Village Monographs: A qualitative investigation of Sky membership

1. Village Monographs:A qualitative investigation of Sky membership Mrs. Kim Hour Ramage Director Domrei Research and Consulting Raffles Hotel Le Royale Oct 4th, 2011

2. 1. What is it? SKY Evaluation: Village Monographs Report • One of five components of the SKY impact evaluation. • A study of SKY membership in seven villages. • A detailed map of the distribution of SKY members (and drop-outs). • A new approach to the research question: “Of beneficiaries who have already joined the program, why do some continue to pay for SKY insurance, while others do not?”

3. 2. Whom does it study? • The monographs attempted to locate and interview all past and present SKY beneficiaries in each of the seven villages. • Maps were created to show the location (and inter-relation) of members (and ex-members) classified by four colours or types. • 164 interviews.

5. 3. What Does Mapping Reveal? Why Does Location Matter? Distance to the nearest clinic or hospital. • Prior studies have shown that the logic of health-seeking behaviour does relate to the (limited) available options, transportation costs and distances. • Location within a village tends to directly reflect socio-economic factors. • We can directly “see” clusters of respondents who make similar decisions on the map. • We can also contrast households that make different decisions, with all of these factors being equal. • Location provides a great deal of empirical information as context for qualitative (and anecdotal) data. • It shows the ramifications of a household’s experiences (good or bad) at the neighbourhood level. Distance to the road, river, or market… Distance to the SKY-partnered clinic or hospital Word-of- mouth within the community

6. 4. What Do the Maps look Like? They are • Schematic • Household-specific • Anonymous And note the locations of: • Pharmacies/Drug Stores • Private and Public Health Centres • Midwives • Traditional healers (Kru Khmer) • Roads, rice-fields, schools, lakes, etc.

7. 5. An Example of a Cluster of Sequent Members From “Kulehn” Village • Instead of viewing this as an anecdote in isolation, we can see the knock-on effects in the map of her neighbourhood.

8. 6. An Example of Cause and Effect in a Family Network. From “Oaleuk” Village • All Four purple-coded houses are family relations of the blue household. • The blue household joined first, and, apparently, their positive experience influenced relatives to do the same. • The blue house in this cluster gave a very simple account of their reasons for joining (and staying with) SKY: • The one “red” house in this cluster also praises SKY, and only quit because her family moved to an area with no SKY coverage. We seem to have a whole neighbourhood satisfied with SKY.

9. 7. An Example of a Cluster of Recently-Joined Members From “Oaleuk” Village • A cluster of three households, joining (or re-joining) at the same time, and following the same logic, despite the stated constraint of poverty and difficulty in paying the premium.

10. 8. Why do Clusters Show Up on the Maps? • In rural Cambodia, neighbours are often relatives, because of the long-term effects of the redistribution of land ownership in the early 1980s. • Common socio-economic factors often group the relatively poor and relatively wealthy into different neighbourhoods. • Social networks link households, and “word of mouth” (about good and bad experiences) are shared. • Access to healthcare does vary with • Location, • Wealth, • Social networks, …and so the logic of health-care decisions will vary with these factors too.

11. 9. An Example of a Cluster of “Positive” Drop-Outs From “Oaleuk” Village • All three of the “red” homes in this cluster praised SKY, and think the service is “good”, but regret that they have dropped out because they cannot afford the premium. • This is a cluster of 3 that share positive experiences, but follow the same “logic” and financial constraints.

12. 10. In Aggregate, What Were the Study’s Findings? Some findings are familiar from earlier research: • Transportation time and costs (to reach the clinic or hospital) are very important in Cambodia. • Both negative and positive experiences of individuals have consequences for the whole community (and their trust in SKY). • Trust in SKY is communicated through family networks and community connections of various kinds. Some findings are more surprising: • Virtually all respondents made deliberative decisions about their family’s health-care coverage, based on the logical consideration of a number of well-articulated factors. • What are they… ? From “Saomao” Village In some cases… this means that SKY can’t win… This village was a 30 to 40 minute trip from four different health facilities. Partly for this reason, the drop-out rate was 100%.

13. 11. Factors Determining Membership • Members compare the savings of SKY to the total cost of care, including referrals between facilities, and the cost of reverting to private/non-covered service providers when public services fail (… next slide…). • Beneficiaries are aware of services and conditions excluded from SKY coverage, and consider this as part of the value/cost. • Members evaluate both the performance of SKY and of the (partnered) public health staff; most of the comments clearly distinguished these two as having separate responsibilities, but the decision to remain with SKY depends on both. • These deliberations never end: some members quit with an interest in re-joining, and some join for “short term” reasons (with an interest in quitting from the start).

14. 12. SKY as a Supplementary Health Care Strategy High Cost (& infrequent) • The study found that beneficiaries consider the value of SKY as a supplement to their health costs, and generally continue to pay for private and public healthcare outside of the SKY partnership (with some of those costs being minor or trivial). • In praxis, the savings that SKY offers covers a limited range: The scope of services sought outside of SKY at the low end (c) will vary with the convenience of the partnered health centre. The scope of services sought outside of SKY at the high end (a) will vary with the quality and reliability of partnered hospitals. • Where proximity and speed of service are favourable, (c) will be a minor consideration; if the health centre is remote, or has long waiting times, or sends SKY members to pay for medication outside of the system (either due to real shortages or corruption), this becomes a major consideration. • Within this study, awareness of (a) seems to rely on word-of-mouth, as it is important but infrequent. a) Major health problems (sudden or chronic) addressed by going outside of SKY. b) Health problems that justify time, transport, etc., in going to the SKY- supported hospital (or HC), but are not too serious to entrust to the local public health staff (nor too sudden to go through, Referral, nor chronic conditions excluded…). c) Minor health problems, faster or cheaper to address outside of SKY. Low Cost (but frequent)

15. 13. The Good News: Positive Change Results in Positive Public Perception. Despite a negative experience with a life-threatening illness (cancer), this household rejoined SKY, and is now spreading positive word-of-mouth on the program’s behalf. 13. The Bad News: Any Change in the Benefits Promised (Or Provided) Erodes Public Trust There are long-term, negative consequences whenever SKY • Cancels a benefit (such as in-home care), • Cancels a partnership with a health centre, • Excludes coverage for something formerly covered.

16. 14. Conclusions and Generalizations • Some respondents have crossed a threshold of negative experiences, and, beyond this point, they can no longer trust SKY and/or the public health sector. • Conversely, some respondents have crossed a threshold of positive experiences and they continue to support SKY despite their own bad experiences and the bad experiences reported by others. • Some respondents sincerely want to maintain their membership with SKY, but cannot afford to do so. • Conversely, some respondents are less inclined to rely on SKY because they have enough money for more convenient forms of care.