1

International Forum on the Development of

Social Health Protection in Southeast Asian

Region

27-28 October 2014, Hanoi, Vietnam

CAMBODIA Country Team

LO Veasnakiry, M.D.; MA(HMPP), MoH

Sum Sophorn, NSSF

1. Basic Data

2. Health System Organization

3. Health Financing and Coverage

4. Challenges

5. SHP: Ways moving forwards

6. Concluding Remark

2

Source: NSDP 2014-2018, RGC

• Total geographical areas 181,035 Sq. Kms

• Total population 14.7 M (Nov. 2013 CIPS)

• Annual growth rate 1.46%

• Total fertility rate 2.8

(per 1,000 live births)

• Life expectancy at birth M 67.1/F 71

756

1.138

2.216

3.355

3.658

9,1% 8,8% 13,3%

6,0% 6,9%

63,3%

47,8%

21,1% 19,8%

0%

10%

20%

30%

40%

50%

60%

70%

0

500

1000

1500

2000

2500

3000

3500

4000

1994 2000 2004 2005 2006 2007 2008 2009 2010 2011

(GD

P

pe

r ca

pit

a i

n t

ho

usan

d)

GDP per capita (in '000 Riel) Growth rate in GDP Poverty rate

Source: MoP, Cambodia: Poverty in Cambodia; Redefining the poverty line & Progress

Report of NSDP updated 2009-2013.

1,01

0,87

1,31

4,41 4,28

10,67 13,16

0

2

4

6

8

10

12

14

0

0,5

1

1,5

2

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

as %

of

GD

P

GHE as % of GDP GHE per capita (in $US)

Source: MoH (DBF, DPHI), WB(GDP) 5

6 “Operational District level (81)”

Central Level

Provincial Level provincial hospitals

(24)

Referral Hospitals (68)

1000,000-200,000 J

Health Centers (1.024)

JKLJKL

Community

J8,000-10,000

Health Post (121)

1

2

3

National

hospital (8)

Health Sector Reform (HSR) in post conflict

setting

• Initiated 1993, implemented in 1995

• The reform implies entails important

transformations, both organizational

(including human resources) and financial

Changing from administrative to

population base system organization—

Population size and accessibility criteria.

Redefine management & service delivery

functions of each level, HC-MPA and RH-

CPA

Reallocation and training health workforce:

pre-service training, in-service training

(Health Service Management)

Introducing new ways of health system

financing (Health Financial Charter)

7

95 66 45 50

125 83

54

690 640

437 472

206 250

37 28 27 60

0

50

100

150

200

250

300

350

400

450

500

550

600

650

700

750

800

1990 1995 2000 2005 2010 CMDG2015

Infant Mortality Rate

U5 Mortality Rate

MMR

Neonatal Mortality Rate

MMR development in Cambodia 1990-2010. Estimates for 1990 and 1995 from WHO, the remainder from CDHS

For 2005 and 2010 with 95% confidence intervals. Analyzed CSES 2004, 2007 and 2009 using methods developed by the World Health Organization (MoH, WHO,

GIZ), 2010, 2011

8

1,9 1,2

0,8 <0.6

5,2

2,34

1,11

0,33 0,78

2000 2005 2010 2012 CMDG2015

Trends in Reduction of HIV Prevalence and Malaria Mortality Rate

HIV prevalence among adults 15-40 ys) Malaria Mortality Rate

1.670

1.670

1.620 1.230

817

718

155 135 128 93 63 87

1990 1995 2000 2005 2010 CMDG2015

Trends in Tuberculosis Prevalence and Death Rate

TB prevalence per 100,000 population

TB death Rate per 100,000 population

9

Country overall development

Peace, security, Political stability, economic growth, road

infrastructure, poverty reduction, telecom, ITC, education and health

(infrastructure, training…)

Supply-side

Interventions

Demand-side

Interventions

1993 1995 2000 2005 2010 2015 2020

1993 1995 2000 2005 2010 2015 2020

User charges with exemption for the poor

HEALTH EQUITY FUNDS

Contracting Health Service

Special Operation Agency

Community Based Health Insurance

Midwifery Incentives

Voucher for Reproductive Health

3. Health financing Interventions

Work Injury scheme (NSSF)

Planned HI scheme (NSSF)

Features Health Equity Funds and Subsidy CBHI

Main

Objective

Removing financial barriers in access to quality

health services by the poor

Beneficiary All poor (under the national poverty rate)

Pre-ID poor, and Post-ID poor

Benefit

packages

• HEF: MPA, CPA, transportation cost, referral, food

allowance for 1 care taker of IPD patient, funeral

grant.

