertension care in Cambodia: what are the barriers to health system performance?

Background: Non-communicable diseases (NCDs) such as type-2 diabetes (T2D) and hypertension (HTN) pose a massive burden on health systems, especially in low- and middle-income countries. In Cambodia, to tackle this issue, the government and partners have introduced several limited interventions to ensure service availability. However, scaling-up these health system interventions is needed to ensure universal supply and access to NCDs care for Cambodians. This study aims to explore the macro-level barriers of the health system that have impeded the scaling-up of integrated T2D and HTN care in Cambodia. Methods: Using qualitative research design comprised an articulation between (i) semi-structured interviews (33 key informant interviews and 14 focus group discussions), (ii) a review of the National Strategic Plan and policy documents related to NCD/T2D/HTN care using qualitative document analysis, and (iii) direct field observation to gain an overview into health system factors. We used a health system dynamic framework to map macro-level barriers to the health system elements in thematic content analysis. Results: Scaling-up the T2D and HTN care was impeded by the major macro-level barriers of the health system including weak leadership and governance, resource constraints (dominantly financial resources), and poor arrangement of the current health service delivery. These were the result of the complex interaction of the health system elements including the absence of a roadmap as a strategic plan for the NCD approach in health service delivery, limited government investment in NCDs, lack of collaboration between key actors, limited competency of healthcare workers due to insufficient training and lack of supporting resources, mis-match the demand and supply of medicine, and absence of local data to generate evidence-based for the decision-making. Conclusion: The health system plays a vital role in responding to the disease burden through the implementation and scale-up of health system interventions. To respond to barriers across the entire health system and the inter-relatedness of each element, and to gear toward the outcome and goals of the health system for a (cost-)effective scale-up of integrated T2D and HTN care, key strategic priorities are: (1) Cultivating leadership and governance, (2) Revitalizing the health service delivery, (3) Addressing resource constraints, and (4) Renovating the social protection schemes.

Descriptive assessment of COVID-19 responses and lessons learnt in Cambodia, January 2020 to June 2022.

As a member state of the International Health Regulations 2005, Cambodia is continuously strengthening its capacity to respond to health emergencies and prevent the international spread of diseases. Despite this, Cambodia's capacity to prevent, detect and rapidly respond to public health threats remained limited at the onset of the pandemic, as was the case in most countries. This paper describes epidemiological phases, response phases, strategy and lessons learnt in Cambodia between 27 January 2020 and 30 June 2022. We classified epidemiological phases in Cambodia into three phases, in which Cambodia responded using eight measures: (1) detect, isolate/quarantine; (2) face coverings, hand hygiene and physical distancing measures; (3) risk communication and community engagement; (4) school closures; (5) border closures; (6) public event and gathering cancellation; (7) vaccination; and (8) lockdown. The measures corresponded to six strategies: (1) setting up and managing a new response system, (2) containing the spread with early response, (3) strengthening the identification of cases and contacts, (4) strengthening care for patients with COVID-19, (5) boosting vaccination coverage and (6) supporting disadvantaged groups. Thirteen lessons were learnt for future health emergency responses. Findings suggest that Cambodia successfully contained the spread of SARS-CoV-2 in the first year and quickly attained high vaccine coverage by the second year of the response. The core of this success was the strong political will and high level of cooperation from the public. However, Cambodia needs to further improve its infrastructure for quarantining and isolating cases and close contacts and laboratory capacity for future health emergencies.

A descriptive assessment of the National Institute of Public Health's contribution to the COVID-19 response in Cambodia, 2020-2021.

