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VILLAGE MONOGRAPHSSUMMARY REPORT

Ian Ramage, Kim Hour Ramage, Eisel Mazard, Mark Kavenagh, Gabriel Pictet and David Levine

SKY IMPACT EVALUATIONCAMBODIA

2010

omrei Research and ConsultingMeaningful research for advocacy and action

SKY Village Monographs Summary Report 2

ACKNOWLEDGEMENTS

The Village Monographs are an important element of the SKY micro health insurance Impact Evaluation, funded by AFD, 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 the research design as well as the analysis and reporting stages together 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 each 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, Domrei’s intern for her assistance with preparing the Village Reports.

We also express 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 micro health insurance.

Special thanks to our friends at GRET who assisted with the Village monographs. Thanks to Marielle Goursat for her ongoing assistance throughout the project. Thanks also to Peo Pisey and Nev Vannak for their help supplying and clarifying figures. In addition, we would like to thank Cedric Salze for the assistance and support he has always offered with 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 for sharing valuable information with our team that will contribute to improving SKY micro health insurance.

Domrei Research and ConsultingMeaningful research for advocacy and action


TABLE OF CONTENTS

Acknowledgements.....................................................................................................................2Table of Contents.........................................................................................................................3

Tables.........................................................................................................................................4

Figures........................................................................................................................................4

Acronyms......................................................................................................................................5Section 1: Introduction................................................................................................................6

SKY Health Insurance................................................................................................................6

Research Objective....................................................................................................................7

Section 2: Methodology...............................................................................................................7Data Collection and Analysis......................................................................................................7

Section 3: Village Maps and Findings........................................................................................9Number of Interviews by Village.................................................................................................9

Kulehn Village...........................................................................................................................10

Tiap Village...............................................................................................................................12

Oaleuk Village..........................................................................................................................14

Saomao Village........................................................................................................................17

Mongkhut Village......................................................................................................................21

Khnau Village...........................................................................................................................24

Lhung Village............................................................................................................................26

Section 4: How and Why do People Become SKY Members?...............................................30Satisfied SKY Clients...............................................................................................................30

People Initially Dissatisfied with or Unconvinced by SKY........................................................33

Primary SKY Members.............................................................................................................34

Secondary SKY Members........................................................................................................35

Section 5: Influences on Sustaining Membership..................................................................36Why Members Stay With SKY..................................................................................................36

Why Members Drop Out...........................................................................................................39

Why Members Rejoin After Dropping Out................................................................................42

Section 6: Health Services........................................................................................................43Impact of SKY on Health Centres............................................................................................43

Section 7: Summary of Likes and Dislikes..............................................................................43Section 8: Discussion and Recommendations.......................................................................44

Key findings..............................................................................................................................44

Recommendations...................................................................................................................47

Appendices.................................................................................................................................48Domrei Research and ConsultingMeaningful research for advocacy and action


TABLES AND FIGURES

TABLES

Table 1: Interviews by village.............................................................................................................9

Table 2: How families first learned about SKY.................................................................................10

FIGURES

Figure 1: Small Map of Kulehn Village.............................................................................................10

Figure 2: Small Map of Tiap Village.................................................................................................12

Figure 3: Tiap Village in Detail.........................................................................................................13

Figure 4: Small map of Oakleuk Village...........................................................................................15

Figure 5: Oaleuk Village in Detail.....................................................................................................17

Figure 6: Small Map of Saomao Village...........................................................................................18

Figure 7: Somao Village in Detail.....................................................................................................19

Figure 8: Small Map of Mongkhut Village........................................................................................21

Figure 9: Mongkhut Village in Detail................................................................................................23

Figure 10: Mongkhut Village in Detail 2...........................................................................................23

Figure 11: Small Map of Khnau Village............................................................................................24

Figure 12: Small Map of Lhung Village............................................................................................27



ACRONYMS

AFD Agence Française de Développement (French Development Agency)

SKY Sokhapheap Krousar Yeung (Health for our Families)

GRET Groupe d'échange et de Recherche Technologiques (Research and Technological Exchange Group)



SECTION 1: INTRODUCTION

The SKY micro health insurance program, run by the Research and Technological Exchange Group (GRET) is an innovative attempt to extend health insurance to Cambodians, with special initiatives reaching out to both the rural and urban poor.

The University of California, Berkeley in collaboration with the Cambodian Research Firm, Domrei Research and Consulting are conducting a longitudinal impact evaluation of the SKY micro health insurance project. The study aims to measure the impacts of health insurance on the rural poor in Cambodia and to shed light on the reasons households choose to purchase, or abstain from purchasing, voluntary health insurance. The project includes both quantitative and qualitative components. As part of the qualitative component, the Village Monograph surveys were completed in 2009.

The Village Monographs, summarised in this report, provide detailed qualitative analysis of the dynamics of SKY membership over time and the effects of SKY on members and non-members. The reasons why people refuse to join SKY have been documented in several complementary studies1. This qualitative study builds on this knowledge and adds to our understanding of why some people continue with health insurance and why others discontinue.

This report complements other components of the evaluation of SKY health insurance including a randomised encouragement (using a lottery for discount coupon) to purchase SKY, a longitudinal household survey and longitudinal data collection on health centre quality.

SKY HEALTH INSURANCE

SKY micro health insurance is a voluntary community based health insurance program, relying on a monthly registration and premium collection system at the family level. It covers both primary health care and hospital care with a mandatory referral mechanism. Benefits include totally free and unlimited access to all contracted health centres for primary health care or emergencies and contracted referral and provincial hospitals when referred by the health centres. Sky has limited exclusions including long-term treatment of chronic diseases and also HIV and TB, which are already covered by vertical funding national programmes.

Full-time Insurance Agents work in each SKY district to provide information about and sell SKY health insurance. Member Facilitators, recruited from the local community, also provide information to clients, sell insurance and facilitate the process at health facilities. SKY is designed in consultation with direct beneficiaries in the villages. When SKY is launched in a new area, GRET holds village meetings in each village to introduce villagers to the program and its benefits. These meetings are very interactive and include a video and a quiz. During and after the meeting, the Insurance Agent and Member Facilitators then follow up with villagers to encourage sign ups.

In addition to SKY health insurance, another health financing initiative, Health Equity Funds (HEF) also operates in these villages. HEFs are dedicated funds ran by a local Cambodian NGO to provide the different services needed by the poor to access health care. The HEF criteria is designed to reach the poorest and most vulnerable. The latest phase of SKY expansion (2008-2010) includes linkages with HEF to reach the poorest and to increase the efficiency of these dedicated funds.

1 For example the Insurance Agent and Member Facilitator Report and also a number of surveys by GRET. Domrei Research and ConsultingMeaningful research for advocacy and action


RESEARCH OBJECTIVE

The Village Monographs aim at answering the main research question ‘Of beneficiaries who have already joined the program, why do some continue to pay for SKY insurance, while others do not?’ In particular, this study looks at what specific factors lead people to sustain or discontinue their membership and how these factors compare with problems that patients may encounter in the Cambodian public health system in general or with SKY in particular. Furthermore, if faced with similar problems, why do some households continue with SKY while others discontinue their membership?

In order to answer these research questions, this report explores how social networks influence SKY uptake and dropout, how people understand and explain the concept of health insurance in their village context, and how people recommend (or fail to recommend) SKY to others.

SECTION 2: METHODOLOGY

This report uses a number of qualitative data collection methods:

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

2. Narratives: interviews that establish the local history of SKY from villagers’ perspectives and key informants’ ideas about the future of SKY in their villages. Key informants were selected from current and former SKY members (i.e., dropouts), “almost customers,” the insurance agent, the village chiefs and health centre staff.

3. Case studies: discussions with current and past SKY members on their experience with SKY; why they bought SKY, why they stayed or why they dropped out, and what changes they recommend to improve uptake and lower drop out rates.

DATA COLLECTION AND ANALYSIS

Seven villages in Takeo and Kandal Provinces were selected from the SKY village lists using the following criteria:

Each village is situated in a different Health Centre catchment area.

None of the villages were exposed to the coupon randomisation scheme (as this influences membership uptake).

SKY implementation started no later than 2006.

Domrei recruited and trained two teams of village researchers during late February 2009. Training was conducted over five days at the Domrei office and included a field visit to trial the interview process and gave researchers the chance to become familiar with the methodology. Village visits and interviews were then conducted between March 6th and April 3rd, 2009.

Two teams of two researchers spent approximately three days in each village. One researcher conducted the interviews while the other took detailed notes. At the end of each interview, the team members discussed interview results and ensured details were complete in the interview notes.

At the end of each day, immediately after completing interviews, and while still in the village, the two teams debriefed and discussed findings and began to develop a village report. When necessary, teams could return to informants to ask additional questions to complete the data if unresolved issues had arisen in reviewing the findings. Ongoing data analysis meant that



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

When interviews were completed in any given village, work on the final village report could begin. Separate village monograph reports for each of the six villages are appended to this summary report (appendixes 1-6). Village reports were translated at Domrei by the researchers who conducted the interviews to ensure contextual information was retained. Domrei’s bilingual Co-Directors oversaw this translation process. Transcripts were coded using computer program Atlas.ti. The code families in the data were then explored in the framework of the initial generative questions to provide a comprehensive summary of responses.



SECTION 3: VILLAGE MAPS AND FINDINGS

NUMBER OF INTERVIEWS BY VILLAGE

The village chief was interviewed in each village as well as a selection of current and former SKY members. We attempted to interview all active members and as many former members as possible in the three days that teams were in each village. Pseudonyms have been assigned to each village, to preserve the anonymity of participants in the study. For the same reason, other geographically specific information, such as the operational district, is also generally omitted.

