Achieving equity of access to services is a key challenge for all developing country health system. In Cambodia, Health Equity Funds has helped many of the poorest members of the population access health care by paying for their costs. Although Health Equity Funds appear to be a low-cost solution to reducing financial constraints to accessing health care services, other barriers still remain.

Many low-income countries do not provide universal free health care services. But, the poorest sectors of the population are often unable to pay for the health care they need. The introduction of fee exemptions for the poor is often ineffective because it relies on health providers to target the relevant populations, a task that they are often not qualified or interested in doing effectively.

Research carried out by Médecins sans Frontières and the Institute of Tropical Medicine in Antwerp, Belgium, followed the introduction of a Health Equity Fund (HEF) in a poor rural district of Cambodia over a two year period. The HEF is designed to pay for the health care (in particular user fees and transport costs) of the poorest sections of the population. It is administered by an independent Cambodian NGO that has both the expertise to identify target groups and is independent of the health care providers.

The researchers combined their own observations with in-depth interviews with HEF staff and with community leaders. In addition, they interviewed 68 patients in order to gain a better insight into both their experiences of the fund and access to services.

The study found that the HEF was able to support the health care costs of nearly all the poorest people who attended the hospital. It effectively tackled the financial constraints related to the cost of health care and travel.  About 87 per cent of those deemed extremely poor had more than 50 per cent of their costs met by the HEF. Also, the likelihood of being financially supported by the HEF for ambulance costs increased according to need.

However, ability to pay for health care did not guarantee total equity as:

• the poorest were also the group that faced the biggest problems in reaching the hospitals and health centres. Distance to the hospital and the quality of the roads made travelling with an ill person difficult
• many of the poor were still not aware of the HEF or were uncertain about support from the HEF because beneficiaries were identified only upon arrival at the hospital
• the abundance of informal private health providers complicated the types of information available to villagers. Mixed messages about certain conditions and treatments confused some and discouraged others to attend public clinics.

In sum, it appears that the HEF served its purpose by providing financial assistance to the poorest groups of the population with little leakage of resources into non-poor categories. However, people continue to rely too much on expensive and ineffective private health provision often leading to debt and loss of productive assets. Some of the poorest sectors of society continue to be deterred from using the public health system either for lack of funds or clear information.

The HEF model appears to work best when:

• it helps prevent unnecessary health expenditure in the largely-ineffective private sector
• marketing and information sharing reaches everybody in the community
• careful regulation and monitoring of the NGOs administering the HEF can guarantee accountability and effectiveness in identifying and targeting the poor
• there is a relatively well functioning health service available.

More experience with HEFs in different contexts and health systems is needed. Identification of the poor when they enter hospital and within communities should be considered, allowing for comparisons of possible HEF models.

Source(s):
'Access to health care for all? User fees plus a Health Equity Fund in Sotnikum, Cambodia', Health Policy and Planning 19(1): 22-32, by W. Hardeman et al., 2004

Funded by: Médecins sans Frontières; Belgian Directorate General of Development Cooperation

id21 Research Highlight: 28 April 2004

Further Information:
Wim Van Damme
Professor of Public Health
Institute of Tropical Medicine
Nationalestraat 155
2000 Antwerpen
Belgium

Tel: +32 3 247 6286
Fax: +32 3 247 6258
Contact the contributor: wvdamme@itg.be

Médecins sans Frontières

Institute of Tropical Medicine, Antwerp, Belgium

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