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User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes


  • Akashi, Hidechika
  • Yamada, Takako
  • Huot, Eng
  • Kanal, Koum
  • Sugimoto, Takao


User-fee programs have been introduced at health care facilities in many developing countries. Difficulties have been encountered, however, especially at public hospitals. This report describes the effects of user fees introduced in April 1997 at a public hospital, the National Maternal and Child Health Center (NMCHC) of Cambodia, on patient utilization, revenue and expenditure, quality of hospital services, provider attitudes, low-income patients, and the government, by reviewing hospital data, patient and provider surveys, and provider focus group discussions. Before the introduction of user fees, the revenue from patients was taken directly by individual staff as their private income to compensate their low income. After the introduction of user fees, however, revenue was retained by the hospital, and used to improve the quality of hospital services. Consequently, the patient satisfaction rate for the user-fee system showed 92.7%, and the number of outpatients doubled. The average monthly number of delivery of babies increased significantly from 319 before introduction of the system to 585 in the third year after the user-fee introduction, and the bed occupancy rate also increased from 50.6% to 69.7% during the same period. As patient utilization increased, hospital revenue increased. The generated revenue was used to accelerate quality improvement further, to provide staff with additional fee incentives that compensated their low government salaries, and to expand hospital services. Thus, the revenue obtained user fees created a benign cycle for sustainability at NMCHC. Through this process, the user-fee revenue offered payment exemption to low-income users, supported the government financially through user-fee contributions, and reduced financial support from donors. Although the staff satisfaction rate remained at 41.2% due to low salary compensation in the third year of user-fee implementation, staff's work attitude shifted from salary-oriented to patient-oriented--with more attention to low-income users.

Suggested Citation

  • Akashi, Hidechika & Yamada, Takako & Huot, Eng & Kanal, Koum & Sugimoto, Takao, 2004. "User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes," Social Science & Medicine, Elsevier, vol. 58(3), pages 553-564, February.
  • Handle: RePEc:eee:socmed:v:58:y:2004:i:3:p:553-564

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    Cited by:

    1. Jean-Paul Moatti & Bruno Ventelou, 2009. "Économie de la santé dans les pays en développement des paradigmes en mutation," Revue économique, Presses de Sciences-Po, vol. 60(2), pages 241-256.
    2. Ensor, Tim & Ronoh, Jeptepkeny, 2005. "Effective financing of maternal health services: A review of the literature," Health Policy, Elsevier, vol. 75(1), pages 49-58, December.
    3. Matsuoka, Sadatoshi & Aiga, Hirotsugu & Rasmey, Lon Chan & Rathavy, Tung & Okitsu, Akiko, 2010. "Perceived barriers to utilization of maternal health services in rural Cambodia," Health Policy, Elsevier, vol. 95(2-3), pages 255-263, May.
    4. Flores, Gabriela & Ir, Por & Men, Chean R. & O’Donnell, Owen & van Doorslaer, Eddy, 2013. "Financial protection of patients through compensation of providers: The impact of Health Equity Funds in Cambodia," Journal of Health Economics, Elsevier, vol. 32(6), pages 1180-1193.
    5. Danyliv, Andriy & Groot, Wim & Gryga, Irena & Pavlova, Milena, 2014. "Willingness and ability to pay for physician services in six Central and Eastern European countries," Health Policy, Elsevier, vol. 117(1), pages 72-82.
    6. Vian, Taryn & Grybosk, Kristina & Sinoimeri, Zamira & Hall, Rachel, 2006. "Informal payments in government health facilities in Albania: Results of a qualitative study," Social Science & Medicine, Elsevier, vol. 62(4), pages 877-887, February.
    7. Ir, Por & Bigdeli, Maryam & Meessen, Bruno & Van Damme, Wim, 2010. "Translating knowledge into policy and action to promote health equity: The Health Equity Fund policy process in Cambodia 2000-2008," Health Policy, Elsevier, vol. 96(3), pages 200-209, August.
    8. Xu, Ke & Evans, David B. & Kadama, Patrick & Nabyonga, Juliet & Ogwal, Peter Ogwang & Nabukhonzo, Pamela & Aguilar, Ana Mylena, 2006. "Understanding the impact of eliminating user fees: Utilization and catastrophic health expenditures in Uganda," Social Science & Medicine, Elsevier, vol. 62(4), pages 866-876, February.
    9. Ensor, Tim & Chhun, Chhim & Kimsun, Ton & McPake, Barbara & Edoka, Ijeoma, 2017. "Impact of health financing policies in Cambodia: A 20 year experience," Social Science & Medicine, Elsevier, vol. 177(C), pages 118-126.
    10. Witter, Sophie, 2012. "Health financing in fragile and post-conflict states: What do we know and what are the gaps?," Social Science & Medicine, Elsevier, vol. 75(12), pages 2370-2377.
    11. Tim Ensor & Robin Thompson, 2012. "Unofficial Payments in Low- and Middle-income Countries," Chapters,in: The Elgar Companion to Health Economics, Second Edition, chapter 15 Edward Elgar Publishing.


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