Objective: This paper examines the contributions made by the National Institute of Public Health to Cambodia's response to the coronavirus disease (COVID-19) pandemic during 2020-2021. Methods: The activities conducted by the Institute were compared with adaptations of the nine pillars of the World Health Organization's 2020 COVID-19 strategic preparedness and response plan. To gather relevant evidence, we reviewed national COVID-19 testing data, information about COVID-19-related events documented by Institute staff, and financial and technical reports of the Institute's activities. Results: The main contributions the Institute made were to the laboratory pillar and the incident management and planning pillar. The Institute tested more than 50% of the 2 575 391 samples for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and provided technical advice about establishing 18 new laboratories for SARS-CoV-2 testing in the capital city of Phnom Penh and 11 provinces. The Institute had representatives on many national committees and coauthored national guidelines for implementing rapid COVID-19 testing, preventing transmission in health-care facilities and providing treatment. The Institute contributed to six other pillars, but had no active role in risk communication and community engagement. Discussion: The Institute's support was essential to the COVID-19 response in Cambodia, especially for laboratory services and incident management and planning. Based on the contributions made by the Institute during the COVID-19 pandemic, continued investment in it will be critical to allow it to support responses to future health emergencies in Cambodia.

Determinants of the continuum of maternal health care in Cambodia: an analysis of the Cambodia demographic health survey 2014.

INTRODUCTION: Cambodia has achieved significant progress in maternal health, yet remains in the group of countries with the highest maternal mortality ratio in South-East Asia. Extra efforts are needed to improve maternal health through assessing the coverage of maternal health services as a continuum of care (CoC) and identifying the gaps. Our study aims to explore the coverage level of the Optimal CoC by (1) measuring the continuity of optimal antenatal care (ANC), skilled birth attendance (SBA) and optimal post-natal care (PNC), (2) identifying the determinants of dropping out from one service to another and (3) of not achieving the complete CoC. METHOD: The study employed data from the Cambodia Demographic Health Survey 2014. We restricted our analysis to married women who had a live birth in the five years preceding the survey (n = 5678). Bi-variate and multivariate logistic regression were performed using STATA version 14. RESULTS: Almost 50% of women had achieved the complete optimal CoC, while the remaining have used only one or two of the services. The result shows that the level of women's education was positively associated with the use of optimal ANC, the continuation to using optimal PNC and achieving the complete CoC. More power of women in household decision making was also positively associated with receiving the complete CoC. The birth order was negatively associated with achieving the complete CoC, while exposure to the mass media and having health insurance increased the odds of achieving the complete CoC. Household wealth consequently emerged as an influential predictor of dropping out and not achieving the complete CoC. Receiving all different elements of ANC care improved the continuity of care from optimal ANC to SBA and from SBA to optimal ANC. CONCLUSION: The findings urge policy makers to approach maternal health care as a continuum of care with different determinants at each step. Household wealth was found to be the most influential factor, yet the study discovered also other barriers to optimal maternal health care which need to be addressed: future intervention should thus not only aim to increase wealth or health insurance coverage but also stimulate the education of women and empower women to claim power in household decision-making.

Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications.

In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities exist between the standard of care in neighbouring countries. While awareness of South-South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regional trade liberalization to perceptions about the quality of care and the pressure of relatives and other advisers in local communities. Furthermore, there is a diversity of medical travels from Cambodia, ranging from first class travels to international hospitals in Bangkok and cross-border 'medical tourism' to perilous overland journeys of poor patients, who regularly resort to borrowing or liquidating assets to cover costs. The implications of the research findings for health sector development and equitable access to care for Cambodians deserve particular attention. To some extent, the increase in medical travels can stimulate improvements in the quality of local health services. However, concerns remain that these developments will mainly affect high-cost private services, widening disparities in access to care between population groups.

Can social accountability improve access to free public health care for the poor? Analysis of three Health Equity Fund configurations in Cambodia, 2015-17.

Within the context of universal health coverage, community participation has been identified as instrumental to facilitate access to health services. Social accountability whereby citizens hold providers and policymakers accountable is one popular approach. This article describes one example, that of Community-Managed Health Equity Funds (CMHEFs), as an approach to community engagement in Cambodia to improve poor people's use of their entitlement to fee-free health care at public health facilities. The objectives of this article are to describe the size of its operations and its ability to enable poor people continued access to health care. Using data collected routinely, we compare the uptake of curative health services by eligible poor people under three configurations of Health Equity Funds (HEFs) during a 24-month period (July 2015-June 2017): Standard HEF that operated without community engagement, Mature CMHEFs established years before the study period and New CMHEFs initiated just before the study period. One year within the study, non-governmental organizations (NGOs) stopped operating the HEF nationwide and only the community-participation aspects of New CMHEF continued receiving technical assistance from an NGO. Using utilization figures for curative services by non-poor people for comparison, following the cessation of HEF management by the NGOs, outpatient consultation figures declined for all three configurations in comparison with the year before but only significantly for Standard HEF. The three HEF configurations experienced a highly statistically significant reduction in monthly inpatient admissions following halting of NGO management of HEFs. This study shows that enhancing access to free health care through social accountability is optimized at health centres through engagement of a wide range of community representatives. Such effect at hospitals was only observed to a limited extent, suggesting the need for more engagement of hospital management authorities in social accountability mechanisms.

