Safe Motherhood ProgrammeImpact Evaluation

SKY Health InsuranceMaternal & Infant ProtectionPhnom Penh & Kampot

Presented by Rajpreet Sandhu, ConsultantOctober 5, 2011

Safe Motherhood Programme

Objective of Programme

(a) To improve the health status of women of reproductive age by escalating the degree and accessibility of medically attended deliveries

(b) To provide a continuum of support and care to women from the pre-pregnancy period right through to the neonatal period

SMP Maternity Grant

• All female members, aged between 15-49 years of age, must register as a SMP member within 1st-6th months of pregnancy (up to 28 weeks)

• Direct Cash Incentive to all registered pregnant women who actively comply with certain conditions

• Programme active in Phnom Penh (2006) and Kampot (2008)

SKY Maternal Healthcare Services

• In-patient standard ward accommodation,• Antenatal care,• Referral of high risk pregnancies to Ob-Gyne specialist,• Coverage of medically-necessary abortions and post-abortion care,• Coverage of normal and caesarean-section deliveries,• Referral to Family Planning/ Birth Spacing services,• Referral to the VCCTs for HIV testing, and to the PMTCT services if

results positive,• Provision of essential drugs, including Ferrous if the mother is

recognised as being anaemic,• Provision of micronutrients and advice on nutrition relevant to safe

pregnancy,• Post-natal care,• Referral of the newborn to immunization services.

Maternity Grant Conditions

Part I: Grant amount- Phnom Penh - $15 , Kampot - $10

• Attendance of a minimum of 3 antenatal-care check-ups,• Testing for HIV, and to further access PMTCT services if positive, • To have a medically attended delivery either at the health-centre

or referral hospital.

Part II: Grant amount- Phnom Penh - $20 , Kampot - $20

• Attendance of a minimum of 2 post-natal-care check-ups,• To have the newborn immunized within the first 4 months of birth.

Methodology

• Quantitative Component: Extracted from the available GRET/SKY database between 2007-2010

• Qualitative Component: Employed focus group discussion’s (FGD’s) for data generation

11 FGD’s were conducted in Kampot and 5 FGD’s were conducted in Phnom Penh A total of 100 women, representing 12% of the total number of SMP beneficiaries and 8% of the total target population, participated in the discussion groups

• Limitations: Lack of representation from beneficiaries who half

complied with the SMP Protocol

Findings: SMP Beneficiaries Urban & Rural

A total of 851 women have benefited from the SMP in Phnom Penh and Kampot, over a period of five years (2006-2010) :

• 23% of beneficiaries from urban Phnom Penh, 195 women – Programme commenced April 2006

• 77% of beneficiaries from rural Kampot 656 women – Programme commenced May 2008.

Key Data, Urban & Rural

SMP Start Date

Total Nb of Beneficiaries

Nb of HEF Members

Nb of Voluntary Members

Total Nb Received 1st Grant

Total Nb Received 2nd Grant

Kampot 05/2008 656 77% 226 34.5% 430 65.5% 656 420 64%

Phnom Penh 04/2006 195 23% 0 0% 195 100% 195 135 69%

All 55

Months 851 226 625 851 555 65%

Jan - Jun 06

Jul - Dec 06

Jan - Jun 07

Jul - Dec 07

Jan - Jun 08

Jul - Dec 08

Jan - Jun 09

Jul - Dec 09

Jan - Jun 10

Jul - Dec 10

1 1

1320

1621 23

32 3137

No. of Registered SMP Members, Phnom Penh

Apr - Jun 08 Jul - Dec 08 Jan - Jun 09 Jul - Dec 09 Jan - Jun 10 Jul - Dec 100 11

3258 46

79

430

57

112127

100

No. of Registered SMP Members, Kampot

HEF Members SKY Vol Members

SKY-Insured Birth Deliveries• Between 2006 and 2010, within a time-span of 55 months, a

total of 1,307 birth deliveries took place amongst SKY members, of which 65% registered onto the SMP

• 65% SKY insured members registered and complied fully or partially with the SMP protocol

? ? ? ? ? ? ?

Rural Birth Deliveries• KAMPOT: A total of 1,013 deliveries took place, of which 65%

were registered SMP members • 2:5 of all birth-deliveries in rural Kampot went unregistered

onto the SMP

2008 2009 20100

50

100

150

200

250

33%

38%

48%

45%

26%18%

11%

21%

26%

11%

15%

7%

SMP SKY Members NON-SMP SKY MEMBERSSMP HEF Members NON-SMP HEF MEMBERS

Urban Birth Deliveries• Phnom Penh has an SMP representation of an average of 66%

per year amongst all SKY-insured deliveries, indicating that near to 1:3 of all SKY-insured pregnant women in urban Phnom Penh went without registering onto the SMP

Jan-Mar 0

7

Apr-Jun 07

Jul-Sept 0

7

Oct-Dec

07

Jan-Mar

08

Apr-Jun 08

Jul-Sept 0

8

Oct-Dec 0

8

Jan-Mar 0

9

Apr-Jun 09

Jul-Sept 0

9

Oct-Dec 0

9

Jan-Mar 1

0

Apr-Jun 10

Jul- Sept 1

0

Oct-Dec 1

002468

101214161820

SMP MEMBERS NON-SMP MEMBERS

2007-2010 SKY Birth Deliveries

Urban Rural Urban Rural Urban Rural Urban Rural2007 2008 2009 2010

0

50

100

150

200

250

300

350

400

450

500

52

0

56

102 89

439

95

472

63% 66% 44% 62%

59%

72%

75%

Total SKY Member Deliveries Total SMP Member Deliveries

Rural & Urban Compliance with Protocol

• 3:4 members of the SMP fully complied with the conditions of the programme

• Kampot, July 2008 – September 2010 (27 months): 78% of total beneficiaries fully complied with SMP protocol, 22% were recorded to have partially complied.

