1. Evaluation of a Voucher Program in Reducing Inequities in Maternal Health Utilization in Cambodia: A Quasi-Experimental Study
Ashish Bajracharya*
Antonia Dingle London School of Hygiene and Tropical Medicine
Population Council
Ben Bellows Population Council
Presentation prepared for
Global Health Metrics and Evaluation:
Data, Debates and Directions
2013 Conference
Seattle, WA, June 2013

2. Key Objectives of Study
Examine the trends and equity in maternal health service utilization in Cambodia focusing particularly on Facility Deliveries and ANC use using household survey data.
Examine key correlates and determinants of Facility Delivery and ANC use in Cambodia a multivariate framework, focusing on the influence of existing social health protection programs.
Examine implications of these results for the evaluation of targeted voucher program that uses a rigorous quasi-experimental design within a complicated health financing landscape in Cambodia
Structure of the presentation

3. Background
Maternal Health in Cambodia Among the poorest in the region but improving rapidly
Cambodia: MMR=472 (2005) to 206 (2011) [DHS]
Increases in maternal health services impressive:
Facility Deliveries 10% (2000) to 53% (2010)
4 ANC Visits  9% (2000) to 57%(2010)
These average gains, however, mask inequities within Cambodia

4. Background Conceptual Framework: Determinants
Draws from Gabrysch and Campbell’s (2009) framework on Determinants of Delivery Care
Socio Cultural Factors: Maternal age, marital status, ethnicity, religion, educational attainment and women’s autonomy
Economic Accessibility: Occupation, ability to pay, household wealth/SES status
Perceived Need or Benefit of Skilled Attendance: Health knowledge, perceived quality of care, previous use of maternal health services, whether pregnancy was wanted, birth order
Physical Accessibility: Urban or rural residence, distance to facilities

5. In this paper…
This paper goes one step further: Includes as determinants of maternal healthcare use Social Health Protection Financing Strategies:
e.g. HEF, CBHI
Targeted to bridge inequities: Ties into Equity Analysis
Community Level Variables:
Proxies Awareness and Access
Represents influences on health seeking behavior at levels higher than the individual
Community Level variables are being increasingly used in studies of determinants of maternal healthcare
Some evidence on community level influences: Babalola & Fatusi 2009; Kesterton et al. (2010); Jat et al. (2011)

6. Data
From baseline household survey of a quasi-experimental evaluation study of an RH voucher and accreditation program
In three pilot provinces: Kampong Thom, Kampot, and Prey Veng.
Evaluation conducted by Population Council funded by the Bill and Melinda Gates Foundation. Data collected by the Center for Advanced Studies (CAS), Phnom Penh.
Vouchers run by Cambodia MoH and funded by KfW, managed by AFH and EPOS Consulting
Survey samples 2201 women of reproductive age (18-49 yrs)
In nine Operational Districts (ODs) in 3 provinces with the RH voucher services and nine propensity score matched control ODs without vouchers from non voucher provinces.
Analytic Sample
For ANC: N=2083 women who gave birth in last 12 months or are currently pregnant
For FBD: N=1439 women who gavee birth in the last 12 months

7. Measures Dependent Variables Independent Variables
Facility Based (Institutional) Delivery (FBD)
Attendance of Atleast 4 Antenatal Care Visits (ANC)
Independent Variables
Socioeconomic Status (Key in Equity Analysis)
Wealth Quintiles using HH Asset Index
Generated using Principal Components Analysis
Has some form of Social Health Protection
Health Equity Fund (HEF)
Community Based Health Insurance (CBHI)
Voucher (Non MoH-KfW)
Health Priority Provision Card
Other forms of SHP

8. Measures Control Variables
Sociocultural Variables: age, marital status, religion family size, mother’s educational attainment.
Economic Accessibility: Mother and husband’s occupation, perceived difficulty of spending $13 to treat illness
Perceived need for Maternal Healthcare Services: Parity number of previous births; whether had 4 or more ANC visits
Community Level Variables (Multilevel Model)
Proportion of Commune that Delivered in Facility
Proportion of Commune that had 4 or more ANC visits
Proportion of Commune that had some form of SHP

9. Empirical strategy Descriptive Trend Analysis Equity Analysis
Births and pregnancies over the last 5 years for up to 5 pregnancies ( )
For FBD and ANC Use
Equity Analysis
Quintile Ratios over last five years
Concentration Curves
Multivariate Logistic Regression Analysis
Most recent pregnancy (ANC) or Birth (FBD)
Sequential stepwise models: Increasingly restrictive
Add SHP and SES
Add Community Level Variables

10. Results: Trends in Facility Births

11. Results: Trends in ANC 4+ Use

12. Results: Equity in Facility Deliveries

13. Results: Equity in ANC 4+ Use

14. Results: Facility Delivery Concentration Curve
Concentration index = (0.02 , 0.06)
Standard error = 0.012

15. Results: ANC 4+ Concentration Curve
Concentration index =
0.07 (0.05, 0.09)
Standard error = 0.012

16. Results Based on Descriptive Statistics and T-tests :
Women who deliver in facilities and have more than 4 ANC visits are a distinct group compared to women who do not; they are:
Younger at their most recent birth
Better educated
More likely to have some form of Social Health Protection
Wealthier (represented more in higher quintiles)
Have high prior use or live in communities with higher proportions of use of maternal healthcare services

17. Results: Logistic Regression for Facility Delivery

18. Results: Logistic Regression for ANC 4+ Use

19. Discussion & Conclusions
Key Findings:
Impressive rise in the last decade in maternal healthcare services: FBD and ANC
May mask disparities between the rich and the poor: Rising inequality seen in equity analyses
Early lessons on SHP programs: Health Equity Fund is an effective targeting tool to serve the poor in accessing health services
Associations with use of maternal and reproductive healthcare services significant: Robust in sequential models

20. Discussion & Conclusions
Implications for Targeted vs. Universal Strategies
HEF is a nationwide flagship program  covers primary and other forms of healthcare
Significantly associated with utilization of RH healthcare
RH Vouchers targeted towards RH and maternal healthcare services Impact will be known after completion of quasi-experimental study
Similar if not greater influences on maternal health service utilization can be expected
Association with wealth is also consistent poorer women have poor access to RH services
Pro poor financing strategies like Vouchers  potential to be effective at improving service use among vulnerable populations

21. Discussion & Conclusions
Implications for Targeted vs. Universal Strategies
Community Level variables Significant | Mediators
Important Indicator Social norms around use of RH and maternal healthcare services matter
Targeted RH Voucher strategy aimed towards generating demand for use of services
A suitable strategy for creating social normative changes around use of services  Sustainability
Point to note: increasing inequity does not mean worsening of service access for the poor
Current utilization rates are increasing across all quintiles  but at different rates
More steadily at top peaks and troughs among poor
Targeted finance strategies like vouchers may help bridge gaps

22. Acknowledgement Bill and Melinda Gates Foundation We are grateful to
for their generous support of this project

23. Population Council The
conducts biomedical, social science, and public health research. We deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world.