Volume 4, Issue 4, December 2019, Page: 122-131
Healthcare Access Among Cambodia’s Poor: An Econometric Examination of Rural Care-seeking and Out-of-Pocket Expenditure
Robert John Kolesar, The Palladium Group/Health Policy Plus, Phnom Penh, Cambodia; General Secretariat of the National Social Protection Council, Ministry of Economy and Finance, Phnom Penh, Cambodia; Centre d’Etudes et Recherche sur le Développement International (CERDI), Université Clermont Auvergne, Clermont-Ferrand, France
Sambo Pheakdey, General Secretariat of the National Social Protection Council, Ministry of Economy and Finance, Phnom Penh, Cambodia
Bart Jacobs, Deutsche Gesellschaft Fuer Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia; Social Health Protection Network, Bonn, Germany
Rebecca Ross, The Palladium Group, Washington D.C., United States
Received: Sep. 26, 2019;       Accepted: Oct. 23, 2019;       Published: Oct. 30, 2019
DOI: 10.11648/j.hep.20190404.12      View  111      Downloads  54
Abstract
To inform efforts to improve Cambodia’s social health protection system and advance universal health coverage, health care-seeking and out-of-pocket expenditure (OOPE) were assessed using the 2016 Cambodia Socioeconomic Survey data. This study focuses on the poorest wealth quintile who reside in rural areas- the primary target population of Cambodia’s largest social health protection scheme, the Health Equity Fund (HEF). The study also estimates the proportion of poor with an Equity card which provides access to HEF benefits at public facilities. Overall, 76% of people who sought healthcare in the past 30 days went to private providers, paying, on average, US$39.43 for treatment. About 18% of patients first sought care from public facilities, paying, on average, US$38.15. Though HEF aims to provide free healthcare for the rural poor, this analysis found that 67.2% of such patients seeking first care at public health facilities pay, on average, US$11.61 after controlling for confounding factors. However, treatment expenditure among the rural poor is about 52% less compared to third wealth quintile patients (p<0.01). About 36% of people under the national poverty line do not hold an Equity card to access HEF benefits. Thus, we conclude that HEF is not yet fully reaching its intended impact of removing OOPE as a barrier to access among the poor. Finally, free access to healthcare should incentivize utilization of public services; however, this study was unable to isolate such an effect among patients from the poorest wealth quintile. Access to healthcare can be strengthened with policy directives focused on further reducing OOPE and addressing other challenges to improve patient demand for public services such as quality of care. Enrollment exclusion errors should be corrected by relaxing the eligibility criteria with population coverage expansion. In addition, health service access should be systematically monitored by integrating service utilization, OOPE, and quality indicators into national monitoring and evaluation systems.
Keywords
Universal Health Coverage, Social Health Protection, Out-of-Pocket Expenditure, Social Protection Policy, Cambodia, Vulnerability, Rural Poor
To cite this article
Robert John Kolesar, Sambo Pheakdey, Bart Jacobs, Rebecca Ross, Healthcare Access Among Cambodia’s Poor: An Econometric Examination of Rural Care-seeking and Out-of-Pocket Expenditure, International Journal of Health Economics and Policy. Vol. 4, No. 4, 2019, pp. 122-131. doi: 10.11648/j.hep.20190404.12
Copyright
Copyright © 2019 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Reference
[1]
UN, "Transforming Our World: The 2030 Agenda for Sustainable Development," United Nations, New York, 2015.
[2]
D. Hogan, G. Stevens, A. Hosseinpoor and T. Boerma, "Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services," Lancet Glob Health, vol. 6, p. e152–68, 2018.
[3]
RAND Corporation, "Health Care Access," 2019. [Online]. Available: https://www.rand.org/topics/health-care-access.html. [Accessed 12 May 2019].
[4]
D. Evans, J. Hsu and T. Boerma, "Universal health coverage and universal access," Bulletin of the World Health Organization, vol. 91, pp. 546-546A, 2013.
[5]
M. Thiede, P. Akweongo and D. McIntyre, "Exploring the dimensions of access," in The economics of health equity, McIntyre D, Mooney G, editors., Cambridge, Cambridge University Press, 2007, p. DOI: 10.1017/CBO9780511544460.007.
[6]
M. Gulliford, J. Figueroa-Munoz, M. Morgan, D. Hughes, B. Gibson, R. Beech and M. Hudson, "What does 'access to health care' mean?," Journal of Health Services Research and Policy, vol. 7, no. 3, pp. 186-188, 2002.