Table 1: Interviews by village

Interviewed for monographsNumber of households

currently active

members

Number of households

ever members

Total number of

households in village

SKY has been

operating in village

sinceActive Inactive Total

Kulehn Village 10 5 16* 10 15 36 2005

Tiap Village 14** 11 25 23 49 282 2005

Oaleuk Village 14 6 20 15 47 191 2005

Saomao Village 1 13 15* 1 15 104 2007

Mongkhut 18 12 31* 23 103 209 1997

Khnau 10 16 27* 10 51 121 1997

Lhung 17 12 30* 17 33 62 1998

* Village chief was never a member, so is included separately in total.** Includes village chief



KULEHN VILLAGE

Kulehn is the smallest village surveyed in this study, comprising only 36 households. Agriculture is the predominant mode of employment, with some supplemental income from raising livestock. Some households also receive additional income from relatives working in the garment factories near Phnom Penh. SKY was first promoted in Kulehn village in 2005. Data was collected from respondents who had been exposed to SKY for about 4 years.

Figure 1: Small Map of Kulehn Village

Kulehn village has only one traditional health provider (Kru Khmer), no pharmacies, and no other sources of health services.2 SKY began cooperating with a Health Centre in a neighbouring village in 2005; it is about 20 minutes away on a moto-taxi (costing two to three thousand riel per trip). This village is distinctive as a high proportion of the village have joined SKY and only a few have dropped out (in contrast to the patterns of some of the other villages as detailed in this report).

Table 2: How families first learned about SKYKulehn Village current members (?xx) %Our family first learned about SKY from…

The SKY Village Meeting 9 60.00%

A relative 4 26.67%

The Insurance Agent, at our home 2 13.33%

Of the 15 current members, 9 first learned about the program at the initial village meeting organised by SKY/GRET to introduce villagers to the program (see table 2 above). Three of the

2 The location of the traditional healer is not shown on the map; it was not reported in interviews.Domrei Research and ConsultingMeaningful research for advocacy and action


four households shown on the map in red (as current “drop outs”) learned about SKY from the village meeting. 4 respondents stated that they learned of SKY through family relations.

The village map of Kulehn indicates that social networks were clearly influential on membership. The village chief was one of the primary members; secondary members lived close by primary members and were linked through the influence of these primary members.

Neighbours are very often relatives in rural Cambodia. The pervasive pattern of land-ownership that often results in extended families living on adjacent plots of land is an effect of redistribution policies of the early 1980s (under the Salvation Front3 government of the PRK). This is one of the reasons why “clusters” of health seeking behaviour consistently emerge from the map data.

Across the river, in the bottom-left corner of the map the five households who were interviewed (as past or present SKY members) are members of two extended families. As they’re colour-coded, this means that one green, one blue and one purple household are all SKY members that joined at different times; though they are members of the same extended family. The primary member (blue) joined first, after attending a village meeting. The following quotation comes from the “primary member” of 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 [showing me] around the place before treatment. [As for] the treatment there, I didn’t pay money for [the] operation. […] Many people in the village saw that my family had a good experience there and this encouraged them to join.

Mother of 5, age 56, Kulehn Village

Evidently, the positive experience that this respondent had resulted in at least two other households joining, and quite possibly impacted all of the (purple-coded) recently joined members. By contrast, this cluster of three households are adjacent to a pair of homes (one red, one green) also relatives, that joined SKY simultaneously, but while one of the two remains a member to this day, and the other has dropped out.

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

…I went for treatment to [the local] health centre. The staff told me that ‘we don’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 staff said, ‘I don’t have medicine,’ and they wrote a receipt saying, ‘let’s buy it outside’. I spent 15,000 riel. I hoped that SKY would pay me back for this. But when I gave the receipt to someone from the SKY agency in 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 about my problem and 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

3 In 1981, the name Salvation Front was formally replaced with Kampuchean United Front for National Construction and Defence, however, informally,* the prior term continued to be used.Domrei Research and ConsultingMeaningful research for advocacy and action


a complicated process and more difficult than the private sector.

Agriculturalist and mother of 3, age 60, Kulehn Village

In this instance, none of the adjacent households (nor her relatives) dropped out as a result of the respondent’s negative experience. The respondent is at the top centre of the map, next to two (purple-coded) new members (excerpted above-left).

One family that had dropped out later re-joined SKY and one further household stated that while they had dropped out, they would like to re-join when their economic situation improves enough to allow it. In this manner, even some drop-outs may be spreading positive “word of mouth” about SKY.

TIAP VILLAGE

First exposed to SKY in 2005, Tiap is a medium-sized village situated close to the border with Vietnam and with an official population of 1,226. There are 2 private health providers, 4 drug stores, and the village chief is a traditional healer. The village also has a veterinarian, a secondary school and a small market (near the centre of the map) containing three of the drug stores.

Figure 2: Small Map of Tiap Village

The health centre partnered with SKY is 15 minutes away by moto-taxi and costs 1500 Riel for most residents to reach. However, for more serious diseases, the referral hospital that SKY is likely to refer them to is roughly 30km away and would cost 10,000 riel to reach by moto-taxi. This expense was a deterrent to SKY membership in this village. Tiap was chosen as it has a reasonably high proportion of long-tern members, but about half the members have dropped out. In total, 49 households joined SKY in Tiap, and 23 remained active members at the time of the study.



The Insurance Agent in Tiap was reported to be very active and visits people often, conducting many promotions in the village. With only four known exceptions, all present and past members attributed their joining SKY to this industrious Insurance Agent.

Perhaps for this reason, the clustering effect is much less evident on this map than in the other villages studied. The only apparent cluster of primary members is formed by the Deputy Village Chief and the Commune Chief, who are cousins (as well as working together in local government). Along with the Veterinarian, living in the same part of town, this cluster may have had a positive influence on the two (green-coded) households nearby who joined later; the research team reported that many people wanted to join SKY after learning that the Commune Chief and Deputy Village Chief had joined.

Figure 3: Tiap Village in Detail

In the following example, we see how the role of SKY agents advocating on behalf of patients can have a positive effect, both in disambiguating SKY’s role from that of the Health Centre and in compensating for any negative experiences that the respondent may endure.

… 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 drug 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 incurred from 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 [nor how to ensure that his name was on a waiting list]. My son waited for two hours full of pain. When the SKY agents saw this, they shouted to the public health staff. … After that, my son went for treatment [in several non-SKY hospitals in other cities]… However, I still like SKY service and the health staff in [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 2, age 55, Tiap Village

As can be seen from the excerpted detail of the map, above-left, the green household that provided the quotation does not form a part of any obvious cluster. In effect, we could think of the more far-reaching influence of the Commune Chief and the town’s highly active Insurance Agent as a form of linkage that goes beyond the clusters more readily observed in the other villages. To some extent, this difference can be quantified: in this village, only one respondent stated that they first heard about SKY through a relative (a sibling), with 18 other answers either directly indicating SKY staff or SKY promotions (such as the village meeting to promote SKY, mentioned by 5 households). As a corollary, when asked why they had decided to join SKY, none of the



respondents in this village mentioned the previous positive experiences of their relatives. However, respondents did report that they joined SKY because their neighbours were members and so some of the same logic is at work here. One household stated that they joined SKY “because I saw that so many of my neighbours had joined”, and one respondent reported that, “[I saw that] my neighbour had joined SKY, but still always goes to the private provider when he is sick.”

In the following example, the respondent is aware of the significant ramifications of the family’s own bad experience, and directly states that this changed the neighbours’ perception of SKY.

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 AM 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-time.5

There was only one impolite member of staff and most of the staff took good care of my grandson. My grandson was in 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 told back home, I told my neighbours [about what had happened] and they are also disappointed with SKY.

Resident of Tiap Village

Although complaints about transportation costs are nearly universal, the residents of Tiap have more choice in health provision than most of the villages in the study. In addition to the convenience of the private providers near the centre of the village, Tiap is situated on a major paved road (one the country’s most frequented National Highways), leading them directly or indirectly to a broader range of public and private health services. The moderate success of SKY in retaining members here is, thus, in a context of relatively diverse competition.

OALEUK VILLAGE

Oaleuk village has an official population of 1003. Nearly 100% of the households are employed by agriculture. Rice watermelons, potatoes and peanuts are among the cash crops grown by households.

SKY has been operating in the village since 2005. The village is roughly divided into two parts: those who live in the area closer to the larger road at the top of the map have a somewhat higher level of income than those further away from the main road, at the bottom of the map (the western side the village) in the area known as Phum Thmey [new village]. As the name implies, Phum Thmey was settled relatively recently; and the construction of the Village Chief’s home there was described as a recent relocation. Many of the farmers living in this area are new arrivals in the village, and are generally in greater poverty than the longer-term residents. The Buddhist monastery and the highest density of homes are all in the older part of the village, situated along an unpaved road of earth improved with a layer of pebbles.

4 Presumably, the type of “oil” in question is something like motor oil or engine lubricant, as the effects of the poisoning were so grave. Describing illness 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!Domrei Research and ConsultingMeaningful research for advocacy and action


Figure 4: Small map of Oakleuk Village

The village has one midwife, one traditional midwife and a private healthcare provider. The preferred health centre is around 30 minutes away and costs about 4000 Riel to reach by motorcycle-taxi. SKY also cooperates with another Health Centre, but villagers almost exclusively use the Oaleuk’s own health centre because of its location, both closer to many of the villagers’ homes and en route to the regional referral hospital. Villagers reported that if they can’t get treated at Oaleuk, they proceed on to seek treatment at the regional referral hospital.

Oaleuk has had SKY for a longer, continuous period of service than any of the other villages and has a higher proportion of persons who had ever been members of SKY. However, the village also has a significant rate of dropouts with two thirds of those who have ever joined having left SKY.

