Introduction
Maternal mortality remains a significant problem in Cambodia, particularly for women in rural areas. Despite efforts by the Ministry of Health and affiliated organizations to address the problem, the Cambodian Millennium Development Goal of reducing the Maternal Mortality Ratio to 243 by 2010 is unlikely to be achieved. Access to quality maternal health services was identified as a critical shortfall to meeting the CMDGs.
This document describes CARE’s Village Emergency Referral System (VERS), an activity designed to help the poorest families and high-risk pregnant women to access emergency health services in a timely manner. The activity encourages villages to establish community funds and organize transportation for cases of emergency referral. The implementation strategy is described, as are results and lessons learned from communities with active VERS projects.
Background
The Maternal Mortality Ratio in Cambodia is 472 maternal deaths per 100,000 live births, signifying that one in 50 women is at risk of dying from pregnancy or pregnancy-related complications (CDHS, 2005). The risk of maternal death is particularly high for women in rural areas: 80% of maternal deaths in Cambodia occur in women who reside far away from emergency delivery services. For these women, reaching a healthcare facility (the second delay in the “3 Delays” Model) is influenced by the distance to the health center, means of transportation, condition of the road, and cost of transportation (CARE Bangladesh, 2002).
Cambodia’s Millennium Development Goals aim to reduce the MMR to 243 by 2010 and to 140 by the year 2015. Despite current interventions, the MMR actually increased from 437 in 2000 to 472 in 2005, according to CDHS estimates. “Access to quality health services especially in case of women and maternal health” was identified as a critical shortfall to meeting the MDGs (Ministry of Planning, 2007).
To address these issues, the Ministry of Health (MOH) and affiliated national and international NGOs are working to increase the number of women who deliver in a health facility. Cambodia’s National Safe Motherhood 5 Year Action Plan for 2001-2005 aimed to “increase access to safemotherhood services, especially emergency obstetric care” in an effort to reduce maternal mortality (MOH, 2001). While the MOH is strengthening emergency obstetric care (EmOC) services in health centers (MOH, National Strategy for RSH, 2007), the challenge of accessing EmOC remains a problem in remote areas of Cambodia.
CARE-Cambodia is working to address this need through its Strengthening Capacity for Improved Community Health (SCICH) Program, designed to bridge the gap between the health system and communities by generating demand for quality health services. Koh Kong Province is the focus of SCICH efforts because it is one of the poorest, most challenged areas.
In Koh Kong Province, 40 percent of its 135,000 inhabitants have limited access to health facilities. 41.9 percent of women received no antenatal care at all and 71.1 percent of all deliveries took place at home, further increasing the risk of complications during pregnancy and delivery. 69.8 percent of women reported having at least one problem accessing health care, and rural women were twice as likely to have problems related to distance to the health facility and need for transportation as urban women (CDHS, 2005). Because transportation is so expensive and difficult, referrals of emergency obstetric complications (EmOC) often occur late, if at all, driving up maternal mortality rates. This reality provides the impetus for the initiation of the Village Emergency Referral System (VERS) in the region.
Goals & Objectives
VERS has been developed as a part of SCICH’s Birth Preparedness Program, a series of activities aimed to decrease delay in accessing and receiving quality EmOC. These activities include community-wide Birth Preparedness education, increasing access to transportation and funds for emergency referral, and improving the quality of EmOC at public health facilities.
VERS has been created and implemented by SCICH, in collaboration with local authorities, to facilitate access to emergency healthcare services in rural areas. VERS is a type of community support system (CmSS): collective efforts to provide support to women during pregnancy, childbirth, and the post-partum period, particularly for obstetric complications (CARE-Bangladesh, 2002).
VERS aims to help the poorest families and high-risk pregnant women to access health services in a timely manner in order to prevent the risk of complications and encourages all members to utilize health facilities.
The activity encourages villages to establish community funds and organize transportation for cases of emergency referral. VERS funds can be used by community members in the case of obstetric emergency or an accident to provide transport from their village to the nearest health center or referral hospital for treatment.
Implementation Strategy
Communities in Sre Ambel and Smach Meanchey ODs have implemented VERS using the steps mentioned below, although slight changes may have been made in some villages at the discretion of VERS teams. It should be noted that this strategy represents the ideal implementation of the activity, and not all steps have been enacted effectively by all communities.
Steps of Implementation
I. Initiation of VERS
CARE organizes a workshop for members of the Operational District (OD), District and Commune Authorities, and Health Center Management Committees (HCMC) to introduce VERS and brainstorm ideas about the best intervention practices.
