Better HealtH ServiceS Project

Technical brief
Better Health Services Project:
Conditional Cash Transfers: Better Health for Women and Children
Background
C
ambodia has made significant progress in reducing
child mortality, the focus of Millennium Development
Goal (MDG) 4. Maternal mortality has also declined,
putting Cambodia on track to reach national goals and
to accelerate efforts to reach MDG5. Reducing maternal
and child mortality further requires a targeted strategy
to address remaining gaps. One such strategy is the
conditional cash transfer (CCT) program which creates
demand for maternal and child health (MCH) services by
pregnant women and parents of children under two.
The Better Health Services Project (BHS) funded by the
U.S. Agency for International Development (USAID) and
implemented by University Research Co., LLC (URC)
is working with community-based health cooperatives
(CBHCs) to provide CCTs in the three operational districts
(OD) of Angkor Chum (Siem Reap), Bakan, and Sampov
Meas (Pursat). The CCT program covers all 50 health
centers and three referral hospitals in the districts.
CBHCs are locally managed structures that operate
integrated social health protection mechanisms in a lowcost, flexible, and coordinated manner that encourages
accountability to the community. Local authorities from
the provincial, district, and commune levels participate
in CBHC management through a board of directors that
supervises CBHC staff.
In Angkor Chum OD and Pursat Province in Cambodia,
the CBHCs have registered with the Ministry of Interior as
community-based organizations. Both operate health equity
funds (HEFs) and community-based health insurance as well as
CCT programs. HEFs are a pro-poor health financing scheme
that targets identified poor households in a given area and
provides financial and social support so that these households
can better access government health services. HEFs cover not
only the direct costs of health services and medications for
the poor but also reimburse patients for transport and their
caretakers for food expenses during patients’ hospitalizations.
About 35% Cambodians are poor, as defined by the Ministry
of Planning, and thus eligible for HEFs.
November 2012
The project brief is made possible by the support of the American People through the United States Agency for International Development (USAID). The
contents of this project brief are the sole responsibility of URC and do not necessarily reflect the views of USAID or the United States Government.
What is the purpose of CCTs?
CCTs are direct incentive payments to families which encourage
certain behaviours (conditions). A Conditional Cash Transfer
means that “cash transfers” or payments are provided directly
to a family at regular intervals once certain “conditions” are met.
Angkor Chum and Pursat’s CCT programs create
incentives that encourage positive health practices and
health-seeking behavior by pregnant women and new
mothers. CCT programs vary in the types of behavior
they try to encourage: these CCTs focus on the first 1000
days, the critical period from the start of a pregnancy to
the baby’s second birthday. Each cash transfer targets a
specific set of preventive health and nutrition services and
behaviors that have been proven to reduce maternal and
newborn/infant/child deaths, disease, and malnutrition.
The CCTs help families overcome financial barriers that may
restrict their use of key services, and they support membership
in the CBHC program since only families enrolled in CBHC
are eligible for CCTs. The CCTs also support the government’s
fixed-facility strategy by encouraging the use of public health
centers, fostering their ability to meet the curative and
preventive needs of rural families.
CCT program design
The design of the CCT program in Angkor Chum and Pursat
was based on an analysis of existing utilization patterns of
key MCH services and practices. This analysis identified
key services where utilization dropped off significantly and
specified key behaviors that needed significant improvement.
Since a family receives a CCT by engaging in a behavior that
the program supports, the program design provides that
payments will be made at the points where usage is too low.
For example, Figure 1 illustrates nationwide use of postnatal
services. While nearly 60% of expecting mothers come for
at least one postnatal consultation at health facilities, only
16% make it to their third consultation. Completing at least
three postnatal visits is one of the key steps that contribute
to better maternal, newborn and child health.
All CBHC member households with a pregnant woman or
child under 2 years are eligible to receive CCTs following
documented completion of the services on the schedule. Such
documentation uses three documents that the family retains:
the Ministry of Health (MOH) Mother’s Pink Book, the child’s
Yellow Card, and the newly developed MCH Book which the
MOH has approved for use in these ODs. The MCH Book also
contains essential health education messages used for counseling
at health centers, as well as at home or in the community.