A classic clustering pattern is found near the banks of the river (see illustration, below left) where the three newly joined households (colour-coded purple) are all linked by blood relations, and live on adjacent plots of farmland. This case study also reveals the interlocking mandates of SKY and the 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 money to me to buy milk. My other children and my mother are living 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 5, age 53, Oaleauk Village

In the example above, the “cluster” of households is clearly making deliberative choices, and making the same decisions for the same reasons. While one sister had HEF coverage, neither sister joined SKY; after the HEF coverage was cancelled, both sisters decided to join SKY (one a widow, the other married).

Coincidentally, the survey team found one example of the opposite pattern in the same village: one respondent related that she had dropped out of SKY because she was busy with rice farming, and didn’t have the money to pay the premium (complaining of school expenses for her children), but mentioned that she had a HEF card, and so was able to get free medication at the local health centre anyway.

Sometimes, there’s considerably more to the story than the colour-coding on the map would suggest: the following positive experience with SKY comes from a cluster of three “red” homes in the bottom-right corner of the map, and while this former member has dropped out, and she apparently continues to spread positive word-of-mouth about the SKY program.

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

Mother of two, age 30, Oaleauk Village

This cluster of three homes all said they regard SKY as “good” and regret having dropped out due to their inability to pay the premium. One of the households in this cluster specified that while she had dropped out, it was only due to lack of money, and that “my family had no problems with the

6 Different H.E.F. schemes use different definitions of poverty, but this family was apparently disqualified (i.e., were no longer deemed to be sufficiently poor to merit assistance) after upgrading their roofing. The home’s building materials usually are considered in the identification of potential beneficiaries.Domrei Research and ConsultingMeaningful research for advocacy and action


health workers”. She reflected that she thought SKY is good, partly because she was impressed that SKY had paid money to support a funeral in the village after a member had died.

At the top of the map, there are four purple-coded households (i.e., recently joined) who are all linked to the one blue-coded household (who had joined significantly earlier) by a family relation of some kind. Three of the five had attended the initial SKY village meeting. The blue household choose to join SKY because: “I joined SKY because I thought that if I paid a little money every month, my father is old, so when he gets sick, he can get pills or treatment without having to pay and also the health workers will pay a lot of attention to him.”

Figure 5: Oaleuk Village in Detail

Evidently, the positive experience of the first person who joined in this cluster spread to a minimum of two relatives’ households (coded purple in the excerpt, above) – and quite likely to four. The one dropout (red-coded) household in this area (pictured above) is also worth considering: it turns out that this drop-out also holds the SKY program in high esteem, but regrets that most of her family now lives in an area of Siem Reap province with no SKY coverage, so it no longer makes sense for her to pay to be a member of the program. She made positive comments about SKY, and had become a member (previously) in order to ensure that she had coverage during the period of her pregnancy and the delivery of her child.

SAOMAO VILLAGE

Saomao is a small village of only 584 persons that manages to maintain two Buddhist Monasteries7 and a relatively large school complex, with all of these institutions presumably serving a greater population from the surrounding area. Rice farming is the village’s predominant source of income, with some people employed in basket weaving, and others producing and trading in fermented fish paste (prahok) or growing cash-crop vegetables on a small scale. The village is close enough to urban sources of employment that a few men were reported as leaving to work in construction or as moto-taxi drivers, and a few women were reported to be working in garment factories in cities elsewhere. The village chief estimated that only 10% of the village’s inhabitants were poor enough to meet the requirements to qualify for a Health Equity Fund card.8

The village has one drug vendor and one Kru Khmer (both shown on the map; the traditional healer is also the deputy village chief). SKY cooperates with two nearby health centres, and two referral hospitals in the area:

The first health centre is thirty minutes away by moto-taxi and costs 4000 riel to reach, The second health centre is 25 minutes away and costs 2500 riel to reach, The regional referral hospital is 35 minutes away and costs 4000 riel to reach, The provincial referral hospital is 40 minutes away and costs 5000 riel to reach.

It is significant to note that this village is already pre-disposed to failure, as it is roughly half-an-hour away from at least three different health facilities, and transportation difficulties are always a

7 Technically, both of the monasteries are located just beyond the village limits (see map, below), and the limit itself has a bit of a detour around the temples, that are otherwise a natural part of the town.

8 Theoretically, this would suggest that only 10% of the village would be categorized as part of the poorest 30% of the Cambodian population overall, though the actual guidelines for the definition and identification of the poor are inconsistent in comparing one HEF district to another.Domrei Research and ConsultingMeaningful research for advocacy and action


major factor in retaining beneficiaries. From an initial glance at the map, it seems fair to say that the SKY program has failed here, as only a single current member was found by the research team, with all other respondents interviewed being drop-outs.

Figure 6: Small Map of Saomao Village

SKY has been operating in the village since 2007. The only active SKY member at the time of the survey was the deputy village chief, who also works for the village health support group (a health education program supported by the Ministry of Health). He reported that he was pleased with the service he had received from SKY, but also that he felt he was setting a good example for others by remaining a member of SKY.

As is immediately apparent from the map, the drop-outs form a single cluster of 14 households. Five of them are linked as members of the 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).



Figure 7: Somao Village in Detail

Within this cluster, three households had four profoundly negative experiences with SKY and the public health system. To sum up these negative experiences:

One family member suffering from cholera received extremely poor treatment (and found that no SKY Member Facilitator was at the health centre at the time). The patient was at first refused medicine on the premise that the health staff did not have any, but the same medicine was later offered if the family agreed to pay cash. As a result, the family switched to a private provider.

One patient was misdiagnosed with fever, and given treatment for a normal fever (that was ineffective) at the public facility. When the family switched to a private facility, the condition was immediately diagnosed as dengue fever, and effective treatment was administered.

Treatment for shortness of breath (apparently combined with high blood pressure) was ineffective, and so the respondents sought private sector health care.

In a separate instance, treatment of asthma was not taken seriously by staff at the referral hospital: “the staff said that I was not truly sick and then they took me to the funeral (cremation) place. Although I was so sick that I nearly died, still the doctors didn’t take me seriously and were very careless.” Here, too, the negative experience resulted in the patient seeking care at a private health provider.

It seems plausible that these negative experiences, distributed among four households within the cluster of 14, would have a “knock-on effect,” encouraging more SKY members to leave the program.

One household stated that they were “very satisfied” with SKY, that they had received excellent treatment at the hospital (based on “6 or 7” visits made by the family during their membership). This household stated that they wished to become members again in future, but could not do so due to poverty (“in the future, if my family has more money, then I will join SKY again”). This pattern of values was more common in Oaleuk, but it is noteworthy that it can still be found here, in the 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 (prior to joining or around the time they joined); most commonly, these were statements of praise for the basic premise of getting unlimited health care for free in exchange for a monthly premium.

While the reported experiences of others are important, evidently rural Cambodians do not lack any confidence in giving primacy to their own experiences and opinions (i.e., even if these are contradicted by relatives and neighbours).



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

Resident of Saomao Village

As the quotation above demonstrates, after the negative experiences have reached a certain critical mass in a given neighbourhood, even those who choose to join SKY do so with a degree of scepticism and apprehension.

Although almost everyone had dropped out of the program, when asked “is SKY popular in this village (and why)?” Six of the families said that SKY is popular because it has a car that offers transportation home from the hospital, and because it provides free treatment. This shows that even in the midst of perceived failure, there is an awareness of the specific benefits that SKY has to offer among past and potential beneficiaries.

Various respondents reflected that many people had joined SKY when it was first launched in the village, but had since dropped out because they heard bad things about the medical staff, ineffectiveness of treatment, and that the health centre does not prescribe enough medication. As this is the type of complaint that conflates SKY with the public health service, it is noteworthy that one respondent differentiated between the two “Everyone likes the SKY service, but it is difficult with public health staff because they do not know us.”



MONGKHUT VILLAGE

SKY has been operating in the village of Mongkhut since 1997, when SKY was first launched. The village has a population of 872, who are primarily employed in agriculture, with a small number finding employment in garment factories and construction work.

Figure 8: Small Map of Mongkhut Village

The village has two traditional healers (both located by the 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 public health centre (in the top-right quarter of the map, i.e. the southeast part of town). However, as is explained below, the health centre shown on the map is not partnered with SKY.

Whereas the public health centre shown on this map is, obviously, a short walk for many of the villagers (and a motorcycle-taxi ride of only one or two minutes for most of the rest, possibly costing 500 riel) the nearest major hospital for cases that are sent elsewhere is a full hour away, costing 5000 riel to reach. It is the latter hospital, roughly an hour’s distance away (and not shown on this map) that is now partnered with SKY.

The Insurance Agent in Mongkhut has changed a number of times and the benefits offered by SKY have also changed. The range of benefits offered, and those that were “retracted,” have been a major consideration in respondents sustaining their membership or dropping out of the program. Six of the families interviewed stated that they dropped out of SKY because the program had switched to a more remote location (though this reason was rarely stated in isolation, and was normally combined with complaints of the staff being inattentive and impolite). A further four families stated that the remoteness of hospital made the SKY option more expensive than visiting a local private sector provider for minor ailments, and, conversely, it made serious ailments more onerous.



The sequence of changes is somewhat confusing:

In its first five years of operations, SKY provided home-care treatment in the area. In 2003, SKY began cooperating with the local health centre (shown on the map), and cancelled the

at-home services. In 2008, SKY stopped cooperating with the local health centre (due to complications arising in the

relationship). This results in the current situation (aforementioned) local residents needing to travel a full hour to

the nearest SKY-partnered hospital; the provision of at-home-care did not resume.

Thus, in this region SKY now covers only in-patient and out-patient care at the local hospital. When asked what would result in more people buying SKY health insurance, 11 of the 31 households interviewed in this village stated that SKY should go back to offering home care.

The former member advisor who had worked with SKY during their era of co-operation with the local health centre was very popular among the villagers; he was responsible for many people joining and trusting SKY in earlier years.

At one time or another, nearly half the village households have been a member of SKY, and roughly a fifth remain members today, despite a number of significant obstacles. In roughly 12 years (between the commencement of SKY activities and the present survey), 103 families joined SKY in Mongkhut, and 23 remain as members today.

