SKY Impact Evaluation Cambodia, 2010 Village Monographs by Agence Française de Développement

N° 09

August 2012

Impact Analyses Series

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Sky Impact Evaluation, Cambodia, 2010 Village Monographs

Ian Ramage, Kim Hour Ramage, Eisel Mazard, Mark Kavenagh, Gabriel Pictet, and David Levine, Domrei Research and Consulting Contact: Stéphanie Pamies, Evaluation and Capitalisation Division, AFD

Research Department Evaluation and Capitalisation Division Agence Française de Développement 5, rue Roland Barthes 75012 Paris - France www.afd.fr

Série Analyses d’impact • n° 6

Disclaimer The analysis and conclusions of this document are those of the authors. They do not necessarily reﬂect the ofﬁcial position of the AFD or its partner institutions.

Publications Director: Dov ZERAH Editorial Director: Laurent FONTAINE ISSN: 2101-9657 Legal Deposit: 3rd Quarter 2012 Layout: Marcelle LARNICOL

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Acknowledgements The village monographs are an important element of the SKY health microinsurance impact evaluation funded by AFD and conducted by Domrei Research and Consulting in collaboration with the University of California, Berkeley. Co-directors of Domrei Research and Consulting, Ian Ramage and Kim Hour Ramage designed, coordinated and supervised this research. Kim Hour designed the research instrument and trained and supervised the survey team during data collection. Ian worked specifically on research design and the analysis and reporting stages along with Domrei research consultants Mark Kavenagh and Eisel Mazard. Research consultant Gabriel Pictet collaborated on the design of the village monographs. Domrei would like to thank every member of the field team for their dedication and hard work in gathering high quality data for this survey: Keo Kimhorth, Kouern Saly, Eut Sokkea, Lenh Vanny and Chan Sodine. In addition, we would like to thank Ariella Leaffer, Domreiâ&#x20AC;&#x2122;s intern, for her assistance preparing the village reports. We would also like to extend our gratitude to Professor David Levine from the University of California, Berkeley, for his excellent support and collaboration during the planning, design and implementation of the village monographs, and for his valuable feedback on the report. Domrei would also like to thank AFD and BASIS for funding this innovative impact evaluation of SKY health microinsurance. We extend our special thanks to our friends at GRET who assisted with the village monographs, and thank Marielle Goursat for her ongoing assistance throughout the project. We would also like to thank Peo Pisey and Nev Vannak for their help supplying and clarifying figures. In addition, we would like to thank Cedric Salze for his constant assistance and support during the SKY impact evaluation. Most importantly, Domrei would like to thank each of the respondents who gave up their time to participate in this survey and shared valuable information with our team that will help improve SKY health microinsurance.

ÂŠ AFD 2012

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

CONTENTS Introduction

Methodology

1. Village Maps and Findings

1.1 Number of interviews in each village

1.2 Kulehn Village

1.3 Tiap Village

1.4 Oaleuk Village

1.5 Saomao Village

1.6 Mongkhut Village

1.7 Khnau Village

1.8 Lhung Village

2. How and Why Did People Become SKY Members?

2.1 Satisﬁed SKY clients

2.2 People initially dissatisﬁed with or unconvinced by SKY

2.3 Primary SKY members

2.4 Secondary SKY members

3. Inﬂuences on Sustaining Membership

3.1 Why members stay with SKY

3.2 Why members drop out

3.3 Why members rejoin after dropping out

4. Health Services

5. Summary of Likes and Dislikes

6. Discussion and Recommendations

6.1 Key ﬁndings

6.2 Recommendations

Acronyms

Appendices

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Ceremonial Gate

Main Health Centre

Village Limits

Deputy Village Chief

Rice Fields

Rice Fields Town Hall

Rice Fields Primary Members Later Members Newly Joined Ex-Members

Veterinary Hospital

Not Interviewed (Member or ex-member)

Private Provider Village Chief Traditional Healer Drug Store Ceremonial Gate

Rice ﬁelds Lake or marsh

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Introduction

The SKY health microinsurance programme, run by the

The village monographs summarised in this report provide

GRET is an innovative attempt to extend health insurance to

detailed qualitative analysis of SKY membership dynamics

Cambodians, with special initiatives reaching out to both the

over time and the effects that SKY has had on members and

rural and urban poor.

non-members. The reasons why people refuse to join SKY have been documented in several complementary studies.1

The University of California, Berkeley, and the Cambodian

This qualitative study builds on this knowledge and adds to our

research ﬁrm Domrei Research and Consulting are conducting

understanding of why some people continue with health

a longitudinal impact evaluation of the SKY health

insurance and why others drop out.

microinsurance project. The study aims at measuring the impacts of health insurance on the rural poor in Cambodia and shedding light on why households decide to purchase, or

This report complements other components of the evaluation of

SKY

health

insurance,

including

randomised

abstain from purchasing, voluntary health insurance. The

encouragement to purchase SKY (using a lottery for discount

project includes both quantitative and qualitative components.

coupons), a longitudinal household survey, and longitudinal

As part of the qualitative component, the village monograph

data collection on health centre quality.

surveys were completed in 2009.

Sky Health Insurance

SKY health microinsurance is a voluntary community-based

in consultation with direct beneﬁciaries in the villages. When

health insurance programme, relying on a monthly registration

SKY is launched in a new area, GRET holds village meetings

and premium collection system at the family level. It covers

in each village to introduce villagers to the programme and its

both primary healthcare and hospital care with a mandatory

beneﬁts. These meetings are very interactive and include a

referral mechanism. Beneﬁts include totally free and unlimited

video and a quiz. During and after the meeting, the insurance

access to all contracted health centres for primary healthcare

agents and member facilitators follow up with villagers to

or emergencies and to contracted referral and provincial

encourage enrolment.

hospitals when referred by the health centres. SKY has limited exclusions including long-term treatment of chronic diseases,

In addition to SKY health insurance, another health ﬁnancing

and HIV and tuberculosis, which are already covered by

initiative, Health Equity Funds (HEF), operates in these villages.

national vertical funding programmes.

HEFs are dedicated funds run by a local Cambodian NGO to provide the different services needed by the poor to access

Full-time insurance agents work in each SKY district to

healthcare. The HEF criteria are designed to reach the poorest

provide information about the programme and sell SKY health

and most vulnerable. The latest phase of SKY expansion (2008-

insurance. Member facilitators, recruited from the local

2010) included linkages with HEFs to reach the poorest and

community, also provide information to clients, sell insurance

increase the efﬁciency of these dedicated funds.

and facilitate the process at health facilities. SKY is designed 1 For

example, the insurance agent and member facilitator report and a number of surveys by GRET.

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Research Objective

The village monographs aim at answering the main research question: “Why among the beneﬁciaries who have already

problems, some households continue with SKY while others discontinue their memberships.

joined the programme, do some continue to pay for SKY insurance while others do not?” In particular, this study looks

In order to answer these research questions, this report

at the speciﬁc factors that lead people to sustain or discontinue

explores how social networks inﬂuence SKY uptake and

their memberships, and how these factors compare with

dropout, how people understand and explain the concept of

problems patients may encounter in the Cambodian public

health insurance in their villages, and how people recommend

health system in general or with SKY in particular.

(or fail to recommend) SKY to others.

Furthermore, it examines why, when faced with similar

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Methodology

This report uses a number of qualitative data collection methods:

members (i.e. dropouts), “almost customers”, insurance agents, village chiefs, and health centre staff.

1. Village maps: graphic representations of membership and social networks, and how they inﬂuence SKY membership.

3. Case studies: discussions with current and past SKY members on their experience with SKY, why they bought

2. Narratives: interviews that establish the local history of

SKY, why they stayed or why they dropped out, and what

SKY from villagers’ perspectives and key informants’ ideas

changes they recommend to improve uptake and lower drop

about the future of SKY in their villages. Key informants

out rates.

were selected from among current and former SKY

Data collection and analysis Seven villages in Takeo and Kandal Provinces were selected from the SKY village lists based on the following criteria:

while the other took detailed notes. At the end of each interview, the team members discussed the interview results and made sure that details were complete in the interview notes.

•

Each village was located in a different health centre catchment area.

At the end of each day, immediately after completing the interviews and while still in the village, the two teams

•

None of the villages were exposed to the coupon

debriefed, discussed ﬁndings, and began to develop a village

randomisation scheme (since this scheme inﬂuences

report. When necessary, the teams could return to informants

membership uptake).

to ask additional questions to complete the data if unresolved issues had arisen in reviewing the ﬁndings. Ongoing data

•

SKY implementation started no later than 2007.

analysis meant that subsequent interviews in the same village could focus on ﬁndings as they emerged from the results.

Domrei recruited and trained two teams of village researchers during late February 2009. Training was

Once interviews were completed in a given village, work on

conducted over ﬁve days at the Domrei ofﬁce and included a

the ﬁnal village report could begin. The village reports were

ﬁeld visit to test run the interview process and give researchers

translated at Domrei by the researchers who conducted the

a chance to become familiar with the methodology. Village

interviews to ensure contextual information was retained.

visits and interviews were then conducted between 6 March

Domrei’s bilingual co-directors oversaw the translation

and 3 April 2009.

process. Transcripts were coded using Atlas.ti computer software. The code families in the data were then explored in

Two teams of two researchers spent approximately three days in each village. One researcher conducted the interviews

the framework of the initial generative questions to provide a comprehensive summary of responses.

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1. Village Maps and Findings 1.1 Number of interviews in each village The village chief was interviewed in each village along with a

Pseudonyms were assigned to each village to preserve the

selection of current and former SKY members. We attempted

anonymity of the participants in the study. For the same

to interview all active members and as many former members

reason, other geographically speciďŹ c information such as the

as possible in the three days that teams were in each village.

operational district was also generally omitted.

Table 1. Number of interviews per village Interviewed for monographs Active Kulehn Village

Tiap Village

14**

Oaleuk Village Saomao Village

Inactive

Total

Number of households currently active members

Number of households ever members

Total number of households in village

SKY has been operating in village since

16*

2005

282

2005

191

2005

15*

104

2007

Mongkhut

31*

103

209

1997

Khnau

27*

121

1997

Lhung

30*

1998

* The village chief was never a member, and is therefore included separately in the total. ** Includes the village chief.

1.2 Kulehn Village Kulehn is the smallest village surveyed in this study,

income from relatives working in the garment factories near

comprising only 36 households. Agriculture is the predominant

Phnom Penh. SKY was ďŹ rst promoted in Kulehn in 2005. Data

mode of employment, with some supplemental income from

was collected from respondents who had been exposed to

raising livestock. Some households also receive additional

SKY for about four years.

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Figure 1: Small map of Kulehn Village Primary Members Later Members Newly Joined Ex-Members Approx. 2km separate the village from the main road (not to scale)

Not Interviewed (Member or ex-member)

Private Provider Village Chief Traditional Healer Drug Store Rice ﬁelds

Village Gender Issues Advocate Deputy Village Chief

Kulehn has only one traditional health provider (Kru Khmer),

is unique in that not only a high proportion of the village joined

no pharmacies, and no other sources of health services.2 SKY

SKY, but also only a few households have dropped out (unlike

began cooperating with a health centre in a neighbouring

the patterns seen in some of the other villages, as discussed

village in 2005. This centre is about 20 minutes away by moto-

in this report).

taxi (the cost is two to three thousand riel per trip). This village Table 2: How households ﬁrst learned about SKY Kulehn Village Current Members

Our family ﬁrst learned about SKY from… the SKY village meeting

60.0

a relative

26.7

the insurance agent, at our home

13.3

The location of the traditional healer is not shown on the map; it was not reported in the interviews.

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Of the 15 ever members, nine ﬁrst learned about the

extended families living on adjacent plots of land is one of the

programme at the initial village meeting organised by

results of the redistribution policies in the early 1980s (under

SKY/GRET to introduce villagers to the programme (see

the PRK’s Salvation Front3 government). This is one of the

Table 2 above). Three of the four households shown on the

reasons why “clusters” of health-seeking behaviours

map in red (as current “dropouts”) learned about SKY at the

consistently emerge from the map data.

village meeting. Four respondents said that they learned of Across the river, in the bottom-left corner of the map, the ﬁve

SKY from relatives.

households that were interviewed (as past or present SKY The Kulehn village map indicates that social networks clearly

members) are members of two extended families. The colour-

inﬂuenced membership. The village chief was one of the

coding for one extended family group (one green, one blue

primary members; secondary members lived close to primary

and one purple household) indicates that they are all SKY

members and were linked through the inﬂuence of these

members that joined at different times despite being members

primary members.

of the same extended family. The primary member (blue) joined ﬁrst, after attending a village meeting. The following

Neighbours are very often relatives in rural Cambodia. The pervasive pattern of land ownership that often results in

quotation comes from the “primary member” in this cluster of three households:

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 insurance agent introduced me [showed 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 five, age 56, Kulehn Village

This respondent’s positive experience evidently led to at least two other households joining, and quite possibly inﬂuenced all

simultaneously. One of the two households is still a member to this day, but the other has dropped out.

of the (purple-coded) recently-joined members. In comparison, this cluster of three households is adjacent to a pair of homes (one red, one green, also relatives) that joined SKY

One respondent dropped out because she had a particularly bad experience with both SKY and the health centre:

In 1981, the name Salvation Front was formally replaced by Kampuchean United Front for National Construction and Defence. The prior term continued to be used informally however.