[7]
D. Peters, A. Garg, G. Bloom, D. Walker, W. R and W. Brieger, "Poverty and Access to Health Care in Developing Countries," Annals of the New York Academy of Sciences, vol. 1136, no. 1, p. doi.org/10.1196/annals.1425.011, 2008.
[8]
A. Donabedian, "The quality of care: How can it be assessed?" JAMA, vol. 260, no. 12, p. 1743–8, 1988.
[9]
P. Annear, D. Wilkinson, M. Rithy Chean and M. van Pelt, "Study of financial access to health services for the poor in Cambodia," Canberra & Melbourne: Ministry of Health Government of Cambodia, Cambodian office of the World Health Organization, AusAID and RMIT University, Phnom Penh, 2006.
[10]
P. Annear, M. Bigdeli, R. Chhun Eang and P. James, "Study of financial access to health services for the poor in Cambodia," Canberra & Melbourne: Ministry of Health Government of Cambodia, Cambodian office of the World Health Organization, AusAID and RMIT University, Phnom Penh, 2007.
[11]
P. Diehr, D. Yanez and A. Ash, "Methods for Analyzing Health Care Utilization and Costs," Annu. Rev. Public Health, vol. 20, p. 125–44, 1999.
[12]
M. Bigdeli and P. Annear, "Barriers to access and the purchasing function of health equity funds: lessons from Cambodia," Bulletin of the World Health Organization, vol. 87, pp. 560-564, 2009.
[13]
W. Van Damme, L. Leemput, I. Ir Por, W. Hardeman and B. Meessen, "Out-of-pocket health expenditure and debt in poor households: evidence from Cambodia," Tropical Medicine & International Health, vol. 9, no. 2, pp. 273-280, 2004.
[14]
WHO, "Evidence to inform policy towards universal health coverage in Cambodia," in World Health Day, Phnom Penh, 2018.
[15]
A. Fernandes Antunes, B. Jacobs, R. de Groot, K. Thin, P. Hanvoravongchai and F. Steffen, "Equality in financial access to healthcare in Cambodia from 2004 to 2014," Health Policy and Planning, vol. 33, pp. 906-19, 2018.
[16]
WHO, "The Kingdom of Cambodia Health System Review, Vol. 5, No. 2," World Health Organization, Phnom Penh, 2015.
[17]
P. Annear, K. Khim, E. Moscoe, T. Jordanwood and T. Bossert, "National Coverage and Health Service Utilization by Health Equity Fund Members, 2004–2015," ADRA Research Report, Phnom Penh, 2016.
[18]
M. Noirhomme, B. Meessen, F. Griffith, P. Ir, B. Jacobs, R. Thor, B. Criel and W. Van Damme, "Improving access to hospital care for the poor: comparative analysis of four health equity funds in Cambodia," Health Policy and Planning, vol. 22, pp. 246-262, 2007.
[19]
WHO, "Strengthening Domestic Financing Institutions for Universal Health Coverage in Cambodia Situation analysis of health financing policy and implementation (in publication)," World Health Organization, Phnom Penh, 2017.
[20]
M. White Kaba, K. Baesel, B. Poch, S. Bun, S. Cerceau, L. Bur, B. Schwarz, O. Keo, R. Tung and K. Cheang, "IDPoor: a poverty identification programme that enables collaboration across sectors for maternal and child health in Cambodia," BMJ, vol. 363, p. doi.org/10.1136/bmj.k4698, 2018.
[21]
OECD, "Social Protection System Review of Cambodia," OECD Publishing, Paris, 2017.
[22]
T. Kelsall and S. Heng, "Inclusive Healthcare and the Political Settlement in Cambodia," New Political Economy, vol. 21, no. 2, p. 238–255, 2015.
[23]
NIS, "Cambodia Socio-economic Survey 2014.," National Institute of Statistics, Ministry of Planning, Phnom Penh, 2015.
[24]
P. Deb, E. Norton and W. Manning, Health Econometrics Using Stata, College Station, TX: Stata Press, 2017.
[25]
R. Paternoster, R. Brame, P. Mazerolle and A. Piquero, "Using the Correct Statistical Test for Equality of Regression Coefficients," Criminology, vol. 36, no. 4, pp. 859-866. DOI: 10.1111/j.1745-9125.1998.tb01268.x., 1998.
