Cambodia has to tackle a "double epidemiological burden". The country faces the typically characteristic pathologies of developing countries (tuberculosis, dengue, malaria...), and also diseases more specific to prosperous societies (diabetes, cardiovascular diseases, cancer...). Exacerbating the problem is the fact that Cambodia is poorly equipped to address these issues.
Self-prescription and self-treatment are common practice (Poursat, 2004). Members of the population frequently consult private doctors and traditional therapists who have had widely varying amounts of training. The public authorities do not yet have control over this lucrative private sector. Meanwhile, public facilities go underused (according to the 2010 Demographic and Health Survey (DHS) only around 25% of the population sought first treatment in the public sector (DHS, 2010)). Unofficial payments often add to the costs of official treatment prices (Meessen et al., 2008). Public staff are poorly paid, which often encourages doctors and nurses to look for work in the private sector. This lack of regulation allows the flagrant abuse of the price setting of services and of the quality of prescriptions (Duffau, Diaz Pedregal, 2009).
The Cambodian Government finances only 10% of national health expenditure, while international donors contribute more than 20%. The remaining 70% of the total cost has to be met by the users. This represents a considerable burden for the average household in Cambodia, especially in rural zones. Health costs are around 25 USD per person per year in these zones, which is more or less a month's salary for a rural inhabitant.
First steps towards universal social health protection in Cambodia
Social health protection in Cambodia combines an assistance scheme for poor people (health equity funds - HEF), a voluntary insurance scheme for the informal sector (community health-based insurance - CBHI), a mandatory scheme for the formal sector (social health insurance - SHI), as well as a private health insurance scheme (PHI) for the wealthiest of the population. Other types of health financing schemes are also found in Cambodia - although these remain minor in terms of coverage (Annear, Ahmed, 2012) - such as maternal health vouchers, global health initiatives and national programmes for patients with tuberculosis, malaria, AIDS and for child vaccination schemes. The majority of Cambodians (89% of women and 92% of men) still do not have health insurance (DHS, 2010).
HEFs provide the most important health protection scheme in Cambodia, in terms of the number of individuals covered. The Cambodian Government considers 26% to 30% of its population as poor (Royal Government of Cambodia, 2011) and that the majority of the poor are eligible for HEF or fee exemption. However, due to discrepancies between official statistics and actual coverage, this represents only around 6% to 9% of the Cambodian population (DHS, 2010).Poor individuals who do not benefit from an equity fund have to finance their own health care expenditure ("out-of-pocket expenditure").
The second most important social health protection scheme, when considering the number of individuals insured, is CBHI. Today, however, only 1% of the population is insured by one of the nine CBHIs in Cambodia. A State objective is for the whole informal sector (with the exception of the poor) to have access to CBHI (see figure 1). In practice, there are many reasons why so few people are covered by CBHI, these include: a lack of knowledge or understanding of the concept of "insurance"; the low level of trust towards legal institutions; a lack of "willingness to pay" for a hypothetical risk of disease; and the weakness of the medical infrastructure and public care services (Duffau, Diaz Pedregal, 2009; Ramage et al, 2012; Polimeni and Levine, 2012).
At present, SHI is still under construction. This type of insurance is intended to be obligatory for people working in the formal sector (mainly civil servants) and will be wage-based. The objective is that SHI will eventually cover approximately 15% of the population.
Finally, PHI targets the wealthiest section of the Cambodian population, which represents approximately 0.1% of the population (DHS, 2010). These insurance packages are expensive but quite efficient, giving a reasonable level of social health protection to affiliated individuals.
A tentative assessment of social health protection schemes
The combined coverage of these four social health protection schemes amounts to less than 10% of the Cambodian population (HEFs: 6% to 9%; CBHI: 1%; SHI and PHI: 0.5%). Social health protection schemes usually cover the costs of primary care and hospitalization, but this does not always extend to medicines. The international Global Fund finances the treatment of certain diseases, such as tuberculosis, malaria and AIDS. This means that people affected by these diseases should not have to face out-of-pocket expenses (except for the costs incurred by travelling to and from the health care centres). In theory, the Government provides the necessary funding to cover chronic diseases (such as high blood pressure, diabetes, etc.). Conversely, most of the for-profit health schemes (such as private insurance) do not cover these diseases, as such coverage is not financially profitable. The disturbing reality is that 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.
