The Exploring the Effects of Recent Health Equity Fund Reforms on Hospital Performance: A Case Study in Kralanh Referral Hospital, Cambodia.


Hospital performance
Case study
Krolanh referral hospital
Health equity fund reforms



Lihov Mann1, Por Ir1,Kanha Sok1, 2

  1. School of Public Health, National , NIPH, Phnom Penh, Cambodia
  2. Department of Planning and Health Information, Ministry of Health, Cambodia

*Corresponding author: Mann Lihov, Email:


In developing countries with scarce resources and poor governance, access to effective and affordable health care remains a major problem, especially for the poor and disadvantaged population groups. In Cambodia, Health Equity Fund (HEF) took its role as a decentralized pro-poor health financing mechanism to enable access to public health services for the poor by paying user fees and associated costs on their behalf. HEF accounted for 7% to 52% of total hospital use and had a positive impact on the volume of hospital service utilization by poorest patients. In order to improve the impact and sustainability of HEF, the Ministry of Health has streamlined the HEF system and initiated a number of reforms. We explore positive and the negative effects of the HEF reforms on hospital performance and provide recommendations for improvement.


We conducted an in-depth case study, focusing on the implementation of HEF in Kralanh referral hospital from 2016 to 2019. Data was collected from routine monthly HEF monitoring and quality score assessed quarterly as part of Health Equity and Quality Improvement Project, coupled with qualitative primary data collected through in-depth interviews. Quantitative data was analyzed by using Microsoft Excel and qualitative data was analyzed manually and thematically. In addition, literature review and document analysis were conducted.


The hospital service utilization decreased after HEF operator transferred its roles and responsibilities to the hospital along with the removal of HEF promotion and post-ID. However, the decline was gradually recovered after the introduction of new benefit package and the restart of post-ID. Monthly user-fee revenues doubled between 2016 and 2019. The total quality assessment score increased from 29% in the first quarter of 2017 to 72% in the second quarter of 2019. Client satisfaction level increased to over 95% in 2018 and 2019. Along with HEF reforms, there were other reforms such as the introduction of H-EQIP which could also contribute to improving the hospital and staff revenue and quality of care.


The recent HEF reforms generally have had a positive effect on hospital performance in terms of increased service utilizations, improved quality of health service and level of client satisfaction. The drop of patients’ utilization after transfer of roles and responsibilities from HEF operator to the hospital gradually recovered especially after introducing new HEF reforms and monthly monitoring by HEF implementer. This provides the opportunity for strengthening management, building awareness, ownership of staff, and sustainability. However, there are remaining challenges such as the absence of health promotion activity, long waiting time for clients and insufficient of health care staff. We propose recommendations to overcome these challenges and inform future reforms.