Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia

Abstract

BackgroundIn many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up.MethodsData on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation.ResultsFacility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for self-paid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme.ConclusionsVouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.

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

“…This observation was true even for universal schemes, which suggests that mainly the poorest women were encouraged by vouchers to give birth in a public facility, perhaps because of a perception that the quality of care is lower and staff attitudes are worse than in private facilities. 13 Targeting may, therefore, increase the administrative costs of a voucher scheme without having an effect on how different population groups benefit from the vouchers.…”

Perceived barriers to utilizing maternal and neonatal health services in contracted-out versus government-managed health facilities in the rural districts of Pakistan

“…A combination of demand and supply side incentives, as seen in Nicaragua, has improved utilization of preventive services among the poor and our study favors a combined approach (28). In remote rural settings measures are needed at facilitating transport access and a number of measures have been identified including community revolving funds for transport, transporter-community links facilitated by NGOs, and transport vouchers (29)(30)(31). BCC has proved to be effective for birth preparedness and newborn care (32), and in this case calls for inclusion of husbands and inlaws.…”

The Inverse Equity Hypothesis: Analyses of Institutional Deliveries in 286 National Surveys

“…34,35,[43][44][45] Several initiatives have been launched since the 1980s to address these barriers faced by poor and rural women in low-and middle-income countries, such as increased access to institutional deliveries for poor women, home delivery by skilled attendants, training of traditional birth attendants, and vouchers for delivery in a health facility, among others. [46][47][48][49] Although some of these initiatives were successful at local or national level, they were not sufficiently scaled up to have an impact at global level. An analysis of 75 countries with high maternal and child mortality showed that coverage with skilled birth attendance increased by less than 1 percentage point a year from 41% in 1990 to 65% in 2015.…”