Wearable health monitors are a rapidly evolving technology which may offer new opportunities for strengthening health system responses to cardiovascular and other non-communicable diseases (NCDs) in ...low- and middle-income countries (LMICs). In light of this, we explored opportunities for, and potential challenges to, technology adoption in Cambodia, considering the complexity of contextual factors that may influence product uptake and sustainable health system integration. Data collection for this study involved in-depth interviews with national and international stakeholders and a literature review. The analytical approach was guided by concepts and categories derived from NASSS - an evidence-based framework that was developed for studying health technology adoption and the challenges to scale-up, spread, and sustainability of such technologies in health service organisations. Three potential applications of health wearables for the prevention and control of NCDs in Cambodia were identified: health promotion; follow up and monitoring of patients; surveys of NCD risk factors. However, several challenges to technology adoption emerged across the research domains, associated with the intended adopters, the organisation of the national health system, the wider infrastructure, the regulatory environment, and the technology itself. Our findings indicate that, currently, wearables could be best used to conduct surveys of NCD risk factors in Cambodia and in other LMICs with similar health system profiles. In the future, a more integrated use of wearables to strengthen monitoring and management of patients could be envisaged, although this would require careful consideration of feasibility and organisational issues.
Abstract
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.
In this sixth paper of the Series, we review health-financing reforms in seven countries in southeast Asia that have sought to reduce dependence on out-of-pocket payments, increase pooled health ...finance, and expand service use as steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor-supported health equity funds to reach the poor, and reliable funding and appropriate identification of the eligible poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam, social health insurance financed by payroll tax is commonly used for formal sector employees (excluding Malaysia), with varying outcomes in terms of financial protection. Alternative payment methods have different implications for provider behaviour and financial protection. Two alternative approaches for financial protection of the non-poor outside the formal sector have emerged—contributory arrangements and tax-financed schemes—with different abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both important in accelerating financial protection. Expanding coverage of good-quality services and ensuring adequate human resources are also important to achieve universal coverage. As health-financing reform is complex, institutional capacity to generate evidence and inform policy is essential and should be strengthened.
Low birth weight (LBW), an important risk factor for early childhood mortality and morbidity, is a major public health concern in developing countries including Cambodia. This study examined the ...prevalence of LBW across provinces in Cambodia and changes over time, and identified the factors associated with such condition.
We used children datasets from Cambodia Demographic and Health Survey (CDHS) 2010 and 2014. There were 3,522 children and 4,991 children in both surveys. Maps illustrating provincial variation in LBW prevalence were constructed. Then, multivariate analyses were conducted to assess factors independently associated with LBW in CDHS 2014.
LBW prevalence remained stable between 2010 and 2014, at around 7.0% 95% CI: 5.8-8.1). all institutional births, but within significant variation across provinces. Factors independently associated with LBW included mother's no education compared with those whose mothers had secondary or higher education (AOR = 1.6, 95% CI: 1.0-2.6), babies born to mothers with < 4 antenatal care (ANC) visits during the pregnancy compared with those whose mothers had at least 4 ANC visits (AOR = 2.0, 95% CI: 1.5-2.8). Also, first-born babies were at greater risk of LBW compared with second-born babies (AOR = 1.4, 95% CI: 1.0-2.0).
The study points to key sub-populations at greater risk and regions where LBW is particularly prevalent. Programs should target provinces where LBW prevalence remains high. Illiterate women, especially those pregnant for the first time should be the program priority. The current national program policy, which recommends that pregnant women have ≥ 4 ANC visits during pregnancy should be further reinforced and implemented. Program design should consider ways to communicate the importance of making the recommended number of ANC visits among women with no formal education.
Abstract
Introduction
Cambodia has achieved significant progress in maternal health, yet remains in the group of countries with the highest maternal mortality ratio in South-East Asia. Extra efforts ...are needed to improve maternal health through assessing the coverage of maternal health services as a continuum of care (CoC) and identifying the gaps. Our study aims to explore the coverage level of the Optimal CoC by (1) measuring the continuity of optimal antenatal care (ANC), skilled birth attendance (SBA) and optimal post-natal care (PNC), (2) identifying the determinants of dropping out from one service to another and (3) of not achieving the complete CoC.
Method
The study employed data from the Cambodia Demographic Health Survey 2014. We restricted our analysis to married women who had a live birth in the five years preceding the survey (
n
= 5678). Bi-variate and multivariate logistic regression were performed using STATA version 14.
Results
Almost 50% of women had achieved the complete optimal CoC, while the remaining have used only one or two of the services. The result shows that the level of women’s education was positively associated with the use of optimal ANC, the continuation to using optimal PNC and achieving the complete CoC. More power of women in household decision making was also positively associated with receiving the complete CoC. The birth order was negatively associated with achieving the complete CoC, while exposure to the mass media and having health insurance increased the odds of achieving the complete CoC. Household wealth consequently emerged as an influential predictor of dropping out and not achieving the complete CoC. Receiving all different elements of ANC care improved the continuity of care from optimal ANC to SBA and from SBA to optimal ANC.
Conclusion
The findings urge policy makers to approach maternal health care as a continuum of care with different determinants at each step. Household wealth was found to be the most influential factor, yet the study discovered also other barriers to optimal maternal health care which need to be addressed: future intervention should thus not only aim to increase wealth or health insurance coverage but also stimulate the education of women and empower women to claim power in household decision-making.