Protecting the poor? Impact of the national health equity fund on utilization of government health services in Cambodia, 2006-2013.

INTRODUCTION: Cambodia's health equity fund (HEF) is the country's most significant social security scheme, covering the poorest one-fifth of the national population. During the last two decades, the HEF system was scaled up from an initial two health districts to national coverage of public health facilities. This is the first national study to examine the impact of the HEF on the utilisation of public health facilities. METHODS: We first investigated the level of national HEF population coverage and health service use made by HEF eligible members using an administrative HEF operational dataset. Second, through multilevel interrupted time series analysis of routine monthly utilisation statistics during 2006-2013, we evaluated the impact of the HEF on hospital and health centre utilisation. RESULTS: The proportion of HEF beneficiaries using hospital services in a given year (4.6%) appeared to exceed rates in the general population (3.3%). The introduction of the HEF was associated with: a significant level change in the monthly number of consultations at HCs followed by a gradual slope increase in time trend and a significant level change in the monthly number of deliveries. Overall, this was equivalent to a 15.6% net increase in number of consultations and 5.3% in deliveries in the first year. At RHs: a significant level change in the number of RH inpatient cases, followed by a sustained slope increase; a significant slope increase in the number of outpatient consultations and in the overall number of newborn deliveries. Overall, this was equivalent to a 47.9% net increase in inpatient cases, 24.1% in outpatient cases and 31.4% in deliveries in the first year. CONCLUSION: The implementation of the HEF scheme was associated with increased utilisation of primary and secondary care services by the poor.

The impact of reimbursed user fee exemption of health centre outpatient consultations for the poor in pluralistic health systems: lessons from a quasi-experiment in two rural health districts in Cambodia.

Fees charged at the point of use are a barrier to the health services' users, especially for the poorest. Two decades ago, Cambodia introduced the so-called health equity fund (HEF) strategy, a waiver scheme which enhances access to public health services for the poor without undermining the economic situation of facilities. Evidence suggests that hospital-based HEF effectively removed financial barriers and reduced out-of-pocket expenditures. There is less evidence on the effectiveness of the HEF when assistance is extended to the primary level of healthcare. This research explores the impact of a HEF extended to health centres in two rural health districts. Two household surveys and 16-month diary data allowed to assess the impact of the intervention on health-seeking behaviours and expenditure of poor households. Though HEF effectively removed user fees at public health facilities, health centre utilization of sick and poor people did not budge much in the intervention district; self-medication and private provider consultations remained the preferred health-seeking behaviours, by far, even if more expensive. Difference-in-difference estimates confirmed that HEF had a slight impact on health-seeking behaviours, but only for the subgroups of HEF beneficiaries living close to the health centre and ready to test their new entitlement. This research reminds on the importance of the context for the effectiveness of any policy: in a highly pluralistic health sector, waiving already low-user fees in public health centres may be insufficient to increase rapidly the use of those facilities and reduce catastrophic spending. In such context, apart from distance to health centres, perceived quality of services at the health centres, which was relatively low compared with other providers, also matters. Although the HEF scheme plays a role in improving perceived and objective quality of care, complementary means are to be deployed.

Exploring the determinants of distress health financing in Cambodia.

Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty-the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt-even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.

Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy.

Cambodia's healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012-14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of -0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.

Low birth weight of institutional births in Cambodia: Analysis of the Demographic and Health Surveys 2010-2014.