As disease frequencies in Cambodia are often unknown, calculating the "risk factor" is a complex process that makes the design of appropriate insurance-based schemes all the more difficult. With regard to CBHI, a 2010 experimental study conducted in rural areas showed that these types of schemes have the potential to significantly decrease the health-related out-of-pocket expenditure of insured households, leading to less debt and less asset sales (Levine et al., 2012; also see box)
It is also worth noting that the financial cost of utilizing the social health protection system varies considerably, ranging from zero to quite high figures, depending on the scheme considered (see figure 2).
Cambodian social health protection has been conceived on the basis of individual wealth and employment type (formal or informal sector). In 2012, State objectives to extend the breadth of protection are still far from being reached, thus leaving the great majority of Cambodian people without access to social health protection.
To improve social health protection coverage and reduce inequalities, other criteria in addition to individual wealth and employment formality should be taken into account. Schemes to target medically vulnerable individuals (the elderly, disabled people, patients suffering from chronic diseases...) are urgently required. There is also a need for systems that take less socially visible groups into account (women, children, ethnic minorities, homosexuals, and so on). A good start in this direction is to give healthcare vouchers to pregnant women (Annear, Shakil, 2012).
For the continuation of the struggle against inequalities in developing countries, these new ways of targeting beneficiaries should be incorporated into Cambodian public policy, while the sustained financial support of donors is also essential.
Insuring health or insuring wealth? Main results from an experimental evaluation of health insurance in Cambodia
In 2007, AFD initiated1, in conjunction with the University of California, Berkley and DOMREI, a Cambodian
research institute, one of the first rigorous micro-health insurance impact evaluations, based on a randomized control trial, in Cambodia2,3.
2. All the results of this research program can be found on http://www.skyie.org and on the AFD website.
3. This study partially drew on the only large-scale randomized experiment examining the effects of health insurance, set in the1980s in the United States, called the RAND Health Insurance Experiment.
The study aimed to measure the impacts of a micro-health insurance programme, known as SKY (Sokhapheap krousar yeung – health for our families), and also to analyse the determinants of its take-up. The SKY insurance programme had originally been developed by an NGO called GRET in 1998.
This study highlights the difficulties faced by such a scheme in terms of reaching the large populations in rural Cambodia. Without subsidies, take-up of the micro-health insurance programme is shown to be very low (less than 5% on the “control group”) and proves unstable (drop-outs are frequent after the initial six-month coverage). It is found that some households are unfamiliar with the concept of insurance, therefore indicating that educational and cognitional barriers are involved. Some evidence indicates that the less (financially) risk-averse households are the ones that purchase SKY insurance, suggesting that SKY is perceived as a “risky product”. However, demand for insurance is found to be rather elastic to the level of the premium. A decrease of 80% of the insurance price leads to a 41 percentage points increase in purchase.
Despite the slow “adoption” of micro-health insurance in rural Cambodia, the experiment confirms its strong potential economic benefits. SKY decreases total health care costs of serious health shocks by over 40%, leading to a one-third reduction in debt compared to uninsured households and to a significant reduction of asset sales. SKY is also successful in terms of its goal to shift rural Cambodians away from unregulated private providers and drug sellers and into the public system. However, the experiment does not find any reduction in the delay period prior to individuals seeking first healthcare; and nor an increase in the overall level of care received (in particular, preventive care).
Finally, the study points to the strong influence of the public healthcare supply in sustaining insurance membership. Many households think of public facilities as being of poor quality (compared to private ones). When this perception is compounded by the fact that people often have to travel very long distances to reach such facilities, then it is enough to persuade many new SKY members to continue using costly private care (in particular for minor health problems), and eventually to drop-out of SKY. Overall, the evaluation highlights the advantages but also the limits of voluntary health insurance, compared to other health protection schemes like HEF.
The construction of heath insurance
Assessing the equity and quality of health protection mechanisms