• Phnom Penh, June 2006 – September 2010 (52 months): 76% of the total beneficiaries fully complied with the SMP protocol, 24% partially complied with the programme.

KAMPOT, Total Beneficiaries 2008 - Sept 2010 (52 months)

PHNOM PENH Total Beneficiaries2006 - Sept 2010 (27 months)

Total SMP Beneficiaries

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

420

135

555

122

42

164

Total > Full Compliance with Part I & Part II of MG Protocol

Total > Half Compliance with MG Protocol (Part I Only)

Change of Grant Amount in Phnom Penh

• Maternity Grant decreased by $10 in 2008• No impact on enrolment- Registered members

increased by 4%

• Impact on full compliance: 2nd Grant = $30, 84% fully completed the SMP2nd Grant = $20, 65% fully completed the SMP

Antenatal Care Check-ups (ANC)

• Advice on how to detect dangers and complications during pregnancy highly valued by members. The educational aspect goes beyond primary objective of the programme.

• SMP Protocol motivates expecting mothers to progressively attend the required number of check-ups, and to seek advice when needed.

“When I became a SKY member I became more knowledgeable on health. It’s good because I didn’t know anything before. Everything you offer I would like to do. If you added more steps I will still follow. I am uneducated and so I have to follow for my health. Before I did not know how to take care of myself during pregnancy. I am getting treatment for not paying, so I am very happy with this.”- HEF Member, Kampot

“I can know more about taking care of my own health. We get more knowledge from this programme as it teaches us. If for our own we would not think to take care of our health like this, but the programme pushes us to take care of the health.”- SKY Volunteer Member, Kampot

Micronutrients, Dietary Advice, and Medication Appropriate for Safe Pregnancy

“I know how to protect my health. The nurse and doctor gave me medicine, and nutritional vitamin to make me healthier for the baby’s delivery. I can take this medicine in my house. The vitamin supplements were new for me”- SKY Volunteer Member, Inactive, Kampot

“When I get sick I know about the medicine to take during pregnancy. If I take the other medicine without the advice from the doctor I know it is dangerous now. Now I know I can not take antibiotics without advice from doctor. When I go to the check-up I can get this advice.” - SKY Member, Phnom Penh

HIV Testing for Prevention of Mother-to-Child Transmission

• 54% of the total number of beneficiaries of the SMP in Kampot is aged 15-26 years.

• 100% of all the women on the SMP were tested for the virus.

“For me not being a SKY member means I would probably not go get my blood tested for HIV. With SKY I have to get my blood tested and this is good for me”- SKY Volunteer Member, Ethnic Cham, Kampot

“First I got the advice from the nurse. And also I got the medicine, the vitamin for my health, and got the injections/ vaccine of Tetanus. Also I got blood tested for HIV. If I was on my own self I would not have checked this, but finally the programme gave me a chance to get this done on the programme.”- SKY Member, Phnom Penh

Impact on HEF Members“Before becoming a SKY member I did not follow everything – the HIV testing or ANC. I never knew about this before. Now as a SKY member the nurse has given me advice and informed me about this. Now I know more as a SKY member.”

“I have 3 children. Two were delivered at home, and one delivered at the health centre when I became a SKY member. I know a lot now, especially about the dangers of delivering in the house. The doctor and nurse tell me they can guarantee with the healthy and the safety. But if we deliver in the house they cannot guarantee, so I know to come to the health centre to check my health and for delivery.”

“Before I would just stay in my house. But now when I am sick I go to the HC. When the baby has a problem we go to the HC.”

Identified Challenges

• Negative perception of services delivered at the Provincial/ Referral hospital– Discrimination based on presenting SKY booklet– Unfriendly/ impolite service

“We don’t want the bad service. An example: I go to the hospital to check with my sister. When we showed the SKY booklet they say ‘oh SKY, you are a SKY member, you are lucky you come and don’t pay. We are busy so wait and come again’. This happened to me during pregnancy. I am old and so decided to have an abortion during the pregnancy. The provincial hospital staff ignored me and asked me to come again and again another time. This is why I do not want the SKY.”- SKY Volunteer Member, Ethnic Cham, Kampot

Identified Challenges• Opportunity costs: Transportation expenses and loss of earnings

– Physical constraints to walk and cycle to Health Centre– Loss of daily earnings to attend check-ups (Phnom Penh)

“I have no problem but my husband does, because he must get permission to take me to the hospital to do the check-up.”

“I work selling in my store. When I come to check-up I have to close the shop and lose profit. But I know I will get the grant which would give me money for where I have lost profit.”

- Respondents from Phnom Penh FGD

Greatest Impact – Reassurance!• No out-of-pocket expense at time of delivery• Assured of birth delivery with a skilled practitioner

“A grant is a part useful. The priority for me is when I became a SKY member with SMP, I can deliver my baby in safety and it will not cost. Sometimes I do not know when the baby will arrive and if the family will have any money or not. When I became a SMP member I was not afraid, I feared nothing to do with money. I was happy. I protected my health until delivery. The grant that I got was just a part of being useful too. I could spend the money.”

- SKY Volunteer Member, Kampot

Recommendations• The practice of payments given to health care providers as a condition

for care by SKY members should be curbed as such practices hinder the objective of SKY and impose severe burdens on poorer families.

• Ensure HEF members are informed about SMP benefits and efforts are made to ensure the information is correctly digested by working in closer collaboration with the Pagodas and Mosques component

• Improve enrolment and full compliance rates with continuous training of SKY agents on communication. Through this use the Village Meetings to further increase awareness on safe motherhood and the necessity of post natal care and infant-vaccination.

End of Presentation