BACKGROUND: Low birth weight (LBW), an important risk factor for early childhood mortality and morbidity, is a major public health concern in developing countries including Cambodia. This study examined the prevalence of LBW across provinces in Cambodia and changes over time, and identified the factors associated with such condition. METHODS: We used children datasets from Cambodia Demographic and Health Survey (CDHS) 2010 and 2014. There were 3,522 children and 4,991 children in both surveys. Maps illustrating provincial variation in LBW prevalence were constructed. Then, multivariate analyses were conducted to assess factors independently associated with LBW in CDHS 2014. RESULTS: LBW prevalence remained stable between 2010 and 2014, at around 7.0% 95% CI: 5.8-8.1). all institutional births, but within significant variation across provinces. Factors independently associated with LBW included mother's no education compared with those whose mothers had secondary or higher education (AOR = 1.6, 95% CI: 1.0-2.6), babies born to mothers with < 4 antenatal care (ANC) visits during the pregnancy compared with those whose mothers had at least 4 ANC visits (AOR = 2.0, 95% CI: 1.5-2.8). Also, first-born babies were at greater risk of LBW compared with second-born babies (AOR = 1.4, 95% CI: 1.0-2.0). CONCLUSION: The study points to key sub-populations at greater risk and regions where LBW is particularly prevalent. Programs should target provinces where LBW prevalence remains high. Illiterate women, especially those pregnant for the first time should be the program priority. The current national program policy, which recommends that pregnant women have ≥ 4 ANC visits during pregnancy should be further reinforced and implemented. Program design should consider ways to communicate the importance of making the recommended number of ANC visits among women with no formal education.

Building informed trust: developing an educational tool for injection practices and health insurance in Cambodia.

Unnecessary injections increase the risk of blood-borne infections as well as pose an avoidable financial burden on patients. Perceptions in rural Cambodia that medical drug injections provide the best quality medical care have resulted in a large proportion of the population seeking injections across medical conditions. As private providers have a higher propensity to offer injections, patients pursue more expensive care contributing to a greater financial burden. This study aimed to use an educational intervention to improve participant knowledge about injections and health insurance in order to build informed trust in safer injection practices and health insurance. Using an experimental study design, villages in rural Cambodia were randomly assigned to an intervention or control arm. Community educational workshops were implemented to improve participant knowledge about injections and health insurance. Pre-and post-intervention assessments were used to record the resulting changes in knowledge and trust in providers. Statistical analysis of survey results from the two study arms showed increases of 16.8% and 15.9% in study participant knowledge regarding injections and health insurance, respectively. Trust in health insurance increased by 12.9%. However, trust in healthcare providers proved to be resilient with small to no change. These results show that knowledge about injection safety and health insurance, as well as trust in health insurance, can be increased through information dissemination in rural Cambodia. However, health information campaigns may not easily influence people's trust in healthcare providers. Education of the general populace about safe injection practices and health insurance can contribute toward the country's efforts to reach universal health coverage.

System-wide analysis of health financing equity in Cambodia: a study protocol.

BACKGROUND: To assess progress towards universal health coverage, countries like Cambodia require evidence on equity in the financing and distribution of healthcare benefits. This evidence must be based on a system-wide perspective that recognises the complex roles played by the public and private sectors in many contemporary healthcare systems. OBJECTIVE: To undertake a system-wide assessment of who pays and who benefits from healthcare in Cambodia and to understand the factors influencing this. METHODS: Financing and benefit incidence analysis will be used to calculate the financing burden and distribution of healthcare benefits across socioeconomic groups. Data on healthcare usage, living standards and self-assessed health status will be derived from a cross-sectional household survey designed for this study involving a random sample of 5000 households. This will be supplemented by secondary data from the Cambodian National Health Accounts 2014 and the Cambodian Socioeconomic Survey (CSES) 2014. We will also collect qualitative data through focus group discussions and in-depth interviews to inform the interpretation of the quantitative analyses. POTENTIAL IMPACT: This study will produce previously unavailable information on who pays for, and who benefits from, health services across the entire health system of Cambodia. This evidence comes at a critical juncture in healthcare reform in South-East Asia with so many countries seeking guidance on the equity impact of their current financing arrangements that include a complex mix of public and private providers.