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… I went to the [local] health centre for treatment. The staff told me that “[they didn’t] have enough equipment and drugs for treatment in the health centre” and sent me to the [provincial] hospital with a referral letter. At the [provincial] hospital, the staff said, “I don’t have medicine” and wrote a receipt, saying “let’s buy it outside.” I spent 15,000 riel. I hoped that SKY would reimburse me for this. But when I gave the receipt to someone from the SKY agency at the hospital, he told me that they were sorry but couldn’t give me the money back. I was very upset with SKY. Five days later when I came home, the insurance agent came to my home and asked me why I was upset and I told him. The insurance agent was very nice and felt sorry for my problem. He said that he would try to get the money back. I waited for two months, but never got the money back. After that, I decided to drop out of SKY… Using SKY is complicated and more difficult than the private sector. Farmer and mother of three, age 60, Kulehn Village

In this case, none of the adjacent households (and none of

One family that had dropped out later rejoined SKY. Another

her relatives) dropped out as a result of the respondent’s

household stated that while they had dropped out, they would

negative experience. The respondent’s house is at the top

like to rejoin when their economic situation improves enough

centre of the map, next to two (purple-coded) new members

to allow it. In this manner, even some dropouts may be

(see map close-up above).

spreading positive word of mouth about SKY.

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1.3 Tiap Village First exposed to SKY in 2005, Tiap is a medium-sized village

The village also has a veterinarian, a secondary school and a

with an ofﬁcial population of 1,226 located near the

small market (near the centre of the map) containing three of

Vietnamese border. There are two private health providers and

the drug stores.

four drug stores; the village chief is a traditional healer. Figure 2: Small map of Tiap Village

Primary Members Later Members Newly Joined

Rice Fields

Rice Fields Rice Fields

Private Provider

Rice Fields

Village Chief Traditional Healer Town Market

Commune Chief

Ex-Members Not Interviewed (Member or ex-member)

Deputy Village Chief

Drug Store

Town Hall

Rice ﬁelds Market area

Veterinarian Ceremonial Gate

School PP Road to Phnom Penh

Rice Fields

Rice Fields Rice Fields

The health centre partnered with SKY is 15 minutes away by

This expense was a deterrent to SKY membership in the

moto-taxi and costs most residents 1,500 riel to reach.

village. Tiap was chosen because it has a reasonably high

However, for more serious diseases, the referral hospital to

proportion of long-term members, but about half the members

which SKY is likely to refer patients is roughly 30 kilometres

have dropped out. In total, 49 households joined SKY in Tiap,

away and would cost 10,000 riel to reach by moto-taxi.

and 23 were still active members at the time of the study.

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The insurance agent in Tiap was reported to be very active

apparent cluster of primary members consists of the deputy

and visit people often, conducting many promotional activities

village chief and the commune chief, who are cousins (and

in the village. With only four known exceptions, all present and

work together in the local government). Along with the

past members attributed their joining SKY to this industrious

veterinarian, living in the same part of town, this cluster may

insurance agent.

have had a positive inﬂuence on the two (green-coded) households nearby who joined later. The research team

Perhaps for this reason, the clustering effect is much less obvious on the map than in the other villages studied. The only

reported that many people wanted to join SKY after learning that the commune chief and deputy village chief had joined.

Figure 3: Close-up of Tiap Village

Commune Chief

Deputy Village Chief

Veterinarian

In the following example, we see how SKY agents advocating on behalf of patients can play a positive role in distinguishing

SKY’s role from that of the health centre and offsetting any negative experiences that the respondents may have.

[…] I got medicine at the [local SKY-partnered] health centre many times. The health staff always provided the same drugs – paracetamol and a small red drug with a bad smell. They always give the same drugs for different diseases and it is not effective. And then, maybe in March of 2009, my son had pain in his legs [from a prior injury caused by a land mine roughly 10 years earlier]. Because of his serious injury, his legs were swollen and blood fell down. My son went for treatment at the [same] health centre. Because the situation was serious, the staff referred him to the [regional referral] hospital. My son didn’t understand the hospital rules clearly, and he took his SKY book with him, but didn’t know how to take a number [or how to ensure that his name was on the waiting list]. My son waited for two hours in severe pain. When the SKY agents saw this, they shouted at the public health staff. […] After that, my son went for treatment [in several non-SKY hospitals in other cities]… However, I still like SKY’s service and the health staff at the [local] health centre. There are many aspects of SKY and the public health service that should improve, such as the quality of drugs. […] [However,] if a person is poor, they are extremely happy when someone talks to them and takes care of them. Although my family did have a little problem with SKY, we will stay with SKY because the SKY agent tries to take care of us. Mother of two, age 55, Tiap Village

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As can be seen in the map close-up above, the green

However, respondents did report that they joined SKY

household quoted is not part of any obvious cluster. In effect,

because their neighbours were members, so some of the

we can think of the more far-reaching inﬂuence of the

same logic is at work here. One household stated that it had

commune chief and the town’s very active insurance agent as

joined SKY “because I saw that so many of my neighbours had

a form of linkage that goes beyond the clusters more readily

joined”, and one respondent said, “[I saw that] my neighbour

observed in the other villages. To some extent, this difference

had joined SKY, but still always goes to the private provider

can be quantiﬁed: in this village, only one respondent stated

when he is sick”.

that they ﬁrst heard of SKY from a relative (a sibling), while 18 others answered directly from SKY staff or SKY promotions

In the following example, the respondent is aware of the

(such as the village meeting to promote SKY, mentioned by

signiﬁcant ramiﬁcations of the family’s own bad experience,

ﬁve households). As a corollary, when asked why they had

and directly states that this changed the neighbours’

decided to join SKY, none of the respondents in this village

perception of SKY.

mentioned previous positive experiences by their relatives.

My grandson [became sick because he] drank oil and it made him so hot.4 I took him to [the provincial] hospital maybe at 2:00 A.M. and I met only one staff member at the hospital. He was angry at me for coming so late and told me that my grandson would die and not to disturb him at night.5 There was only one impolite staff member and most of the staff took good care of my grandson. My grandson was in a very serious condition. I stayed there one night, but then I took him to a private provider, where I spent 40,000 riel. He continued to take drugs at [another] heath centre until he got better. The [provincial] hospital was clean, but I didn’t meet any SKY staff. When I got back home, I told my neighbours [about what had happened] and they were also disappointed with SKY. Resident of Tiap Village

Although complaints about transportation costs are nearly

country’s most frequented national highways), directly or

universal, the residents of Tiap have more choice in health

indirectly giving the village access to a broader range of public

services than most of the villages in the study. In addition to the

and private health services. Therefore, SKY’s moderate

convenience of the private providers near the centre of the

success in retaining members here takes place in a context of

village, Tiap is located on a major paved road (one of the

relatively diverse competition.

Presumably, the type of “oil” in question is something like motor oil or engine lubricant, as the effects of the poisoning were so serious. Describing illnesses in terms of heat is traditional, but only relates to symptoms.

5 That

is, the employee complained that the patient should not disturb the doctor or medical staff with this problem, but that the child should instead simply die without treatment!

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1.4 Oaleuk Village Oaleuk has an ofﬁcial population of 1,003. Nearly all the

known as Phum Thmey [new village]. As the name implies,

households work in agriculture. Rice, watermelons, potatoes,

Phum Thmey was settled relatively recently; and the

and peanuts are among the cash crops grown by households.

construction of the village chief’s home there was described as a recent relocation. Many of the farmers living in this area are

SKY has been operating in the village since 2005. The village

new arrivals in the village, and are generally living in greater

is roughly divided into two parts: those who live in the area

poverty than the longer-term residents. The Buddhist

closer to the larger road at the top of the map have somewhat

monastery and the highest housing density are both in the

higher incomes than those further away from the main road at

older part of the village, located along an unpaved dirt and

the bottom of the map (the western side the village) in the area

pebble road.

Figure 4: Small map of Oaleuk Village

Rice Fields

Buddhist Monastery

Primary Members

Lake

Later Members Newly Joined

Rice Fields

Ex-Members Not Interviewed (Member or ex-member)

Rice Fields

Private Provider Village Chief Traditional Healer Drug Store Rice ﬁelds Lake or marsh

Rice Fields

Deputy Village Chief

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

The village has one midwife, one traditional midwife, and a

proportion of people who had ever been members of SKY.

private healthcare provider. The preferred health centre is

However, the village also has a signiﬁcant dropout rate, with

around 30 minutes away and costs about 4,000 riel to reach

two thirds of those who had ever joined SKY having left the

by moto-taxi. SKY also cooperates with another health centre,

programme.

but villagers use the Oaleuk health centre almost exclusively because of its location, both closer to many of the villagers’

A classic clustering pattern is found near the banks of the

homes and en route to the regional referral hospital. Villagers

river (see illustration below) where the three newly joined

reported that if they cannot be treated at Oaleuk, they go on to

households (colour-coded purple) are all linked by blood

seek treatment at the regional referral hospital.

relationships, and live on adjacent plots of farmland. This case study also reveals the overlapping mandates of SKY and the

Oaleuk has had SKY for a longer continuous period of service than any of the other villages, and has a signiﬁcant

local Health Equity Fund (HEF) operator to reach the poorest and increase the efﬁciency of these dedicated funds.

…I am an old widow… [and] my older daughter is also a widow. She has a 7-month-old son who lives with me. She is a waitress in Phnom Penh. At the end of the month, she sends me money to buy milk. My other children and my mother live with me too. I am a farmer and also grow plants around my house. … [The local insurance agent] 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 form of tile/covering] my HEF card was taken away.6 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 five, age 53, Oaleuk Village

In the example above, the “cluster” of households is clearly

Coincidentally, the survey team found one example of the

making choices together, and making the same decisions for

opposite pattern in the same village: one respondent stated

the same reasons. While one sister had HEF coverage,

that she had dropped out of SKY because she was busy with

neither sister joined SKY; after the HEF coverage was

rice farming, and did not have the money to pay the premium

cancelled, both sisters decided to join SKY (one a widow, the

(complaining of school expenses for her children), but

other married).

mentioned that she had a HEF card, and so was able to get free medication at the local health centre anyway. 6 Different

HEF schemes use different definitions of poverty, but this family was apparently disqualified (i.e. was no longer deemed to be sufficiently poor to merit assistance) after upgrading their roofing. The home’s building materials are usually considered in identifying potential beneficiaries.

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Impact Analysis Series . N° 09

Sometimes, there is considerably more to the story than the

homes in the bottom-right corner of the map. Although this

colour-coding on the map would suggest: the following positive

former member dropped out, she apparently continues to

experience with SKY comes from a cluster of three “red”

spread positive word-of-mouth about the SKY programme.

When I [was still a member of] SKY, our family had many illnesses, such as stomach aches, dizziness, pain in the abdomen, and tired and sick legs. For these illnesses, I always got effective treatment and took good pills at the commune health centre, so our illnesses 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 the 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, Oaleuk Village

This cluster of three homes all said they saw SKY as “good”

At the top of the map, there are four purple-coded

and regretted having dropped out due to their inability to pay

(i.e. recently joined) households that are all linked to the one

the premiums. One of the households in this cluster speciﬁed

blue-coded household (that had joined signiﬁcantly earlier) by

that even though it had dropped out, this was only due to a

some kind of family relationship. Three of the ﬁve had attended

lack of money, and that “[her] family had no problems with the

the initial SKY village meeting. The blue household chose to

health workers”. She stated that she thought SKY was good,

join SKY “because I thought that if I paid a little money every

partly because she was impressed that SKY had paid money

month, my father is old, so when he gets sick, he can get pills

to support a funeral in the village after a member had died.

or treatment without having to pay and also the health workers will pay a lot of attention to him”.

Figure 5: Close-up of Oaleuk Village

Evidently, the positive experience of the ﬁrst person who

and regrets that most of her family now lives in an area of Siem

joined in this cluster spread to a minimum of two relatives’

Reap province with no SKY coverage so that it no longer

households (coded purple in the close-up above) – and quite

makes sense for her to pay to be a member of the programme.

likely to four. The one dropout (red-coded) household in this

She had positive things to say about SKY, and had (previously)

area (pictured above) is also worth considering. As it happens,

become a member in order to ensure that she was covered

this dropout also holds the SKY programme in high esteem,

during her pregnancy and the delivery of her child.

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

1.5 Saomao Village Saomao is a small village of only 584 people that manages to maintain two Buddhist monasteries7 and a

•

relatively large school complex, with all of these institutions

The provincial referral hospital is 40 minutes away and costs 5,000 riel to reach.

presumably serving a greater population from the It is signiﬁcant to note that this village is already pre-disposed

surrounding area. Rice farming is the village’s predominant source of income, with some people employed in basket

to failure, as it is roughly half an hour away from at least three

weaving, and others producing and trading in fermented

different health facilities, and transportation difﬁculties are

fish paste (prahok) or growing cash-crop vegetables on a

always a major factor in retaining beneﬁciaries. From an initial

small scale. The village is close enough to urban sources of

glance at the map, it seems fair to say that the SKY

employment that a few men were reported as leaving to

programme has failed here, as only a single current member

work in construction or as moto-taxi drivers, and a few

was found by the research team, and all other respondents

women were reported to be working in garment factories in

interviewed were dropouts.

cities elsewhere. The village chief estimated that only 10% SKY has been operating in the village since 2007. The only

of the village’s inhabitants were poor enough to qualify for a Health Equity Fund card.8

active SKY member at the time of the survey was the deputy village chief, who also works for the village health support

The village has one drug vendor and one Kru Khmer (both

group (a health education programme supported by the

shown on the map; the traditional healer is also the deputy

Ministry of Health). He reported that he was pleased with the

village chief). SKY cooperates with two nearby health centres,

service he had received from SKY, and that he felt he was

and two referral hospitals in the area.

setting a good example for others by remaining a SKY member.

•

The first health centre is 30 minutes away by moto-taxi and costs 4,000 riel to reach.

As is immediately apparent from the map, the dropouts form a single cluster of 14 households. Five of them are part of the

•

The second health centre is 25 minutes away and costs 2,500 riel to reach.

same extended family as the deputy village chief (who, alone, remains a SKY member). Nine of these 14 households joined after attending a village meeting (promoting SKY).

•

The regional referral hospital is 35 minutes away and costs 4,000 riel to reach.