• Subsidy: only MPA and CPA

Provider

payment

• HEFs: Standardized case base payment

• Subsidy: flat rate

Implementing

arrangements

Providers: public facilities

• HEFs: contract base, 3rd party (HEF Implementer

(monitoring) & HEF Operator (implementing),

• Subsidy: HC & RH via OD & PHD

Financing • HEFs: National budget and DP since 2009 (40%

vs 60% share of direct cost, respectively, in 2013).

• Subsidy: National budget

Coverage 78% and 93% of the poor peoples in 2012 and 2013 10

MoH: Annual Performance Report 2012, Analyzed CSES 2004, 2007 and 2009 using methods developed by the

World Health Organization(MoH, WHO, GIZ). CDHS 2010. MoH, Health Financing Policy final draft. May 2013.

11

5573

581274

1033316

13926

106083 135090

101

370

44 64 0

200

400

600

800

1000

1200

0

200000

400000

600000

800000

1000000

1200000

2005 2006 2007 2008 2009 2010 2011 2012 2013

num

ber

of

case

s

OPD IPD # HC with HEF & subsidy # RH with HEFs & subsidy

Financial protection Determinants of financial burden • Residents of ODs with HEFs have lower OOP and less likely to suffer catastrophic

spending of medical indebtedness • Rural areas are more prone to medical indebtedness and catastrophic payments

Financial burden of payment • Declined catastrophic health expenditure (>40% of CTP on OOP) from 6.20% (2004) to

4.27% (2009). Similar decrease across quintiles • Incidence of indebtedness due to illness decreased from 5.3% (2004) to 3.8% (2009)

Health Equity Funds- demand side

Overall health care access:

• More people seeking care, mainly HC, bigger increases in lower economic quintiles

• 2004-2007 (the poorest quintile): IDP: 3.1% increase vs. 1.1%, previously, OPD: 20% increase.

• 2005-2010: 35% of delivery at HF by the poorest quintile women.

1. Epidemiological view point

•Despite significant reduction, maternal and child mortality in

Cambodia remain high if compared with countries in the

region.

•HIV/AIDS, TB and Malaria continue to pose a major public

health problem and require sophisticated clinical expertise

and considerable financial resources.

•The most important areas that deserve attention are non-

communicable and chronic diseases that increase burden on

health system - to provide better primary prevention, improve

detection and management, and improve treatment and care

for acute events- and other health related problems.

2. Health system perspective

• Improving equitable access to quality health services need to pay

attention to service delivery expansion and quality improvement, and

financial protection for the poor and vulnerable.

• Requiring considerable investment in physical infrastructure, medical

technology, ICT, clinical expertise.

• Adequate staffing and skills of health personnel, appropriate

remuneration and right incentive with improved accountability and

performance monitoring.

• licensing, accreditation, quality control mechanisms-well regulated

private sector participation linked to a national accreditation and quality

improvement system.

• Scaling up the coverage of Health Equity Funds, and integrating social

health protection mechanism by rationalizing, harmonizing and

transforming the existing financing schemes- Universal Health

Coverage.

Historical Development Process of Social Security for Formal Sector

The current Labour Law of Cambodia was passed in 1997 by

amending the 1992 Labor Law. The first Social Security Law was passed by the Parliament in

September 2002. In 2004 the ILO experts came to study the feasibility of the

scheme and the administrative design. In 2007 the sub-degree concerning the establishment of the

National Social Security Fund (NSSF) was adopted. NSSF was fully functional at end of 2008

Administration

Legal entity with autonomy in administration and self-

financing.