From Scheme to System (Part 1): Notes on Conceptual and Methodological Innovations in the Multicountry Research Program on Scaling Up Results-Based Financing in Health Systems.

Abstract-This article presents conceptual and methodological developments made in analyzing the scale up of results-based financing (RBF) as part of a multicountry research program supported by the Alliance for Health Policy and Systems Research. Following a brief overview of the research process, the article proposes a new five-dimensional conceptualization of scale-up (population coverage, service coverage, health system integration, cross-sectoral diffusion, and knowledge expansion) to capture various facets of RBF scale-up. It also presents how Walt and Gilson's health policy triangle framework was modified to identify the enablers and barriers to scale-up in the country case studies included in this research program. The article then puts forth a four-phase model of scale-up, including phases of generation, adoption, institutionalization, and expansion, developed for the purpose of this research program. The article concludes by providing some lessons learned on the use of the methods and theoretical frameworks developed for this multicountry research program.

Impact of Performance-Based Financing in a Low-Resource Setting: A Decade of Experience in Cambodia.

This paper exploits the geographic expansion of performance-based financing (PBF) in Cambodia over a decade to estimate its effect on the utilization of maternal and child health services. PBF is estimated to raise the proportion of births occurring in incentivized public health facilities by 7.5 percentage points (25%). A substantial part of this effect arises from switching the location of institutional births from private to public facilities; there is no significant impact on deliveries supervised by a skilled birth attendant, nor is there any significant effect on neonatal mortality, antenatal care and vaccination rates. The impact on births in public facilities is much greater if PBF is accompanied by maternity vouchers that cover user fees, but there is no significant effect among the poorest women. Heterogeneous effects across schemes differing in design suggest that maintaining management authority within a health district while giving explicit service targets to facilities is more effective in raising utilization than contracting management to a non-governmental organization while denying it full autonomy and leaving financial penalties vague. Copyright © 2015 John Wiley & Sons, Ltd.

Boosting facility deliveries with results-based financing: a mixed-methods evaluation of the government midwifery incentive scheme in Cambodia.

BACKGROUND: Increasing the coverage of skilled attendance at births in a health facility (facility delivery) is crucial for saving the lives of mothers and achieving Millennium Development Goal five. Cambodia has significantly increased the coverage of facility deliveries and reduced the maternal mortality ratio in the last decade. The introduction of a nationwide government implemented and funded results-based financing initiative, known as the Government Midwifery Incentive Scheme (GMIS), is considered one of the most important contributors to this. We evaluated GMIS to explore its effects on facility deliveries and the health system. METHODS: We used a mixed-methods design. An interrupted time series model was applied, using routine longitudinal data on reported deliveries between 2006 and 2011 that were extracted from the health information system. In addition, we interviewed 56 key informants and performed 12 focus group discussions with 124 women who had given birth (once or more) since 2006. Findings from the quantitative data were carefully interpreted and triangulated with those from qualitative data. RESULTS: We found that facility deliveries have tripled from 19% of the estimated number of births in 2006 to 57% in 2011 and this increase was more substantial at health centres as compared to hospitals. Segmented linear regressions showed that the introduction of GMIS in October 2007 made the increase in facility deliveries and deliveries with skilled attendants significantly jump by 18 and 10% respectively. Results from qualitative data also suggest that the introduction of GMIS together with other interventions that aimed to improve access to essential maternal health services led to considerable improvements in public health facilities and a steep increase in facility deliveries. Home deliveries attended by traditional birth attendants decreased concomitantly. We also outline several operational issues and limitations of GMIS. CONCLUSIONS: The available evidence strongly suggests that GMIS is an effective mechanism to complement other interventions to improve health system performance and boost facility deliveries as well as skilled birth attendance; thereby contributing to the reduction of maternal mortality. Our findings provide useful lessons for Cambodia to further improve GMIS and for other low-income countries to implement similar results-based financing mechanisms.

Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia.