Technically, both of the monasteries are located just outside the village limits (see map, below), and the limit itself makes a slight detour around the temples, which are otherwise a natural part of the town.

Theoretically, this would suggest that only 10% of the village would be categorised as part of the poorest 30% of the Cambodian population overall, although the actual guidelines for the definition and identification of the poor are inconsistent from one HEF district to another.

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Impact Analysis Series . N° 09

Figure 6: Small map of Saomao Village Primary Members Later Members Newly Joined Ex-Members

Buddhist Monastery

Village Limits

Ceremonial Gateway School

Private Provider Village Chief Midwife

School

Drug Store Rice ﬁelds

Village Well

Lake or marsh

Deputy Village Chief & Traditional Medicine Provider

Village Limits

Buddhist Monastery

Figure 7: Close-up of Saomao Village

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Ceremonial Gateway

Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Within this cluster, three households had four profoundly negative experiences with SKY and the public health system.

Here, too, the negative experience resulted in the patient seeking care from a private health provider.

These negative experiences can be summarised as follows: It seems plausible that these negative experiences, spread

•

One family member suffering from cholera received

among four households within the cluster of 14, would have a

extremely poor treatment (and found that no SKY member

“knock-on effect” encouraging more SKY members to leave

facilitator was at the health centre at the time). The patient

the programme.

was at first refused medicine on the pretext that the health staff did not have any, but the same medicine was later

One household stated that they were “very satisﬁed” with

offered if the family agreed to pay cash. As a result, the

SKY and had received excellent treatment at the hospital

family switched to a private provider.

(based on “six or seven” visits made by the family during their membership). This household stated that they wished to

•

One patient was misdiagnosed with fever, and given

become members again in future, but could not do so due to

treatment for a normal fever (which was ineffective) at the

poverty (“in the future, if my family has more money, then I will

public facility. When the family switched to a private

join SKY again”). This pattern of values was more common in

facility, the condition was immediately diagnosed as

Oaleuk, but it is noteworthy that it can still be found here, in the

dengue fever, and effective treatment was administered.

midst of a solid “red” cluster of drop-out households. Six of the 14 families did say that they had heard good things about SKY

•

Treatment for shortness of breath (apparently combined

(prior to joining or around the time they joined), most

with high blood pressure) was ineffective, and so the

commonly praise for the basic premise of getting unlimited

respondents sought private sector healthcare.

healthcare for free in exchange for a monthly premium.

In a separate instance, asthma was not taken seriously by

While the reported experiences of others are important, rural

staff at the referral hospital: “The staff said that I was not

Cambodians evidently do not lack conﬁdence when it comes

truly sick and then they took me to the funeral (cremation)

to giving primacy to their own experiences and opinions

place. Although I was so sick that I nearly died, still the

(i.e. even when they are contradicted by the experiences and

doctors didn’t take me seriously and were very careless.”

opinions of relatives and neighbours).

When I came back home, I told my husband that I barely believe in the SKY programme. I will wait to see SKY’s activity because I heard from [other] villagers that joining is easy, but going to the hospital is difficult and the health centre staff don’t care about us. Resident of Saomao Village

As the quotation above demonstrates, after negative experiences have reached a critical mass in a given

neighbourhood, even those who choose to join SKY do so with a degree of scepticism and apprehension.

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Impact Analysis Series . N° 09

Although almost everyone had dropped out of the

Various respondents reﬂected that many people had joined

programme, when asked, “Is SKY popular in this village (and

SKY when it was ﬁrst launched in the village, but had since

why)?”, six of the families said that SKY is popular because it

dropped out because they heard bad things about the medical

has a car that offers transportation home from the hospital, and

staff, ineffectiveness of treatment, and that the health centre

because it provides free treatment. This shows that even in the

does not prescribe enough medication. Since this is the type

midst of perceived failure, past and potential beneﬁciaries are

of complaint that confuses SKY with the public health service,

aware of the speciﬁc beneﬁts that SKY has to offer.

it is noteworthy that one respondent differentiated between the two, saying “Everyone likes the SKY service, but it is difﬁcult with public health staff because they do not know us”.

1.6 Mongkhut Village SKY has been operating in the village of Mongkhut since it

and most people are employed in agriculture, with a small

was ﬁrst launched in 1997. The village has a population of 872,

number employed in garment factories and construction work.

Figure 8: Small map of Mongkhut Village Ceremonial Gate

Main Health Centre

Village Limits

Deputy Village Chief

Rice Fields

Rice Fields Primary Members Later Members Newly Joined Ex-Members

Veterinary Hospital

Not Interviewed (Member or ex-member)

Private Provider Village Chief Traditional Healer Drug Store

Bridge

Rice ﬁelds Lake or marsh

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

The village has two traditional healers (both located by the

(shown on the map), and cancelled the in-home services.

bridge, at the bottom of the map, i.e. the west end of the village as the map is oriented). The town has one veterinarian and a

•

In 2008, SKY stopped cooperating with the local health centre (due to complications arising in the relationship).

public health centre (in the top-right quarter of the map, i.e. the southeast part of town). However, as explained below, the health centre shown on the map is not partnered with SKY.

•

This resulted in the current situation (mentioned above) in which local residents need to travel a full hour to the nearest SKY-partnered hospital. The provision of in-home

While the public health centre shown on this map is,

care did not resume.

obviously, a short walk for many of the villagers (and a mototaxi ride of only one or two minutes for most of the rest, possibly costing 500 riel), the nearest major hospital for cases

Thus, in this region, SKY now covers only in-patient and out-

that are sent elsewhere is a full hour away, costing 5,000 riel

patient care at the local hospital. When asked what would

to reach. It is this hospital roughly an hour away (not shown on

make more people buy SKY health insurance, 11 of the

the map) that is now partnered with SKY.

31 households interviewed in this village stated that SKY should go back to offering in-home care.

The insurance agent in Mongkhut has changed a number of times and the beneﬁts offered by SKY have also changed.

The former member advisor who had worked with SKY

The range of beneﬁts offered – and “retracted” – has been a

during the period of co-operation with the local health centre

major consideration in respondents maintaining their

was very popular among the villagers; he was responsible for

memberships or dropping out of the programme. Six of the

many people joining and trusting SKY in earlier years.

families interviewed stated that they dropped out of SKY Nearly half the village households have been SKY members

because the programme had switched to a more remote location (though this was rarely the only reason given, and was

at one time or another, and roughly a ﬁfth are still members

normally combined with complaints that the staff was

today despite a number of signiﬁcant obstacles. In roughly

inattentive and impolite). A further four families stated that the

12 years (between the commencement of SKY activities and

remoteness of the hospital made the SKY option more

the present survey), 103 families joined SKY in Mongkhut, and

expensive than visiting a local private sector provider for minor

23 remain members today.

ailments, and, conversely, it made serious ailments more Given that Mongkhut has had such long-term exposure to the

onerous.

programme, it is not surprising to ﬁnd respondents who have The sequence of changes is somewhat confusing:

nuanced

understanding

the

advantages

and

disadvantages of coverage. The following respondent dropped

•

In its first five years of operation, SKY provided in-home

out of SKY after a negative experience but later rejoined (and

care in the area.

is thus part of a purple-coded household, in the top-right corner

In 2003, SKY began cooperating with the local health centre

programme as having improved.

of the map close-up next to the quotation) and sees the

•

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Impact Analysis Series . N° 09

I had dropped out of SKY and later bought SKY again. […] I had heart disease [later diagnosed as cancer] and went to the referral hospital for treatment [the same referral hospital currently partnered with SKY in this area]. The doctor injected serum [i.e. glucose serum by intravenous drip] until I had swollen hands, feet and chest. I told the doctor that the difficulty was in my chest. The doctor said “don’t worry” because I had oxygen. The doctor there threatened me, said that he didn’t care about the treatment. I stayed at the hospital for a few days and then I left [covertly], telling the doctor I was going to the bathroom, but I left. My husband took me to Calmette hospital [i.e. one of the best hospitals in the country, in the capital city] for an operation that cost $5,000 [and where the condition was evidently revealed to be cancer]. This was paid for by the Christian church. I decided to drop out of SKY because the doctors and nurses were not friendly, were careless and impolite to 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. […] When I decided to buy SKY again, I paid for it myself, but two or three months later, the church [offered to] pay the SKY monthly fee for my family. 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,

serious disease. It is interesting to note that she stated this

this household rejoined SKY, and is now spreading positive

was more important for her, personally, because she did not

word-of-mouth on the programme’s behalf. The family had

have children to take care of her. The one other primary

recently brought their daughter in for treatment for a tumour of

member (blue-coded) in this neighbourhood is 80 years old,

the nose, but it seems that in their telling of the story, the

and joined individually in 2004, but her relatives (living in the

emphasis is on the change in attitude among health providers

same household) have not joined SKY since then. She praised

(i.e. not a comparative statement that the daughter’s treatment

the friendliness, gentleness, and politeness of SKY staff, and

was better than the mother’s, etc.).

stated that she encouraged others to join SKY too.

In the neighbourhood surrounding the respondent quoted

Given the change in the location (and nature) of services

above, we see a small cluster of four households that are

offered by SKY since it started offering services in the village,

either primary members (blue) or members who have recently

not everyone in the village sees SKY as having improved. The

joined or rejoined (purple). One of the primary members is a

changes in insurance agent and other SKY staff were also

widow whose husband and children all died during the

frequently mentioned. In the cluster of dropouts shown below,

Communist era (of Democratic Kampuchea) who gave a

three of the four (red-coded) households interviewed said

simple and positive report that she had paid for SKY

positive things about SKY that revolved around one speciﬁc

continuously since 2004 to protect herself against the cost of

employee who no longer works for the programme.

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Figure 9: Close-up of Mongkhut Village

Households in this cluster dropped out for a variety of

In the smaller cluster of two households at the centre of town

reasons. One complained that the hospital divides SKY

(Figure 10, below), the explanations consistently emphasise

patients into a separate group and makes them wait longer

the relocation of SKY services to the more remote hospital.

than patients paying in cash. One of the others spoke of the

Additionally, one of these two households (apparently after

issues of distance and transportation, saying that it could be

having lost trust in the programme) decided to pay for an

more expensive to travel to receive free medicine than to pay

appendix operation at a private clinic, and then dropped out of

for medicine locally. Another negative experience that may

the programme. These two households are linked as members

have been inﬂuential in this cluster was a man who waited for

of the same extended family; it is likely that they made this

“many hours” to get treatment for a broken leg and eventually

decision together.

left without getting treatment; the family paid $250 for treatment at a traditional provider instead and evidently left the programme seriously disappointed.

Figure 10: Close-up #2 of Mongkhut Village

Although there are various unique aspects to Mongkhut’s

did so because they felt that they were getting good value for

situation, the reasons for continuing to stay with SKY were not

their money and because they were afraid of getting sick in the

unique: those who continued to pay premiums said that they

future.

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Impact Analysis Series . N° 09

1.7 Khnau Village The village of Khnau has a population of 558 and a large

The nearest referral hospital is 25 or 30 minutes away,

number of institutions and services for a town of its size:

costing 6,000 riel to reach by moto-taxi. As noted on the map

• A school, • Three private health-care service providers, • One public health centre within walking distance (on

(lower right corner), the local health centre no longer co-

• • • •

the map), Two drug stores, Two midwives, One traditional midwife, and One Buddhist monastery.

operates with SKY. The ensuing situation is somewhat comparable to the situation in Mongkhut (discussed above). After SKY’s partnership with the local health centre broke down, free services for policyholders became much more onerous and difﬁcult to access.

Figure 11: Small map of Khnau Village

Rice Fields

Road to Phnom Penh Buddhist Monastery h Sc

Ri Primary Members Later Members

e Fi

s Lake

Lake

Newly Joined Ex-Members Private Provider Village Chief

Rice Fields

Midwife Drug Store Rice ﬁelds Lake or marsh

Rice Fields

Lake

Rice Fields

This road leads to another local school

exPost exPost

Town Hall (Used for ceremonies)

The town’s main health centre (formerly but no longer part of the SKY program)

Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

By Cambodian standards, this village is not considered poor,

higher percentage of members. On the contrary, only 13 out of

but moderately afﬂuent. Farming is supplemented by the

the 51 families that had ever joined the programme are

income earned by garment factory labour by many (reportedly,

currently active members.

“most”) of the town’s women. The town’s afﬂuence also reﬂects its access to markets via Phnom Penh, to which it connects by road directly (as shown on the map, upper right corner).

Located close to the Buddhist monastery, the following respondent (blue-coded) clearly describes his decision to return to (and maintain his membership in) SKY as having

As poverty (and inability to pay the premiums) was given as

been made despite bad word-of-mouth. The map shows that

a reason for dropping out of the programme so often in the

he is an exception to the rule, living in a (red-coded) cluster of

other villages, we might expect Khnau to have retained a

dropout households.

Buddhist Monastery

In 2007, my family dropped out of SKY because SKY services changed and SKY started cooperating directly with [the more remote] hospital [and not the local health centre]. The hospital is far away from here, and my children were not sick. But now I decided to buy SKY again because [I am concerned about the possibility of] getting a serious illness because nobody can ever predict what will really happen. 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

One of the other factors that can clearly inﬂuence people’s

time. The same respondent also stated that the hospital and its

decisions to remain with SKY despite a bad reputation (or

staff are both improving (perhaps reﬂecting that she is aware

living in a cluster of people who are dissatisﬁed with the

of past problems).

programme) is the beneﬁciary’s frequency of experience with the service itself. One current member spoke with great

One extreme example shows how one household’s very

conﬁdence about the money she had saved through SKY in

negative experience can affect both relatives’ and neighbours’

the course of a long series of treatments for herself while

conﬁdence in the service. The following respondent is located

suffering from tuberculosis, and in caring for her elderly father

in the midst of a (red-coded) cluster of dropouts. He relates his

(who has reached the age of 94, which is particularly

own family tragedy as part of a context in which “many families

remarkable in rural Cambodia). In this case at least, empirical

in the village lost conﬁdence in SKY and dropped out” despite

experience trumps all other concerns: the respondent was

the fact that he found the employees to be “friendly […]

very conﬁdent that SKY had saved her family money over

responsible and supportive”.

