Equity of access to reproductive and maternal health services in Cambodia: equity trends, poverty targeting and demand-side financing

Health inequities are a serious public health concern. Achievements in health equity are particularly challenging to attain in reproductive and maternal health in developing countries. Research exploring this issue is of great relevance, given the extent of such disparities, and as pressure builds to include universal health coverage in the post-­‐ 2015 development goals. This thesis examines equity in reproductive and maternal health services in Cambodia, and two health financing interventions aiming to improve health equity, Vouchers for Reproductive Health Services (VRHS) and Health Equity Funds (HEFs). Study objective 1 was to estimate equity in reproductive and maternal health services in Cambodia over the last decade. Analysis was conducted with Demographic and Health Survey data for six health services between 2000 and 2010, revealing that dramatic improvements have been made in reproductive and maternal health equity since 2000, however inequity remains in use of facility-­‐based deliveries and skilled birth attendance. Objective 2 was to qualitatively explore Cambodia’s poverty identification programme, the ID Poor. Semi-­‐structured interviews were conducted with women, service providers and programme implementers. Extensive targeting errors within the programme were found, with implications for the targeting effectiveness of VRHS and HEFs. Objective 3 was to qualitatively explore low uptake of vouchers in the VRHS project, also using interview data. It was found that vouchers were positively received by beneficiaries and had the potential to influence health-­‐seeking behaviour. However several factors were found to improve future voucher performance. Objective 4 assessed the impact of HEFs on financial protection, service utilisation and health outcomes, using difference-­‐in-­‐differences analysis. Evidence of a financially protective effect of HEFs was found; no effect was found for service use or health outcomes. The thesis contributes to knowledge gaps in the health equity, poverty targeting and demand-­‐side financing literature, and provides practical policy implications based on empirical findings