Barriers to access and the purchasing function of health equity funds: lessons from Cambodia.
OBJECTIVE
High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined.


METHODS
Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers.


METHODS
Two-thirds of total health expenditure consists of patients' out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes.


RESULTS
HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care.


CONCLUSIONS
HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully.
Bigdeli
Maryam
M
Department of Health Systems, Cambodian office of the World Health Organization, Phnom Penh, Cambodia. bigdelim@wpro.who.int
Annear
Peter Leslie
PL
D002160:Cambodia; D005378:Financial Support; D005382:Financing, Personal; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics*; D054625:Healthcare Disparities; D006801:Humans; D011203:Poverty