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Cambodia is a lower-middle income country with a population of 17.17 million in 2022,2 and had a gross domestic product (GDP) per capita of US$1,543.7 in 2020.3 Cambodia has found political stability since 1997. It is a country undergoing economic expansion, particularly through strong production in the garment and tourism industry. While the Cambodian economy maintained an average growth rate of 7.7 per cent between 1998 and 2019, making it one of the fastest growing economies in the world, the global shock triggered by the covid-19 pandemic significantly impacted Cambodia's economy in 2020. The economy in 2020 registered negative growth of -3.1 per cent, the sharpest decline in Cambodia's recent history, while its growth was estimated at 7.1 per cent in 2019.4 With relaxed travel restrictions and the 'reopening' of the country, the World Bank and the International Monetary Fund have forecast that the Cambodian economy will grow around 4.5 per cent in 2022.5
In Cambodia, health remains an important challenge and a development priority. Poverty has declined sharply, from 47.8 per cent in 2007 to 13.5 per cent in 2014 according to official estimates. Cambodia thus reached the Millennium Development Goal of halving poverty in 2009. Cambodia has also made considerable progress in improving maternal and child health, early childhood development and primary education in rural areas.6
Citizens' right to healthcare in Cambodia is ensured by Article 72 of the Constitution of the Kingdom of Cambodia, dated 21 September 1993. Article 72 provides that: 'The health of the people shall be guaranteed. The state shall give full consideration to disease prevention and medical care. Poor people shall receive free medical consultations in public hospitals, infirmaries and maternities. The state shall establish infirmaries and maternities in rural areas.' The Ministry of Health (MOH) is responsible for all healthcare matters, and it has worked with several international development agencies to reform the country's healthcare system. Before the Khmer Rouge years, Cambodia's pharmaceutical sector had operated a rudimentary but effective system, which is gradually being rebuilt.7
In the early stages after being reconstituted, the government implemented social health programmes such as health equity funds (HEFs), voucher schemes, voluntary community-based health insurance (CBHI) and private insurance. These programmes were well received by the public and yielded positive results. The MOH has continued to invest in these healthcare programmes and is now focused on improving Cambodia's healthcare system.
Cambodia is confronted with both pathologies characteristic of developing countries (tuberculosis, dengue fever, malaria, etc.) and diseases more typical in prosperous societies (diabetes, cardiovascular diseases, cancer, etc.).8 In 2019, total health expenditure represented about 6.99 per cent of Cambodia's GDP and has been increasing in the context of the country's high-growth economy, and of course in the covid-19 context.9
In Cambodia, health expenditure is divided between public and private sectors. The Health Strategic Plan 2016–2020 reveals that there are approximately 1,000 public healthcare facilities and 8,000 private healthcare facilities or providers across Cambodia.
The MOH is responsible for governing healthcare, the healthcare industry, public health and health-related non-governmental organisations (NGOs) in Cambodia. It governs and regulates the activity of medical professionals, hospitals and clinics in the country. On a local level, the public health service is provided by 24 provincial health departments, which themselves manage a provincial hospital and govern several operational health districts. Currently, more than half of the government's health expenditure is spent on medical supplies. Despite this decentralisation effort of the public health services, the quality of and access to public health services is not entirely satisfactory. In 2016, the number of hospital beds per 1,000 people was 0.9 (compared to 2.2 hospital beds per 1,000 people in Thailand). In addition, the low remuneration of government health workers, which is US$100 to US$150 a month when the living wage is US$350 per month, and the general shortage of health professionals, remain major problems. As a result, many public health sector employees work for both the public and private sectors.
The public sector in Cambodia therefore remains insufficient, which has caused a considerable increase in private health expenditure in recent years. In 2015, about 60 per cent of patients sought private providers. As a result of the growth of the private healthcare sector, the MOH now aims to regulate the private sector more effectively by putting in place required licences and strengthening law enforcement.10
There are four main forms of social health protection in Cambodia. One, consisting of the HEFs, is a free-of-charge assistance scheme for people considered 'extremely poor' (unable to afford doctors' fees or trips to the hospital). It is the most extensive protection system in terms of the number of individuals covered. In 2018, the government categorised three million people as extremely poor, which represents around one-fifth of the population. The prerequisite for this care is what is known as 'IDPoor' status, with an individual or family-based 'membership' card issued as part of a comprehensive identification process.11
CBHIs constitute the voluntary insurance scheme for the informal sector, and are the second most important of the social health protection schemes. However, currently only 1 per cent of the population is insured by one of the nine CBHIs in Cambodia. A state objective is for the whole informal sector to have access to a CBHI. In practice, the lack of knowledge or understanding of the concept of insurance, the low level of trust of legal institutions, the lack of willingness to pay for a hypothetical risk of disease, and the weakness of the medical infrastructure and public care services, explain why so few people are covered by a CBHI.