Given that Mongkhut village has had such long-term exposure to the program; it is not surprising to find respondents who have a nuanced understanding of the advantages and disadvantages of coverage. The following respondent dropped out of SKY after a negative experience, but later re-joined (and is thus part of a purple-coded household, in the top-right corner of the excerpted map next to the quotation), and regards the program as having improved.

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 then 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 $5000 [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 with my family. After that, I decided to join SKY again because I got advice from [a doctor and SKY agent]. I found out that I used to be confused about SKY services. […] 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, this household rejoined SKY, and is now spreading positive word-of-mouth on the program’s behalf. The family had recently brought in their daughter for treatment for a tumor of the nose, but it seems that the emphasis in their own



telling of the story is on the change in attitude among the health providers (i.e. not a comparative statement that their daughter’s treatment was better than the mother’s, etc.).

In the neighbourhood surrounding the respondent quoted above, we do see a small cluster of four households that are either primary members (blue) or who have recently joined or re-joined (purple). One of the primary members is a widow whose husband and children all died during the Communist era (of Democratic Kampuchea) who gave a simple and positive report that she had paid for SKY continuously since 2004 to protect herself against the cost of serious disease. It is interesting to note that she stated this was more important for her, personally, because she did not have children to take care of her. The one other primary member (blue-coded) in this neighbourhood is 80 years old, and joined individually in 2004, but her relatives (living in the same household) have not joined SKY since that time. She praised the friendliness, gentleness, and politeness of SKY staff, and reported that she encouraged others to join SKY, too.

Given the change in the location (and nature) of services offered by SKY since it started offering services in the village, not everyone in the village regards SKY as having improved. The changes in Insurance Agent and other SKY staff were also frequently mentioned. In the cluster of drop-outs shown below, three of the four (red-coded) households interviewed said positive things about SKY that revolved around one specific employee who no longer works for the program.

Figure 9: Mongkhut Village in Detail

Households in this cluster dropped out for a variety of reasons. One complained that the hospital divides SKY patients into a separate group and makes them wait longer than patients paying in cash. One of the others spoke of issues of distance and transportation, relating that the cost of transport to receive free medicine could be more expensive than paying for medicine locally. Another negative experience (that may have been influential) in this cluster was a man who waited for “many hours” to get treatment for a broken leg, and eventually left without getting treatment; the family paid $250 for treatment at a traditional provider instead, and evidently left the program with grave disappointment.

In the smaller cluster of two households at the centre of town (figure below), the explanation put consistent emphasis on the relocation of SKY services to the more remote hospital. Additionally, one of these two households (apparently after having lost trust in the program) decided to pay for an appendix operation at a private clinic, and then dropped out of the program. These two are linked as members of the same extended family; it is likely that they made this decision jointly.

Figure 10: Mongkhut Village in Detail 2

Although there are various unique aspects to Mongkhut’s situation, the reasons for continuing to stay with SKY were not distinctive: those who continued to pay premiums said that they did so because they felt that they were good value for money and because they are afraid of getting sick in the future.



KHNAU VILLAGE

The village of Khnau has a population of 558 but has a large number of institutions and services for a town of its size:

A school, Three private health-care service providers, One public health centre within walking distance (on the map), Two drug stores, Two midwives, One traditional midwife, One Buddhist monastery.

The nearest referral hospital is 25 or 30 minutes away, costing 6000 riel to reach by motorcycle-taxi. As is marked on the map (bottom-right corner) the local health centre no longer co-operates with SKY. The ensuing situation is somewhat comparable to Mongkhut Village (discussed above). After SKY’s partnership with the local health centre broke down, free services for policy holders became much more onerous and difficult to access.

Figure 11: Small Map of Khnau Village

By Cambodian standards, this village is not considered poor, but moderately affluent. Farming is supplemented by the income earned by garment factory labour by many (reportedly, “most”) of the town’s women. The town’s affluence also reflects its access to markets via Phnom Penh, to which it directly connects by road (as shown on the map, top-right corner).

As poverty (and inability to pay the premiums) was so often given as a reason for dropping out of the program in the other villages, we might expect Khnau village to have retained a higher rate of members. On the contrary, only 13 out of the 51 families who had ever joined the program are now active members.



The following respondent, located close to the Buddhist Monastery (blue-coded), clearly describes his decision to return to (and sustain his membership with SKY) as taking place despite bad word-of-mouth, and the map shows that he is the exception to the rule, living in a (red-coded) cluster of drop-out households.

In 2007, my family dropped out of SKY because SKY services changed and and SKY started co-operating 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 to remain with SKY, despite a bad reputation (or living in a cluster of people who are dissatisfied with the program) is the beneficiary’s frequency of experience with the service itself. One current member spoke with great confidence about the money she had saved through SKY in the course of a long series of treatments for herself while suffering from tuberculosis, and in caring for her elderly father (who has reached the age of 94, especially remarkable in rural Cambodia). In this case, at least, empirical experience trumps all other concerns: the respondent was very confident that SKY had saved her family money over time. The same respondent also stated that the hospital and its staff are both improving (perhaps reflecting that she is aware of problems in the past).

One extreme example shows how one very negative experience of one household can affect both relatives and neighbours confidence in the service. The following respondent is situated in the midst of a (red-coded) cluster of drop-outs; he relates his own family tragedy as part of a context in which “many families in the village lost confidence in SKY and dropped out”, despite the fact that he found the employees to be “friendly… responsible and supportive”.

I [first joined SKY in] 2004… 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 center and my diseases 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 were careless and did not inject him with medicine or serum until he died in the health centre. For this reason, my family dropped out of SKY. Many families in the village lost confidence in SKY and dropped out.

Father of four, age 56, Khnau Village

In the quotation above, it is noteworthy that he says so much to praise SKY, and mentions that he did have positive experiences with them at all, in the preamble to the tragedy that compelled him to leave the program. It does seem that the respondent himself is aware that negative experiences of this kind have a knock-on effect, with other families losing confidence in the system for the same reasons. Lack of money to pay the premiums was not mentioned in his account; in some cases, cost is simply not an important factor.



In this village, one long-term member (blue-coded) reflected on the limitations of coverage, and her own resolution to stay with the program even though her own disease is not 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 did state that poverty was among the reasons why they decided to drop out of the program, the leading considerations in this relatively affluent context are somewhat different from poorer villages surveyed in the study. The following quotation comes from a respondent who decided to remain with SKY, but who still sees the household’s position as one of ongoing, self-interested decision-making, and that they can (and perhaps will) drop out if they’re ever dissatisfied.

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 program are not unusual in this village: specific bad experiences overlap with the difficulty of reaching the (relatively remote) SKY-partnered hospital. Six families in this village stated that their primary reason for leaving SKY was the distance to the hospital, combined with some remarks about the family not owning a motorcycle, or not having anyone to take care of the family if they departed on such a trip, and other concerns. 10 families reported that while they had been SKY members, they ended up paying for private services anyway, because it made more sense to pay for medical care than to pay for transportation, reflecting the pattern (or strategy) of only using SKY for major, expensive diseases, and private health care for more immediate (and sometimes minor) concerns.

Fully 26 families remarked that SKY had a better reputation in this village in the past, when there was a particular employee who was very popular (“he was friendly, good at treatment, worked hard, and paid attention to SKY members”) and whose name was mentioned frequently in the reasons for first signing up to SKY. The departure of this employee, however, seems to be less significant than the relocation of SKY services to the more remote hospital: virtually all of the households remarked on the latter contrast.

Overall, the residents of Khnau village have been disappointed, and have most commonly left SKY because it failed their expectations: in other villages, we found people dropping out because they could not afford to continue with SKY, but here we instead see people dropping out in part because they can afford to switch to paying directly for services. In this village, the respondents who have stayed with SKY generally appear as isolated, individual households and do not form clusters (in part simply because they are so few).

LHUNG VILLAGE

Lhung is a small village of 267 persons, a 15-minute trip from the nearest health centre (1500 riel by motorcycle taxi) but a full hour away from the nearest hospital (costing 10,000 riel). The village has a large number of services relative to its small size, with two private providers of health care, one of them doubling as a drug store, as well as one additional drug store. This level of Domrei Research and ConsultingMeaningful research for advocacy and action


development is perhaps linked to the village’s administrative status, as it is home to the area’s commune hall and commune police headquarters, as well as one school. The population is primarily employed in agriculture.

Figure 12: Small Map of Lhung Village

SKY has a long history in the village, dating back to 1998. Almost half of the households in the village have at one time been members of SKY, although about half of these have since dropped out. The research team interviewed 18 active households (including the village chief) and 12 inactive households (a total of 30 households, a significant portion of a town comprised of only 62 families). Although targets may be higher, the proportion of SKY beneficiaries here could be regarded as reasonably successful.

One factor in the early uptake of SKY membership in Lhung seems to have been the personality of the previous Member Facilitator who also provided (in-home) health care in the village. The Member Facilitator had lived in the village and regularly provided care and counselling in villagers’ homes. However, SKY now only offers in-patient and specialised out-patient hospital care, and this may have resulted in disappointment with the program. As in Khnau village, discussed above, the relatively long journey to the nearest SKY-partnered hospital is also a problem for Lhung.

As a result of these circumstances, we find that many of the respondents who stay with SKY have done so on the pattern (or “strategy”) of using private health care for immediate needs, and only having recourse to (the more remote) SKY services for serious ailments, sometimes after first paying for private services.

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 parnered 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 is situated in a small cluster of persons with positive opinions about SKY, living near the Village Chief.

In some cases, the colour coding can be misleading: the Village Chief had a very negative experience with SKY, and had already resolved to leave the program, but remained a member at the time of the study only because he had paid some number of months in advance. As the Chief’s negative opinion of the program could have far-reaching consequences over a larger social network, it would be interesting to know if membership declines, or if promoting the program becomes more difficult for SKY employees, after this incident.

