摘要：Objective To evaluate the effect of vouchers for maternity care in public health-care facilities on the utilization of maternal health-care services in Cambodia. Methods The study involved data from the 2010 Cambodian Demographic and Health Survey, which covered births between 2005 and 2010. The effect of voucher schemes, first implemented in 2007, on the utilization of maternal health- care services was quantified using a difference-in-differences method that compared changes in utilization in districts with voucher schemes with changes in districts without them. Findings Overall, voucher schemes were associated with an increase of 10.1 percentage points (pp) in the probability of delivery in a public health-care facility; among women from the poorest 40% of households, the increase was 15.6 pp. Vouchers were responsible for about one fifth of the increase observed in institutional deliveries in districts with schemes. Universal voucher schemes had a larger effect on the probability of delivery in a public facility than schemes targeting the poorest women. Both types of schemes increased the probability of receiving postnatal care, but the increase was significant only for non-poor women. Universal, but not targeted, voucher schemes significantly increased the probability of receiving antenatal care. Conclusion Voucher schemes increased deliveries in health centres and, to a lesser extent, improved antenatal and postnatal care. However, schemes that targeted poorer women did not appear to be efficient since these women were more likely than less poor women to be encouraged to give birth in a public health-care facility, even with universal voucher schemes. a Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands. b Institute of Health Economics and Management, University of Lausanne, Lausanne, Switzerland. c Institute of Tropical Medicine, Antwerp, Belgium. d University of Macedonia, Thessaloniki, Greece. Correspondence to Ellen Van de Poel (e-mail: vandepoel@bmg.eur.nl). (Submitted: 19 August 2013 – Revised version received: 5 November 2013 – Accepted: 28 November 2013 – Published online: 17 March 2014 ) var currentpos,timer; function initialize() { timer=setInterval("scrollwindow()",10);} function sc(){clearInterval(timer); }function scrollwindow() { currentpos=document.body.scrollTop; window.scroll(0,++currentpos); if (currentpos != document.body.scrollTop) sc();} document.onmousedown=scdocument.ondblclick=initialize Bull World Health Organ 2014;92:331–339 | doi: http://dx.doi.org/10.2471/BLT.13.129122 332 Research Subsidies for maternal health care in Cambodia Ellen Van de Poel et al. To isolate the effect of vouchers on the utilization of maternal health care, it is important to control for other inter- ventions that could have an influence. Since 1999, various forms of perfor- mance-based financing have linked the funding of public health-care facilities in some operational districts to predefined targets, most of which involved the provision of maternal and child health services. 14 Health equity funds and a government fee waiver scheme com- pensate facilities, mostly hospitals, for exempting poor patients from the need to pay fees. 15 , 16 In addition, at the end of 2007, the government introduced the nationwide Midwife Incentive Scheme, which pays midwives 10 United States dollars (US$) for each live birth they at- tended in a referral hospital and US$ 15 for each delivery they attended in a health centre, on top of the fee charged to the patient. 13 , 17 Methods We used data from the 2010 Cambodian Demographic and Health Survey (DHS), a nationally representative sample of 18 754 women of reproductive age. The Table 1. Characteristics of voucher schemes for maternal health-care services, Cambodia, 2007–2013 Characteristic Targeted scheme Universal scheme Population eligible for vouchers The poorest women during pregnancy and after delivery All women during pregnancy and after delivery Implementation period 2007–2010 2008 to present Number of operational districts 8 (including 4 that changed to a universal scheme) 18 (including 4 that changed from a targeted scheme) Benefit package i) Three antenatal care visits, delivery and one postnatal care visit at a contracted health-care facility; ii) reimbursement of transportation costs for up to five trips between home and the nearest health-care facility, or arranged transportation; iii) fees for hospital referral covered by a health equity fund. i) Four antenatal care visits, delivery and one postnatal care visit within 24 hours at a contracted health-care facility; ii) transportation costs covered in three operational districts; iii) fees for hospital referral covered only if a health equity fund was operating. Health-care facility compensation i) The facility was paid according to posted user fees (i.e. US$ 7.50 for each delivery and US$ 0.25 for each antenatal or postnatal care visit); ii) in a few operational districts only, the facility was paid even if a referral was made to a hospital for delivery. i) The facility was paid US$ 10 per package of four antenatal care visits, delivery and one postnatal care visit; ii) the facility was paid even if a referral was made to a hospital for delivery. US$, United States dollar. Table 2. Maternal health care outcomes and observations from the 2010 Cambodian Demographic and Health Survey (DHS) Outcome variable Definition of outcome variable 2010 Cambodian DHS Description of sample No. of observations in sample Mean value of outcome variable for sample Antenatal care The variable was set to 1 if the child's mother had at least three antenatal care visits at a public health-care facility, 0 otherwise Most recent births 4916 0.79 Delivery The variable was set to 1 if the child was born in a public health-care facility, 0 otherwise Births in the 5 years preceding the survey 7270 0.42 Place of delivery Home The variable was set to 1 if the child was born at home, 0 otherwise Births in the 5 years preceding the survey 3485 0.48 Public hospital The variable was set to 1 if the child was born in a public hospital, 0 otherwise Births in the 5 years preceding the survey 1289 0.18 Health centre The variable was set to 1 if the child was born in a health centre, a health post or another public facility, a 0 otherwise Births in the 5 years preceding the survey 1776 0.25 Private facility The variable was set to 1 if the child was born in a private facility, 0 otherwise Births in the 5 years preceding the survey 664 0.09 Postnatal care b The variable was set to 1 if the child's mother had at least one postnatal care visit with a skilled provider, 0 otherwise Most recent births 5685 0.59 NA, not applicable. a Fewer than 3% of deliveries took place in a health post or another public facility. b The Cambodian DHS did not include information on the place where the postnatal care visit took place.