II. Village Selection and Mapping
These members select remote villages eligible for VERS. Selections are made according to criteria set by the team, such as a history of maternal deaths from transportation delays or a distance of more than 5 kilometers from the nearest health center.
III. VERS Committees
VERS is introduced at the village level and VERS Committee members are selected.
Village Health Committee (VHC) members are consulted about the village’s major problems accessing healthcare. VHCs have 5-7 members, including village chiefs, teachers, traditional healers, HCMC members, or other respected villagers. All VHC members are elected by the community as an effort to ensure sustainability.
The structure of VERS Committees follows the government’s decentralization strategy which gives power to the local level. Each village’s VERS Committee is comprised of VHC members, Commune Council members, and CARE staff that operate and manage VERS on behalf of the community. All VHC members working on VERS at the village level work closely with Commune Council members, who oversee the activity. There is a CARE Community Mobilization and Development Coordinator for each OD that supports local teams in the implementation and facilitation of VERS.
IV. Fundraising
Each village is given a charity box by CARE for the collection of funds, which the VERS Committee manages. Each community is given $20-30 by CARE to begin the fund, depending on the OD and the size of the community. Tools for fundraising include placing the emergency box at pagoda or collecting funds monthly from members (either 500R or 1,000R per month as designated by the VERS Committee). In many villages, between 70 and 100 families contribute. The type of revolving fund depends on the village. Some villages can’t afford to pay, in which case they may receive subsidized support from CARE. If the community fund is large, CARE can assist the VERS Committee in establishing a bank account or finding a safe place for the funds.
V. Monitoring
Monthly or bimonthly meetings are conducted between members of the VHC and Commune Council to monitor VERS fundraising efforts and address problems. VERS Committees operate transparent accounting of funds by recording all VERS transactions in ledgers. In some communities, a rigid process of monitoring the process has been established: borrowers (the husband and wife) and the Commune Council member must sign and fingerprint the record book. CARE helps communities to manage the fund with transparency and skill by providing financial management training to VERS Committee members. VHC members prepare a quarterly financial report to present to the Commune Council to ensure transparency and accountability.
VI.
Accessing the Fund
In Sre Ambel OD, only villagers that contribute to VERS can access the funds in the case of an emergency. If a member needs to borrow money for emergency referral, they need the approval of the Commune Council. In most cases, borrowers repay the loan in small monthly increments, and no interest is charged. For individuals or families that don’t have the capacity to repay the loan, their loan is forgiven.
In most villages in Smach Meanchey OD, women are transported to the referral hospital in the case of an emergency because there are no health centers nearby or the health centers do not have sufficient supplies. All women are eligible to receive VERS funds for emergency referral; not only VERs members. If a woman or child is referred to the hospital, CARE or VERS Committees give the women money for transportation and they are not asked to repay the funds; however, they are expected to pay the hospital fees.
Methodology
To purpose of this review is to document the implementation of VERS, its significance and sustainability, and lessons learned from communities with active VERS projects with a view of dissemination and replication.
In collaboration with CARE staff, the Principal Investigator (PI) created separate field tools for CARE staff, CC Members, VHC Members, and women. Using these field tools, data was gathered from 11villages in 6 communes in Sre Ambel and Smach Meanchey Operational Districts. The PI conducted interviews with CARE Staff (4 interviews), CC Members (6), VHC Members (7), and 1 focus group discussion with women. All interviews were conducted in Khmer and the responses were translated into English. Using the data gathered, the PI created this document to be used for dissemination to partners, and one internal-use document of recommendations to be used by CARE program staff for strengthening the VERS activity.
Results & Lessons Learned
There are 33 communes in Koh Kong Province representing 134 villages. Teams have been very active organizing VERS in communities across the province since the project’s inception in February 2007. In Smach Meanchey, 30 villages have established VERS and in Sre Ambel, 37 villages, totaling 67 villages as of July 2008.
To learn more about the implementation of VERS throughout the region, information was gathered through in-depth interviews and focus group discussions with local CARE Staff, Commune Council members, VHC members, and women in various communities with active VERS programs.
There are some similarities and differences with the operation of VERS in Sre Ambel and Smach Meanchey ODs. Where the operation has been similar, reflections will be presented together; where VERS attributes are unique to a specific OD, reflections will be discussed separately.
Need for VERs
As in many rural areas, communities in Sre Ambel and Smach Meanchey ODs often have difficulty securing transport during an emergency. Some areas do not have a car, ‘moto,’ or ‘tuk tuk,’ and many drivers do not want to be contracted out; other drivers want to charge more at night in remote areas. In Smach Meanchey, many villages are only accessible by boat, and the journey for emergency treatment can be long and expensive, if a boat is available at all. These difficulties often make receiving treatment difficult for villagers, making the establishment of VERS funds crucial in these areas.
