1. Transportation Voucher Impact Assessment Kampot & Koh Thom, June 2011 Presented by Rajpreet Sandhu, Consultant October 5, 2011

2. Introduction to the Transportation Voucher (TV) Programme Participation towards travel costs to improve access to health services for SKY members in Kampot & Koh Thom Assist SKY members living in remote areas Reimburses members to ‘near-full’ amount, as opposed to the absolute full amount Reimbursements based on distance from village to Health Centre (GIZ calculations in Kampot, SKY field-staff calculations in Koh Thom)

3. TV Beneficiaries Voluntary Members who reside more then 6 Km in Koh Thom, and 4km in Kampot from the Health Centre All HEF Members irrespective of distance travelled to the Health Centre (Kampot alone)

4. Transportation Voucher Provisions 1 TV per member, for every household Valid for up to 6 months Non-refundable No restrictions on use – can be used by any member of the household, at any times TV’s distributed door-to-door by SKY field-staff

5. Assessment Methodology Quantitative: Data from SKY database and reports between 2009-2011 on Health Centre contact rate and voucher utilisation Qualitative: 15 Focus Group Discussions (FGD’s) with 100 TV beneficiaries FGD Limitations: (i) Under-representation of Voluntary Members in Kampot, (ii) Bias in participant perceptions & staff presence (Koh Thom)

7. Health Centre Average Contact Rate

8. TV Villages HC Contact Rate 2009-2010

9. Koh Thom Average HC Contact Rate, TV & non-TV HC

10. Kampot VM, Average Contact Rate at HC 2009-2011

11. Kampot HEF, Average Contact Rate at HC 2009-2011

12. Kampot Voluntary Member Contact Rate 2009-2011

13. Kampot HEF Members Average Contact Rate 2009-2011

14. SKY Member Retention Koh Thom - 4% of TV beneficiary-households withdrew SKY membership during period of utilisation - New registered households decreased by 41% from March to December 2010, and a further 8% by March 2011 Kampot - 4% of TV beneficiary-households withdrew SKY membership during period of utilisation - New registered households increased by 35% from March to December 2010, and further increased by 12% by March 2011

15. Beneficiary Perceptions More than one passenger = additional expenses “It is enough for one person, but if I am ill I need to take someone with me. It is not always enough to travel with more than one person because the driver charges more” -HEF Member, Kampot

16. Size of family = Number of TV awarded “I am by myself with no family members. I have only one TV every six months and no more that I can use. I need more” -HEF Member, Kampot “I have many children so I go more sometimes with the vouchers because of my illness” -Volunteer Member, Koh Thom.

17. Reimbursed costs not equal to actual costs “It is not enough. It takes sometimes two hours by bicycle to come to the health-centre and 6,000 Riel does not cover the costs. If I am very ill I can not come by bicycle” - HEF Member, Kampot “My village is far from the centre of the village and actually much closer to the next village. I must get a ride to the main road first and then get a tuk-tuk. SKY does not realise the first part of my journey”. -HEF Member, Kampot

18. Costs + Strength + Time Counterweighs opportunity to seek local care at Pharmacy “People drop-out from SKY often because when the medicine is not here for treatment or sometimes the medicine does not help, its poor quality and private is better. Why would people travel so far, pay, for a waste? They prefer to stay near their home and go to the pharmacy” - Volunteer Member, Koh Thom, Kandal Province “I go to the health centre and get medicine that SKY gives. If I get the pains again I go to the pharmacy and get the same medicine again. It takes me less time and energy than to go to the health centre and I know they will just give me the same medicine I can buy nearby anyway. If I get very ill then I go to see the health centre of course, no matter what the cost. I would borrow money even if I have no voucher” - Volunteer Member, Koh Thom, Kandal Province

19. Road conditions & access to motor-transportation an obstacle in rural Koh Thom “If we are very ill it becomes more difficult. There are no tuk-tuk’s here, you can see for yourself. If it rains then the road is impossible to travel by to get to the health centre. It is much easier to get to Vietnam that way. The road is better to head there” -Volunteer Member, Koh Thom “If I was strong I would still go. Sometimes I go to the pharmacy if I have a small problem and not go to the health centre. Even though I get the TV I do not always go” - Volunteer Member, Koh Thom “I cycle all the time. I can not look for a moto where I live, and so what do I do? How do I get to the main road, and then what do I do with my bicycle? I do all the journey like this. Transport is possible, like a car, but very expensive” -67 years old SKY Member, Resides 26km away from the Health Centre, Koh Thom

20. Conclusion Why Transportation Vouchers go un-used remains unclear HEF under-consumption reflective of the partial- reimbursement towards the actual costs? Worthy of a far more rigorous analysis looking at the socio-economic factors of the various villages where members reside

21. Recommendations Reconsider the transportation voucher costs provided to members in Kampot. Take into account the various locations within a village and provide travel costs accordingly. Re-asses the number of TV’s provided to older-aged members, in all zones of operation. They are likely to be weaker and have less strength to make the distance, which creates many challenges in accessing immediate health care services. Consider awarding SKY voluntary members and HEF members, who have a membership consisting of one or two members, and who live at great distances from the nearest health centre, to receive supplementary TV’s. Conduct a follow-up assessment, with door-to-door questionnaires to understand at depth the challenges they face when accessing health- centre care.

22. End of Presentation