[26]
World Bank, "Guidelines for Constructing Consumption Aggregates for Welfare Analysis: Living Standards Measurement Study Working Paper No. 135," World Bank, Washington, D.C., 2002.
[27]
K. Xu, J. Klavus, K. Kawabata, D. Evans, P. Hanvoravongchai, J. Ortiz, R. Zeramdini and M. CJL, "Household Health System Contributions and Capacity to Pay: Definitional, Empirical, and Technical Challenges," in Health Systems Performance Assessment: Debates, Methods and Empiricism, edited by Christopher J. L. Murray and David B. Evans, Geneva, World Health Organization, 2003a, p. 533–542.
[28]
A. Deaton, "Understanding Consumption," Oxford University Press, Oxford, 1992.
[29]
K. Xu, D. Evans, K. Kawabata, R. Zeramdini, J. Klavus and M. CJ, "Household Catastrophic Health Expenditure: A Multicountry Analysis," The Lancet, vol. 362, no. 9378, pp. 111-117, 2003b.
[30]
D. Ghosh and A. Vogt, "Outliers: An Evaluation of Methodologies," in Presented at the Joint Statistical Meetings, San Diego, 2012.
[31]
StataCorp, Stata Statistical Software: Release 15, College Station, TX: StataCorp LLC, 2017.
[32]
R. J. Kolesar, S. Pheakdey, B. Jacobs, N. Chan, S. Yok and M. Audibert, "Expanding Social Health Protection in Cambodia: an assessment of the current coverage potential, gaps, and social equity considerations.," International Social Security Review, vol. 73, no. 1, in press, 2020.
[33]
K. Tong, "Analsysing Chronic Poverty in Cambodia: Evidence from Panel Data, Working Paper Series No. 66," CDRI, Phnom Penh, 2012.
[34]
C. Chhim, S. So, V. Theng and K. Tong, "Understanding Poverty Dynamics: Evidence from Nine Villages in Cambodia, Working Paper Series No. 69," CDRI, Phnom Penh, 2012.
[35]
B. Jacobs, C. Men, M. Bigdeli and P. Hill, "Limited understanding, limited services, limited resources: patients’ experiences with managing hypertension and diabetes in Cambodia," BMJ Global Health, vol. 2, pp. doi: 10.1136/ bmjgh-2016-000235, 2017.
[36]
B. Jacobs, A. Bajracharya, J. Saha, C. Chhea, B. Bellows, S. Flessa and A. Fernandes Antunes, "Making free public healthcare attractive: Optimizing health equity funds in Cambodia," International Journal for Equity in Health, vol. 17, no. 88, pp. doi.org/10.1186/s12939-018-0803-3, 2018.
[37]
G. Flores, P. Ir, C. Men, O. O’Donnell and E. Van Doorslaer, "Financial protection of patients through compensation of providers: The impact of Health Equity Funds in Cambodia," Journal of Health Economics, vol. 32, p. 1180–93, 2013.
[38]
T. Ensor, C. Chhun, T. Kimsun, B. McPake and I. Edoka, "Impact of Health Financing Policies in Cambodia: A 20-Year Experience," Social Science & Medicine, vol. 177, p. 118–126, 2017.
[39]
T. Ensor, "Informal Payments for Health Care in Transition Economies," Social Science & Medicine, vol. 58, no. 2, pp. 237–246. DOI: 10.1016/S0277-9536(03)00007-8., 2004.
[40]
B. Shengelia, A. Tandon, O. Adams and C. Murray, "Access, utilization, quality, and effective coverage: An integrated conceptual framework and measurement strategy," Social Science & Medicine, vol. 61, pp. 97-109, 2005.
[41]
J. Abraham, B. Sick, J. Anderson, A. Berg, C. Dehmer and A. Tufano, "Selecting a Provider: What Factors Influence Patients' Decision Making?," Journal of Healthcare Management, vol. 56, no. 2, p. 99–116, 2011.
[42]
S. Kwon and L. Keo, "Social health protection in Cambodia: Challenges of policy design and implementation," International Social Security Review, vol. 72, no. 2, pp. 97-111, 2019.
[43]
E. Smith, R. Brugha and A. Zwi, "Working with Private Sector Providers for Better Health Care, an Introductory Guide," Options and LSHTM, London, 2001.
Browse journals by subject