Overcoming Challenges Fundraising
As can be expected, there were some initial challenges in implementing the project. In some villages, the community didn't understand the process very well; in others, they didn’t believe in the budget or fundraising. Some villagers refused to become members because they didn’t feel like they could benefit from the fund (i.e. families without children or pregnancy). However, VERS players are working together to address all of these issues.
Families in many villages were initially hesitant to contribute to the VERS fund. To combat this, the Commune Chief in several communities contributed his own money to demonstrate his commitment to the project. Villagers recognized his conviction and also contributed to VERS. A CARE staff member said, “When the villagers see the commitment of the leader they will follow. It is part of the culture to follow the top people.”
The Commune Chiefs have been very active in meeting with villagers to explain the benefits of VERS, especially targeting pregnant women to speak of the benefits of using health facilities. The Commune Council has also been integral in facilitating agreements with drivers to secure transportation in the event of an emergency. Collaboration with local authorities is essential for VERS Committees to be successful.
Accessing the Fund
As discussed previously, Sre Ambel and Smach Meanchey have different criteria of eligibility and different procedures for accessing VERS funds. In most communities in Sre Ambel OD, only VERS members can borrow funds in the case of an emergency, including pregnant women, OVC, and elders. In Smach Meanchey OD, only pregnant women can receive funds for complications during pregnancy and delivery.
These inconsistencies and poor communication on VERS objectives have created confusion in some communities which has complicated VERS operations. For example, in one village in Smach Meanchey OD, a woman requested VERS funds for transport to the referral hospital for delivery. She had no danger signs and was denied access to the fund and was forced to deliver at home. The community was very angry at this, assuming that all pregnant women should be given subsidized funds for referral (in Smach Meanchey, women are not asked to repay VERS funds) for delivery. Subsequently, the community lost faith in VERs and has not contributed their monthly dues since the incident 3 months ago.
There is great need for consistent use of this fund and clarification of both VERS objectives and procedures in all communities. CARE staff in Smach Meanchey OD has expressed great interest in collaboration with Sre Ambel OD to exchange best practices. This exchange has a lot of potential to strengthen VERS Committees and improve the implementation and operations of VERS.
Monitoring
Communities in Sre Ambel have developed an impressive system of documentation for all VERS transactions. Every month, a VHC member goes house to house to collect monthly contributions. One VHC member records the name of contributors and amount in a ledger and all individuals (husband, wife, and VHC member) sign the book. Villages report total amounts to the Commune Council, who creates and submits a written quarterly report for the commune to CARE. When a VERS member needs to borrow the money in the event of an emergency, an equally transparent process is followed (please see “Accessing the Fund” on page 6). For general follow-up, the Commune Chief visits villages each month or contacts VHC members by telephone.
The monitoring process is different for Smach Meanchey and less developed than Sre Ambel’s. Although some villages regularly record VERS transactions, some villages have no monitoring system in place. At the Commune Council level, the members interviewed knew little or nothing about the monitoring tools used, signifying that there is no monitoring support at the Commune Council level, which could signify a lack of transparency. Although initial financial management training may have been provided at the initiation of VERS, VERS members expressed great interest in learning or relearning these techniques.
Unanticipated Costs
VERS has faced some difficulties that are not easily fixed: the rising cost of fuel. Due to increased fuel prices, drivers of vehicles and boats are asking for more money, and threaten withdrawing from their established contracts. In addition, fuel costs have limited the frequency of CARE staffs’ visits to villages. In Smach Meanchey, CARE staff had planned monthly visits to VERS communities; however, the rising cost of fuel has reduced this to visits once every 3 months.
Significance Successful Referrals
In Sre Ambel, 15-20 women have used VERS for referral of obstetric complications and10 children or adults have used VERS funds for accidents since the initiation of the activity in July 2007. In Smach Meanchey, approximately 22 women have utilized VERS for cases of obstetric emergency from December 2007-June 2008; there have been no cases of general accidents utilizing the funds.
Community Change
All those interviewed strongly praised the VERS project and recognize the resulting changes to the community. Most importantly, poor families now have access to health care, particularly, pregnant women, orphans and vulnerable children (OVC), and elders who are often the most vulnerable in the community. Due to greater access to care at health facilities, villagers have reduced delivery by traditional birth attendants and increased delivery at health center which has reduced maternal and infant death in the community.