2
Better Health Services Project
Figure 1. Postnatal Care Visits Before CCTs (2011)
70%
60%
60%
50%
37%
40%
30%
20%
16%
10%
6%
0%
PNC 1
PNC 2
PNC 3
PNC 4
All pregnant women (CBHC members and non-members)
receive the Mother’s Pink Book and the MCH Book when
they come for their first antenatal visit and the Yellow
Card after the birth. In addition, if a child under 2 years
lacks a card and is brought to the health center, his or her
caretaker receives an MCH Book for that child. When
giving one of these documents, health center staff explain
that only CBHC members qualify for the CCT program
and that it is one advantage of being a CBHC member.
Figure 2 describes the eight conditions for receiving CCTs. If
a mother-child pair completes all eight conditions, the family
would receive 20,000 riel eight times over a 2 ½-year period,
for a total of 160,000 riel or $40. CCTs are not allowed retroactively, even if full documentation is presented. Completion
of each CCT condition is easily verifiable by referring to the
appropriate document, and payment is made to the mother at
the health center as soon as each condition has been met.
In addition to the benefits which are provided directly
to women who receive a CCT, this program generates
additional income for the health center that provides the key
MCH services. The CBHC program also reimburses health
centers and hospitals for all services provided to its members,
including preventive services. Such services were previously
free to clients but not always reimbursable to the facility.
Implementation
Working with the Angkor Chum, Sampov Meas, and
Bakan operational districts and the Pursat Provincial Health
Department, a comprehensive capacity-strengthening program
for health center staff was designed and implemented to
Figure 2. Schedule, Payment Amounts, Conditions, and Verification of CCTs
#1
20,000
KHR
#2
20,000
KHR
#3
20,000
KHR
#4
20,000
KHR
#5
20,000
KHR
#6
20,000
KHR
#7
20,000
KHR
#8
20,000
KHR
After 4th ANC
At Birth
At 6 Weeks
At 6 Months
At 9-12 Months
At 12 Months
At 18 Months
At 24 Months
•4 ANC Visits
•First ANC
must be before
20th week of
gestation
•Delivery at a
health facility
•Birth is
registered with
commune
•3 PNC visits for
mother and for
newborn
•At least 2 must
take place after
discharge from
facility delivery
•4 growth
monitoring and
promotion visits
by 6 months
•Fully
Immunized
•Feeding
Enriched Bobor
•4 growth
monitoring and
promotion visits
from months
7-12
•4 growth
monitoring
and promotion
visits from
months 13-18
•Still
breastfeeding
at 18 months
•4 growth
monitoring and
promotion visits
from months
19-24
•Still
breastfeeding
at 2 years
Confirm #1
from MOH
Mother’s Pink
Book
Confirm #2
from CBHC
Book
Confirm #3
from CBHC
Book
•Place of birth on
page 47 (Birth
Registration) is
Hospital or HC
•Box for commune
council on page
47 is signed by
commune council
•3 visits entered
on pages 48-49
(postpartum
mother), and
•3 visits entered
on pages 50-51
(Newborn record)
•At least 2 of 3
visits took place
after discharge
from a facility
birth
Confirm #4
from Yellow
Card & CBHC
Book
Confirm #5
from Yellow
Card & CBHC
Book
Confirm #6
from Yellow
Card & CBHC
Book
Confirm #7
from Yellow
Card & CBHC
Book
Confirm #8
from Yellow
Card & CBHC
Book
•At least 4 weights
plotted on Yellow
Card between 0-6
months
•Actual feeding
practice and
advice for same
visits recorded on
page 60 of CBHC
Book
•All immunizations
completed and
recorded on
Yellow Card
•‘Borbor Kroeung’
recorded as
Actual Feeding
Practice at
9-month GMP
visit on page 60 in
CBHC Book
•At least 4 weights
plotted on Yellow
Card between
7-12 months
•Actual feeding
practice and
advice for same
visits recorded
on page 60-61 of
CBHC Book
•At least 4 weights
plotted on Yellow
Card between
13-18 months
•Actual Feeding
Practice and Advice
for same visits
recorded on page
61 of CBHC Book
•‘BF’ recorded as
actual feeding
practice at
18-month GMP
visit in CBHC Book
•At least 4 weights
plotted on Yellow
Card between
19-24 months
•Actual Feeding
Practice and Advice
for same visits
recorded on page
61 of CBHC Book
•‘BF’ recorded as
Actual Feeding
Practice at 2-year
GMP visit in CBHC
Book
•4 ANC visits
entered in MOH
Mother’s pink
book, and
•Gestational age
recorded at first
ANC is <20
weeks
introduce the CCT program. The training program was built
around key competencies that ensure that the quality of
health services and counseling at participating health centers
encourages participation in the CCT and CBHC programs.