Abstract
Cambodia’s healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The ...government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012–14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of −0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.
Abstract
In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities ...exist between the standard of care in neighbouring countries. While awareness of South–South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regional trade liberalization to perceptions about the quality of care and the pressure of relatives and other advisers in local communities. Furthermore, there is a diversity of medical travels from Cambodia, ranging from first class travels to international hospitals in Bangkok and cross-border ‘medical tourism’ to perilous overland journeys of poor patients, who regularly resort to borrowing or liquidating assets to cover costs. The implications of the research findings for health sector development and equitable access to care for Cambodians deserve particular attention. To some extent, the increase in medical travels can stimulate improvements in the quality of local health services. However, concerns remain that these developments will mainly affect high-cost private services, widening disparities in access to care between population groups.
Abstract
Background
Hypertension (HTN) is a leading cause of cardiovascular diseases and deaths globally. To respond to the high HTN prevalence (23.5% among adults aged 40–69 years in 2016) in ...Cambodia, the government (and donors) established innovative interventions to improve access to screening, care, and treatment at different public health system and community levels. We assessed the effectiveness of these interventions and resulting health outcomes through a cascade of HTN care and explored key determinants.
Methods
We performed a population-based survey among 5070 individuals aged ≥ 40 years to generate a cascade of HTN care in Cambodia. The cascade, built with conditional approach, shows the patients’ flow in the health system and where they are lost (dropped out) along the steps: (i) prevalence, (ii) screening, (iii) diagnosis, (iv) treatment in the last twelve months, (v) treatment in the last three months, and (vi) HTN being under control. The profile of people dropping out from each bar of the cascade was determined by multivariate logistic regression.
Results
The prevalence of HTN (i) among study participants was 35.2%, of which 81.91% had their blood pressure (BP) measured in the last three years (ii). Over 63.72% of those screened were diagnosed by healthcare professionals as hypertensive patients (iii). Among these, 56.19% received treatment in the last twelve months (iv) and 54.26% received follow-up treatment in the last three months (v). Only 35.8% of treated people had their BP under control (vi). Males, those aged ≥ 40 years, and from poorer households had lower odds to receive screening, diagnosis, and treatment. Lower odds to have their BP under-control were found in males, those from poor and rich quintiles, having HTN < five years, and receiving treatment at a private facility.
Conclusions
Overall, people with HTN are lost along the cascade, suggesting limited access to appropriate screening, diagnosis, and treatment and resulting poor health outcomes, especially among those who are male, aged 40–49 years, from poorer households, and visiting a private facility. Efforts to improve the quality of facility-based and community-based interventions are needed to prevent inequitable drops along the cascade of care.
Abstract
Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter ...termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty—the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt—even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.
Cambodia aims to eliminate malaria by 2025, however tackling Plasmodium vivax (P.v) presents multiple challenges. The prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency has prevented ...the deployment of 8-aminoquinolones for "radical cure", due to the risk of severe haemolysis. Patients with P. vivax have therefore continued to experience recurrent relapses leading to cumulative health and socioeconomic burden. The recent advent of point of care testing for G6PD deficiency has made radical cure a possibility, however at the time of the study lack of operational experience and guidance meant that they had not been introduced. This study therefore aimed to design, implement and evaluate a new care pathway for the radical cure of P.vivax. This implementation study took place in Pursat province, Western Cambodia. The interventions were co-developed with key stakeholders at the national, district, and local level, through a continuous process of consultations as well as formal meetings. Mixed methods were used to evaluate the feasibility of the intervention including its uptake (G6PD testing rate and the initiation of primaquine treatment according to G6PD status); adherence (self-reported); and acceptability, using quantitative analysis of primary and secondary data as well as focus group discussions and key informant interviews. The co-development process resulted in the design of a new care pathway with supporting interventions, and a phased approach to their implementation. Patients diagnosed with P.v infection by Village Malaria Workers (VMWs) were referred to local health centres for point-of-care G6PD testing and initiation of radical cure treatment with 14-day or 8-week primaquine regimens depending on G6PD status. VMWs carried out follow-up in the community on days 3, 7 and 14. Supporting interventions included training, community sensitisation, and the development of a smartphone and tablet application to aid referral, follow-up and surveillance. The testing rate was low initially but increased rapidly over time, reflecting the deliberately cautious phased approach to implementation. In total 626 adults received G6PD testing, for a total of 675 episodes. Of these 555 occurred in patients with normal G6PD activity and nearly all (549/555, 98.8%) were initiated on PQ14. Of the 120 with deficient/intermediate G6PD activity 61 (50.8%) were initiated on PQ8W. Self-reported adherence was high (100% and 95.1% respectively). No severe adverse events were reported. The pathway was found to be highly acceptable by both staff and patients. The supporting interventions and gradual introduction were critical to success. Challenges included travel to remote areas and mobility of P.v patients. The new care pathway with supporting interventions was highly feasible with high levels of uptake, adherence and acceptability in this setting where high prevalence of G6PD deficiency is high and there is a well-established network of VMWs. Scaling up of the P.v radical cure programme is currently underway in Cambodia and a decline in reduction in the burden of malaria is being seen, bringing Cambodia a step closer to elimination.
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