Do exemptions from user fees mean free access to health services? A case study from a rural Cambodian hospital.

OBJECTIVES: To assess the effects of a user fee scheme, and related fee exemption system, on the health care seeking behaviour, the out-of-pocket expenditure and the coping mechanisms of fee-exempted patients (FEP) at Kirivong Referral Hospital in Cambodia.

METHODS: A pre-coded structured questionnaire administered to pre-identified FEP and fee-paying patients (PP) of the same age group and with the same medical condition, who were paired for comparison. Survey data were supplemented with unstructured in-depth interviews.

RESULTS: 199 pairs of patients were compared. The timing of the start of health care seeking was equal for FEP and PP, although significantly more FEP consulted first-line public health providers than PP. Only a third of interviewees who visited public health facilities prior to hospitalization were referred. The direct costs of health care seeking were US$4.3 for FEP and US$15.3 for PP. FEP borrowed at a ratio of 3.4:1 to direct costs incurred, vs. 0.74:1 for PP. Hospitalization rates were 32.5/1000 population and 18.4/1000 population for FEP and PP, respectively.

CONCLUSIONS: User fee exemption schemes can be pro-poor provided that the fee exemption system is based on effective pre-identification of intended beneficiaries, that these beneficiaries are informed of their right to free health care and that health care providers are reimbursed for the revenue foregone due to exemptions. To be effective in the Cambodian context, exemption schemes need to be underpinned by a range of additional interventions.