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Waterworth CJ, Marella M, Bhutta MF, Dowell R, Khim K, Annear PL. Access to ear and hearing care services in Cambodia: a qualitative enquiry into experiences of key informants. J Laryngol Otol 2024; 138:22-32. [PMID: 36154944 PMCID: PMC10772024 DOI: 10.1017/s0022215122002158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE In Cambodia, little is known about the state of ear and hearing care, or the roles providers or key stakeholders play in delivering services. METHOD This was an exploratory study using semi-structured qualitative interviews and a questionnaire addressed to key stakeholders to explore their perceptions and experiences in providing services to people suffering from ear disease or hearing loss in Cambodia. RESULTS Several challenges were described including a lack of hearing services to meet the demand, especially outside Phnom Penh in primary care and aural rehabilitation. Supply-side challenges include a shortage of trained professionals, facilities and resources, poor co-ordination between providers, unclear referral pathways, and long wait times. CONCLUSION Now is an opportune time to build on the positive trend in providing integrated care for non-communicable diseases in Cambodia, through the integration of effective ear and hearing care into primary care and strengthening the package of activities delivered at government facilities.
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Affiliation(s)
- C J Waterworth
- Department of Audiology and Speech Pathology, University of Melbourne, Australia
- Nossal Institute for Global Health, University of Melbourne, Australia
| | - M Marella
- Nossal Institute for Global Health, University of Melbourne, Australia
| | - M F Bhutta
- Clinical and Experimental Medicine, Brighton & Sussex Medical School, Brighton, UK
- Department of ENT, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - R Dowell
- Department of Audiology and Speech Pathology, University of Melbourne, Australia
| | - K Khim
- Monitoring, Evaluation and Learning, Access Program, Phnom Penh, Cambodia
| | - P L Annear
- Nossal Institute for Global Health, University of Melbourne, Australia
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Bigio J, Hannay E, Pai M, Alisjahbana B, Das R, Huynh HB, Khan U, Mortera L, Nguyen TA, Safdar MA, Shrestha S, Venkat Raman A, Verma SC, Yellappa V, Srivastava D. The inclusion of diagnostics in national health insurance schemes in Cambodia, India, Indonesia, Nepal, Pakistan, Philippines and Viet Nam. BMJ Glob Health 2023; 8:e012512. [PMID: 37479500 PMCID: PMC10364157 DOI: 10.1136/bmjgh-2023-012512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/10/2023] [Indexed: 07/23/2023] Open
Abstract
The Lancet Commission on Diagnostics highlighted a huge gap in access to diagnostic testing even for basic tests, particularly at the primary care level, and emphasised the need for countries to include diagnostics as part of their universal health coverage benefits packages. Despite the poor state of diagnostic-related services in low-income and middle-income countries (LMICs), little is known about the extent to which diagnostics are included in the health benefit packages. We conducted an analysis of seven Asian LMICs-Cambodia, India, Indonesia, Nepal, Pakistan, Philippines, Viet Nam-to understand this issue. We conducted a targeted review of relevant literature and applied a health financing framework to analyse the benefit packages available in each government-sponsored scheme. We found considerable heterogeneity in country approaches to diagnostics. Of the seven countries, only India has developed a national essential diagnostics list. No country presented a clear policy rationale on the inclusion of diagnostics in their scheme and the level of detail on the specific diagnostics which are covered under the schemes was also generally lacking. Government-sponsored insurance expansion in the eligible populations has reduced the out-of-pocket health payment burden in many of the countries but overall, there is a lack of access, availability and affordability for diagnostic-related services.