A third form of social protection, a mandatory scheme for the formal sector (social health insurance (SHI)), is still under construction. The intention is for this type of insurance to be obligatory for people working in the formal sector (mainly civil servants) and it will be wage-based. The objective is that the SHI will eventually cover approximately 15 per cent of the population.
The last system is a private health insurance scheme that targets the wealthiest section of the Cambodian population, which represents approximately 0.1 per cent of the population. This system is expensive but quite efficient, giving a reasonable level of social health protection to affiliated individuals.
Other types of health financing schemes are also found in Cambodia although these remain minor in terms of coverage, such as maternal health vouchers, global health initiatives and national programmes for patients with tuberculosis, malaria or AIDS and for child vaccination schemes.
Although an effort has been made by the government to set up these protection systems, the majority of them have not yet been effectively implemented and the proportion of people covered by these insurance schemes remains very low. The combined coverage of these four social health protection schemes amounts to less than 10 per cent of the population. The majority of Cambodians (89 per cent of women and 92 per cent of men) still do not have health insurance.12 Moreover, social health protection schemes usually cover the costs of primary care and hospitalisation, but these do not always extend to medicines. An effort to ensure the effectiveness of these measures and to communicate the existence and necessity of these measures has yet to be made – and must be – if the Cambodian population is to be effectively covered.
The International Global Fund also finances the treatment of certain diseases, such as tuberculosis, malaria and AIDS. Nevertheless, patients suffering from chronic diseases do not always know how to access public healthcare services, while many live too far away from public health centres, making regular treatment impossible.13
During the past two decades, Cambodia has made significant progress in economic growth and improvements in key health indicators, particularly through the national social security fund (NSSF) system, and the objective of implementing universal health coverage (UHC).
The NSSF is a public, autonomous and self-financed institute under the Ministry of Labour and Vocational Training (MLVT). Daily operations are supervised by the MLVT while the Ministry of Economy and Finance (MEF) administers all finance-related issues. The NSSF protects everyone who works in Cambodia in an enterprise or establishment, trainees, apprentices and persons who are attending a rehabilitation centre, as well as seasonal and occasional workers. In the past, the NSSF only applied to enterprises and establishments with eight employees or more, but this has changed. Prakas No. 448 on the registration of enterprises, establishments and workers in the NSSF for the persons defined by the provisions of the Labour Law states in its Provision 4 that: 'The Employer refers to natural or legal persons in the public or private sector with one worker or more in spite of regular or casual workers.' Further, Article 5 thereof states that: 'The employer or enterprise/establishment under the scope of the Law on Social Security Schemes for persons defined by the provisions of the Labour Law is compulsory to register his or her own enterprise/establishment in the National Social Security Fund (NSSF).' Thus, any employer who has at least one employee must register with and pay the monthly contribution to the NSSF. The NSSF does not apply to public civil servants, diplomatic staff or officials who are temporarily appointed to public service. Occupational risk started at the end of 2008 and covers companies throughout the Kingdom of Cambodia. Even though there is an authority within each province, companies located in the provinces tend to register in Phnom Penh.
Until recently, the NSSF had provided social insurance under two schemes.
The first was healthcare for employees relating to accidents at work. It was established by the first Cambodian Social Security Law, currently known as the Law on Social Security Schemes for Persons Defined by the Provisions of the Labour Law, passed by Parliament in September 2002. It protects workers via an employment injury scheme, with a view to mitigating the social burdens and promoting social stability. Currently, 17,355 enterprises are registered with the NSSF system. The services covered are pre-established and are classified as follows:14
Since 2016, coverage by the NSSF has not been limited only to occupational accidents but also has a role in health insurance by covering the personal (non-work related) injuries of registered persons. This social security scheme was established by Phase II of Healthcare, which was issued in the Rectangular Strategy Phase III of the Royal Government and established by Sub-Decree No. 01 SDE, dated 6 January 2016, concerning the Establishment of a Social Security Scheme on Healthcare for Persons Defined by the Provisions of the Labour Law. Therefore, currently, there are two complementary mechanisms because health protection of workers is not limited to diseases or injuries directly linked to work but includes the prevention of risk to personal health or non-work injury. Both schemes are linked and sufficiently comprehensive to ensure workers are protected. This system has contributed to promoting health and preventing disease and injury for workers.15 The system ensures and provides benefits and a safe income to members in the event of a contingency such as invalidity, old age, miscellaneous accidents and death.
