Journal Article

Evaluation of a voucher programme in reducing inequities in maternal health utilization in Cambodia: A quasi-experimental study

Background
Recent figures from the Cambodian Demographic Health Survey 2010 on maternal health (MH) service utilisation have been impressive. These figures, however, indicate average gains and mask large inequalities in MH service utilisation within Cambodia. In this study, we aim to measure socioeconomic inequities in MH use and to evaluate the impact of a targeted reproductive health (RH) voucher intervention in reducing inequities.

Methods
Using data from the Population Council's ongoing RH voucher study conducted in three provinces, this study presents a rigorous analysis of equity in MH services using concentration curves and indices in a quasi-experimental evaluation framework. With the availability of end-line data in June, 2013, the study will also present results from difference-in-difference analyses on service utilisation and equity on three outcomes: facility-based delivery, antenatal care (ANC), and postnatal care. Concentration curves will also be employed to determine dominance of any aforementioned service over the others.

Findings
Analysis of service utilisation in baseline data indicates significant inequity for facility delivery and ANC use, with concentration index values of 0·04 (SE 0·012) and 0·07 (SE 0·012), respectively (both concentration curves below the line of equality), affirming inequities favouring the rich for both services, also observed in quintile ratio analyses.

Interpretation
With end-line data, our findings on equity before and after the voucher intervention will generate evidence on the potential role of vouchers as a targeted, pro-poor strategy to accelerate uptake of MH services among the poor. In generating this evidence, we not only heed Gwatkin and Ergo's 2011 caution to policy makers to prioritise efforts for the poorest and most marginalised populations in the drive for universal health care, but we also lay the groundwork for delivering the critical evidence necessary to scale effective programmes that bridge health inequities in developing countries like Cambodia.