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Affiliation(s)
- Jacob Bigio
- Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
- McGill International TB Centre, Montréal, Quebec, Canada
| | | | - Madhukar Pai
- Department of Epidemiology & Biostats, McGill University, Montréal, Quebec, Canada
| | - Bachti Alisjahbana
- Research Center for Care and Control of Infectious Diseases (RC3ID), Universitas Padjadjaran, Bandung, Jawa Barat, Indonesia
| | - Rishav Das
- Research Institute of the McGill University Health Centre, Montréal, Quebec, Canada
- McGill International TB Centre, Montréal, Quebec, Canada
| | - Huy Ba Huynh
- Friends for International TB Relief, Ho Chi Minh City, Vietnam
| | - Uzma Khan
- Interactive Research & Development, Singapore
| | | | - Thu Anh Nguyen
- Woolcock Institute of Medical Research, Hanoi, Viet Nam
- Faculty of Medicine and Health, The University of Sydney, Syndey, New South Wales, Australia
| | | | - Suvesh Shrestha
- School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - A Venkat Raman
- Faculty of Management Studies, University of Delhi, New Delhi, India
| | | | | | - Divya Srivastava
- Department of Health Policy, London School of Economics and Political Science, London, UK
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3
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Chham S, Van Olmen J, Van Damme W, Chhim S, Buffel V, Wouters E, Ir P. Scaling-up integrated type-2 diabetes and hypertension care in Cambodia: what are the barriers to health system performance? Front Public Health 2023; 11:1136520. [PMID: 37333565 PMCID: PMC10272385 DOI: 10.3389/fpubh.2023.1136520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023] Open
Abstract
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.
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Affiliation(s)
- Savina Chham
- National Institute of Public Health, Phnom Penh, Cambodia
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
| | - Josefien Van Olmen
- Department of Family Medicine and Population Health (FAMPOP), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Gerontology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Srean Chhim
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Veerle Buffel
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
| | - Edwin Wouters
- Centre for Population, Family and Health, Department of Social Sciences, University of Antwerp, Antwerp, Belgium
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
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Waterworth CJ, Watters CTM, Sokdavy T, Annear PL, Dowell R, Grimes CE, Bhutta MF. Disparities in access to ear and hearing care in Cambodia: a mixed methods study on patient experiences. J Laryngol Otol 2023; 137:373-389. [PMID: 35698817 PMCID: PMC10040287 DOI: 10.1017/s0022215122001396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Chronic suppurative otitis media is a major global disease disproportionately affecting low- and middle-income countries, but few studies have explored access to care for those with ear and hearing disorders. METHOD In a tertiary hospital in Cambodia providing specialist ear services, a mixed method study was undertaken. This study had three arms: (1) quantitative analysis of patients undergoing ear surgery, (2) a questionnaire survey and (3) semi-structured in-depth interviews. RESULTS Patients presented with advanced middle-ear disease and associated hearing loss at rates that are amongst the highest per capita levels globally. Patients reported several structural, financial and socio-cultural barriers to treatment. This study showed a significant burden of ear disease in Cambodia, which reflects a delay in receiving timely and effective treatment. CONCLUSION This study highlights the opportunity to integrate effective ear and hearing care into primary care service provision, strengthening the package of activities delivered at government facilities.