The NSSF administers schemes of social security protection in accordance with the National Social Security Law and the provisions of the sub-decrees relating to social security. Between 1 January and 31 August 2019, the NSSF provided 19.9 billion riels in postnatal benefits to 49,480 workers.16 The aims of this benefit are to support the livelihood of workers when they have children, to promote social protection and the growth of the Cambodian population, and to relieve the hardship of workers.17 This system now has a central role in the healthcare system in Cambodia. This social insurance is legitimate and compulsory, ensures comprehensive protection and provides long-term social security to workers and their dependants. The objective is for the NSSF to become the leading organisation that provides social security services.
This system considerably facilitates the regulation of social and health services for all workers. In addition, the government is in charge of cooperating with the competent organisations to disseminate strategies to prevent injuries at work. The NSSF must operate efficiently and transparently.
It is important to note that the NSSF covers only the medical services sought at its panel hospitals or medical institutions, and may only cover services sought at private hospitals in an emergency. Therefore, a patient will only have his or her medical expenses reimbursed if the NSSF considers that the medical care was provided in response to an emergency.
In addition, there is often little incentive for public medical institutions to receive patients registered with the NSSF because the cost of the medical services being sought is not very high; and the medical institutions may not be reimbursed by the NSSF until long after the treatment is completed, creating a cash flow problem for them.
For these reasons, and although the situation is improving, some medical institutions try to limit the number of patients registered with the NSSF, for example, by receiving them only in the mornings or by claiming that there are not sufficient beds to receive them. Therefore, companies that have employees registered with the NSSF may also subscribe to private group medical insurance for their employees, especially through micro-insurance.
Since the recent promulgation of the Law on Social Security, dated 2 November 2019,18 a third scheme was introduced under the NSSF: the pensions scheme, aiming to provide income support to retired workers.19 This Law was followed by Sub-Decree No. 32 on the Social Security Pension Scheme, dated 4 March 2021, detailing the registration requirement, contribution rate and benefits for the individuals.20
In March 2016, the government committed to achieving UHC, through which all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need while also ensuring that use of these services does not cause financial hardship.21
The National Social Protection Working Group led by the MEF has been tasked with advancing the development of a social health protection (SHP) strategy that will help Cambodia achieve its UHC goals. A comprehensive social health protection reform requires multiple decisions to be made relating to health financing. For Cambodia to sustainably finance its ambitious SHP strategy, the MEF will need to identify ways to generate new revenue and improve the efficiency of health spending. Furthermore, international experiences with UHC, particularly those of Cambodia's neighbours, stand to provide useful lessons for the various aspects of social health protection reform that Cambodia will need to consider.22
On 12 December 2018, Cambodia celebrated its annual International Universal Health Coverage Day. The government convened the Second Cambodia UHC Forum to present and discuss new data on health spending and financial risk protection and the way forward for UHC.23 The Minister of Health, Dr Mam Bun Heng, opened the gathering, encouraging the assembled officials to expand financial risk protection coverage to cover more people, focus on service expansion and quality, increase equity in service delivery, especially in primary care, and tackle the rising challenge of noncommunicable diseases. Two reports – National Health Accounts 2012–2016, providing information on health expenditure in Cambodia; and Financial Health Protection 2009–2016, providing information on how much people are paying for health services out of their own pocket – were presented, in order to enable inequities to be addressed. A study on people forced to finance healthcare by borrowing money, which is a significant trend in Cambodia, was also presented.
This ambitious project is being carried out in collaboration with Result For Development (R4D), through the USAID-funded Health Finance and Governance Project, and with Abt Associates. R4D conducted a fiscal space analysis to assess where and to what extent new resources can be generated for health in Cambodia. R4D's work will help Cambodia to structure its social health protection initiatives to achieve its goal of UHC in the long term.24
The World Health Organization (WHO) also works closely with the government, particularly the MOH, and other development partners to achieve health for all in Cambodia.
However, within the health system, out-of-pocket expenditure remains high (60 per cent of total health expenditure). Although the country has initiatives to provide financial protection to particular population groups, there is not a national system that provides universal health protection to the entire population. Despite efforts to improve public health services and to establish universal social security, Cambodia's social protection system faces structural difficulties that affect the quality of care provided.25
Micro-insurance26 is a system that uses the insurance mechanism, among other things, and whose beneficiaries are (at least partly) excluded from formal social protection systems, in particular informal economy workers and their families. It differs from systems created to provide legal social protection for workers in the formal economy. Membership is not compulsory (but may be automatic) and members contribute, at least partially, to the financing of benefits.