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Impact Analysis Series . N° 09

I [first joined SKY in] 2004 […] because I thought that SKY could help my family lower our poverty. It was especially important to me that I could have a baby delivered without having to pay the public provider. After becoming a SKY member, I got services at the health centre and my illnesses got better. The staff was friendly and always seemed very responsible and supportive. Right now, my family dropped out of SKY because my cousin had high blood pressure and received bad treatment. The staff was careless and did not inject him with medicine or serum and he died in the health centre. For this reason, my family dropped out of SKY. Many families in the village have lost confidence in SKY and dropped out. Father of four, age 56, Khnau Village

In the quotation above, it is noteworthy that he says so much to praise SKY and mentions that he did have positive

to pay the premiums was not mentioned in his account; in some cases, cost is simply not an important factor.

experiences with SKY at all in the preamble to the tragedy that compelled him to leave the programme. It does seem that the

In this village, one long-term member (blue-coded) reﬂected

respondent himself is aware that negative experiences of this

on the limitations of coverage and her own resolution to stay

kind have a knock-on effect, with other families losing

with the programme even though her own disease is not

conﬁdence in the system for the same reasons. Lack of money

covered by SKY health insurance.

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

Although at least one household in this village listed poverty

from a respondent who decided to remain with SKY, but who

among the reasons why they decided to drop out of the

still sees the household’s position as one of ongoing self-

programme, the leading considerations in this relatively

interested decision-making, and that they can (and perhaps

afﬂuent context are somewhat different from the poorer

will) drop out if they are ever dissatisﬁed.

villages surveyed in the study. The following quotation comes

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

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. I stayed in SKY because I saw that SKY has emergency services and I got effective service without having to pay. Resident of Khnau Village

The reasons given for leaving the programme are not

who was very popular (“he was friendly, good at treatment,

unusual in this village: speciﬁc bad experiences overlap with

worked hard, and paid attention to SKY members”) and whose

the difﬁculty reaching the (relatively remote) SKY-partnered

name was mentioned frequently in the reasons for ﬁrst signing

hospital. Six families in this village stated that their primary

up with SKY. The departure of this employee, however, seems

reason for leaving SKY was the distance to the hospital,

to have been less signiﬁcant than the relocation of SKY

combined with remarks about the family not owning

services to the more remote hospital: nearly all of the

a motorcycle or not having anyone to take care of the family

households remarked on the latter.

if they went on such a trip, and other concerns. Ten families reported that they ended up paying for private services

Overall, the residents of Khnau have been disappointed, and

anyway while they were SKY members because it made more

most commonly left SKY because it did not live up to their

sense to pay for medical care than to pay for transportation,

expectations. In other villages, we found people dropping out

reﬂecting the pattern (or strategy) of only using SKY for major,

because they could not afford to continue with SKY, but here

expensive diseases, and private healthcare for more

we saw people dropping out in part because they could afford

immediate (and sometimes minor) concerns.

to pay for services directly instead. In this village, the respondents who stayed with SKY generally appear as

All 26 families remarked that SKY had a better reputation in this village in the past, when there was a particular employee

isolated, individual households that do not form clusters (in part simply because they are so few in number).

1.8 Lhung Village Lhung is a small village of 267 people, a 15-minute trip from

SKY has a long history in the village, dating back to 1998.

the nearest public health centre (1,500 riel by moto-taxi) but a

Almost half of the households in the village have at one time

full hour away from the nearest hospital (10,000 riel). The

been members of SKY, although about half of these have

village has a large number of services relative to its small size,

since dropped out. The research team interviewed 18 active

with two private healthcare providers (one of them doubling as

households (including the village chief) and 12 inactive

a drug store), and one additional drug store. This level of

households (a total of 30 households, a signiﬁcant portion of a

development is perhaps linked to the village’s administrative

town comprised of only 62 families). Although targets may be

status as it is home to the area’s commune hall, the commune

higher, the proportion of SKY beneﬁciaries here could be seen

police headquarters, and one school. The population is

as reasonably successful.

primarily employed in agriculture.

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Impact Analysis Series . N° 09

Figure 12: Small map of Lhung Village

Special lot for raising chickens

Rice Fields

Feed Lot

This road leads to another local school

Bridges (two)

Rice Fields

Rice Fields Primary Members Later Members Newly Joined

Rice Fields Commune Police HQ School

Ex-Members

Rice Fields

Not Interviewed (Member or ex-member)

Private Provider

Commune Hall

Village Chief Traditional Healer Drug Store Rice ﬁelds Lake or marsh

One factor in the early uptake of SKY membership in Lhung seems to have been the personality of the previous member

relatively long journey to the nearest SKY-partnered hospital is also a problem for Lhung residents.

facilitator who also provided (in-home) healthcare in the village. The member facilitator lived in the village and regularly

As a result of these circumstances, we ﬁnd that many of the

provided care and counselling in villagers’ homes. However,

respondents who have stayed with SKY have done so on the

SKY now only offers in-patient and specialised out-patient

pattern (or “strategy”) of using private healthcare for immediate

hospital care, and this may have resulted in disappointment

needs and only utilising (the more remote) SKY services for

with the programme. As in Khnau, discussed above, the

serious ailments, sometimes after ﬁrst paying for private services.

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

About two months after I joined SKY, my child got dengue fever and I sought help from a private provider. But when it became very serious, I took my child to the […] hospital [that is partnered with SKY, but further away]. When I arrived, the doctor and nurse were friendly and honest, and my child recovered. SKY’s insurance policy has provided many benefits to my family. […] I have not dropped out of SKY because it helps my family grow and keeps my children healthy so they can go to school every day. Mother of two, age 33, Lhung Village As it happens, the quotation above comes from a household

programme, but remained a member only because he had

located in a small cluster of people with positive opinions of

paid a number of months in advance. As the chief’s negative

SKY, living near the village chief.

opinion of the programme could have far-reaching consequences in a larger social network, it would be

In some cases, the colour coding can be misleading. At the

interesting to know if membership declines or if promoting the

time of the survey, the village chief had had a very negative

programme becomes more difﬁcult for SKY employees after

experience with SKY and had already resolved to leave the

this incident.

After I started with SKY, my youngest daughter became sick with a stomach tumour. I took my daughter to the [SKY-partnered] hospital for treatment, but the doctors and nurses said they didn’t have the instruments for the operation. After that, they told me that I should take my daughter to [another] hospital. When I arrived there, the doctor blamed me, saying, “Why do you keep her like this when she is in such a serious condition?” Then the doctor operated on my daughter [and] referred her to [a major hospital in the capital city] for continued treatment. I spent $600. When I returned from the hospital [I had already decided that] my family would drop out of SKY after we finished using our last two months that were already paid for in advance. Village chief and father of four, age 55, Lhung Village

Although the chief’s disappointment was probably serious,

cruel nurse”. Although the grieving father may feel some

there are much more serious examples to be found in the

satisfaction in dropping out of SKY after this terrible

same village. One respondent near the centre of town

experience, sadly, it will not improve the quality of healthcare

explained that his daughter died from a respiratory infection,

his family can access, and may only put them at greater risk

and that his neighbours encouraged him to complain to the

over time.

police as they shared his impression that the cruel indifference and incompetence of the medical staff at the health centre

There is a signiﬁcant cluster of long-term SKY members

were responsible for her death. However, while he stated that

gathered right around the town’s two private healthcare

he was very angry at the time, he decided not to complain to

providers. The following quotation comes from one of the

the police because it would make no difference and it would be

primary members (blue-coded) on the south side of the road,

useless to complain, stating instead, “I don’t care about the

two doors over from a private clinic.

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I bought SKY for several reasons, including that the SKY agency used to provide home care for its members that included daily visits, follow-up, and treatment in the home. The [SKY agent] provided good counselling to SKY members. SKY’s medicine is good quality. In addition, I have children, a grandchild, and parents who are very old and I want to protect them because we never know when they will get sick. […] SKY’s treatment provided a cure that was better than the private provider. Some private providers don’t have enough skill and are careless.

Father of three, age 36, Lhung Village

This comment is very unusual. In this case, the family

were careless with SKY patients because they did not receive

appears to be part of a cluster that would know quite a lot

cash payments from them, and that they had been warned that

about the services offered by the two private providers located

they would need to pay separately for medicine at a private

nearby. However, the relative convenience of the private

drug store even if they had SKY coverage. One respondent

option does not seem to tempt them at all. On the contrary,

said that the public health employees (as distinct from SKY

they see the public health service as superior, and had a lot of

employees) did not know anything about SKY, and so SKY

praise for SKY in particular.

members are “kept in a separate place and it is very difﬁcult”. A nuanced understanding of how SKY works with the public

One of the immediate neighbours of the respondent quoted above is a war veteran who now describes himself as

sector (but remains a separate entity) shows up in both praise and blame in Lhung.

physically disabled at age 60. He reported negative experiences with private healthcare providers, and attributed

In general, all of the problems seen in other villages were

his positive experience speciﬁcally to the SKY member

also seen here, including numerous complaints about

facilitators advocating for patients and not to the public health

transportation difﬁculties, the impoliteness of hospital staff, the

service in general. He has been a member since 2004, and it

ineffectiveness of treatment, and so on. The distance from the

seems that his family will remain with the programme

partnered hospital was the primary reason so many former

permanently after this positive experience.

members had dropped out, along with the cessation of inhome treatment. Here, too, it was pointed out that medicine

Perhaps because the full range of options is available within

from a local provider could be cheaper than the cost of

and around this village, the responses from Lhung show a

transport to the hospital. In a village this small, it is reasonable

clear awareness of the respective roles of private and public

to suppose that negative experiences with the health service

healthcare, and that SKY is a distinct entity from the latter. One

(especially those resulting in death) would be known to all, and

respondent stated that people “should believe in SKY because

the village chief’s disappointment with the programme will also

GRET SKY is an NGO and not the private sector”. One

likely have ramiﬁcations beyond this immediate cluster of

household stated that they had heard rumours that doctors

homes.

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2. How and Why Did People Become SKY Members?

eSection 4 contains data from the village interviews that reﬂect the dominant themes in responses to our questions about initially taking up SKY membership.

2.1 Satisfied SKY clients

In answer to why respondents decided to become SKY members, responses ﬁt into eight main categories:

SKY members. Many villagers said that they joined SKY because they only have to pay a small amount per month and they get “free” treatment when they are sick. Some stated that

2.1.1 The perceived benefits of free healthcare for SKY health insurance members

they did not have enough money to pay should they get a serious disease, while others saw SKY as a form of saving for the future.

The most common reason to have joined SKY in the villages sampled was the perceived beneﬁts of health treatment for

I thought about my experiences and realised that if we go to the health centre to get medicine once, we spend 2,000 to 3,000 riel. If we go there two or three times, we will end up spending the same amount as the SKY monthly fees, where we would be insured for the whole month. (Oaleuk) I joined SKY as a protection for the future when we might have a serious disease, especially because my family doesn’t have the money to pay if we get a serious disease. (Saomao) By joining SKY, I can avoid spending a lot of money when I get a serious disease or need an operation. (Lhung)

Some respondents genuinely feared the health and ﬁnancial effects of a serious disease or accident, seen as random

dangers that could arise at any time. They saw SKY as a possible way of preparing for such shocks.

I stay with SKY in case of a serious disease. SKY provides strong support for my family because we can never know clearly when we are going to get a serious disease. (Khnau)

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2.1.2 Household member(s) already had chronic disease(s) at the time of joining

members also joined because they already knew that they needed operations and could get them if they were a member

Some respondents joined because household members had

(after a six-month waiting period).

chronic diseases already or the family “got sick often”. Some

I bought SKY because I get beneﬁts from buying it and because we have a chronic disease. (Mongkhut) I got some advice from my cousin and neighbours who said my family has a lot of members and that my children have diseases [one has cancer of the nose and another has typhoid with stomach ache and heart disease]. They said that we should become SKY members because SKY insurance covers many diseases, especially serious diseases. (Kulehn) Since I have stayed with SKY this year, I have had high blood pressure. I take drugs at the health centre because it is easy, and [some of the] hospital staff [there] were [formerly] my students so I take drugs for free. The health centre is clean and I like the treatment. I joined SKY because I am afraid that in the future I may need an operation. (Kulehn) My family is poor because I have the chronic disease asthma. I heard about SKY through a village meeting in September 2000. The day after the village meeting, I decided to join SKY. I stayed with SKY until September 2005. The reason that my family decided to join SKY is because I think that it is easy when we have serious diseases without having to pay. (Saomao)

2.1.3 Effects of family networks on membership uptake

in villages, often because of land being split to form new households when children marry.

Family members were a major inﬂuence on SKY membership. For example, in the Saomao village report, the

Many members initially learnt about SKY through

research team noted that “almost all of the SKY members in

discussions with family members. In some cases, members

that village were related”. The village maps for each village

ﬁrst joined after hearing about positive experiences that

(see appendices) also pictorially indicate these family

relatives had with SKY. In some cases, the family as a whole

networks. Family members frequently live close to each other

decided to join and a number of households joined together.

I heard about SKY for the ﬁrst time through my sibling in Traw-em village [also in Takeo] maybe one or two months before SKY started in my village. When SKY had a meeting in my home, my family decided to buy SKY immediately because we had discussed it since we had heard about it. (Saomao) The main reason I joined SKY was because I saw my siblings join SKY and my father advised me to join. (Saomao) My relatives [who live in the same village] joined SKY after seeing that I received good treatment. (Kulehn)

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2.1.4 Effects of community networks on membership uptake provides treatment without charge. Hearing real stories from SKY Information sharing by community networks had a positive

members in the village conﬁrmed that what SKY had promised

effect on membership uptake. Respondents were asked what

at the initial village meeting was in fact true. (N.B: there were also

other villagers thought were the beneﬁts of SKY. Responses

corresponding negative effects from what other villagers saw as

varied and included that SKY pays for medicine and that SKY

SKY’s negative points, discussed in section 5.)