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Affiliation(s)
- C J Waterworth
- Department of Audiology and Speech Pathology, University of Melbourne, Melbourne, Australia
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - C T M Watters
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - T Sokdavy
- Children's Surgical Centre, Kien Khleang Rehabilitation Centre, Phnom Penh, Cambodia
| | - P L Annear
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - R Dowell
- Department of Audiology and Speech Pathology, University of Melbourne, Melbourne, Australia
| | - C E Grimes
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - M F Bhutta
- Clinical and Experimental Medicine, Brighton & Sussex Medical School, Brighton, UK
- Department of ENT, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Chhim S, Te V, Buffel V, van Olmen J, Chham S, Long S, Yem S, Van Damme W, Wouters E, Por I. Healthcare usage and expenditure among people with type 2 diabetes and/or hypertension in Cambodia: results from a cross-sectional survey. BMJ Open 2023; 13:e061959. [PMID: 36635032 PMCID: PMC9843177 DOI: 10.1136/bmjopen-2022-061959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To assess usage of public and private healthcare, related healthcare expenditure, and associated factors for people with type 2 diabetes (T2D) and/or hypertension (HTN) and for people without those conditions in Cambodia. METHODS A cross-sectional household survey. SETTINGS Five operational districts (ODs) in Cambodia. PARTICIPANTS Data were from 2360 participants aged ≥40 years who had used healthcare services at least once in the 3 months preceding the survey. PRIMARY AND SECONDARY OUTCOME The main variables of interest were the number of healthcare visits and healthcare expenditure in the last 3 months. RESULTS The majority of healthcare visits took place in the private sector. Only 22.0% of healthcare visits took place in public healthcare facilities: 21.7% in people with HTN, 37.2% in people with T2D, 34.7% in people with T2D plus HTN and 18.9% in people without the two conditions (p value <0.01). For people with T2D and/or HTN, increased public healthcare use was significantly associated with Health Equity Fund (HEF) membership and living in ODs with community-based care. Furthermore, significant healthcare expenditure reduction was associated with HEF membership and using public healthcare facilities in these populations. CONCLUSION Overall public healthcare usage was relatively low; however, it was higher in people with chronic conditions. HEF membership and community-based care contributed to higher public healthcare usage among people with chronic conditions. Using public healthcare services, regardless of HEF status reduced healthcare expenditure, but the reduction in spending was more noticeable in people with HEF membership. To protect people with T2D and/or HTN from financial risk and move towards the direction of universal health coverage, the public healthcare system should further improve care quality and expand social health protection. Future research should link healthcare use and expenditure across different healthcare models to actual treatment outcomes to denote areas for further investment.
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Affiliation(s)
- Srean Chhim
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
- School of Public Health, National Institute of Public Health, Phonm Penh, Cambodia
| | - Vannarath Te
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
- School of Public Health, National Institute of Public Health, Phonm Penh, Cambodia
- Department of Public Health, Prince Leopold Institute of Tropical Medicine, Antwerpen, Belgium
| | - Veerle Buffel
- Centre for Population, Family & Health, University of Antwerp, Antwerpen, Antwerp
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Savina Chham
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
- Department of Social Sciences, University of Antwerp, Antwerpen, Belgium
| | - Sereyraksmey Long
- School of Public Health, National Institute of Public Health, Phonm Penh, Cambodia
| | - Sokunthea Yem
- Technical Office, National Institute of Public Health, Phnom Penh, Cambodia
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
- Gerontology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Edwin Wouters
- Centre for Population, Family & Health, University of Antwerp, Antwerpen, Antwerp
| | - Ir Por
- Management team, National Institute of Public Health, Phonm Penh, Cambodia
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Koy S, Fuerst F, Tuot B, Starke M, Flessa S. The Flipped Break-Even: Re-Balancing Demand- and Supply-Side Financing of Health Centers in Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1228. [PMID: 36674006 PMCID: PMC9858853 DOI: 10.3390/ijerph20021228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Supply-side healthcare financing still dominates healthcare financing in many countries where the government provides line-item budgets for health facilities irrespective of the quantity or quality of services rendered. There is a risk that this approach will reduce the efficiency of services and the value of money for patients. This paper analyzes the situation of public health centers in Cambodia to determine the relevance of supply- and demand-side financing as well as lump sum and performance-based financing. Based on a sample of the provinces of Kampong Thom and Kampot in the year 2019, we determined the income and expenditure of each facility and computed the unit cost with comprehensive step-down costing. Furthermore, the National Quality Enhancement Monitoring Tool (NQEMT) provided us with a quality score for each facility. Finally, we calculated the efficiency as the quotient of quality and cost per service unit as well as correlations between the variables. The results show that the largest share of income was received from supply-side financing, i.e., the government supports the health centers with line-item budgets irrespective of the number of patients and the quality of care. This paper demonstrates that the efficiency of public health centers increases if the relevance of performance-based financing increases. Thus, the authors recommend increasing performance-based financing in Cambodia to improve value-based healthcare. There are several alternatives available to re-balance demand- and supply-side financing, and all of them must be thoroughly analyzed before they are implemented.