After I stayed with SKY, my youngest daughter became sick with a stomach tumor. 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 will drop out of SKY after we finishing 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, there are much more grave examples to be found in the same village. One respondent near the centre of town explained that his daughter died from a respiratory infection, and that his neighbours encouraged him to complain to the police as they shared his impression that the cruel indifference and incompetence of the medical staff at the health centre were responsible for this death. However, while he stated that he was very angry at the time, he decided not to complain to the police because it would make no difference or would be useless to complain and stated instead, “I don’t care about the cruel nurse.” Although the grieving father may feel some satisfaction in dropping out of SKY after this terrible experience, sadly, it will not improve the quality of healthcare his family can access, and may only put them at greater risk over time.

There is a significant cluster of long-term SKY members gathered right around the town’s two private healthcare providers. The following quotation comes from one of the primary members (blue-coded) on the south side of the road, two doors over from a private clinic.



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 counseling 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 appears to be part of a cluster that would know quite a lot about the services offered at the two private providers that are located nearby. However, the relative convenience of the private option does not seem to tempt them at all. On the contrary, they regard the public health service as superior, and had a lot of praise for SKY in particular.

One of the immediate neighbours of the respondent quoted above is a war veteran who now describes himself as physically disabled at age 60. He reported negative experiences with private healthcare providers, and attributed his positive experience specifically to the SKY member facilitators advocating for the patients and not to the public health service in general. He has been a member since 2004, and it seems that his family will remain with the program permanently after this positive experience.

Perhaps because the full range of options is available within and around this village, the responses from Lhung show a clear awareness of the respective roles of private and public healthcare, and that SKY is a distinct entity from the latter. One respondent stated that people “should believe in SKY because GRET SKY is an NGO and not the private sector.” One household stated that they had heard it rumoured that doctors were careless with SKY patients because they didn’t receive payment in cash from them, and that they had been warned that they would need to pay separately for medicine at a private drug store even if they had SKY coverage. One respondent stated that the public health employees (as distinct from SKY employees) don’t know anything about SKY, and so SKY members are “kept in a separate place and it is very difficult”. A nuanced understanding of how SKY works with the public sector (but remains a separate entity) shows up in both praise and blame in Lhung village.

In general, all of the problems observed in other villages were also observed here, including numerous complaints about the difficulty of transportation, the impoliteness of hospital staff, the ineffectiveness of treatment, and so on. The distance from the partnered hospital was the primary reason why so many former members had dropped out, along with the cessation of in-home treatment. Here, too, it was pointed out that medicine from a local provider could be cheaper than the cost of transport to the hospital. In a village this small, it is reasonable to suppose that negative experiences with the health service (especially those resulting in death) would be known to all, and the Village Chief’s disappointment with the program will also be likely to have ramifications beyond this immediate cluster of homes.



SECTION 4: HOW AND WHY DO PEOPLE BECOME SKY MEMBERS?

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

SATISFIED SKY CLIENTS

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

1 The perceived benefits of free health treatment for SKY health insurance members

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

4.1.1 I thought about my experiences and realised that if we go to the health center to get medicine once, we spend 2000-3000 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 with 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 and saw these as random dangers that could arise at any time. They saw SKY as a possible way of preparing for such shocks.

4.1.2 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).

2 Household members already suffered chronic diseases at the time of joining

Some respondents joined because household members had chronic diseases already or the family “got sick often.” Some members also joined because they already knew that they needed operations and could get them if they were a member (after waiting for a six-month period).

4.2.1 I bought SKY because I get benefits from buying it and because we have chronic disease (Mongkhut)

I got some advice from my cousin and neighbors who said my family has a lot of members and that my children have diseases (one has cancer of the nose and one more 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 center because it is easy, and [some of the] hospital staff [there] were [formerly] my students so I take drugs for free. The health center 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 during September of 2000. One 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)

3 Effects of family networks on membership uptake

Family members were a major influence on SKY membership. For example, in the Saomao Village report, the research team noted that “almost all of the SKY members in that village were related’. The village maps for each village (see appendices) also pictorially indicate these family networks. Family members frequently live close to each other in villages, often because of land being split to form new households when children marry.

Many members initially learnt about SKY through discussions with members of their family. In some cases members first joined after hearing about positive experiences that family members had with SKY. In some cases, the family as a whole decided to join and a number of households joined together.

4.3.1 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)

4 Effects on community networks on membership uptake

Community networks of information sharing had a positive effect on membership uptake. Respondents were asked what other villagers thought were the benefits of SKY. Responses varied and include that SKY pays for medicine and that SKY provides treatment without charge. Hearing real stories from SKY members in the village confirmed to villagers that what SKY had promised at the initial village meeting was in fact true. (NB There were also corresponding negative effects from what other villages saw were the negatives of SKY, discussed in section 5).

4.4.1 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 neighbors 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)

5 Knowledge and perceptions of services available to SKY members (provided by SKY staff and public health staff)

Members regularly stated their perceptions of the available services and facilities as a SKY member were an influence on their decision to join. The services and information provided by SKY staff were a big influence on joining. Having the chance to gain a good understanding of what SKY was and how it worked was important to many members. It is evident that some SKY staff worked Domrei Research and ConsultingMeaningful research for advocacy and action


hard to explain and persuade potential members to join and to solve problems when they arose. (Section 3 also presents data that illustrates that services and information from SKY staff were an influence on sustaining membership or dropping out.)

4.5.1 I like SKY because SKY has good staff like Doctor [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)

The perceived quality of services available to SKY members provided by public health staff was also an influence on membership uptake.

In one village, trust in SKY was particularly evident as one staff member had a very good reputation and worked hard to build and maintain relationships with members.

4.5.2 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 on the support that SKY offers when someone dies, particularly the assistance covering funeral costs.

4.5.3 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 like if we die, SKY gives money for music and the funeral ceremony. (Oaleuk)

The perceived quality of services provided by public health facilities for SKY members was also an influence on uptake of membership. (This section includes comments about public health facilities as they relate to membership uptake. Section 6 describes in more detail the perceptions of members and non-members of public health facilities).

4.5.4 I joined SKY because SKY helps us to 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 center. 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 relations 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 staffs are friendly and pay a lot of attention. (Oaleuk)

6 Joined because they trust and believe in SKY

Some members indicated that they became SKY members because they trusted and believed in SKY for various reasons. Some knew or were related to the Insurance Agent and some had seen other people who had positive experiences with SKY.

9 The Doctor, whose name has been omitted here, provided in-home care in an earlier era of the program.Domrei Research and ConsultingMeaningful research for advocacy and action


4.6.1 I was interested in SKY because it can provide treatment for free and I heard that it is 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)

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

A small number of members said that they joined SKY because they saw many others in the village join. This could perhaps be an indication of a belief in ‘the safety of numbers’ and it could also show how trust is transferred amongst village members.

4.7.1 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 of 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 neighbors joined SKY. (Tiap)

8 Joined for reasons of convenience

Similarly, a small number of members explained that they joined SKY simply as it was convenient for them.

4.8.1 [I joined because] SKY has good services and medicine, Dr. [name omitted] is very experienced, it [the health centre] is near the home, and the treatment is free. (Lhung)

I joined SKY because they provide treatment at the home and at night time. We can easily take medicine in the health center because it is near our house. (Mongkhut)

PEOPLE INITIALLY DISSATISFIED WITH OR UNCONVINCED BY SKY

While it was not the focus of this study (as there is already some good research into the barriers to uptake of SKY) a small number of reasons why people did not join SKY at first but later did decide to do so were elicited.

9 Previously didn’t understand or didn’t believe it was true

Some comments indicate that people didn’t initially join SKY as they did not understand SKY well. Particularly, in one village (Kulehn) the research team noted in their summary that some villagers did not completely understand or trust SKY.

4.9.1 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)

10 Didn’t have money immediately

While some people reported being very interested in SKY, they said that they didn’t join straight away as they didn’t have enough money.

4.10.1 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)

11 Wanted to learn more before committing or they had heard bad rumours

A small number of people said that they didn’t join at first as they had heard things about SKY that were negative. However, despite this there were also people who said even though they had heard bad things they wanted to see for themselves so joined to try it out.

4.11.1 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)

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 neighbors. They said that the health workers and SKY agency don’t pay attention to SKY members when they get treatment in the health center, 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 activities. (Oaleuk)

12 Some diseases are not covered

One household reported that they did not join because SKY covers treatment for certain diseases but not others.

4.12.1 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)

PRIMARY SKY MEMBERS

Primary SKY members are defined as those who joined SKY right away at the village meeting. Primary members sometimes had some knowledge of SKY prior to the program launching in their own village. This may have been through family members in nearby villages or through family members connected with SKY. One deputy village chief who could see the benefits of SKY also indicated that he joined to set an example for others in his village after the meeting was held in his house (Saomao).

10 This proverb suggests that you cannot follow through with a promise because something principle 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 wherein a lack of resources results in a company failing to deliver a promised service.Domrei Research and ConsultingMeaningful research for advocacy and action


Primary members also tended to understand the benefits of SKY well from the beginning. They understood that if they paid a little money regularly, then they would receive free health coverage.

Primary members also tended to trust what they knew about SKY thanks to their family networks – either they had heard about SKY operating elsewhere through family connections, or else through discussions with their extended family they decided to join. This was particularly evident in Saomao where almost all the current members were related to each other and lived in one area of the village (see village map).

In six of the seven villages, at least half of members were primary members (sometimes as high as two thirds) who chose to join soon after they first heard about SKY at village meetings. Oaleuk was a notable exception where a high proportion of those interviewed were secondary members.

SECONDARY SKY MEMBERS

Secondary SKY members are defined as those who did not join SKY immediately, (for a range of reasons summarised above), but did become members at a later stage.

