Cambodia

Cambodia

In 2007 per capita expenditure on health was $108  per year.

The HLSP survey recorded that health finance comes from public taxes (4%), aid partners (22%), private out of pocket (62%) and private risk pooling (12%). There is an official policy to charge user fees, with exemption for the poor, orphans, TB, leprosy, immunisation, malaria and HIV. However, demands for informal charges are common and high.  Approximately 20% of public revenues for health are raised from user fees.

The three principal sources of health financing in Cambodia are (i) the government health budget, (ii) donors and other health partners and (iii) households. On the supply side, financing may come from government, donor agencies or nongovernmental organizations. Out-of-pocket expenditures go to either user fees in public facilities or the private sector. Demand-side financing schemes are characterized by health insurance systems of various types or social transfers including health equity funding.  Cambodia has an increasing level of recurrent government spending for health, reaching 12% of national budget, although remaining a low share of GDP at little more than 1% in 2007 (or approximately US$6 per capita per year in 2007). There is also a very high level of private, out-of-pocket (OOP) household spending that accounts for approximately two-thirds of all health expenditure (or approximately US$25 per capita per year), and a high dependence on donor funding for health care, reaching US$ 103 million or US$7 per capita per year in 2007.1

The MOH’s aim is to deliver full Minimum Package of Activities (MPA) at all Health Centres and Complementary Package of Activities (CPA) at all Referral hospitals in all health districts, and to provide access to health services for the poor. This, however, is still many years away. In response to this, a number of different health financing mechanisms have emerged independently: donor funding, donor funded pools, user fees at public facilities, fee-exemptions for the poor, contracting of public service delivery, health equity funding (HEF), community-based health insurance (CBHI) and proposals for different social health insurance schemes (SHI).Out-of-pocket spending however still frequently occurs within an unregulated private sector of dubious quality or in the form of unofficial public sector fees.

The Cambodian MOH started discussions in 1995 to improve health care financing and initiated a user-fee pilot program in selected national health facilities in 1997, but left the actual designing of programmes to individual pilot hospitals. Prior to this staff in public facilities had often charged informally in order to augment their inadequate pay. Exemptions were also dependant on individual hospital policies and could include such groups as low-income patients, hospital staff and their families. Studies in 2004 of the effects of user fees in some of these pilot initiatives concluded that they could produce supplemental hospital revenue, which could be used to improve hospital services, and thus attract more patients. Consequently, greater revenue will then be brought to the institution, making more cost recovery possible. This sustainability cycle can also contribute to establishing a financial basis for an exemption program for low income patients, alleviating the government’s financial burden and decreasing donor aid. However, the takeup of exemptions was often still low. Pilot attempts are also being made to improve health staff salaries and thus reduce the need for informal charges, and to pilot the establishment of a Health Equity Fund to cover the costs of poorer patients.

1 http://www.who.int/health_financing/documents/cam_frmwrk.pdf