I joined SKY because I saw that villagers joined and they said good things about SKY. (Oaleuk) Many people in the village saw that my family had a good experience with SKY and this encouraged them to join. (Kulehn) Most important for me, I saw the advantages that other people in the village got by joining SKY. They got more attention for treatments, had successful operations, and when the village chief’s mother died, SKY helped take the body back home and SKY gave money for the funeral music. I witnessed these things and also other SKY members advised me that joining SKY is good and that SKY will support us. (Kulehn) My daughter was sick again in March two years ago. When I came back home the neighbours came to ask me a lot of questions. And I told them that joining SKY was good. My brother-in-law also joined SKY after this. (Kulehn)

2.1.5 Knowledge and perception of services available to SKY members (provided by SKY staff and public health staff)

what SKY was and how it worked was important to many members. It is evident that some SKY staff worked hard to

Members regularly stated that their perceptions of the

explain and persuade potential members to join and solve

available services and facilities as a SKY member were an

problems when they arose. (Section 3 also presents data that

inﬂuence on their decision to join. The services and

illustrates that services and information from SKY staff were an

information provided by SKY staff were a big inﬂuence on

inﬂuence on sustaining membership or dropping out.)

joining. Having the chance to gain a good understanding of

I like SKY because SKY has good staff like Dr. [name omitted].9 He is a good communicator, is friendly, and always visits to solve SKY members’ problems. I have strong conﬁdence in his treatment and his attention. (Mongkhut) I heard about SKY through Mr. [name omitted], who works for the SKY agency. I joined SKY because I received a clear explanation from Mr. [name omitted]. My husband and I decided to join SKY immediately. (Oaleuk)

9 The

doctor, whose name has been omitted here, provided in-home care during an earlier phase of the programme.

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The perceived quality of services available to SKY members

In one village, trust in SKY was particularly evident as one

provided by public health staff also had an inﬂuence on

staff member had a very good reputation and worked hard to

membership uptake.

build and maintain relationships with members.

The reason I bought SKY was because the doctor provided home care treatment, the SKY agency and the public health staff always visited and followed up daily, and the medicine was effective. I trusted Dr. [name omitted] because he is good at treatment and many people like him and joined SKY because of him. (Mongkhut)

Also worth noting is the proportion of people who commented

particularly the assistance covering funeral costs.

on the support that SKY offers when someone dies,

I joined SKY because when someone dies, SKY helps pay for the music at the funeral and helps by providing some money. (Saomao) I joined SKY because it provides more beneﬁts such as, if we die, SKY gives money for music and the funeral ceremony. (Oaleuk)

The perceived quality of services provided by public health

public health facilities as they relate to membership uptake.

facilities for SKY members also had an inﬂuence on

Section 6 describes members’ and non-members’ perceptions

membership uptake. (This section includes comments about

of public health facilities in more detail.)

I joined SKY because SKY helps us receive treatment for free. We only pay a little money every month. My family had strong conﬁdence in SKY and in the public provider. (Saomao) I joined SKY because I preferred the services of the public provider. I have strong conﬁdence in the nurses and doctors at the health centre. They provide treatment until we are better and they have enough equipment and supplies. It’s better than the private provider as some private providers are not specialists – they make pills with their parents or relatives and sometimes their drugs can make us die. (Mongkhut) I joined SKY because I can get medicine and treatment without having to pay. I thought that SKY and health staff are friendly and pay a lot of attention. (Oaleuk)

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2.1.6 Joined because they trust and believe in SKY Some knew or were related to an insurance agent, and some Some members indicated that they became SKY members

had seen that other people had positive experiences with SKY.

because they trusted and believed in SKY for various reasons.

I was interested in SKY because it can provide treatment for free and I heard that it was good and easy. After the promotion, I trusted SKY because they had a video and I know the SKY staff because they have a relative in this village. (Kulehn) I joined SKY because I saw that SKY really helps and supports its members. Their words are true. For example, SKY gave money to a SKY member who had someone in their family die. (Oaleuk)

2.1.7 Joined because they saw that a lot of other villagers joined

perhaps be an indication of a belief in “safety in numbers” and it could also show how trust is transferred among village

A small number of members said that they joined SKY

members.

because they saw many others in the village join. This could

My family joined SKY because I saw my siblings and [other] villagers joined SKY too. (Oaleuk) I ﬁrst heard about SKY at the village meeting in 2008. I decided to join SKY immediately after the meeting because I understood SKY clearly and saw that other members had good experiences with SKY and because I saw a lot of other villagers joined SKY. (Kulehn) My family decided to join SKY because I saw many people joined SKY and they said SKY was good. (Tiap) I joined SKY because I saw a lot of the neighbours joined SKY. (Tiap)

2.1.8 Joined for reasons of convenience Similarly, a small number of members explained that they joined SKY simply because it was convenient for them.

[I joined because] SKY has good services and medicine, Dr. [name omitted] is very experienced, it [the health centre] is near my home, and the treatment is free. (Lhung) I joined SKY because they provide treatment at home and at night. We can easily take medicine in the health centre because it is near our house. (Mongkhut)

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2.2 People initially dissatisfied with or unconvinced by SKY 2.2.1 Previously did not understand or did not believe it was true While it was not the focus of this study (as there is already some good research into the barriers to SKY uptake), a small

Some comments indicate that people did not initially join SKY

number of reasons why people did not initially join SKY but

as they did not understand SKY very well. In one village

later decided to do so emerged.

(Kulehn), the research team noted in their summary that some villagers did not completely understand or trust SKY.

What’s the point of joining SKY and paying every month because nobody gets sick every single month? (Kulehn) My nephew said that he paid money to join SKY but doesn’t know what for. He paid for it but it’s not useful. He said it’s like “they make cake without ﬂour”.10 It’s like we are feeding them. (Kulehn)

2.2.2 Did not have money right then While some people reported being very interested in SKY,

they said that they did not join straight away because they did not have enough money.

My family didn’t join SKY immediately because I didn’t have enough money to pay the premium. (Oaleuk) I wanted to join SKY soon after the meeting ﬁnished, but I didn’t have the money. (Kulehn)

2.2.3 Wanted to learn more before committing or had heard bad rumours

this, there were also people who said that even though they had heard bad things they wanted to see for themselves and

A small number of people said that they did not join at ﬁrst as

joined to try it out.

they had heard negative things about SKY. However, despite

I wanted to join but I heard villagers say that SKY “makes cake without ﬂour” so I didn’t believe what the SKY agent said. (Kulehn) They [villagers] said that SKY members get treatment after other people. (Kulehn)

10 This

proverb suggests that you cannot follow through with a promise because a key element is missing (i.e. the cake has sugar and decorations, but no flour). The phrase is most often used to describe a scam, although it could also describe a situation in which a lack of resources results in a company failing to deliver a promised service.

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I heard people in my village say that joining SKY is not useful and that it is a waste of money. (Oaleuk) When I ﬁrst heard of SKY, I wasn’t interested because I never knew anything about it and I didn’t understand what they said about it. Also, I heard some bad things about SKY from my neighbours. They said that the health workers and SKY agency don’t pay attention to SKY members when they get treatment in the health centre, that they still must go to the private provider, and also that they don’t have enough money to pay for the SKY premium. Because of hearing about these problems, I waited for two years and observed SKY’s activities. (Oaleuk)

2.2.4 Some diseases are not covered One household reported that they did not join because SKY covers treatment for some diseases but not others.

I understood that SKY is useful and better than private providers because they pay more attention for treatment, but it depends on [the particular] diseases. They have exceptions for some diseases out of principle. (Lhung)

2.3 Primary SKY members Primary SKY members are deﬁned as those who joined SKY

Primary members also tended to trust what they knew about

right away at the village meeting. Primary members

SKY thanks to their family networks – either they had heard

sometimes had some knowledge of SKY prior to the

about SKY operating elsewhere through family connections, or

programme’s launch in their own village. This may have been

they had decided to join through discussions with their

through family members in nearby villages or through family

extended family. This was particularly evident in Saomao

members connected with SKY. One deputy village chief who

where almost all the current members were related to each

could see the beneﬁts of SKY also indicated that he joined to

other and lived in one area of the village (see village map).

set an example for others in his village after the meeting was held in his house (Saomao).

In six of the seven villages, at least half of members were primary members (sometimes as high as two thirds) who

Primary members also tended to understand the beneﬁts of

chose to join soon after they ﬁrst heard about SKY at village

SKY well from the beginning. They understood that if they paid

meetings. Oaleuk was a notable exception where a high

a little money regularly, then they would receive free health

proportion of those interviewed were secondary members.

coverage.

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2.4 Secondary SKY members

Secondary SKY members are deﬁned as those who did not

Some reported that they wanted to join because the beneﬁts

join SKY immediately (for a range of reasons summarised

sounded good but they were not sure if SKY was telling the

above) but become members at a later stage.

truth or not. A frequently reported rumour was that SKY “makes cake without ﬂour” (as explained above, the phrase

Of all the villages where interviews were conducted, Oaleuk was an exception in that it had a high proportion of secondary

suggests an inability to follow through with promised services, either as a scam or due to a lack of resources).

members compared to the other villages. Among these secondary members, the most common reason given for

Data from responses and from the village maps indicate that

delaying membership was that they did not have the money.

secondary members regularly joined when primary members

Not having money to join immediately was the most frequent

lived in nearby homes. The uptake of membership for these

response among all of those who delayed joining in other

secondary members is likely the result of seeing the

villages.

experiences of relatives (families often live in houses close to each other) or other community members, leading to greater

Another interesting reason cited for not joining straight away

trust.

was that respondents did not believe in what they heard at ﬁrst, had heard rumours, or wanted to observe SKY in action

A small number of the secondary members in Oaleuk said

to judge for themselves whether the programme was good for

that one of the reasons they eventually joined was because

their family and the programme ofﬁcers true to their word.

the insurance agent explained SKY clearly to them.

Mr. [name omitted] always visits and explained SKY to me many times, maybe 4 or 5 times. (Oaleuk)

The interviews demonstrated that “not clearly understanding”

before they join. They either trust SKY because they have

SKY was a major reason why some secondary members in all

seen it work (the more cautious secondary members), or

the villages had not joined at ﬁrst.

because they heard good things about it from other villagers or members of their extended family.

Both the primary and secondary membership patterns indicate that many members need to be able to trust SKY

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3. Inﬂuences on Sustaining Membership

Section 5 contains data from the village interviews that reﬂect the themes about continuing to remain a member, or deciding to rejoin the programme after dropping out.

3.1 Why members stay with SKY?

People who have continued to remain members were asked what their reasoning was. The reasons fall roughly into the following categories:

3.1.1 Concerns about disease and accidents in the future The most frequently cited reason that members gave for maintaining their memberships was that they were worried about the possibility of illness, serious disease or accidents, and the potential costs associated with them.

I stay with SKY even though I never go to the SKY hospital for treatment because I am scared of serious diseases in the future. If I get them, I can get treatment at the health centre or other hospital where SKY cooperates without paying any money for treatment. Since I joined SKY, I haven’t had a serious disease, just minor illnesses. (Mongkhut) I am afraid and expect that in the future we will get sick. (Kulehn) I believe in the SKY programme and pay for SKY every month because I am afraid of having a serious disease in the future. With SKY, I will get free treatment. (Tiap) I never dropped out of SKY because I am afraid of getting sick in the future and I think that SKY is improving every day and will [eventually] be as good as in a foreign country. (Tiap) I’m afraid of getting a disease in the future. (Saomao) [according to the village report, 13 different families reported this]

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3.1.2 Trust SKY and are satisfied with the level of care they have received

public health facilities also meant overall positive experiences with SKY.

Members stayed with SKY because they had positive experiences with the programme. Positive experiences with

I continue to stay with SKY because I really like the services that SKY provides and my children are healthier than before. SKY provides support when someone in the family has a serious disease or needs an operation. SKY employees pay attention to treatment. SKY treatment provides a cure that is better than the private providers. Some private providers don’t have enough skill and are careless. Now, SKY insurance provides treatment for more diseases [than before]. (Lhung) My family never had problems with SKY or public health staff. Every time I visit, they always provide my family with good medicine and speak politely. (Lhung) The insurance agent worked to persuade many people to join because he was very active, visited people often, and is friendly and speaks softly. The insurance agent is also known to solve SKY members’ problems. (Kulehn) A few months after I joined SKY, I had pleurisy. I got treatment at the Trapeng Pring Health Centre and I got an X-ray at Angroka Hospital. At both locations, the health workers were friendly and also paid attention to me and I got better. After that, in 2008, my wife had high blood pressure. She got treatment at Angroka Hospital for two nights. At that time, the SKY agency and health workers were very friendly and paid a lot of attention to her and my wife got better and was able to come back home. In March 2009, our family had two more illnesses. My wife had a fallen uterus and needed to get an operation. And my daughter had a baby delivered at Kus Health Centre. SKY provided safe treatment without me having to pay. For all these reasons, I continue to stay with SKY. (Oaleuk) For my family I think that I will stay with SKY forever because it is a protection in the future against diseases or if we need operations. I believe in the public services because they have enough equipment and the employees are polite and efﬁcient. My family will stay with SKY forever; however, in this village, a lot of families have dropped out of SKY. (Saomao) My family got good service from SKY when my daughter had a successful operation. Also, the SKY agency and public health staff are friendly. (Saomao)

An interesting subcategory of members did not believe that the services they had received were positive and yet still

remained members because of the protection that SKY offers against possible future serious health problems.