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Affiliation(s)
- Sokunthea Koy
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Franziska Fuerst
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Bunnareth Tuot
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Maurice Starke
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Steffen Flessa
- Department of Health Care Management, University of Greifswald, 17487 Greifswald, Germany
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Strachan DL, Teague K, Asefa A, Annear PL, Ghaffar A, Shroff ZC, McPake B. Using health policy and systems research to influence national health policies: lessons from Mexico, Cambodia and Ghana. Health Policy Plan 2022; 38:3-14. [PMID: 36181467 PMCID: PMC9849714 DOI: 10.1093/heapol/czac083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 07/22/2022] [Accepted: 09/30/2022] [Indexed: 01/22/2023] Open
Abstract
Health system reforms across Africa, Asia and Latin America in recent decades demonstrate the value of health policy and systems research (HPSR) in moving towards the goals of universal health coverage in different circumstances and by various means. The role of evidence in policy making is widely accepted; less well understood is the influence of the concrete conditions under which HPSR is carried out within the national context and which often determine policy outcomes. We investigated the varied experiences of HPSR in Mexico, Cambodia and Ghana (each selected purposively as a strong example reflecting important lessons under varying conditions) to illustrate the ways in which HPSR is used to influence health policy. We reviewed the academic and grey literature and policy documents, constructed three country case studies and interviewed two leading experts from each of Mexico and Cambodia and three from Ghana (using semi-structured interviews, anonymized to ensure objectivity). For the design of the study, design of the semi-structured topic guide and the analysis of results, we used a modified version of the context-based analytical framework developed by Dobrow et al. (Evidence-based health policy: context and utilisation. Social Science & Medicine 2004;58:207-17). The results demonstrate that HPSR plays a varied but essential role in effective health policy making and that the use, implementation and outcomes of research and research-based evidence occurs inevitably within a national context that is characterized by political circumstances, the infrastructure and capacity for research and the longer-term experience with HPSR processes. This analysis of national experiences demonstrates that embedding HPSR in the policy process is both possible and productive under varying economic and political circumstances. Supporting research structures with social development legislation, establishing relationships based on trust between researchers and policy makers and building a strong domestic capacity for health systems research all demonstrate means by which the value of HPSR can be materialized in strengthening health systems.
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Affiliation(s)
- Daniel Llywelyn Strachan
- *Corresponding author. The Nossal Institute for Global Health, University of Melbourne, 333 Exhibition Street, Melbourne, VIC 3004, Australia. E-mail:
| | - Kirsty Teague
- The Nossal Institute for Global Health, The University of Melbourne, 333 Exhibition Street, Melbourne, VIC 3004, Australia
| | - Anteneh Asefa
- The Nossal Institute for Global Health, The University of Melbourne, 333 Exhibition Street, Melbourne, VIC 3004, Australia,Institute of Tropical Medicine, Kronenburgstraat 43, Antwerp (ITM) 2000, Belgium
| | - Peter Leslie Annear
- The Nossal Institute for Global Health, The University of Melbourne, 333 Exhibition Street, Melbourne, VIC 3004, Australia
| | - Abdul Ghaffar
- The Alliance for Health Policy and Systems Research, WHO, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Zubin Cyrus Shroff
- The Alliance for Health Policy and Systems Research, WHO, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Barbara McPake
- The Nossal Institute for Global Health, The University of Melbourne, 333 Exhibition Street, Melbourne, VIC 3004, Australia
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Kim MK, Kim SA, Oh J, Kim CE, Arsenault C. Measuring effective coverage of maternal and child health services in Cambodia: a retrospective analysis of Demographic and Health Surveys from 2005 to 2014. BMJ Open 2022; 12:e062028. [PMID: 36691182 PMCID: PMC9454061 DOI: 10.1136/bmjopen-2022-062028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/09/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To investigate effective, quality-adjusted, coverage and inequality of maternal and child health (MCH) services to assess progress in improving quality of care in Cambodia. DESIGN A retrospective secondary analysis using the three most recent (2005, 2010 and 2014) Demographic and Health Surveys. SETTING Cambodia. PARTICIPANTS 53 155 women aged 15-49 years old and 23 242 children under 5 years old across the three surveys. OUTCOME MEASURES We estimated crude coverage, effective coverage and