Of the villages where interviews were conducted, Oaleuk had a high proportion of secondary members (an exception from the others). Among these secondary members, the most common reason given for delaying membership was that they did not have the money. Not having money to join immediately was the most common response among all of those who delayed joining in other villages.

Another interesting reason cited for not joining straight away was that respondents did not believe in what they heard at first, heard rumours or wanted to observe SKY in action to judge for themselves whether the program was good for their family and the program officers true to their word. Some reported that they wanted to join because the benefits sounded good but they were not sure if SKY was telling the truth or not. A commonly reported rumour was that SKY “makes cake without flour” (explained above, the phrase suggests the inability to follow through with promised services, either as a scam or due to lack of resources).

Data from responses and from the village maps indicates that secondary members regularly joined when primary members lived in homes nearby. The uptake of membership for these secondary members is likely the result of seeing the experiences of relatives (families often live in houses close to each other) or other community members leading to greater trust.

Of those secondary members in Oaleuk there were a small number who said that one of the reasons that they eventually joined was that the Insurance Agent explained SKY clearly to them.

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

The interviews demonstrated that “not understanding clearly” about SKY was a major reason for some secondary members in all the villages not immediately joining.

Both the primary and secondary membership patterns indicate that many members need to be able to trust Sky before they join up. They either trust SKY because they have seen it work (the more cautious secondary members), or because they heard good things about it from other villagers or members of their extended family.

SECTION 5: INFLUENCES ON SUSTAINING MEMBERSHIP

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



WHY MEMBERS STAY WITH SKY

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

1 Concerns about disease and accidents in future

The most frequently cited reason that members gave for sustaining their membership was that they worried about the possibility of illness, serious disease or accidents and the potential costs that could be associated with them.

5.1.1 I stay with SKY even though I never go to the SKY hospital for treatment as 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 program 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 [13 different families reported this according to the village report] (Saomao)

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

Members stayed with SKY because they had positive experiences with the program. Positive experiences with public health facilities also meant overall positive experiences with SKY.

5.2.1 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 Center 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 Center. 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 consider that the services they had received to be positive and yet still remain members because of the protection against possible future serious health problems that SKY offers.

5.2.2 I used to take my grandson to get treatment at the health center 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)

Also in this category were one or two households who trust SKY and remain members because they felt that they have had fewer illnesses since joining SKY. They considered SKY to have had a preventative effect against illness, perhaps because they know more about health and are able to get early treatment.

5.2.3 Some families who aren’t sick often trust SKY because no one in their family got sick often since joining SKY. [team’s summary in village report] (Oaleuk)

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.

5.2.4 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 Services and information provided by SKY staff is appreciated

Some members stayed due to ongoing good relations with and support from SKY staff. SKY staff worked hard to solve the problems of members and assist them when necessary, including meeting them at hospitals and following up when they returned home.

5.3.1 SKY agency are friendly and polite and always provide an easy way to communicate and resolve any problems of SKY member 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 member’s problems. (Kulehn) [From the team’s summary]

4 Understanding the advantages of insurance and related services (referral, etc.)

Linked to trusting and being satisfied with SKY, is data which reflected sustaining membership because of an understanding of SKY services and their advantages. This included acknowledgement of cheap regular payments rather than (sudden) large expenses when ill and access to fast referrals to hospital when necessary.

5.4.1 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 have serious diseases, health center staff will provide a referral quickly. (Tiap)

5 Staying with the program despite the poor reputation of public health facilities

Respondents who stayed with SKY were asked why they continued to stay even though the public health facilities sometimes have a poor reputation in the community. Responses indicated that while rumours may circulate, some people will still check things out for themselves rather than just believing the rumours. Others consider the benefits of SKY support to outweigh the problems associated with public health facilities, especially for serious diseases.

5.5.1 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. [to find out] is what they said right or not. (Khnau)

6 Remaining as a SKY member while seeking treatment at private providers

An interesting finding from the village monographs is that many members were also using private providers for minor illness and incidents, despite retaining their SKY membership. They generally reported that they consider SKY membership a protection against major problems in future, but they use private providers because of their relative convenience. In Kandal province, this trend is the result of SKY ceasing its former coverage of primary healthcare. SKY now offers only inpatient and specialised outpatient hospital coverage. Despite this reduction in SKY services, these members continue to retain their membership.

5.6.1 For small diseases I have 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 to 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)

7 Maintaining membership due to illness, age, or child-rearing

A small number of families indicated that they stayed with SKY because they currently have illnesses or because households include young children or old people.

5.7.1 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)



WHY MEMBERS DROP OUT

There were six main reasons in the data why members chose to discontinue their SKY membership.

1 Perceived poor quality of care provided by public health services

By far the most frequent reasons for dropping out were that members perceived the care that they received to be poor 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 stated that SKY members could be rude to staff and cause problems too).

5.8.1 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 also are 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 skillful 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 the 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 don’t know. (Lhung)

I think that the health staff are 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 center 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 of poor quality or ineffective. Some members reported that the medicine they were given was not effective. This may be true and there are some examples of this that can be objectively affirmed. However, there is also a challenge in interpreting such subjective impressions, given that local knowledge of health care is limited and some people have preconceptions about sickness and efficacious treatment that may prove to be inaccurate or untrue. For example, complaints that a patient received the same medication for different illnesses could be true, but may not indicate medical incompetence (for example paracetamol is given for many types of pain, and the same antibiotics may be issued to people with outwardly dissimilar infectious diseases). In some cases, it may merely reflect the perception that the pills are the same colour as something the patient had before. Another widespread misconception is that glucose serum by intravenous drip is required for any serious treatment.11

5.8.2 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 $5000. This money was supported by the Church. And after that I decided to drop out of SKY because the doctor and nurses were not friendly, were careless and impolite with my family. (Mongkhut)

11 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 value of fees (or to provide the patient with a sense of value-for-money in paying for other services).Domrei Research and ConsultingMeaningful research for advocacy and action


I dropped out from 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 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 center. (Saomao)

Most people, including those who dropped out, are satisfied with SKY. But people who dropped out are unhappy with the health center services [as distinct] from the SKY agency. [Team’s summary report] (Kulehn)

Sometimes members reported that public facilities didn’t have medicine or members were told to buy medicine at outside pharmacies or private providers at their own cost. Given that they were paying anyway they saw no point in continuing with SKY membership.

5.8.3 We dropped out of SKY because when my child needed treatment but 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 as it was inconvenient for them to travel so far for treatment. This was especially a problem in the villages of Khnau, and Mongkhut (and also nearby Lhung) where SKY had stopped working with the local Health Centre, and villagers had to travel all the way to Takmao town. Some transport costs were covered by SKY but not enough to cover the full cost of a moto-taxi and it took a long time.

5.8.4 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 center, I could ride bicycle and take medicine. My family never had problems with SKY. (Lhung)

2 Services and information from SKY staff

Sometimes members dropped out because of problems communicating with SKY staff.

5.9.1 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 are many changes in the SKY agents in this village. (Khnau)

The SKY agent 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 Don’t understand benefits and advantages of insurance well

Some members appeared to drop out of SKY as they did not really understand how SKY worked or the idea of 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 a few comments from members.

5.10.1 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.

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

Just as it had influenced the uptake of membership, the experience of others in the village, especially relatives, led some members to cancel their membership. The following example shows that even though one household had a good experience with SKY, they still dropped out due to the negative experiences of an extended family member.

5.11.1 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 center 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)

5 Families that could not afford to pay the premiums

Some members could not afford to pay premiums, or dropped their memberships when they allocated money from insurance to other expenses.

5.12.1 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)

6 Members are no longer sick

Some members don’t 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).

5.13.1 When I stayed in SKY, our family’s members had many diseases 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 center, 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 disease. (Oaleuk)

I was very satisfied with SKY. I stayed with SKY for 7 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)



WHY MEMBERS REJOIN AFTER DROPPING OUT

A small number of those interviewed were members who had rejoined SKY after they had previously dropped out. Other than the few who rejoined because they had enough money to pay the premiums again, or got assistance from family (or in two cases, were given assistance by their Church), the following were the three main reasons for rejoining reported:

7 Improvements to SKY services were perceived by some members.

5.14.1 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)

8 Members now better understand SKY services (thanks to explanations from Insurance Agent)

5.15.1 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)

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

5.16.1 My family stayed with SKY for many years but in that time I dropped out for a short time. While dropped out, I had a womb disease and I had to get an operation. I spent over one thousand dollars 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 2 or 3 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)



SECTION 6: HEALTH SERVICES

Data presented in Section 4 and 5 provided evidence that the perceptions (and the realities) of services available in government health facilities have a clear influence on membership uptake and drop-out.

Section 6 contains some further data about the impact that SKY is perceived to have had on the health centres cooperating with SKY.

IMPACT OF SKY ON HEALTH CENTRES

According to interviews with SKY staff, the impact of SKY on health centres was evident. SKY generally entailed the increased use of public services and a general improvement in the quality of care through better practices.

6.1.1 When SKY first began cooperating with the Health Center, the staff didn’t understand SKY well. After explaining to the Health Centre staff about SKY in detail, they understood the SKY program and the Health Centre staff improved. (Member Facilitator at a Health Centre)

Since SKY cooperated 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 to 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. (Health care worker at a Health Centre)

As Health Centre staff came to understand SKY better, they also began to explain how SKY works to patients making good advocates for uptake.

6.2.1 The medical doctor explained SKY services to many SKY members. (Health Centre staff)

I told people who came for treatment here to join SKY, especially for people who are often sick and for 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. I promoted SKY to about 30 people, but only about 5 percent of the people listened to me and joined SKY. [Health Centre staff member]

SECTION 7: SUMMARY OF LIKES AND DISLIKES

Respondents were asked directly what they liked and disliked about SKY. There were probably three times more likes than dislikes reported, though this may just be a result of the Cambodian cultural propensity for politeness. Responses are grouped into the following main categories (in no order).