The training program began with a baseline assessment of
health center competencies and then an off-site, handson three-day training. They were followed by semi-annual
on-site coaching and support visits to each health center.
The visiting team provided feedback the health center after
each visit using a participatory method: the team provide
oral and written feedback on a form that has information
on the quality of services organized by the targetted health
center competencies. The health center and team discuss
the feedback and both record and commit to making
recommended improvements before the next visit. Finally,
the health center scores itself on each of its approximately
20 targeted health center competencies. Interestingly, the
scores tend to be lower (more critical) than those that
would have been assigned by the visiting team.
Results
Reports from the follow-up visits indicate that midwives and
nurses are routinely using the documentation to provide
better quality maternal, newborn, and young child care. The
coaching visits after the training have proven to be a key
activity in overcoming the challenges faced by staff in using
their new competencies after returning to their facilities.
Health center competency scores in Angkor Chum improved
dramatically between the first and second coaching visits.
As the MCH Book also serves as a job aid, health center
staff are more easily remembering to provide all needed
care, including monitoring growth and responding to
feeding and health problems in children under two,
providing routine counseling during the 1000 days,
reminding clients to review relevant pages in the MCH
Book at home, and promoting CCTs. A US Peace Corps
volunteer at one health center said she no longer has much
to do as the health center functions so well and mothers
understand and are practicing the key behaviors.
Starting in June 2011 through April 2012, a total of 2,560
CCTs were provided to 1966 mother-child pairs. Of these
payments 60% were provided to poor HEF-based CBHC
members and 40% to non-poor CBHC members. The fact
that the latter account for 25% of the CBHC membership
indicates that households consider CCTs to be a good
reason to join the CBHC. It also indicates that many HEFbased poor CBHC members may not be aware of their
CCT benefits or that the CCT payments are not sufficient.
Conditional Cash Transfers
3
Of the women who received a CCT, 37% had started the
program by completing four antenatal visits; another 48%
started after a delivery, 6% after their third postnatal visit,
and the remainder later still. The “Starting Point” graph
(Figure 3) shows the distribution among starting points in
the program.
To qualify for the first CCT after four ANC visits, a woman
must have had her first ANC visit before the 20th week
of her pregnancy. This requirement plus the fact that four
separate visits are required makes the CCT condition
difficult to achieve. In comparison, earning a CCT for
delivery requires only one visit and a brief visit to the
commune council to register the birth which is usually done
while the mother and newborn are still in the health center
following a facility delivery.
Of the 627 women who received their first CCT after their
fourth antenatal visit, only 258 had received their second
CCT (for delivery). This low rate was most likely driven
by the high-quality free birthing services provided by the
Kantha Bopha hospitals in Siem Reap town in addition to
those who only recently completed their fourth ANC visit
and were awaiting delivery at the time of data collection.
Of the 814 women in Angkor Chum who received their
first CCT payment after a health facility delivery (the
second CCT), 322 (40%) went on to complete the third
postnatal visit. While this may seem low, it is a dramatic
improvement over the national average of only 16%.
Fifty-nine CCTs had been distributed to mothers who
completed four out of six monthly growth monitoring
Figure 3. Starting Point for CCT Benficiaries
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
CCT #1
ANC 4
CCT #2
Delivery
CCT #3
PNC 3
CCT #4 –
CCT #8
and promotion visits, had their children fully vaccinated,
and were practicing appropriate feeding behaviors up to
their child’s second birthday, qualifying them for CCT #4
through #8. However, the number of women eligible for
CCT #4 through #8 is still quite low, because most CCT
beneficiaries join the program during pregnancy or at birth
and the program has been operational for only 10 months.
In addition, before the CCT program virtually no growth
monitoring and promotion services—a crucial government
service for child nutrition—were provided at health
centers in Angkor Chum. These activities have revitalized a
key MCH service for infants and young children.
For more information, please contact:
Christophe Grundmann, PhD, Project Director
[email protected]
or visit the Better Health Services website
www.urccambodia.org
University Research Co., LLC
SUKY MK Building, House #10
Street 214, Sangkat Cheychumneas,
Khan Daun Penh
Phnom Penh, Cambodia
Tel. 855-23-222-420
www.urc-chs.com