inequality in effective coverage for five MCH services over time: antenatal care (ANC), facility delivery and sick childcare for diarrhoea, pneumonia and fever. Quality was defined by the proportion of care seekers who received a set of interventions during healthcare visits. Effective coverage was estimated by combining crude coverage and quality. We used equiplots and risk ratios, to assess patterns in inequality in MCH effective coverage across wealth quintile, urban-rural and women's education levels and over time. RESULTS In 2014, crude and effective coverage was 80.1% and 56.4%, respectively, for maternal health services (ANC and facility delivery) and 59.1% and 26.9%, respectively, for sick childcare (diarrhoea, pneumonia and fever). Between 2005 and 2014, effective coverage improved for all services, but improvements were larger for maternal healthcare than for sick child care. In 2014, poorer children were more likely to receive oral rehydration solution for diarrhoea than children from richer households. Meanwhile, women from urban areas were more likely to receive a postnatal check before getting discharged. CONCLUSIONS Effective coverage has generally improved in Cambodia but efforts remain to improve quality for all MCH services. Our results point to substantial gaps in curative sick child care, a large share of which is provided by unregulated private providers in Cambodia. Policymakers should focus on improving effective coverage, and not only crude coverage, to achieve the health-related Sustainable Development Goals by 2030.
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Affiliation(s)
- Min Kyung Kim
- Department of Korea, Korea Foundation for International Healthcare, Seoul, Republic of Korea
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts, USA
| | - Soon Ae Kim
- Department of Korea, Korea Foundation for International Healthcare, Seoul, Republic of Korea
| | - Juhwan Oh
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chae Eun Kim
- Department of Korea, Korea Foundation for International Healthcare, Seoul, Republic of Korea
| | - Catherine Arsenault
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Binyaruka P, Borghi J. An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania. HEALTH ECONOMICS REVIEW 2022; 12:36. [PMID: 35802268 PMCID: PMC9264712 DOI: 10.1186/s13561-022-00387-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/30/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap. METHODS We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index. RESULTS 71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients. CONCLUSIONS Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility's construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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McPake B, Gilbert K, Vong S, Ros B, Has P, Khuong AT, Phuc PD, Hoang QC, Nguyen DH, Siengsounthone L, Luangphaxay C, Annear P, McKinley J. Role of regulatory capacity in the animal and human health systems in driving response to zoonotic disease outbreaks in the the Mekong region. One Health 2022; 14:100369. [PMID: 35106358 PMCID: PMC8784321 DOI: 10.1016/j.onehlt.2022.100369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/29/2021] [Accepted: 01/03/2022] [Indexed: 11/19/2022] Open
Abstract
We conducted a policy situation analysis in three Mekong region countries, focused on how the animal and human health systems interact to control avian influenza (AI). The study used scoping literature reviews aimed at establishing existing knowledge concerning the regulatory context. We then conducted a series of key informant interviews with national and sub-national government officials and representatives of producers and poultry farmers to understand their realities in managing the complex interface of the two sectors to control AI. We found signs of formal progress in establishing the policy and legislative frameworks needed to enable cooperation of the two sectors but a series of constraints that impede their effective operation. These included the competitive relationships involved, especially with budgetary allocations and mandates that can conflict with each other. Many local actors also view development partners (e.g., bilateral and multilateral donors) as having a dominant role in establishing these collaborations, limiting the extent to which there is local ownership of the agenda. The animal and human health sectors are not equally resourced, with the animal health sector disadvantaged in terms of surveillance and laboratory systems, human resources and financial allocations. Contrasting strategies for achieving objectives have also characterised the two sectors in recent decades, seeing a major shift towards the use of incentive-based approaches in the human health sector but very little parallel development in the animal health sector, largely dependent on command and control approaches. Successful future collaborations between the two sectors are likely to depend on better resourcing in the animal health sector, increasing local ownership of the agenda, and ensuring that both sectors can use the full range of regulatory strategies available to achieve objectives.