I used to take my grandson to get treatment at the health centre before I joined SKY. When I arrived there, I got medicine free too but my grandson did not recover, so I decided to take him to get treatment at the private provider. Even though I had this problem, I still stay with SKY because I am afraid of getting a serious disease or needing an operation in the future. (Oaleuk)

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Also in this category were one or two households that trust

have had a preventative effect against illness, perhaps

SKY and remain members because they felt that they have

because they know more about health and are able to get

had fewer illnesses since joining SKY. They considered SKY to

treatment early.

Some families who aren’t sick often trust SKY because no one in their family got sick often since joining SKY. (Oaleuk) [from the team’s summary in village report] I’m really happy with SKY because my children don’t have diseases anymore and they can go to school everyday. For my wife, she has time to work at the garment factory and I can do other work. All these things mean my family’s economic situation has improved. (Khnau)

A few households reported that they stayed with SKY simply because they trusted them because they had seen SKY deliver on its promises to others.

My family will stay with SKY forever because I saw SKY supported other SKY members with their funeral ceremonies. I trust SKY so much because they did what they said that they would do. (Oaleuk)

3.1.3 Appreciate the services and information provided by SKY staff

solve members’ problems and assist them when necessary, including meeting them at hospitals and following up when

Some members stayed due to ongoing good relationships

they returned home.

with and support from SKY staff. SKY staff worked hard to

SKY agency are friendly and polite and always provide an easy way to communicate and resolve any problems of SKY members on time. (Khnau) [in the research team’s summary, ﬁve different families reported this] The insurance agent worked to persuade many people to join because he was very active and visited people often and is friendly and speaks softly. The insurance agent also is known to solve SKY members’ problems. (Kulehn) [from the team’s summary]

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3.1.4 Understand the advantages of insurance and related services (referral, etc.)

of SKY services and their advantages. This included acknowledgement of cheap regular payments rather than

Linked to trusting and being satisﬁed with SKY are data that reﬂected sustaining membership because of an understanding

(sudden) large expenses when ill, and access to fast hospital referrals when necessary.

Some people understand and like SKY services, and understand the advantages. They believe that it’s worthwhile to pay the premium because they are satisﬁed with the services that they receive. (Insurance agent at a health centre) I still stay with SKY even though people say bad things about SKY because I have never encountered any of the bad things that they talk about. I bought SKY because the insurance agent persuaded me and told me that it is cheaper than going to the private provider. I pay less money for the SKY premium. If I pay for one year it’s like [the cost of] joining in [at] one wedding [party]. It’s better for my family that we pay the premium for SKY rather than keep the money [in saving against the possibility of an accident or illness] because going to the private provider is very expensive. (Mongkhut) I joined SKY and pay every month because when we have serious diseases, health centre staff will provide a referral quickly. (Tiap)

3.1.5 Staying with the programme despite the poor reputation of public health facilities

Responses indicated that while rumours may circulate, some people will still check things out for themselves rather than just believe the rumours. Others consider the beneﬁts of SKY

Respondents who stayed with SKY were asked why they continued to stay even though the public health facilities

support to outweigh the problems associated with public health facilities, especially for serious diseases.

sometimes had a poor reputation in the community. I have never had any bad problems with the public hospital. (Saomao) My family still stays with SKY because SKY helps provide free treatment. Only a few of the health staff have bad ethics, are careless, or impolite. (Oaleuk) I decided to join SKY because I wanted to try it and learn about its services [and ﬁnd out if] what they said [was] right or not. (Khnau)

3.1.6 Remaining a SKY member while seeking treatment from private providers

private providers because of their relative convenience. In

An interesting ﬁnding from the village monographs is that

former coverage of primary healthcare. SKY now offers only

many members were also using private providers for minor

in-patient and specialised out-patient hospital coverage.

illness and incidents while retaining their SKY membership.

Despite this reduction in SKY services, these members

They generally reported that they see SKY membership as

continue to retain their membership.

Kandal province, this trend is the result of SKY ceasing its

protection against major problems in the future, but they use

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For small diseases I get treatment at a private provider because it is closer to my house and if we think of the cost of drugs at a private provider compared to the transportation fees to [the nearest] hospital, it is similar. (Mongkhut) My family stays with SKY and still continues to use a private provider because I think that when we have a minor disease we shouldn’t go to SKY at Takmao because it is far away from here and costs too much money for transportation… The private provider is near home and faster. (Mongkhut) Some families who stay with SKY still use the private provider because the private provider is faster than the public services. (Insurance agent at a health centre)

3.1.6 Maintaining membership due to illness, age, or childrearing

SKY because they currently have illnesses or because their households include young children or old people.

A small number of families indicated that they stayed with

I stay with SKY because I have a chronic disease. (Khnau) I don’t drop out of SKY because my family members have diseases. (Oaleuk) [I stay because] my mother is too old. (Oaleuk)

3.2 Why members drop out? There were six main reasons in the data why members chose to discontinue SKY membership.

and/or had problems with the public health staff. Former members stated that health centre staff were rude or did not pay attention to members. (One insurance agent also

3.2.1 Perceived poor quality of care provided by public health services

stated that SKY members could be rude to staff and cause problems too.)

By far the most frequent reason for dropping out was that members perceived the care that they received to be poor

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I dropped out because the nurse said they didn’t know about SKY members and the SKY book while I was having treatment in [the nearest hospital] with [my] SKY book. And they were impolite too. (Khnau) I dropped out because I used to have arguments with the hospital staff. I like the SKY agency but when I had treatment at the hospital, the doctors and nurses were impolite. The nurse was not skilful and didn’t pay attention to the patient. They provided the same pill for different illnesses and the hospital was also dirty. (Mongkhut) I dropped out of SKY because I was upset with SKY staff: they informed me that I had to get treatment at [the nearest] hospital but when I arrived there, the hospital staff and SKY staff were not there. (Lhung) Staying in the hospital we had to pay. But the staff did not take good care of us, they were not friendly. When we asked them questions, they replied that they didn’t know. (Lhung) I think that the health staff is careless with patients who are SKY members. The SKY agency said that they would provide good treatment, but the treatment was bad. I am upset with the SKY agency for lying and with the health centre staff for not providing good treatment. I talked to my husband and said that we should drop out of SKY. (Saomao)

Members also reported that the treatment they received was

same medication for different illnesses could be true, but may

of poor quality or ineffective. Some members reported that the

not indicate medical incompetence (for example paracetamol

medicine they were given was not effective. This may be true

is given for many types of pain, and the same antibiotics may

and there are some examples of this that can be objectively

be issued to people with outwardly dissimilar infectious

conﬁrmed. However, there is also a challenge in interpreting

diseases). In some cases, it may merely reﬂect the perception

such subjective impressions, given that local knowledge of

that the pills are the same colour as something the patient had

healthcare is limited and some people have preconceptions

before. Another widespread misconception is that glucose

about sickness and effective treatment that may be inaccurate

serum by intravenous drip is required for any serious

or untrue. For example, complaints that a patient received the

treatment.11

I had heart disease [cancer] treatment at [the nearest] referral hospital. The doctor injected serum until I had swollen hands, feet and chest. I told the doctor that it hurt in my chest. The doctor said “don’t worry” because I had oxygen. The doctor there threatened me and said that he doesn’t care about my treatment. I stayed at hospital for a few [more] days and then I left there, telling the doctor that I wanted to use the toilet and then departing with my husband, who took me to Calmette Hospital for an operation that cost $5,000. This money was supplied by the church. And after that I decided to drop out of SKY because the doctor and nurses were not friendly, and were careless and impolite to my family. (Mongkhut)

In different regions of Asia, this may or may not be a result of the active promotion of these intravenous treatments by for-profit medical companies. In mainland China, the proliferation of glucose drip treatment is commonly observed, either as a substitute for accurate diagnosis, or in addition to condition-specific treatment intended to raise the total fees charged (or to provide the patient with a sense of value-for-money in paying for other services).

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

I dropped out of SKY because I had a problem with blood pressure and I was treated at [the nearest] hospital. At the hospital, the staff and the nurses were not friendly and were careless, and the place was dirty. I stayed there for three days and got only three tablets of medicine. It is the same as in the Pol Pot regime. The medicine was not effective and I was still sick. I thought it wasn’t good and then left to see a private provider. (Mongkhut) We left SKY because although the public provider did have enough pills, the pills were not effective for my family. So we had to go to the private provider to get treatment. (Khnau) My father was very, very sick and I suggested staff inject serum into my father, but the health centre staff said that there was no serum available at the health centre and that they need to refer him to Angrokar Hospital. I decided to drop out because the health centre staff said that “if you have money, I will inject serum into your father”. My father was very sick and I decided take my father to a private provider that is in front of health centre. (Saomao) Most people, including those who dropped out, are satisﬁed with SKY. But people who dropped out are unhappy with the health centre services [as distinct] from the SKY agency. (Kulehn) [from the team’s summary report]

Sometimes members reported that public facilities didn’t have medicine or members were told to buy medicine at

They saw no point in continuing with SKY membership if they were paying anyway.

outside pharmacies or private providers at their own cost.

We dropped out of SKY because when my child needed treatment the health centre staff said that there was no medicine for treatment. I went to a private provider and spent 100,000 riel. (Saomao) I dropped out of SKY because I went to get treatment twice but health centre staff told me to buy drugs at the pharmacy, paid for by myself. (Kulehn)

A number of members said they dropped out of SKY because

working with the local health centre, and villagers had to travel

it was inconvenient for them to travel so far for treatment. This

all the way to Takmao Town. Some transport costs were

was especially a problem in the villages of Khnau, and

covered by SKY but not enough to cover the full cost of a

Mongkhut (and also nearby Lhung) where SKY had stopped

moto-taxi and it took a long time.

In 2007, my family dropped out of SKY because SKY services changed and SKY started cooperating directly with [the nearest referral] hospital [instead of the local health centre]. The hospital is far away. (Khnau) Although my family trusts SKY, it is very difﬁcult for us to get to Takhmao because it is far from here. If SKY was at [the local] health centre, I could ride a bicycle and take medicine. My family never had problems with SKY. (Lhung)

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Impact Analysis Series . N° 09

3.2.3 Services and information from SKY staff Sometimes members dropped out because of problems communicating with SKY staff. I dropped out because it is difﬁcult for me to connect with the SKY agent. We don’t know clearly who is the SKY agent because there have been many changes in the SKY agents in this village. (Khnau) The SKY agents used to have a close relationship with SKY members. Now, they don’t visit often, they are careless, and also SKY stopped cooperating with the [the local] health centre. (Lhung)

3.2.4 Do not understand the benefits and advantages of insurance very well

insurance. The insurance agent at a health centre reported that he thought this was the reason why some households dropped out. Examples of misunderstandings are evident in

Some members appeared to drop out of SKY because they

some of the members’ comments.

did not really understand how SKY worked or the idea of

Some families don’t understand about the beneﬁts and advantages of SKY. (Insurance agent at a health centre) I dropped out of SKY in March 2006 because I think that nobody was sick and the insurance agent did not explain clearly about SKY services.

3.2.5 Bad experiences or rumours from others in the village or family

some members to cancel their memberships. The following example shows that even though one household had a good

Just as they had inﬂuenced membership uptake, the experiences of others in the village, especially relatives, led

experience with SKY, they still dropped out due to the negative experiences of an extended family member.

I bought SKY because I thought that SKY could help my family reduce our poverty. It was especially important to me that I could have a baby delivered without having to pay the public provider. After becoming a SKY member, I got services at the health centre and my diseases got better. The employees were friendly and always seemed very responsible and supportive. Right now, my family dropped out of SKY because my cousin had high blood pressure and received bad treatment at the [the local] health centre. The staff were careless with the treatment 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. We were not the only family to drop out of SKY. Many families in the village lost conﬁdence in SKY and dropped out. (Khnau)

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

3.2.6 Families that could not afford to pay the premiums Some members could not afford to pay premiums, or dropped their memberships when they reallocated money from insurance to other expenses.

I don’t have money to pay the premium because my children are studying. (Kulehn) I dropped out of SKY because I had no money because my family members are often sick and don’t get better with treatment and I alone earn money [for the family]. But I will rejoin SKY if my family’s economic situation gets better. (Kulehn)

3.2.7 Members are no longer sick Some members do not understand the preventative aim of insurance and only join to get care when they are sick to then

drop out when nobody is sick. (Some of those in this category later rejoin when they get sick again as is evident in the following section on rejoining.)

When I stayed in SKY, our family’s members had many diseases such as stomach ache, dizzy, pained-abdomen, 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 I decided to drop out because now I don’t have any diseases. (Oaleuk) I was very satisﬁed with SKY. I stayed with SKY for seven months. But, because my family is poor, we couldn’t earn money to keep paying for the monthly premium. My husband doesn’t stay at home since he works as a truck driver in Kampot. He got sick and we had to spend a lot of money on his treatment in Kampot since he is not a SKY member. If in the future my family has more money, I would join SKY again. (Saomao)

3.3 Why members rejoint after dropping out

A small number of those interviewed were members who had

pay the premiums again, or got assistance from family (or in

rejoined SKY after they had previously dropped out. Other

two cases, were given assistance by their churches), the

than the few who rejoined because they had enough money to

following were the three main reasons reported for rejoining:

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Impact Analysis Series . N° 09

3.3.1 Improvements in SKY services perceived by some members

Now, I think that the staff at [the nearest] referral hospital have changed a lot. They are friendly and pay more attention to treatment and it is easy to take drugs. In fact, yesterday my daughter was treated at the referral hospital because she has a growth in her nose. The hospital staff paid more attention and the doctors or nurses who used to be impolite became friendly and polite. I’m very happy that they have changed like this. I bring this good news to other villagers. I said that SKY is better than before. (Mongkhut)

3.3.2 Members now understand SKY services better (thanks to explanations by insurance agents)

In truth, I like SKY and am satisﬁed with SKY because the private provider also buys SKY. [The insurance agent] visited my home often even though we dropped out of SKY. (Lhung) [I rejoined because] the insurance agent explained more about SKY. (Lhung)

3.3.3 Members worry about serious diseases and realised the protection that SKY offers

My family stayed with SKY for many years but during that time I dropped out for a short while. While dropped out, I had a womb disease and I had to get an operation. I spent over $1,000 on this disease. After this, I decided to join SKY again. (Mongkhut) In the three years that I’ve stayed with SKY, my family hasn’t had anyone get sick and I also haven’t gotten medicine many times (only two or three times). For this reason, we dropped out. But in March 2009, my family joined SKY again because when we dropped out, I felt as though I was living alone because I was afraid of getting sick in the future. (Oaleuk) I’m afraid of getting a serious disease in the future or afraid of getting a disease that requires an operation. (Lhung)

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

4. Health Services

The data presented in Sections 4 and 5 provided evidence

Section 6 contains further data on the impact that SKY is

that people’s perceptions (and the realities) of the services

perceived to have had on the health centres cooperating

available in government health facilities have a clear inﬂuence

with SKY.

on membership uptake and dropout.

