village monographs: a qualitative investigation of sky membership mrs. kim hour ramage director...

Village Monographs:A qualitative investigation of Sky

membership

Mrs. Kim Hour RamageDirector

Domrei Research and ConsultingRaffles Hotel Le Royale Oct 4th, 2011

omrei Research and ConsultingMeaningful research for advocacy and action


SKY Evaluation:Village Monographs Report

1. What is it?

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?”


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.

Activemembers

Inactivemembers Total

Village Size(Households)

Kulehn Village 10 5 16* 36

Tiap Village 14 11 25 282

Oaleuk Village 14 6 20 191

Saomao Village 1 13 15* 104

Mongkhut Village 18 12 31* 209

Khnau Village 10 16 27* 121

Lhung Village 17 12 30* 62

* In the cases asterisked, interviews with the village chief raise the total by one

3. What Does Mapping Reveal? Why Does Location Matter?

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.


Distanceto the

road, river,or market…

Distance to thenearest clinicor hospital.

Distance to theSKY-partneredclinic or hospitalWord-of-

mouth withinthe community


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.


5. An Example of a Cluster of Sequent Members

Instead of viewing this as an anecdote in isolation, we can see the knock-on effects in the map of her neighbourhood.

From “Kulehn” Village

Before I joined SKY my daughter had an operation on her intestine… and we had to spend a lot of money. After I joined SKY, maybe in March of 2007, my daughter climbed a tree and fell down. She needed an operation again and I took her to [the Province’s] referral hospital. All the employees there were friendly and paid attention well, and the I.A. introduced me [showing me] around the place before treatment. [As for] the treatment there, I didn’t pay money for [the] operation. […] Many people in the village saw that my family had a good experience there and this encouraged them to join.

Mother of 5, age 56, Kulehn Village


6. An Example of Cause and Effect in a Family Network.

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:

From “Oaleuk” Village

I joined SKY because I thought that if I paid a little money every month, my father is old, so when he gets sick, he can get pills or treatment without having to pay and also the health workers will pay a lot of attention to him.

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.


7. An Example of a Cluster of Recently-Joined Members

From “Oaleuk” Village…I am an old widow… [and] my older daughter is also a widow. She has a 7 month old son who lives with me. … My other children and my mother are living with me, too. I am a farmer and also grow plants around my house. …

[The local I.A.] visited my house many times, but I didn’t join SKY immediately because I didn’t have enough money to pay the premium. My mother was sick often. Previously, I was a HEF member, too, but after we changed the roof of my house [replacing it with a more expensive tile/covering] my HEF card was taken away.

I saw that my sister had joined SKY a long time ago, but she dropped out because she didn’t have enough money to pay the premium. Now my sister and I joined together, because my brother-in-law persuaded us to join. My main reason for joining is so that I can get treatment without having to pay money if I get a serious disease in future…

Widowed mother of 5, age 53, Oaleauk 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.


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.


9. An Example of a Cluster of “Positive” Drop-Outs

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.

When I [remained as a member of] SKY, our family had many diseases, such as stomach aches, dizzy-ness, pain in the abdomen, and tired and sick legs. For these diseases, I always got effective treatment and took good pills at the commune health centre, so our diseases were cured. I stayed with SKY for nearly a year. Now… we are healthy and also don’t have enough money to pay the premium because I spend a lot of money for my children’s studies. … In future, if my family’s financial situation improves and the SKY agency comes back to visit my family, I will join SKY again.

Mother of two, age 30, Oaleauk Village

From “Oaleuk” Village


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… ?

In some cases…this means thatSKY can’t win…

From “Saomao” Village

This village was a 30 to 40 minute trip from four different health facilities. Partly for this reason, the drop-out rate was 100%.


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).

11. Factors Determining Membership

I joined SKY because I have a chronic disease (diabetes) and I think that in the future my family members may get ill or need to have a baby delivered. …Even though SKY insurance doesn’t cover my illness (diabetes), I still continue to stay as a SKY member.

Resident of Khnau Village

I pay [for it] monthly because I want to be a SKY member, but if SKY is not good and its staff and service are not friendly and don’t pay attention, I can drop out without losing money.

Resident of Khnau Village


12. SKY as a Supplementary Health Care StrategyHigh Cost

(& infrequent)

Low Cost(but frequent)

a) Major health problems(sudden or chronic)addressed by going outside of SKY.

c) Minor health problems,faster or cheaper to address outside of SKY.

b) Health problems thatjustify time, transport, etc.,in going to the SKY-supported hospital (or HC),but are not too serious toentrust to the local publichealth staff (nor toosudden to go through,Referral, nor chronic conditions excluded…).

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.

13. The Good News: Positive Change Results in Positive Public Perception.

13. The Bad News: Any Change in the Benefits Promised (Or Provided) Erodes Public Trust


I decided to drop out of SKY because the doctors and nurses were not friendly, were careless and impolite with my family. After that, I decided to join SKY again because I got advice from [a doctor and SKY agent]. I found out that I used to be confused about SKY services. […] Now I think that the staff [in the same] hospital have changed a lot, they are friendly and pay more attention… doctors and nurses who used to be impolite became friendly and polite. I’m very happy because they changed like this, and I bring this good news to other villagers. I say that GRET and SKY are better than before. I don’t know why.

Mother of six, age 46, Mongkhut Village

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.

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.

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.

14. Conclusions and Generalizations…my family dropped out of SKY because my cousin had high blood pressure and received bad treatment… the staff were careless and did not inject him with medicine or serum until he died in the health centre. For this reason, my family dropped out of SKY. Many families in the village lost confidence in SKY and dropped out.

Father of four, age 56, Khnau Village


SKY provides my family with good support and helps our economic prosperity since we don’t have to pay for treatment. Many people said bad things about SKY because of the public health staff, but my family will still continue to stay with SKY because it helps my family’s economic prosperity and helps us learn more about health care.

Father of four, age 35, Khnau Village

village monographs: a qualitative investigation of sky membership mrs. kim hour ramage director...

Documents

sky evaluation

sky insurance

distribution of sky

study of sky membership

sky impact evaluation

present sky beneficiaries

village chief

village monographs report1