There are several micro-insurance organisations in Cambodia, which allows the most disadvantaged populations, who do not have recourse to traditional insurance systems, to have access to basic healthcare.
From 2002 to 2011, the GRET (an international development NGO under French law)27 developed a health micro-insurance offer in Cambodia. It was aimed at the informal sector (SKY project) and offered female workers in the textile sector (HIP project) compulsory health insurance. In 2011, the SKY project covered nearly 73,000 vulnerable rural and urban families for US$5 per year.28 Following a change in the institutional context and in consultation with the MOH, the GRET transferred the SKY and HIP schemes in 2011 to local operators subsidised by the state.
These experiences enabled micro-insurers and, since 2012, general insurance companies, to propose group personal accident insurance, including healthcare benefits, to employers for their employees. The low level of premium and a very efficient network of hospitals and clinics, both private and public, made this very popular, even with the extension of the NSSF. There have been other attempts to target the lower middle class through new technology, including telecommunications and the internet.
In general terms, the government funds only 10 per cent of national health expenditure, while international donors contribute more than 20 per cent. The remaining 70 per cent of the total cost must be borne by users. This represents a considerable burden for poor and middle-income households, especially in rural areas.29
Regarding the NSSF coverage, the institution is funded by contributions from employers. The registration of employees and workers is done by employers at the NSSF office of the MLVT. Employers have 45 days to register with the NSSF after completing their MLVT registration. Registration is mandatory but free of charge. Contributions are borne fully by the employer; they cannot be deducted from an employee's net salary.30 Until recently, the scheme covered the occupational risk scheme for work-related accidents, and the healthcare scheme for preventative healthcare and medical services. The applicable rate for the occupational risk scheme is 0.8 per cent of the employee's salary, subject to a cap of 8,000 riels per employee. The applicable rate for the healthcare scheme is 2.6 per cent of the employee's salary, subject to a cap of 40,800 riels per employee.31 The funding modalities for the pensions scheme introduced in 2019 will also be established in the coming years.32
Primary/family medicine, hospitals and social care
A section of the population frequently consults private doctors and traditional therapists, who have widely varying degrees of training. At present, this lucrative private sector is not regulated by the government. At the same time, public facilities are underused: according to a demographic and health survey in 2010, only a quarter of the population sought initial treatment in the public sector. Public personnel are poorly paid, which often encourages doctors and nurses to seek work in the private sector. Lack of regulation leads to gross abuses in the pricing of services and the quality of prescriptions; informal fees are often added to the formal costs of care. Regarding the quality of care, public hospitals have uneven standards, whereas private hospitals provide a better level of care. Dr Kee Park, a US-trained neurosurgeon and senior consultant in neurosurgery at the Preah Kossamak Hospital in Phnom Penh,33 said: 'A distinction should be made between private versus public facilities where quality and ability are in stark contrast. In the best private facilities, diagnostic capabilities are sufficient for most common conditions. For example, multiple private CT and MRI scanners are available in Phnom Penh.'34
As mentioned above, since the issuance of Sub-Decree No.01 SDE, dated 6 January 2016,35 the NSSF has provided health insurance to all workers for injuries and illnesses that occur outside work. These healthcare services include both comprehensive healthcare and preventive health services.
Healthcare delivery refers to medical care, patient referral, transportation of the injured and daily allowances. It includes medical treatment and hospitalisation (diagnostic, laboratory, medical imaging, surgical, treatment, prescription of drugs and costs of a patient's hospital room if it is necessary to stay in hospital) as well as outpatient and emergency services. The patient has the right to access medical care services in the nearest healthcare institution. Also covered by the NSSF are:
Kinesitherapy and physical therapy are considered as assistance services.36 A daily allowance is granted during a period of absence from work due to sickness, maternity leave, or accident, and medical care services are free of charge.
The NSSF has established reimbursement rates for different categories of patient care. The insurance provided covers healthcare in the following categories:37
Four main categories that are not covered are free services under public health policy, expensive treatments (such as dental care, organ transplantation, heart surgery, haemodialysis, eye laser therapy), non-primary care (such as sexual surgery, plastic surgery, fertility treatment, treatment of alcoholism and drug abuse) and self-treatment.
Health prevention refers to punctual diagnosis, persons identified as having health risks or ill-health, consultation and other necessary interventions with a view to preventing health problems, such as screening, health education and vaccination programmes. These health prevention services shall be provided by the NSSF, national programmes, institutions and relevant organisations involved with healthcare.
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