Administers the schemes of Social Security protection in

accordance with the National Social Security Law and the

provisions of the Social Security related Sub-Decrees.

All technical issues are under the supervision of the Ministry

of Labor and Vocational Training (MoLVT), while the Ministry of

Economy and Finance (MEF) needs to approve all finance

related issues.

Role of the Governing Body

NSSF is guided and monitored by the Governing Body, which consists of a

tripartite representation of employers, employees, and the government.

The chairman of the board gets nominated by the Minister of Labor. The

NSSF Director is an ex-officio Member (automatic).

Other representatives get nominated by their related organization.

They must have never been convicted of misdemeanor or criminal

charges.

The chairman and members of the Governing Body except ex-officio

member (permanent member) are appointed by sub-degree for a 3-year

mandate issued by MoLVT as request from the organization they represent

*Member:

*1,019,130 Members (September of 2014)

*6,915 Employers

*Coverage in 24 Provinces

*Premium: Employers pay 0.8% of each average

staff’s salary.

2007 2008 2009 2010 2011 2012 2013 2014 2015

Work Injury Scheme

Preparation

X

Work Injury Scheme

Implementation

X

Health Insurance

Pilot Project

(HIP/GRET)

X X X X X

Preparation of

National SHI for

formal sector

workers

X X X X X

Implementation of

the SHI Scheme for

formal sector

workers

X X

Objective

• Stabilize statistic and financial data in order to calculate the right premium rate for NSSF

• Develop tools and skills to be transferred to NSSF • Train/inform all stakeholders of major challenges of such

scheme

Start date 2009

Membership in 2014/09 11 GARNMENT factories around Phnom Penh 8,432 workers covered

Benefit package OPD, IPD, Delivery in public contracted health facilities

Premium 1.6 USD/worker – 50% employer, 50% employees

Contact rate at HF OPD: between 1 or 2 contacts per year (depending on the factories) IPD: 6,5% per year

LUMP SUM Payment

(Former) HIP

Fee for Service Payment

WI SCHEME

CASE BASED PAYMENT

WI + SHI

Start SHI National

Scheme at NSSF

MPA 5 Cases

CPA1 8 Cases

CPA2 12 Cases

CPA3 11 Cases

TOTAL 36 Cases

Fee for Service Payment for Special Cases

Prakas on Social

Health Insurance HSPIS System:

- Development/Adaptation

-Test

- Implementation

- Roll out

Software Requirement

definitions

Q1, 2014 Q4, 2014 Q3, 2014 Q2, 2014

SOUND HEALTH FINANCING STRATEGY IN THE CONTEXT OF PUBLIC FINANCIAL MANAGEMENT REFORM AND DECENTRALIUZATION & DECONCENTRATION

Moving forwards: Social health Protection

1. Financial risk

protection

2. Equitable and fair

funding

3. Efficiency of

service delivery

4. Quality services

5. Transparency

• Resource

mobilization

• Pooling: who will

manage them

• Purchasing: buy

services (supply or

demand)

• Stewardship:

regulation and

monitoring

1. Medium term

• Along policy

objectives and

Financing functions

2. Long term

Considering:

• UHC of Social

health Protection

Health Financing Strategic Components

• Institutions: NSSF (private sector), NSSF-C (civil servants), Informal

sector (MoH)--enrolment

• Universal population coverage: risk pooling and financial protection

against the cost of illness--

• Benefit package (criteria for quality of care)- risk pooling and financial

protection against the cost of illness

• Purchasing services: ensure quality of health services that are conducive for

good health while making optimal use of available resources

• Sources, level and management of funds: raise sufficient funds to allow for

the delivery of essential health services and enabling their purchase

• Regulation: ensure the delivery of quality health care and establishment of

rules and regulations with clarifications of stakeholders’ roles

• The Royal Government of Cambodia’s strong political

commitment to achieving MDGs, esp. reducing maternal

and childhood mortality and to reducing poverty and

development of social health protection.

• Evidence base policy interventions – country specific choices

• A combined set of both supply-side interventions (service readiness) and demand-side interventions (removing barriers in access to and utilization of health services, geographically, financially, bureaucratically).

• Technical & financial support of Development Partners

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