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Affiliation(s)
- Barbara McPake
- Nossal Institute for Global Health, Melbourne, Australia
| | | | - Sreytouch Vong
- Independent consultants contracted by the Nossal Institute for Global Health, Phnom Penh, Cambodia
| | - Bandeth Ros
- Independent consultants contracted by the Nossal Institute for Global Health, Phnom Penh, Cambodia
| | - Phalmony Has
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Pham-Duc Phuc
- Center for Public Health and Ecosystem Research, Hanoi University of Public Health, Hanoi, Viet Nam
| | | | - Duc Hai Nguyen
- Pasteur Institute Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | | | | | - Peter Annear
- Nossal Institute for Global Health, Melbourne, Australia
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Feldhaus I, Nagpal S, Bauhoff S. Role of User Benefit Awareness in Health Coverage Utilization among the Poor in Cambodia. Health Syst Reform 2022; 8:e2058336. [PMID: 35583478 DOI: 10.1080/23288604.2022.2058336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The objective of this study was to understand the steps to health coverage benefit utilization in Cambodia toward improving access to health care and financial risk protection for the poor. We particularly examine the role of user awareness in the pathway to care seeking and benefit utilization with respect to the Health Equity Funds (HEF). Using 2016 survey data that were nationally representative of households with children under two years of age, we used a series of logistic regression models to evaluate associations between respondents' awareness of benefits, public health care seeking behaviors, coverage benefit claims, and out-of-pocket expenditures. Beneficiaries were generally aware of their entitlements, although their awareness of specific benefits, such as transport reimbursement, was relatively lower. Awareness of free services at public health centers was associated with twice the odds of having ever visited a public provider for outpatient care, while awareness of free services at public hospitals was associated with higher odds of always seeking inpatient care in the public sector. Study findings point to the decision of where to seek care as the critical point in the pathway to HEF utilization. If the decision had already been made to go to a public provider, it was likely that HEF benefits were claimed. Interventions that prompt appropriate care seeking in the public sector may do the most to improve HEF utilization and subsequently improve access to care through sufficient financial risk protection.
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Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Somil Nagpal
- Global Practice on Health, Nutrition, and Population, World Bank Group, Washington, DC, USA
| | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Feldhaus I, Nagpal S, Verguet S. Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia. PLoS One 2021; 16:e0259628. [PMID: 34739523 PMCID: PMC8570764 DOI: 10.1371/journal.pone.0259628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022] Open
Abstract
In Cambodia, diabetes caused nearly 3% of the country's mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.
