Presented by Rajpreet Sandhu , Consultant October 5, 2011

1. Safe Motherhood ProgrammeImpact EvaluationSKY Health InsuranceMaternal & Infant ProtectionPhnom Penh & Kampot Presented by RajpreetSandhu, Consultant October 5, 2011

2. Safe Motherhood Programme Objective of Programme • To improve the health status of women of reproductive age by escalating the degree and accessibility of medically attended deliveries • To provide a continuum of support and care to women from the pre-pregnancy period right through to the neonatal period

3. SMP Maternity Grant • All female members, aged between 15-49 years of age, must register as a SMP member within 1st-6th months of pregnancy (up to 28 weeks) • Direct Cash Incentive to all registered pregnant women who actively comply with certain conditions • Programme active in Phnom Penh (2006) and Kampot (2008)

4. SKY Maternal Healthcare Services • In-patient standard ward accommodation, • Antenatal care, • Referral of high risk pregnancies to Ob-Gyne specialist, • Coverage of medically-necessary abortions and post-abortion care, • Coverage of normal and caesarean-section deliveries, • Referral to Family Planning/ Birth Spacing services, • Referral to the VCCTs for HIV testing, and to the PMTCT services if results positive, • Provision of essential drugs, including Ferrous if the mother is recognised as being anaemic, • Provision of micronutrients and advice on nutrition relevant to safe pregnancy, • Post-natal care, • Referral of the newborn to immunization services.

5. Maternity Grant Conditions Part I: Grant amount- Phnom Penh - $15 , Kampot - $10 • Attendance of a minimum of 3 antenatal-care check-ups, • Testing for HIV, and to further access PMTCT services if positive, • To have a medically attended delivery either at the health-centre or referral hospital. Part II: Grant amount- Phnom Penh - $20 , Kampot - $20 • Attendance of a minimum of 2 post-natal-care check-ups, • To have the newborn immunized within the first 4 months of birth.

6. Methodology • Quantitative Component: Extracted from the available GRET/SKY database between 2007-2010 • Qualitative Component: Employed focus group discussion’s (FGD’s) for data generation 11 FGD’s were conducted in Kampot and 5 FGD’s were conducted in Phnom Penh A total of 100 women, representing 12% of the total number of SMP beneficiaries and 8% of the total target population, participated in the discussion groups • Limitations: Lack of representation from beneficiaries who half complied with the SMP Protocol

7. Findings: SMP Beneficiaries Urban & Rural A total of 851 women have benefited from the SMP in Phnom Penh and Kampot, over a period of five years (2006-2010) : • 23% of beneficiaries from urban Phnom Penh, 195 women – Programme commenced April 2006 • 77% of beneficiaries from rural Kampot 656 women – Programme commenced May 2008.

8. Key Data, Urban & Rural

10. SKY-Insured Birth Deliveries • Between 2006 and 2010, within a time-span of 55 months, a total of 1,307 birth deliveries took place amongst SKY members, of which 65% registered onto the SMP • 65% SKY insured members registered and complied fully or partially with the SMP protocol

11. Rural Birth Deliveries • KAMPOT: A total of 1,013 deliveries took place, of which 65% were registered SMP members • 2:5 of all birth-deliveries in rural Kampot went unregistered onto the SMP

12. Urban Birth Deliveries • Phnom Penh has an SMP representation of an average of 66% per year amongst all SKY-insured deliveries, indicating that near to 1:3 of all SKY-insured pregnant women in urban Phnom Penh went without registering onto the SMP

13. 2007-2010 SKY Birth Deliveries

14. Rural & Urban Compliance with Protocol • 3:4 members of the SMP fully complied withthe conditions of the programme • Kampot, July 2008 – September 2010 (27 months): 78% of total beneficiaries fully complied with SMP protocol, 22% were recorded to have partially complied. • Phnom Penh, June 2006 – September 2010 (52 months): 76% of the total beneficiaries fully complied with the SMP protocol, 24% partially complied with the programme.

