Department of Public Health, Institute of Tropical Medicine of Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium.
Department of Public Health, Institute of Tropical Medicine of Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium and Technical Bureau, National Institute of Public Health, lot no. 80, Samdach Penn Nouth Blvd (St. 289), Phnom Penh, Cambodia.
Health Policy Plan. 2019 Dec 1;34(10):740-751. doi: 10.1093/heapol/czz095.
Fees charged at the point of use are a barrier to the health services' users, especially for the poorest. Two decades ago, Cambodia introduced the so-called health equity fund (HEF) strategy, a waiver scheme which enhances access to public health services for the poor without undermining the economic situation of facilities. Evidence suggests that hospital-based HEF effectively removed financial barriers and reduced out-of-pocket expenditures. There is less evidence on the effectiveness of the HEF when assistance is extended to the primary level of healthcare. This research explores the impact of a HEF extended to health centres in two rural health districts. Two household surveys and 16-month diary data allowed to assess the impact of the intervention on health-seeking behaviours and expenditure of poor households. Though HEF effectively removed user fees at public health facilities, health centre utilization of sick and poor people did not budge much in the intervention district; self-medication and private provider consultations remained the preferred health-seeking behaviours, by far, even if more expensive. Difference-in-difference estimates confirmed that HEF had a slight impact on health-seeking behaviours, but only for the subgroups of HEF beneficiaries living close to the health centre and ready to test their new entitlement. This research reminds on the importance of the context for the effectiveness of any policy: in a highly pluralistic health sector, waiving already low-user fees in public health centres may be insufficient to increase rapidly the use of those facilities and reduce catastrophic spending. In such context, apart from distance to health centres, perceived quality of services at the health centres, which was relatively low compared with other providers, also matters. Although the HEF scheme plays a role in improving perceived and objective quality of care, complementary means are to be deployed.
在使用点收取的费用是卫生服务用户的障碍，尤其是对最贫困的人来说。二十年前，柬埔寨引入了所谓的健康公平基金（HEF）战略，这是一种豁免计划，旨在增强贫困人口获得公共卫生服务的机会，同时又不影响设施的经济状况。有证据表明，基于医院的 HEF 有效地消除了财政障碍，减少了自费支出。关于将 HEF 援助扩展到初级医疗保健时的有效性的证据较少。这项研究探讨了将 HEF 扩展到两个农村卫生区的卫生中心的影响。两项家庭调查和 16 个月的日记数据使评估干预措施对贫困家庭寻求医疗服务的行为和支出的影响成为可能。尽管 HEF 有效地取消了公共卫生设施的用户费用，但在干预地区，卫生中心的病人和穷人的利用率并没有太大变化；到目前为止，自我医疗和私人提供者咨询仍然是首选的医疗服务行为，即使更昂贵。差异分析估计证实，HEF 对医疗服务的寻求行为有轻微影响，但仅限于靠近卫生中心且愿意检验其新权益的 HEF 受益人的亚组。这项研究提醒我们注意任何政策有效性的背景的重要性：在高度多元化的卫生部门中，免除公共卫生中心已经很低的用户费用可能不足以迅速增加这些设施的使用并减少灾难性支出。在这种情况下，除了距离卫生中心的远近外，卫生中心服务的感知质量也很重要，与其他提供者相比，卫生中心的服务质量相对较低。尽管 HEF 计划在改善可感知和客观的护理质量方面发挥了作用，但还需要部署补充手段。