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Affiliation(s)
- Isabelle Feldhaus
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Somil Nagpal
- World Bank Group, Washington, DC, United States of America
| | - Stéphane Verguet
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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13
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Jithitikulchai T, Feldhaus I, Bauhoff S, Nagpal S. Health equity funds as the pathway to universal coverage in Cambodia: care seeking and financial risk protection. Health Policy Plan 2021; 36:26-34. [PMID: 33332527 DOI: 10.1093/heapol/czaa151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 11/14/2022] Open
Abstract
Cambodia has developed the health equity fund (HEF) system to improve access to health services for the poor, and this strengthens the health system towards the universal health coverage goal. Given rising healthcare costs, Cambodia has introduced several innovations and accomplished considerable progress in improving access to health services and catastrophic health expenditures for the targeted population groups. Though this is improving in recent years, HEF households remain at the higher risk of catastrophic spending as measured by the higher share of HEF households with catastrophic health expenses being at 6.9% compared to the non-HEF households of 5.5% in 2017. Poverty targeting poses another challenge for the health system. Nevertheless, HEF appeared to be more significantly associated with decreased out-of-pocket expenditure per illness among those who sought care from public providers. Increasing population and cost coverages of the HEF and effectively attracting beneficiaries to the public sector will further enhance the financial protection and pave the pathway towards universal coverage. Our recommendations focus on leveraging the HEF experience for expanding coverage and increasing equitable access, as well as strengthening the quality of healthcare services.
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Affiliation(s)
- Theepakorn Jithitikulchai
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.,World Bank Group, 1818 H Street, Washington, DC 20433, USA
| | - Isabelle Feldhaus
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Sebastian Bauhoff
- Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Somil Nagpal
- World Bank Group, 1818 H Street, Washington, DC 20433, USA
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Khim K, Andermann A. Challenges and opportunities in addressing social determinants of child health in Cambodia: perspectives and experience of frontline providers in two health districts. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2021; 112:317-330. [PMID: 33471345 PMCID: PMC7816155 DOI: 10.17269/s41997-020-00442-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 10/25/2020] [Indexed: 12/04/2022]
Abstract
OBJECTIVES Other forces related to socio-economic and cultural factors, besides biomedical and behavioural fields, also influence health but receive little attention in health research. This study aims to illuminate social determinants of health and to identify challenges and opportunities in addressing social determinants of child health (SDCH) in rural Cambodia. METHODS This is a qualitative study based on interviews of frontline primary health care providers, health officials, local authorities and community volunteers in two health districts in Cambodia. The data were supplemented by secondary data on different aspects of the districts and Cambodia. RESULTS Poverty, lack of basic commodities and adverse social conditions remained problems for population health. While access to health services was considered adequate, households and communities had several major risk exposures. Challenges in addressing SDCH were the high prevalence of social and household adverse conditions, and the lack of training of providers, of information about social services, of effective coordination and of trust in public services. Opportunities were present, including social services being existent albeit poor functioning, the traditional practice of social inquiry, existing frontline providers being open to further information and training, existing subnational coordination bodies at district and provincial levels, and use of evidence in planning and resource allocation. CONCLUSION Addressing SDCH requires broad and coordinated efforts of stakeholders from multiple sectors. Among the prerequisites are to leverage the existing structures and mechanisms, training primary health care providers and providing them with adequate information about local resources and available supports. Improving social care services and infrastructures requires strong coordination, planning and adequate resource allocation.
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Affiliation(s)
- Keovathanak Khim
- Public Health Department, University of Health Sciences, 73, Monivong Blvd., Khan Daun Penh, Phnom Penh, Cambodia.
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada.
| | - Anne Andermann
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
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Jacobs B, Sam Oeun S, Ir P, Rifkin S, Van Damme W. Can social accountability improve access to free public health care for the poor? Analysis of three Health Equity Fund configurations in Cambodia, 2015–17. Health Policy Plan 2020; 35:635-645. [DOI: 10.1093/heapol/czaa019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/31/2022] Open
Abstract
AbstractWithin 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.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Project, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
- Social Health Protection Network P4H, Phnom Penh, Cambodia
| | - Sam Sam Oeun
- Buddhism for Health, National Road 1, Borey Peng Huoth, #64, St. P-10E Khan Chbar Ampov, Phnom Penh, Cambodia
| | - Por Ir
- Technical Bureau, National Institute of Public Health, lot no. 80, Samdach Penn Nouth Blvd (St. 289), Phnom Penh, Cambodia
| | - Susan Rifkin
- Distance Learning, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Wim Van Damme
- Public Health Department, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
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