What respondents said they like most about SKY:

We like SKY because we can get treatment for serious diseases or operations. Treatment is free. SKY staff are friendly and have good relationships with members and explain things clearly.



Public Health staff are friendly, professional and attentive. We pay a little and don’t face high costs when sick but can get treated without paying. SKY is like a mode of prevention against serious diseases which are unpredictable. SKY services are convenient and close. SKY provides confidence, and has foreigners who help Khmer. I like it because I have seen that people in the village have had good experiences. SKY offers transport to facilities without paying. SKY has treatment at night. SKY offers support for your funeral if we die. SKY agency works hard and is responsible.

What respondents say they dislike most about SKY:

Facility we must use moved from our village to farther away. It is time consuming to get service at SKY public health services. The process is too complicated (or not understood). Heath Centre treatment and medicine is not effective. Health Centre staff are not friendly. Health Centre is sometimes closed or nobody is working [i.e., nobody on duty] there. Some diseases, like TB, are not covered. SKY staff and Insurance Agent promotions were deceptive; SKY did not provide what they promised. Insurance Agent works in many communes and is not available. Health Centre staff are rude/impolite. You still have to buy drugs outside the Health Centre anyway.

SECTION 8: DISCUSSION AND RECOMMENDATIONS

KEY FINDINGS

Member/non member profilesWe found the following subgroups of respondents:

Some respondents have crossed a threshold of negative experiences, beyond which point they can no longer trust SKY, and, perhaps, will remain (permanently or at least durably) apprehensive of the public health sector. In some cases, this was the avertable death of a loved one, or tremendous pain and suffering that could have been averted; in other cases, the negative experiences were not as grave in isolation, but had accumulated over time.

Conversely, some respondents have crossed a threshold of positive experiences that results in their continuing to support SKY despite their own bad experiences and the reported bad experiences of others. Many examples of this were encountered, including those who had rejoined SKY after quitting, those who said they would like to re-join, and those who had been members continuously despite some very grave experiences with SKY and/or the public healthcare system.

Some respondents sincerely want to maintain their membership with SKY, but cannot afford to do so. This was found among significant numbers of drop-out households in several villages, and could be a special concern for future programming.

Conversely, some respondents are less inclined to rely on SKY because they have enough money to utilise private sector care and/or forms of public sector care that are not partnered with SKY. If these other alternatives are affordable and the household prefers them, the household will not join SKY or will drop membership.

Transport to the nearest facilityProgram changes in three of the villages surveyed meant that members had to travel further and at a higher cost to obtain health care. SKY covers some transport costs, but not all, and it does not take into account the amount of time needed to travel to the health facility and back. Opening



hours were uncertain or not well known in many cases, meaning that some members travelled for an hour only to find a closed facility.

However, this setback didn’t affect membership the same way in all villages. Some members felt that their insurance was worth maintaining and they remained members primarily to protect themselves against major difficulties that would have high costs. They generally maintained SKY membership in conjunction with paying for local private-sector providers for smaller and cheaper problems. Of course this combination implied that sometimes members had been to a private facility (possibly with poor treatment or misdiagnosis) before receiving treatment from a public doctor, extending the length of the illness and subsequent lost days of work and costs. The qualitative data suggests that those villages with the furthest distance to travel to a health facility were more likely to make this decision. Quantitative analysis of data from the household survey taking into account the distance to the closest health facility would be needed to investigate this further.

Economic changesChanges in the local economy at village level obviously have an influence on membership uptake and drop-out and may have an influence on maintaining membership. For example, in villages close to Phnom Penh, women were able to work in nearby garment factories providing a good source of income. These villages tended to maintain membership well and fewer respondents reported that cost was a factor in first joining SKY.

Family NetworksFamily networks were a major influence on membership uptake. Often, members first learnt about SKY through discussions with family members and immediate uptake was often the result of members already knowing about SKY from family in nearby villages and so on. Related households often join SKY together.

Community NetworksCommunity networks also influenced uptake and maintenance of SKY membership. Many members learnt about SKY from neighbours or from watching how SKY helped members in the village respond to health incidents. Conversely, information flows in the community also discouraged SKY membership when members heard about others who had poor experiences with SKY. In some cases, even if they themselves had good experiences, negative stories could cause people to give up their membership.

Trust in SKYBeing able to trust SKY was an important influence on initially joining and also on maintaining membership when other obstacles arose (such as cooperating with a distant facility). Many members indicated that they became members because they trusted and believed in SKY. Trust was both interpersonal (based on relationships with SKY staff in the village) and organisational (based on knowledge of SKY and GRET).

The need for SKY to earn members’ trust was evident in numerous examples – particularly among secondary members who often provided it as a reason for delaying membership. Many members need to see evidence that SKY will live up to its claims; however, when SKY was trusted, it was a very positive influence on membership. Some members based their membership decisions on the fact that others in the village trusted SKY and used this as a basis for their own trust.

Primary members generally trusted SKY because they knew about the organisation from others or they took the risk and decided to trust the organisation based on the first care they received. Secondary members waited to see evidence of SKY services, and joined when they were clear that SKY could be trusted. The length of time that SKY operates therefore influences membership



as it allows more opportunities to build trust. Where SKY services have significantly changed since they were first offered, a proportion of members continue to trust SKY and retain their coverage for serious problems, despite minor problems not being covered.

SKY and the Public Health ServiceRespondents often conflated SKY with the public health system. What would it take to convince members and potential member that SKY is advocating on their behalf? It would have significant effects for poorer members (and potential members) especially, if they felt that they could turn to SKY for support. For example, if the hospital staff demanded improper payments, or denied them services that they should be offered for free from SKY, or referred them to pay at a private clinic for medicines or services that the public health care should provide (all commonly encountered examples). However, if the beneficiaries feel that SKY is working for the public health system, they will feel that they are in an adversarial relationship with their insurance company if they are dissatisfied with the Health Centre’s delivery on SKY’s promises.

Quality of Health ServicesPoor quality healthcare offered in government health facilities was a major factor in members dropping out. Respondents gave numerous examples from public facilities lacking medicine, and SKY beneficiaries having to pay for drugs themselves (despite coverage), to various tragic instances of the wrong treatment being offered, or the surgery being unavailable, in the public system, with families then fleeing to a private hospital or paying at a non-partnered public provider.

However, people seemed to be more willing to try government facilities because of SKY, despite the generally poor reputation of public facilities. Rumours about the quality of services were less influential than expected and generally, we found that if people get treatment for free, they are more willing to try public facilities.

Quality and processes of SKY StaffParticularly good SKY Insurance Agents and Member Facilitators were regularly cited as major reasons for joining and maintaining membership. Secondary members reported that they joined SKY after Insurance Agents visited and explained SKY clearly to them.

Public/Private mixThere is a commonly found pattern of using SKY as a supplement for private (and other paid) services. This household strategy reflects permanently lowered expectations as to what the beneficiaries will get when they approach the SKY-partnered hospital, and a corresponding resignation to the fact that the difficulty of utilising their own SKY membership is only worthwhile for serious (and potentially expensive) diseases. For non-serious illnesses, many SKY members only went to public facilities after attempting to get treatment more quickly in the private sector.



RECOMMENDATIONS

Attracting and Sustaining Members Taking the opportunity to follow up the village meeting with house visits as quickly as

possible to explain more clearly about SKY would attract those members that didn’t understand clearly at first.

Advertising the ‘one free month when you buy 5 months’ incentive more clearly might help those that felt they had no money to join at first.

Since existing members refer many members, a new initiative should be trailed that tries to amplify this process. For example, ‘refer a new member who signs up for six months and get one month free’.

Clearly explaining what coverage includes and excludes is another important component both in selling policies and in facilitating trust. Particularly in the region we studied, where SKY was first experimenting with the benefits package, the explanation was complicated because coverage changed over time. As benefits stabilise, clarity becomes both easier to achieve and more important.

Openly addressing the rumours that circulate and encouraging new members to see for themselves could be an effective strategy (at least where health centres are of sufficient quality. SKY might experiment with “One free health centre visit” so potential new members can see for themselves. Alternatively, SKY might provide a small free trial: “Join SKY, and if you do not like it after your first health centre visit you can cancel your membership and we will refund a month’s past payment plus all future payments.”

Employing and retaining good Insurance Agents and Member Facilitators is one of the foundations for SKY’s long-term growth. Sometimes it took new members 4 or 5 visits from a SKY staff member to understand the program and choose to join.

Continuing to focus on changes and improvements is important, especially related to the public health facilities. Acknowledging that things were not so good at a local Health Centre in the past (but that it has now improved) could be useful. Trust was an important influence on membership so honesty would be respected.

SKY should play a more active role as ombudsman, to collect and relay complaints about public health services. In the short term, this would be help with increasing trust in SKY. In the medium term, SKY would benefit as public facilities improved as the value of public sector services would increase.



APPENDICES

Appendix 1: Kulehn village map (full detail)

Appendix 2: Tiap village map (full detail)

Appendix 3: Oaleuk village map (full detail)

Appendix 4: Mongkhut village map (full detail)

Appendix 5: Saomao village map (full detail)

Appendix 6: Khnau village map (full detail)

Appendix 7: Lhung village map (full detail)

Appendix 8: Evaluation questions used



ANNEX 1: KULEHN VILLAGE MAP (FULL DETAIL)



ANNEX 2: TIAP VILLAGE MAP (FULL DETAIL)



ANNEX 3: OALEUK VILLAGE MAP (FULL DETAIL)



ANNEX 4: MONGKHUT VILLAGE MAP (FULL DETAIL)



ANNEX 5: SAOMAO VILLAGE MAP (FULL DETAIL)



ANNEX 6: KHNAU VILLAGE MAP (FULL DETAIL)



ANNEX 7: LHUNG VILLAGE MAP (FULL DETAIL)



ANNEX 8: GUIDE QUESTIONS

Village Monographs Understanding Reasons Sky Marketing Insurance

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

Introduction

“Hello. How are you? I am ________ working with Domrei Research and Consulting. I came here because I would like to ask you some questions, and discuss with you about SKY service and also I want to know about your satisfaction and dissatisfaction of SKY.