These saved lives have much broader ramifications which include economic security for the family. Before VERS, people in need of emergency transport had to borrow money from rich people who charged high interest rates. People now have access to funds without interest. One Commune Council member said, “[VERS] can make people healthy, which will allow them to find a job and to make money for living.”
In addition, participation in VERS has introduced the idea of community savings. One Commune Chief said, “We never thought about putting money together. Now we work together to raise funds and put the money together.” The idea of sharing funds with each other was a new idea for people in these communities.
VERS funds, in collaboration with CARE’s Birth Preparedness Initiative, have worked also worked to change the communities’ ideas of emergency preparedness. The VERS project works very closely with the TBA training and community trainings in birth preparedness. Virtually all communities interviewed mentioned the importance of delivering n a health center, demonstrating a marked change in previous beliefs in delivery at home with a traditional birth attendant.
Sustainability
It is hard to say with certainty if VERS Committees will be sustainable because the activity is still very new. In some communities, the project is less than 6 months old. Currently, all VERS Committees still coordinate their activities with CARE staff. For the moment, the project needs the continued support of CARE.
One VHC member emphasized that because VERS is so new, it is not strong enough to be sustainable. He believes that it should be centralized in the beginning and can become independent later. He said, "Right now it's still young like a baby. It needs to stand up." He felt VERS in his community could be sustainable forever.
However, VHC members, local authorities, and CARE staff believed the VERS Committees could become sustainable, primarily because key stakeholders are involved. In some villages, VERS is already included in the Commune Council budget, indicating their commitment to the project and the sustainability of the project design. In many other villagers, Commune Council members plan to include it in the budget for 2009.
Conclusion
This review of VERS, the first one of its kind, offered great insight into the implementation of the activity and the potential impact it could have on participating communities. During the interviews, all VERS participants offered good recommendations on how to facilitate implementation and improve current performance of VERS. A separate internal document has been created that includes these recommendations and will be used by SCICH coordinators to strengthen existing VERS Committees and clarify problem areas. Some recommendations include:
• Greater clarification from and between CARE staff on how VERS funds should be accessed. There is confusion in certain communities on how to distribute the funds and performance could be improved with mediation from CARE staff.
• Holding frequent refresher trainings at the village level on financial management to encourage accountability efforts and mass meetings with villagers to speak about the benefits of becoming VERS members.
• Collaboration between all VERS Committee members in Sre Ambel and Smach Meanchey in order to share best practices to improve the project. This exchange has a lot of potential to strengthen VERS Committees and improve the implementation and operations of VERS.
• Incorporating national entities (i.e. MOH, health centers) into VERS operations, which could expand and improve VERS operations and encourage sustainability.
VERS was initiated in some communities in July of 2007, although most communities began VERS work in early 2008. It is clear that communities need the support of CARE at this point. While it is too early to say if the activity will be sustainable without the support of CARE, the community-elected VHC members, investment of local authorities, and the motivation of VERS members at the community level are promising indicators of sustainability.
VERS is only one way to support emergency referral in rural areas and is best used in conjunction with other activities. VERS is being implemented in the context of an integrated intervention strategy and the wider impact has influenced the success of VERS. Most people interviewed referenced the importance of delivering in a health facility: a prominent message in the educational component of SCICH’s Birth Preparedness Initiative. In addition, in collaboration with CARE’s Rural Development team, we are
introducing savings schemes and training to all villages with VERS in attempt to improve fundraising efforts and increase community savings.
VERS has the potential to save lives and to reduce the risk of maternal mortality for women in remote areas in Cambodia, but it also has greater implications. The death of a mother has a huge impact on the heath and economic security of the entire family which means reducing maternal death could influence the development of Cambodia. Despite initial implementation difficulties, VERS is facilitating growth at the individual, family, and community level.
Reference List
1. Central Statistical Agency [Cambodia], & ORC Macro. (2006). Cambodia Demographic and Health Survey 2005. Addis Ababa, Ethiopia, Calverton, Maryland, USA: Central Statistical Agency and ORC Macro.
2. CARE-Bangladesh. (2002). Dinajpur Safe Motherhood Project. Dinajpur: CARE-Bangladesh.
3. Ministry of Planning, Kingdom of Cambodia. Progress in Achieving Cambodia Millennium Development Goals: Challenges and Opportunities. (2007). Phnom Penh: Ministry of Planning.
4. Ministry of Health, Kingdom of Cambodia. National Safe Motherhood 5 Year Action Plan: 2001-2005. (2001). Phnom Penh: Ministry of Health.
5. Ministry of Health, Kingdom of Cambodia. National Strategy for Reproductive and Sexual Health in Cambodia: 2006-2010. (2006). Phnom Penh: Ministry of Health.