15. Change of Grant Amount in Phnom Penh • Maternity Grant decreased by $10 in 2008 • No impact on enrolment- Registered members increased by 4% • Impact on full compliance: 2nd Grant = $30, 84% fully completed the SMP 2nd Grant = $20, 65% fully completed the SMP

16. Antenatal Care Check-ups (ANC) • Advice on how to detect dangers and complications during pregnancy highly valued by members. The educational aspect goes beyond primary objective of the programme. • SMP Protocol motivates expecting mothers to progressively attend the required number of check-ups, and to seek advice when needed. “When I became a SKY member I became more knowledgeable on health. It’s good because I didn’t know anything before. Everything you offer I would like to do. If you added more steps I will still follow. I am uneducated and so I have to follow for my health. Before I did not know how to take care of myself during pregnancy. I am getting treatment for not paying, so I am very happy with this.”- HEF Member, Kampot “I can know more about taking care of my own health. We get more knowledge from this programme as it teaches us. If for our own we would not think to take care of our health like this, but the programme pushes us to take care of the health.”- SKY Volunteer Member, Kampot

17. Micronutrients, Dietary Advice, and Medication Appropriate for Safe Pregnancy “I know how to protect my health. The nurse and doctor gave me medicine, and nutritional vitamin to make me healthier for the baby’s delivery. I can take this medicine in my house. The vitamin supplements were new for me”- SKY Volunteer Member, Inactive, Kampot “When I get sick I know about the medicine to take during pregnancy. If I take the other medicine without the advice from the doctor I know it is dangerous now. Now I know I can not take antibiotics without advice from doctor. When I go to the check-up I can get this advice.” - SKY Member, Phnom Penh

18. HIV Testing for Prevention of Mother-to-Child Transmission • 54% of the total number of beneficiaries of the SMP in Kampot is aged 15-26 years. • 100% of all the women on the SMP were tested for the virus. “For me not being a SKY member means I would probably not go get my blood tested for HIV. With SKY I have to get my blood tested and this is good for me”- SKY Volunteer Member, Ethnic Cham, Kampot “First I got the advice from the nurse. And also I got the medicine, the vitamin for my health, and got the injections/ vaccine of Tetanus. Also I got blood tested for HIV. If I was on my own self I would not have checked this, but finally the programme gave me a chance to get this done on the programme.”- SKY Member, Phnom Penh

19. Impact on HEF Members “Before becoming a SKY member I did not follow everything – the HIV testing or ANC. I never knew about this before. Now as a SKY member the nurse has given me advice and informed me about this. Now I know more as a SKY member.” “I have 3 children. Two were delivered at home, and one delivered at the health centre when I became a SKY member. I know a lot now, especially about the dangers of delivering in the house. The doctor and nurse tell me they can guarantee with the healthy and the safety. But if we deliver in the house they cannot guarantee, so I know to come to the health centre to check my health and for delivery.” “Before I would just stay in my house. But now when I am sick I go to the HC. When the baby has a problem we go to the HC.”

20. Identified Challenges • Negative perception of services delivered at the Provincial/ Referral hospital • Discrimination based on presenting SKY booklet • Unfriendly/ impolite service “We don’t want the bad service. An example: I go to the hospital to check with my sister. When we showed the SKY booklet they say ‘oh SKY, you are a SKY member, you are lucky you come and don’t pay. We are busy so wait and come again’. This happened to me during pregnancy. I am old and so decided to have an abortion during the pregnancy. The provincial hospital staff ignored me and asked me to come again and again another time. This is why I do not want the SKY.”- SKY Volunteer Member, Ethnic Cham, Kampot

21. Identified Challenges • Opportunity costs: Transportation expenses and loss of earnings • Physical constraints to walk and cycle to Health Centre • Loss of daily earnings to attend check-ups (Phnom Penh) “I have no problem but my husband does, because he must get permission to take me to the hospital to do the check-up.” “I work selling in my store. When I come to check-up I have to close the shop and lose profit. But I know I will get the grant which would give me money for where I have lost profit.” - Respondents from Phnom Penh FGD

22. Greatest Impact – Reassurance! • No out-of-pocket expense at time of delivery • Assured of birth delivery with a skilled practitioner “A grant is a part useful. The priority for me is when I became a SKY member with SMP, I can deliver my baby in safety and it will not cost. Sometimes I do not know when the baby will arrive and if the family will have any money or not. When I became a SMP member I was not afraid, I feared nothing to do with money. I was happy. I protected my health until delivery. The grant that I got was just a part of being useful too. I could spend the money.” - SKY Volunteer Member, Kampot

23. Recommendations • The practice of payments given to health care providers as a condition for care by SKY members should be curbed as such practices hinder the objective of SKY and impose severe burdens on poorer families. • Ensure HEF members are informed about SMP benefits and efforts are made to ensure the information is correctly digested by working in closer collaboration with the Pagodas and Mosques component • Improve enrolment and full compliance rates with continuous training of SKY agents on communication. Through this use the Village Meetings to further increase awareness on safe motherhood and the necessity of post natal care and infant-vaccination.

24. End of Presentation