Redeeming qualities: exploring factors that affect women's use of reproductive health vouchers in Cambodia.

BACKGROUND: One approach to delivering healthcare in developing countries is through voucher programs, where vouchers are distributed to a specific population for free or subsidized health care. Recent evaluations suggest that vouchers have the potential to extend coverage of priority health services to the poor in developing countries. In Cambodia, a reproductive health voucher program was implemented in January 2011. This study aims to explore women's early experiences accessing health services with their vouchers at accredited clinics.

METHODS: This qualitative exploratory study used focus group methodology to gather information from five groups of older (>25 years) and four groups of younger (18-25 years) women who were eligible for the voucher program in three rural provinces. Focus groups were digitally recorded, transcribed and translated from Khmer into English. Data analysis was an iterative process, which comprised of open coding to find commonalities that reflected categories or themes and axial coding to relate initial themes to each other. Next, a basic framework for analysis was formed by integrating the themes into the framework.

RESULTS: Two overarching themes were identified in the data: 1) factors that facilitate voucher use and 2) factors that inhibit voucher use. Within each of these themes, three subthemes were identified: 1) pre-existing factors, 2) distribution factors, and 3) redemption factors. Overall, women expressed positive feelings towards the voucher program, while several areas for program improvement were identified including the importance of addressing pre-existing demand-side barriers to using reproductive health services, the need for more comprehensive counselling during voucher distribution, and the persistent cost of unofficial payments expected by midwives after delivery irrespective of voucher use.

CONCLUSIONS: Early information from program beneficiaries can lead to timely and responsive changes that can help to maximize program success. This study highlights the importance of tailoring voucher programs to specific community needs, a strategy that can lead to better program uptake.