SKY’s impact on health centres

According to interviews with SKY staff, SKY’s impact on health centres was evident. SKY generally entailed an

increased use of public services and a general improvement in the quality of care through better practices.

When SKY ﬁrst began cooperating with the health centre, the staff didn’t understand SKY well. After explaining SKY to the health centre staff in detail, they understood the SKY programme and the health centre staff improved. (Member facilitator at a health centre) Since SKY began cooperating with the health centre, I saw that the health centre has changed. Now the health centre is clean, has soap to wash hands in the bathroom, has garbage cans in the treatment room, has pumped water at its disposal, and has a cleaning ofﬁcer who cleans every day. (Member facilitator at a health centre) The health centre changed because SKY had many members and when they went to the health centre, it improved the health centre. More people came than before, because SKY helped the health centre improve… The health centre has more clients than before and this makes it better. SKY also educates and trains the health centre staff so that they can give better information to SKY members. So, now the health centre provides good services. (Healthcare worker at a health centre)

As health centre staff came to understand SKY better, they also began to explain how SKY works to patients, becoming good advocates for uptake.

The medical doctor has explained SKY services to many SKY members. (Health centre staff member) I told people who came for treatment here to join SKY, especially people who are often sick and poor families. I say that if you have a disease and you need to have an operation, you must spend a lot. I told some people who asked me about SKY insurance the monthly premium amount. I promoted SKY to about 30 people, but only about 5% of the people listened to me and joined SKY. (Health centre staff member)

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5. Summary of Likes and Dislikes

Respondents were asked directly what they liked and

the Cambodian cultural propensity for politeness. Responses

disliked about SKY. There were probably three times more

are grouped into the following main categories (in no particular

likes than dislikes reported, though this may just be a result of

order).

What respondents said they liked most about SKY:

•

We like SKY because we can get treatment for serious

• SKY services are convenient and close.

diseases or operations.

• SKY provides conﬁdence, and has foreigners who help

• Treatment is free.

Khmer.

• SKY staff is friendly, has good relationships with members, and explains things clearly.

• I like it because I have seen that people in the village have had good experiences.

• Public health staff is friendly, professional and attentive.

• SKY offers transport to facilities without paying.

• We pay a little and do not face high costs when sick but can

• SKY has treatment at night.

get treated without paying. • SKY is like a mode of prevention against serious diseases

• SKY offers support for your funeral if we die. • SKY agency works hard and is responsible.

which are unpredictable.

What respondents said they disliked most about SKY:

•

Facility we must use moved from our village to further away.

• It is time consuming to get service at SKY public health services.

• Some diseases, like tuberculosis, are not covered. • SKY staff and insurance agent promotions were deceptive. SKY did not provide what they promised.

• The process is too complicated (or not understood). • Heath centre treatment and medicine is not effective.

• Insurance agent works in many communes and is not available.

• Health centre staff is not friendly.

• Health centre staff is rude/impolite.

• Health centre is sometimes closed or nobody is working

• You still have to buy drugs outside the health centre anyway.

[i.e. on duty] there.

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6. Discussion and Recommendations 6.1 Key findings

Member/non-member profiles

sector care and/or forms of public sector care that are not partnered with SKY. If these other alternatives are

We found the following subgroups of respondents:

affordable and the household prefers them, the household will not join SKY or will drop their membership.

•

Some respondents have crossed a threshold of negative experiences, beyond which point they can no longer trust

Transportation to the nearest facility

SKY, and, perhaps, will remain (permanently or at least durably) apprehensive of the public health sector. In some

Programme changes in three of the villages surveyed meant

cases, this was the avoidable death of a loved one, or

that members had to travel further and at a higher cost to obtain

tremendous pain and suffering that could have been averted;

healthcare. SKY covers some transportation costs, but not all,

in other cases, the individual negative experiences were not

and it does not take into account the amount of time needed to

as serious in isolation but had accumulated over time.

travel to the health facility and back. Opening hours were

Conversely, some respondents have crossed a threshold of

members travelled for an hour only to ﬁnd a closed facility.

uncertain or not well known in many cases, meaning that some

•

positive experiences that results in their continuing to support SKY despite their own bad experiences and the

However, this setback did not affect membership the same

reported bad experiences of others. Many examples of this

way in all villages. Some members felt that their insurance was

were encountered, including those who had rejoined SKY

worth maintaining and they remained members primarily to

after quitting, those who said they would like to rejoin, and

protect themselves against major difﬁculties that would have

those who had been members continuously despite some

high costs. They generally maintained SKY membership in

very serious experiences with SKY and/or the public

conjunction with paying for local private sector providers for

healthcare system.

smaller and cheaper problems. Of course this combination implied that sometimes members had been to a private facility

•

Some respondents sincerely want to maintain their

(possibly with poor treatment or misdiagnosis) before receiving

membership with SKY, but cannot afford to do so. This was

treatment from a public doctor, extending the length of the

found among signiﬁcant numbers of dropout households in

illness and subsequent lost days of work and costs. The

several villages, and could be a special concern for future

qualitative data suggests that those villages with the furthest

programming.

distance to travel to a health facility were more likely to make

Conversely, some respondents are less inclined to rely on

survey taking into account the distance to the closest health

SKY because they have enough money to utilise private

facility would be needed to investigate this further.

this decision. Quantitative analysis of data from the household

•

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Impact Analysis Series . N° 09

Economic changes The need for SKY to earn members’ trust was evident in Changes in the local economy at village level obviously

numerous examples – particularly among secondary

have an inﬂuence on membership uptake and dropout, and

members, who often gave this as a reason for delaying

may have an inﬂuence on maintaining membership. For

membership. Many members needed to see evidence that

example, in villages close to Phnom Penh, women were able

SKY would live up to its claims. However, when SKY was

to work in nearby garment factories providing a good source

trusted, this trust had a very positive inﬂuence on membership.

of income. These villages tended to maintain membership

Some members based their membership decisions on the fact

well, and fewer respondents reported that cost was a factor in

that others in the village trusted SKY, and used this as a basis

ﬁrst joining SKY.

for their own trust.

Family networks

Primary members generally trusted SKY because they knew about the organisation from others or they took the risk and

Family networks were a major inﬂuence on membership

decided to trust the organisation based on the ﬁrst care they

uptake. Often, members ﬁrst learnt about SKY through

received. Secondary members waited to see evidence of SKY

discussions with family members and immediate uptake was

services, and joined when they were sure that SKY could be

often the result of members already knowing about SKY from

trusted. The length of time that SKY operates therefore

family in nearby villages and so on. Related households often

inﬂuences membership as it allows for more opportunities to

join SKY together.

build trust. Where SKY services have signiﬁcantly changed

Community networks

to trust SKY and retain their coverage for serious problems

since they were ﬁrst offered, a proportion of members continue even though minor problems are not covered. Community

networks

also

inﬂuenced

uptake

and

maintenance of SKY membership. Many members learnt

SKY and the public health service

about SKY from neighbours or from watching how SKY helped members in the village respond to health incidents.

Respondents often confused SKY with the public health

Conversely, information ﬂows in the community also

system. What would be the effect of convincing members and

discouraged SKY membership when members heard about

potential members that SKY is advocating on their behalf? It

others who had poor experiences with SKY. In some cases,

would have signiﬁcant effects for poorer members (and

even if they themselves had good experiences, negative

potential members) especially if they felt that they could turn to

stories could cause people to drop their memberships.

SKY for support if, for example, the hospital staff demanded

Trust in SKY

offered for free from SKY, or referred them to pay at a private

improper payments, denied them services that they should be clinic for medicine or services that the public healthcare Being able to trust SKY was an important inﬂuence on initially

system should provide (all commonly encountered examples).

joining and also on maintaining membership when other

However, if the beneﬁciaries felt that SKY was working for the

obstacles arose (such as cooperating with a distant facility).

public health system, they would feel that they were in an

Many members indicated that they became members because

adversarial relationship with their insurance company if they

they trusted and believed in SKY. Trust was both interpersonal

are dissatisﬁed with the health centre’s delivery of SKY’s

(based on relationships with SKY staff in the village) and

promises.

organisational (based on knowledge of SKY and GRET).

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Quality of health services

SKY staff quality and processes

Poor quality healthcare offered in government health facilities

Particularly good SKY insurance agents and member

was a major factor in members dropping out. Respondents

facilitators were regularly cited as major reasons for joining

gave numerous examples, ranging from public facilities lacking

and maintaining membership. Secondary members reported

medicine and SKY beneﬁciaries having to pay for drugs

that they joined SKY after insurance agents visited and

themselves (despite coverage) to various tragic instances of

explained SKY clearly to them.

the wrong treatment being offered or surgery being unavailable in the public system, with families then ﬂeeing to a

Public/private mix

private hospital or paying a non-partnered public provider. There is a commonly found pattern of using SKY as a However, people seemed to be more willing to try

supplement for private (and other paid) services. This

government facilities because of SKY, despite the generally

household strategy reﬂects permanently lowered expectations

poor reputation of public facilities. Rumours about the quality

as to what the beneﬁciaries will get when they approach the

of services were less inﬂuential than expected and we

SKY-partnered hospital, and a corresponding resignation to

generally found that people are more willing to try public

the fact that utilising their own SKY membership is only

facilities if they get treatment for free.

worthwhile for serious (and potentially expensive) diseases due to the difﬁculty of utilisation. For non-serious illnesses, many SKY members only went to public facilities after attempting to get treatment more quickly in the private sector.

6.2 Recommendations Attracting and keeping members

important component in both selling policies and facilitating trust. Particularly in the region we studied, where SKY was

•

Taking the opportunity to follow up on the village meeting

initially experimenting with the beneﬁts package, the

with home visits as quickly as possible to explain SKY more

explanation was complicated because coverage changed

clearly would attract those members that did not

over time. As beneﬁts stabilise, clarity becomes both easier

understand the programme clearly at ﬁrst.

to achieve and more important.

Advertising the “one free month when you buy ﬁve months”

•

Openly addressing the rumours that circulate and

incentive more clearly might help those that felt they had no

encouraging new members to see for themselves could be

money to join at ﬁrst.

an effective strategy (at least where health centres are of sufﬁcient quality). SKY could experiment with “one free

•

Since existing members refer many members, a new

health centre visit” so potential new members could see for

initiative should be tested that tries to amplify this process,

themselves. Alternatively, SKY might provide a small no-

such as “refer a new member who signs up for six months

risk trial such as, “Join SKY, and if you do not like it after

and get one month free”.

your ﬁrst health centre visit you can cancel your

Clearly explaining what is and is not covered is another

plus any payments made in advance”.

membership and we will refund one month’s past payment

•

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Impact Analysis Series . N° 09

•

Employing and retaining good insurance agents and

health centre in the past (but that it has now improved)

member facilitators is one of the foundations for SKY’s long-

could be useful. Trust has a large inﬂuence on membership

term growth. Sometimes it took new members four or ﬁve

so honesty would be respected.

visits from a SKY staff member to understand the programme and decide to join.

•

SKY should play a more active role as ombudsman to collect and relay complaints about public health services. In

•

Continuing to focus on changes and improvements is

the short term, this would help increase trust in SKY. In the

important, especially in regard to the public health facilities.

medium term, SKY would beneﬁt as public facilities improve

Acknowledging that things were not so good at a local

because the value of public sector services would increase.