Don’t worry about what we just discuss with you. Everything that you tell me is entirely private and confidential, and I will not talk to other members in your family or people 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 time in this interview. This interview will take only 30 minutes. All 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.

Do you have any question for me?Can I start asking my question now?Now I would like to ask you some questions about SKY insurance.

Question Guide for Sky memberQuestion1:

1. When did you first hear the name of Sky?2. Who told you the first time the name of Sky?3. What did he or she tell you about Sky to tell you?4. Did you understand what are they were saying about Sky or not? or what Sky is?

Question2:1. What did you think when do you first heard about Sky insurance?2. Were you interested in Sky insurance or not?3. Why weren’t you interested?

Question3:



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?1. 4 What bad things did they say about Sky?

Question4:1. 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?

Question5:1. At that time, when you first heard about Sky what was happening in your family?2. When you heard about Sky, were you busy in the season with the harvest? 3. When you heard about Sky, were you busy spending money in your family for a

wedding.4. When you heard about Sky, were your family having any problems or not?5. When you heard about Sky, was anyone in your family having sick or not?

Question6: Another question form the interviewer1. …………………………………………..?2. …………………………………………...?3. ……………………………………………?

Question7: Situation of people who decide to join Sky insurance1. When did you decide to join Sky insurance? 2. Why did you decide to join Sky insurance?3. When the first Sky started in your village how months/years ago after did you join

Sky?

Question8:1. Did you join Sky immediately or did you have to wait and see to join?2. At that time, did you wait because you have you to get money before you join?3. At that 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 IA to come your village or not?

Question9:1. At that time, when you first heard about Sky what was happening in your family?2. When you heard about Sky, were you busy in the season with the harvest? 3. When you heard about Sky, were you busy spending money in your family for a

wedding.4. When you heard about Sky, were your family having any problems or not?5. When you heard about Sky. was anyone in your family having sick or not?

Question10: Another question form the interviewerDomrei Research and ConsultingMeaningful research for advocacy and action


1. …………………………………………..?2. …………………………………………...?3. ……………………………………………?

Question11: The first time people got sick in their family1. Did the people in your family get sick for the first time, after you joined Sky

insurance?2. How did they get sick?3. What sickness did he/she have?4. This sickness, was it serious or not serious?

Question12:1. What did you do when have somebody get sick in your family?2. Did you go to the health centre for treatment?1. 3 What is the health centre environment like that you go to?3. Was the staff in the health centre polite or not?4. Was the staff in the health centre friendly or not?5. Was the MF in the health centre helpful with sickness or not?6. Was the health centre clean or dirty?

Question13: Reason to continue Sky insurance1. When did you pay more money to continue Sky insurance?2. Before you pay money to continue Sky insurance was anybody sick in the family?3. Why did you pay money to continue Sky insurance?4. Was the rational you pay to the continue, was it to help your family for develop or

not? If not how? 5. If have, how to help your family develop?

Question14: Reason leaving Sky insurance 1. When did you leave Sky insurance?2. Was anybody got sick in your family after you joined Sky?3. Why did you leave Sky insurance?4. Was the rational you leave Sky that, was it help your family for develop or not? if not

how?5. If have, how to help your family develop?

Question15: Rejoin SKY insurance1. Why did you stop joining Sky insurance?2. .Did somebody get sick since you stop joining Sky insurance?3. When did you join Sky again?4. Why did you join Sky again?5. Was the rational you join Sky that, it was positive development for your family or

not? If not how?6. If have, how to help your family develop?



7. …………………………………………….?

Question 16: 1. How did you hear or know about SKY?2. Why did you stay with Sky insurance?3. Why did you buy SKY insurance despite the poor reputation of government health

services?4. Why did you stay with SKY insurance not drop out?5. Why did you drop out?6. You bought SKY insurance, have you go to private doctor for treatment or not? 7. If not, Skip to Q8, If has please ask that, You already buy SKY insurance but

when you have health problems, why did you continue go to private doctor for treatment?

8. Let’s you think that people already buy SKY insurance, when they have health problem why did they continue go to private doctor for treatment?

9. Why don’t you drop out, when SKY didn’t come to meet as your want?10.Why did you still waiting and expectations? 11.Why do you like SKY?12.Why did SKY is good and reputation? 13.Can you give use some your opinion, how to change SKY for improve? 14.What do you think, how to make people more like SKY?15.What can we do to make people more buy SKY insurance?

Question Guide for the Village ChiefAsking about situation in village and Sky insurances

1. How many people in your village?2. How many kilometers to big main road?3. How many kilometers to narrow road?4. How many kilometers to health centre?5. How many minutes/ hour by Motto bike go to health centre?6. How much money to go to the HC and return?7. Where did Sky have representation Sky insurance?8. When did they start it?9. Which day did Sky start program? 10. Which day did Sky start next program11. Let’s you think that people already buy SKY insurance, when they have health

problem, 12.Why did they continue go to private doctor for treatment?13.Why some people they like Sky?14. Why some people didn’t they like Sky?15. Why some people don’t they drop out?16. Did Sky membership they happy to have Sky insurance in they village?



17. Do you think pubic health good or not good? If not good how not good?18. I A provide service to people good or not good? If not good how not good?19.16- Why did SKY is good and reputation? 20.17- Can you give use some your opinion, how to change SKY for improve? 21.18 - What do you think, how to make people more like SKY?22.19- What can we do to make people more buy SKY insurance?

For Insurance AgentAsk IA about situation selling Sky health insurance for our family

1- Which day Sky started program?2- Which day Sky started program next?3- Why did they drop out?4- Why did people still stay with Sky insurance don’t drop out?5- Let’s you think that people already buy SKY insurance, when they have health

problem, why did they continue go to private doctor for treatment?6- Why some people like Sky?7- Pleas can you explain use about Sky insurance, what that insurance because we aren’t

rely understand?8- What did you say for convince the people by Sky insurance?9- What do you think, what we do to make Sky market for reputation and improvements?

For Member FacilitatorAsk about situation impact betweens health centre and Sky member ship.

Village monographsInterview with health center staff

Objective: describe the impact of SKY on the health centre, and the health center’s impact on SKY membership

Impact of SKY on the health centre

Questiion1: 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 HC?3. What did they do?4. What did they ask you to do?5. …………………………………?

Question2. Impact of Sky on the health centre staff of works 1. What does SKY do? How does it work?2. What situation is good about SKY and what situation is bad about SKY?3. Have you noticed any changes since SKY is in the health centre?4. What did you see which ones is change?



5. How does SKY affect your work?6. Did you fell any positive changes your work because Sky?7. Did you fell any negative changes your work because Sky?8. …………………………………………………

Question3. Impact of Sky the whole of the health centre 1. How does SKY affect this health centre?2. Did you fell any positive changes the health center because Sky?3. Did you fell any negative changes the health center because Sky?4. …………………………………………………

Question4. Please can you tell me about the MF they worked here?1. What do hey do in the health centre?2. Did you fell do they affect your work3. Did you fell how are they affect your work?4. Did MF have any good ideas to help you? 5. What any good ideas form MF can be more helpful?6. ………………………………………………….

Question5.1. Are there more people coming to the HC because of SKY?2. How do you feel about that when more people coming to the HC?3. Should the health centre have more clients it is normal or not?4. ………………………………………………….

Question6. Are SKY members different from other HC patients?1. How do ordinary people behave when they come at the health centre?2. How do SKY members behave when they come at the health centre?3. How are SKY members different from other clients cane at the health centre?4. When clients came can you knew someone is a SKY member by their behave?5. ………………………………………………….?

Impact of the Health centre on SKY membership

Question7. Do you talk about SKY?1. Did you talk about SKY with other health staff?2. What did you discuss to gather?3. Did you talk about SKY to other people?4. What did you tell them about Sky and what do they say?5. Did you talk about SKY to SKY staff (MF, IA)?6. What did you discuss to gather and what do they say about Sky?

Question8.1. Did you talk about SKY to SKY members?



2. What do they say about SKY?3. What did you tell them about SKY?4. ……………………………………….?

Question9. 1. Did you talk about SKY to non- members?2. What do they say about SKY?3. What did you tell them about SKY?4. ……………………………………….?

Question10. 1. Have you encouraged anyone to join?2. What did you say to them about Sky?3. After you said did they join?4. What do you think convinced them to join Sky?5. …………………………………………………….?

Question11.1. Have you encouraged anyone to drop out of SKY?1. What did say to them for they drop out Sky2. After said did they drop out?3. What do you think convinced them to drop out Sky?4. ………………………………………………………….?

Question12.1. Have you discouraged anyone to join SKY when they wanted to join?2. What did you say to them for discouraged?3. What did they do after you say?4. What do you think convinced them to stop?

1. 5.………………………………………………….?

1- Why did you buy SKY insurance despite the poor reputation of government health services ?

2- Why did people stay with Sky insurance?3- Why don’t people drop out?4- Why did they drop out?5- What change from Sky insurance in the health centre?6- Since have Sky insurance does it have positive result in the heal centre?7- Since have Sky insurance does it have negative result in the health centre? 8- Since have Sky insurance did help develop to health centre?9- How did ordinary people behave when they came the health centre? 10-How did Sky membership behave when they came the health centre? 11-How you feel when the Sky membership come a lot?12-Do you feel happy when Sky member ship are came a lot?Domrei Research and ConsultingMeaningful research for advocacy and action


13-How your feel when the health centre worked with Sky insurance ? 14- Since have the market Sky insurance, the health centre more clean or more dirty?


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