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The Cambodian User Fee Experience and Health Worker Incentives » Women's Courage

The Cambodian User Fee Experience and Health Worker Incentives

February 23rd, 2012 by galaand Leave a reply »

The literature that I’ve explored in my blog series has focused on the variety of experiences that countries have had in changing their health policy as it relates to users fees. Typically, countries raise user fees on people in the health system to promote higher quality of service and  financial sustainability. Often this hits poor people particularly hard. On the other hand, some countries have reduced user fees in order to expand access to people. Both of these approaches have had positive results in certain contexts. However,in my last blog I emphasized how hard it is for countries with weak infrastructure to enforce health care policy in the rural periphery. People weren’t aware of the correct prices for users, and waivers were given on a clientelistic basis. In the article that I approach today, “Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia”, Sarah Barber et al. describe how informal fees at a public hospital were displaced by formalizing user fees as government policy. In this particular case, it seems that user fees increased utilization by standardizing pricing.

I’ve focused insofar on African cases only, but the Cambodia applies because of the low health indicators and recent policy change regarding user fees. Cambodia has the lowest health indicators in Asia, and the footprint of devastating reign of the Khmer Rouge in the 1970’s is certainly partially responsible for this. Before the change in policy, under the table user fees comprised 45% of the hospital’s revenue. In 1996, the National Health Financing Charter was created and implemented by the Cambodian government with support from international donors. In this health center, focus on increasing and standardizing pay for health workers was prioritized, as well as the formalization of user fees with waiver exemptions. The results were remarkable, with an 30% increase in revenue, a severe drop in under the table payments, and utilization increased 50% over a year. This led to the eventual financial sustainability of the hospital, and donor support evaporated over a four year period.

Clearly, the user fee experience was helpful in this case. How and why under the table payments stopped was unclear though. Performance based payment for hospital workers was only implemented as a sanction for poor behavior, but health care worker payment was still low by any standard. This means that the incentive for corruption and coercing people for additional out of pocket funds still exists. Whether this change holds over time would be interesting to find out. Furthermore if I were designing a study, I would want to interview the health workers of this hospital to find out why they stopped seeking extra pay if their salaries didn’t dramatically increase. I don’t mean to pass judgment on the people working at this hospital — they have an extremely difficult job that doesn’t pay well. Corruption in this case isn’t surprising, they need to eat too. Understanding how to change the incentives of health care workers to address this issue could help undercut the problem of price instability in the health systems in the developing world.



  1. nicole says:

    Your post was very interesting because I definitely did not realize that user fees was such a large issue in the developing world. One thing I’m wondering is whether or not there are huge differentials in pay for male versus female workers, even under already low pay standards. I’m wondering if before the charter, the corrupt workers were exploiting more men or women for other out-of-pocket, under-the-table funds? I also agree that it’s doesn’t make sense that out-of-pocket user fees have stopped seeing as their salaries haven’t dramatically increased. I’m wondering if you’ve come across any incentives you think would work in this case or you have seen working in other countries you’ve examined?

  2. rebekah says:

    Your post definitely introduced me to a topic I do not know much about so first, thank you for that. Also, I think you raised valid questions in a respectful manner. Its important to ask questions beyond the main result to see how other issues, worker pay for example, are affected.

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