OBJECTIVE: To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia. METHODS: The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health-care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them. FINDINGS: Overall, voucher schemes were associated with an increase of 10.1 percentage points (pp) in the probability of delivery in a public health-care facility; among women from the poorest 40% of households, the increase was 15.6 pp. Vouchers were responsible for about one fifth of the increase observed in institutional deliveries in districts with schemes. Universal voucher schemes had a larger effect on the probability of delivery in a public facility than schemes targeting the poorest women. Both types of schemes increased the probability of receiving postnatal care, but the increase was significant only for non-poor women. Universal, but not targeted, voucher schemes significantly increased the probability of receiving antenatal care. CONCLUSION: Voucher schemes increased deliveries in health centres and, to a lesser extent, improved antenatal and postnatal care. However, schemes that targeted poorer women did not appear to be efficient since these women were more likely than less poor women to be encouraged to give birth in a public health-care facility, even with universal voucher schemes.

Financial protection of patients through compensation of providers: the impact of Health Equity Funds in Cambodia.

Public providers have no financial incentive to respect their legal obligation to exempt the poor from user fees. Health Equity Funds (HEFs) aim to make exemptions effective by giving NGOs responsibility for assessing eligibility and compensating providers for lost revenue. We use the geographic spread of HEFs over time in Cambodia to identify their impact on out-of-pocket (OOP) payments. Among households with some OOP payment, HEFs reduce the amount paid by 35%, on average. The effect is larger for households that are poorer and mainly use public health care. Reimbursement of providers through a government operated scheme also reduces household OOP payments but the effect is not as well targeted on the poor. Both compensation models raise household non-medical consumption but have no impact on health-related debt. HEFs reduce the probability of primarily seeking care in the private sector.

Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: a study of policy barriers and opportunities in Cambodia.

Reaching out to the poor and the informal sector is a major challenge for achieving universal coverage in lesser-developed countries. In Cambodia, extensive coverage by health equity funds for the poor has created the opportunity to consolidate various non-government health financing schemes under the government's proposed social health protection structure. This paper identifies the main policy and operational challenges to strengthening existing arrangements for the poor and the informal sector, and considers policy options to address these barriers. Conducted in conjunction with the Cambodian Ministry of Health in 2011-12, the study reviewed policy documents and collected qualitative data through 18 semi-structured key informant interviews with government, non-government and donor officials. Data were analysed using the Organizational Assessment for Improving and Strengthening Health Financing conceptual framework. We found that a significant shortfall related to institutional, organisational and health financing issues resulted in fragmentation and constrained the implementation of social health protection schemes, including health equity funds, community-based health insurance, vouchers and others. Key documents proposed the establishment of a national structure for the unification of the informal-sector schemes but left unresolved issues related to structure, institutional capacity and the third-party status of the national agency. This study adds to the evidence base on appropriate and effective institutional and organizational arrangements for social health protection in the informal sector in developing countries. Among the key lessons are: the need to expand the fiscal space for health care; a commitment to equity; specific measures to protect the poor; building national capacity for administration of universal coverage; and working within the specific national context.

Toward a typology of health-related informal credit: an exploration of borrowing practices for paying for health care by the poor in Cambodia.

BACKGROUND: Borrowing money is a common strategy to cope with health care costs. The impact of borrowing on households can be severe, leading to indebtedness and further impoverishment. However, the available literature on borrowing practices for health is limited. We explore borrowing practices for paying for health care by the poor in Cambodia and provide a typology, associated conditions, and the extent of the phenomenon. METHODS: In addition to a semi-structured literature review, in-depth interviews were conducted with representatives of 47 households with health-related debt and 19 managers of formal or informal credit schemes. RESULTS: A large proportion of Cambodians, especially the poor, resort to borrowing to meet the cost of health care. Because of limited cash flow and access to formal creditors, the majority take out loans with high interest rates from informal money lenders. The most common type of informal credit is locally known as Changkar and consists of five kinds of loans: short-term loans, medium-term loans, seasonal loans, loans for an unspecified period, and loans with repayment in labour, each with different lending and repayment conditions and interest rates. CONCLUSION: This study suggests the importance of informal credit for coping with the cost of treatment and its potentially negative impact on the livelihood of Cambodian people. We provide directions for further studies on financial protection interventions to mitigate harmful borrowing practices to pay for health care in Cambodia.