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Acronyms

AFD

Agence Française de Développement (French Development Agency)

SKY

Sokhapheap Krousar Yeung (Health for Our Families)

GRET

Groupe de Recherche et d’Échanges Technologiques (Research and Technological Exchange Group)

HEF

Health Equity Funds

NGO

Non-Governmental Organisation

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Appendices

Appendix 1:

Kulehn Village Map (Full Detail)

Appendix 2:

Tiap Village Map (Full Detail)

Appendix 3:

Oaleuk Village Map (Full Detail)

Appendix 4:

Saomao Village Map (Full Detail)

Appendix 5:

Mongkhut Village Map (Full Detail)

Appendix 6:

Khnau Village Map (Full Detail)

Appendix 7:

Lhung Village Map (Full Detail)

Appendix 8:

Question Guide

ÂŠ AFD 2012

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Impact Analysis Series . N° 09

Appendix 1: Kulehn Village Map (Full Detail)

Primary Members Not Interviewed (Member or ex-member)

Later Members Newly Joined Ex-Members

Approx. 2km separate the village from the main road (not to scale)

Private Provider Village Chief Traditional Healer Drug Store Rice ﬁelds

Village Gender Issues Advocate Deputy Village Chief

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Appendix 2: Tiap Village Map (Full Detail)

Primary Members Later Members Newly Joined

Rice Fields

Rice Fields Rice Fields

Not Interviewed (Member or ex-member)

Private Provider

Rice Fields

Village Chief Traditional Healer Town Market

Commune Chief

Ex-Members

Deputy Village Chief

Drug Store

Town Hall

Rice ďŹ elds Market area

Veterinarian Ceremonial Gate

University

School PP Road to Phnom Penh

Rice Fields

Rice Fields Rice Fields

ÂŠ AFD 2012

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Impact Analysis Series . N° 09

Appendix 3: Oaleuk Village Map (Full Detail)

Rice Fields

Buddhist Monastery

Primary Members

Lake

Later Members Newly Joined

Rice Fields

Ex-Members Not Interviewed (Member or ex-member)

Rice Fields

Private Provider Village Chief Traditional Healer Drug Store Rice ﬁelds Lake or marsh

Rice Fields

Deputy Village Chief

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Appendix 4: Saomao Village Map (Full Detail)

Primary Members Later Members Newly Joined Ex-Members

Buddhist Monastery

Village Limits

Ceremonial Gateway School

Private Provider Village Chief Midwife

School

Drug Store Rice ďŹ elds

Village Well

Lake or marsh

Deputy Village Chief & Traditional Medicine Provider

Village Limits

Buddhist Monastery

Ceremonial Gateway

ÂŠ AFD 2012

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Impact Analysis Series . N° 09

Appendix 5: Mongkhut Village Map (Full Detail)

Ceremonial Gate

Main Health Centre

Village Limits

Deputy Village Chief

Rice Fields

Rice Fields Primary Members Later Members Newly Joined Ex-Members

Veterinary Hospital

Not Interviewed (Member or ex-member)

Private Provider Village Chief Traditional Healer Drug Store

Bridge

Rice ﬁelds Lake or marsh

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Appendix 6: Khnau Village Map (Full Detail)

Rice Fields

Road to Phnom Penh Buddhist Monastery h Sc

Ri Primary Members Later Members

e Fi

s Lake

Lake

Newly Joined Ex-Members Private Provider Village Chief

Rice Fields

Midwife Drug Store Rice ﬁelds Lake or marsh

Rice Fields

Lake

Rice Fields

This road leads to another local school

Town Hall (Used for ceremonies)

The town’s main health centre (formerly but no longer part of the SKY program)

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Impact Analysis Series . N° 09

Appendix 7: Lhung Village Map (Full Detail)

Special lot for raising chickens

Bridges (two)

Rice Fields

Feed Lot

Rice Fields

Rice Fields Primary Members Later Members Newly Joined

Rice Fields Commune Police HQ School

Commune Hall

Rice Fields

Ex-Members Not Interviewed (Member or ex-member)

Private Provider Village Chief Traditional Healer Drug Store Rice ﬁelds Lake or marsh

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Appendix 8: Question Guide Village Monographs – Understanding SKY Membership Decisions

District OD: ……………………….… District: ……………………………… Commune: ……………………….…. Village/Cluster: ……………….…….. Date: ……. Month: …..Year: ……… Name: ………………………………. Introduction

Hello. How are you? My name is ________ and I am working with Domrei Research and Consulting. I came here because I would like to ask you some questions, and discuss SKY’s service with you. I would also like to know if you are satisfied or dissatisfied with SKY. Don’t worry about what we discuss. Everything that you tell me is entirely private and confidential, and I will not talk to other members in your family or anyone about what you have said. If there is a question you do not want to answer you don’t have to answer it and if you want to ask me a question at any time you can. I thank you in advance for spending your time in this interview. This interview will take only 30 minutes. All of your answers are very important. It is not a test. There are no right or wrong answers. Therefore, I want to ask you to answer correctly and honestly. Your answers will be given to our company provider to improve insurance in your village. If you have any questions about this research or the survey, you can contact the Domrei administrator Khim Sarun on 023 222 501.

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Do you have any questions for me?

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Can I start asking my questions now?

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I would now like to ask you some questions about SKY insurance.

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Impact Analysis Series . N° 09

Question Guide for SKY Members

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Question 1: 1. When did you ﬁrst hear the name SKY? 2. Who ﬁrst mentioned the name SKY to you? 3. What did he or she tell you about SKY? 4. Did you understand what they were saying about SKY and what SKY is or not?

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Question 2: 1. What did you think when you ﬁrst heard about SKY insurance? 2. Were you interested in SKY insurance or not? 3. Why weren’t you interested?

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Question 3: 1. At that time, what were other people in the village saying about SKY? 2. Did anyone gossip about SKY? 3. What good things did they say about SKY? 4. What bad things did they say about SKY?

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Question 4: 1. At that time, what were people in your family saying about SKY? 2. What good advice did people in your family give you about SKY? 3. What bad advice did people in your family give you about SKY?

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Question 5: 1. When you ﬁrst heard about SKY, what was happening in your family? 2. When you heard about SKY, were you busy with the harvest? 3. When you heard about SKY, were you busy spending money for a wedding in your family? 4. When you heard about SKY, was your family having any problems or not? 5. When you heard about SKY, was anyone in your family sick or not?

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Question 6: Additional question(s) from the interviewer 1. …………………………………………..? 2. …………………………………………...? 3. ……………………………………………?

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Question 7: Situation of people who decided to join the SKY insurance programme 1. When did you decide to join SKY insurance? 2. Why did you decide to join SKY insurance? 3. How long (months/years) after SKY ﬁrst started in your village did you join SKY?

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

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Question 8: 1. Did you join SKY immediately or did you wait and see before joining? 2. At the time, did you wait because you needed to get the money together before you could join? 3. At the time, did you have to convince other people in the family to join SKY or not? 4. Did you have to wait for the SKY insurance agent to come to your village or not?

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Question 9: The ﬁrst time people got sick in their family 1. Did someone in your family get sick for the ﬁrst time after you joined SKY insurance? 2. How did they get sick? 3. What illness did he/she have? 4. Was it a serious illness or not?

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Question 10: 1. What did you do when someone in your family got sick? 2. Did you go to the health centre for treatment? 3. Please describe the health centre that you attend. 4. Was the staff in the health centre polite or not? 5. Was the staff in the health centre friendly or not? 6. Was the member facilitator in the health centre helpful or not? 7. Was the health centre clean or dirty?

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Question 11: Reasons for continuing SKY insurance 1. When did you pay more money to continue SKY insurance? 2. Had anyone in your family been sick before you paid money to continue with SKY insurance? 3. Why did you pay money to continue SKY insurance? 4. When you paid to continue with SKY, what was your rationale? Was it to help your family develop or for a different reason? What reason? 5. If so, how has this helped your family develop?

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Question 12: Reason(s) for leaving SKY insurance 1. When did you leave SKY insurance? 2. Did anyone in your family get sick after you joined SKY? 3. Why did you leave SKY insurance? 4. When you decided to leave SKY, what was your rationale? Was it to help your family develop or for a different reason? What reason? 5. If so, how has this helped your family develop?

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Impact Analysis Series . N° 09

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Question 13: On rejoining SKY insurance 1. Why did you stop your SKY insurance membership? 2. Did somebody get sick after you left SKY insurance? 3. When did you join SKY again? 4. Why did you join SKY again? 5. Was your rationale for joining SKY that it was a positive development for your family or not? If not, how so? 6. If so, how has this helped your family develop? 7. …………………………………………….?

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Question 14: 1. How did you hear or learn about SKY? 2. Why did you stay with SKY insurance? 3. Why did you buy SKY insurance despite the government health services’ poor reputation? 4. Why did you stay with SKY insurance instead of dropping out? 5. Why did you drop out? 6. Have you gone to a private doctor or not for treatment since you bought SKY insurance? 7. If not, skip to Q8. If yes, please ask: Why did you continue go to a private doctor for treatment when you had already bought SKY insurance? 8. Think about people who already buy SKY insurance. Why would they continue go to a private doctor for treatment when they have health problems? 9. Why don’t you drop out if SKY isn’t meeting your expectations? 10. Why are you still waiting and what are your expectations? 11. Why do you like SKY? 12. Why do you think SKY is good and has a good reputation? 13. In your opinion, what changes could be made to improve SKY? 14. What do you think would make people like SKY more? 15. What can we do to make more people buy SKY insurance?

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

Question Guide for Village Chiefs

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Asking about the situation in the village and SKY insurance 1. How many people are in your village? 2. How many kilometres is your village from a large main road? 3. How many kilometres is your village from a narrow road? 4. How many kilometres to is it to a health centre? 5. How many minutes/hours does it take to reach the health centre by motorbike? 6. How much money does it cost to go to the health centre and return? 7. Where did SKY have its insurance representation? 8. When did they start SKY? 9. When did the SKY programme start? 10. When did SKY start the next programme? 11. Think about people who buy SKY insurance. When they have health problems, why would they continue to go to private doctors for treatment? 12. Why do some people like SKY? 13. Why do some people not like SKY? 14. Why don’t some people drop out? 15. Were SKY members happy to have SKY insurance in their village? 16. Do you think the pubic health service is good or not? If not, how bad is it? 17. Are the services provided by the insurance agent to people good or not? If not, how bad are they? 18. Why are SKY and its reputation good? 19. In your opinion, what changes could be made to improve SKY? 20. What do you think would make people like SKY more? 21. What can we do to make more people buy SKY insurance?

For Insurance Agents

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Ask insurance agents about the situation selling SKY health insurance 1. When did the SKY programme start? 2. When did SKY start the next programme? 3. Why did some people drop out? 4. Why did some people stay with SKY insurance rather than drop out? 5. Think about people who already buy SKY insurance. Why would they continue to go to private doctors for treatment when they have health problems? 6. Why do some people like SKY? 7. Could you please explain using SKY insurance and what insurance is because we don’t really understand? 8. What did you say to convince people about SKY insurance? 9. What do you think we could do to improve SKY enrolment and SKY’s reputation?

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Impact Analysis Series . N° 09

For Member Facilitators

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Ask about the relationship between health centres and SKY membership. (Village monographs – Interviews with health centre staff) Objective: describe SKY’s impact on the health centre, and the health centre’s impact on SKY membership

SKY’s impact on the health centre •

Question 1: Can you tell me about SKY at the health centre? 1. When did you ﬁrst hear about SKY? 2. When did SKY start working with your health centre? 3. What did they do? 4. What did they ask you to do? 5. …………………………………?

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Question 2: SKY’s impact on the health centre staff 1. What does SKY do? How does it work? 2. What is good about SKY and what is bad about SKY? 3. Have you noticed any changes since SKY has been at the health centre? 4. What changes did you see? 5. How does SKY affect your work? 6. Do you feel there have been any positive changes in your work because of SKY? 7. Do you feel there have been any negative changes in your work because of SKY? 8. …………………………………………………

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Question 3: SKY’s impact on the health centre as a whole 1. How has SKY affected this health centre? 2. Do you feel there have been any positive changes in the health centre because of SKY? 3. Do you feel there have been any negative changes in the health centre because of SKY? 4. …………………………………………………

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Question 4: Can you please tell me about the member facilitator that worked here? 1. What did he/she do in the health centre? 2. Do you feel that he/she affected your work? 3. How do you feel he/she have affected your work? 4. Did the member facilitator have any good ideas to help you? 5. What could make good ideas for the member facilitator to be more helpful? 6. ………………………………………………….

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Sky Impact Evaluation, Cambodia, 2010 - Village Monographs

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Question 5: 1. Are more people coming to the health centre because of SKY? 2. How do you feel about more people coming to the health centre? 3. If the health centre has more clients, is this normal or not? 4. ………………………………………………….

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Question 6: Are SKY members different from other health centre patients? 1. How do ordinary people behave when they come to the health centre? 2. How do SKY members behave when they come to the health centre? 3. How are SKY members different from other clients at the health centre? 4. When clients came in, can you tell if someone is a SKY member by how they behave? 5. ………………………………………………….?

Health centre’s impact on SKY membership •

Question 7: Do you talk about SKY? 1. Do you talk about SKY with other health staff? 2. What did you discuss? 3. Do you talk about SKY to other people? 4. What do you tell them about SKY, and what do they say? 5. Do you talk about SKY to SKY staff (member facilitator, insurance agent)? 6. What did you discuss and what do they say about SKY?

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Question 8: 1. Do you talk about SKY to SKY members? 2. What do they say about SKY? 3. What do you tell them about SKY? 4. ……………………………………….?

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Question 9: 1. Do you talk about SKY to non-members? 2. What do they say about SKY? 3. What do you tell them about SKY? 4. ……………………………………….?

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Impact Analysis Series . N° 09

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Question 10: 1. Have you encouraged anyone to join? 2. What did you tell them about SKY? 3. After what you said, did they join? 4. What do you think convinced them to join SKY? 5. …………………………………………………….?

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Question 11: 1. Have you encouraged anyone to drop out of SKY? 2. What did you say to them to encourage them to drop out of SKY? 3. After what you said, did they drop out? 4. What do you think convinced them to drop out of SKY? 5. ………………………………………………………….?

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Question 12: 1. Have you discouraged anyone from joining SKY when they wanted to join? 2. What did you say to them to discourage them? 3. What did they do after what you said? 4. What do you think convinced them not to join? 5. .………………………………………………….?

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Question 13: 1. Why did you buy SKY insurance despite the government health services’ poor reputation? 2. Why do people stay with SKY insurance? 3. Why don’t people drop out? 4. Why do they drop out? 5. What changes in the health centre were caused by SKY insurance? 6. Since SKY insurance began here, has it had a positive impact on the health centre? 7. Since SKY insurance began here, has it had a negative impact on the health centre? 8. Since SKY insurance began here, has it helped develop the health centre? 9. How do ordinary people behave when they come to the health centre? 10. How do SKY members behave when they come to the health centre? 11. How do you feel when SKY members come often? 12. Do you feel happy when SKY members come often? 13. How did you feel when the health centre worked with SKY insurance? 14. Since SKY insurance has been present, has the health centre been cleaner or dirtier?

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