The Cambodia HiT reports that the national health sector reforms initiated two decades ago have had a positive impact on Cambodia’s health sector. The country’s health status has substantially improved since 1993 and is on track to achieve the Millennium Development Goal targets. Improving the quality of care is now the most pressing imperative in health-system strengthening.

1. Health Systems in Transition
Kingdom of Cambodia
Health System Review

2. Technical editor:
Peter Leslie Annear
Authors:
Technical co-editors:
Bart Jacobs Matthias Nachtnebel
Peter Leslie Annear John Grundy
Matthias Nachtnebel Bart Jacobs
Chean Men Por Ir
Sophal Oum Ann Robins
Chhun Eang Ros
Note: Updated with data from Legido-Quigley H, Asgari-Jirhandeh N, editors. Resilient and people-centred health systems: Progress,
challenges and future directions in Asia. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018
Health Systems in Transition:
Kingdom of Cambodia Health System Review
Suggested citation: Annear PL, Grundy J, Ir P, Jacobs B, Men C, Nachtnebel M, et al. The Kingdom of Cambodia Health System
Review. Vol.5 No.2. Manila: World Health Organization, Regional Office for the Western Pacific, 2015.

3. 3
 Cambodia: Socio-demographic profile
 Overview of health system
 Service delivery network
 Governance and administration
 Financing
 Infrastructure
 Human Resources
 Major reforms
 Main findings
 Progress made
 Remaining challenges
 Future prospects
This map is an approximation of actual country borders
Source: https://www.who.int/countries/khm/en/
Presentation outline:

4. 4
Socio-demographic profile
Source: World Bank 2018, UNDP 2016.
Area: 181035 sq. km
Population: • 16 million (2017)
• Population doubled
from 1980-2012
• Rural (79%) (2016)
Life expectancy at birth
(m/f)
67.2/71.4 years (2016)
GDP per capita: USD $1384.40 (2017)
HDI 0.563 (2015)
Health expenditure
% GDP
6.0 (2015)
Cambodia Socioeconomic indicators, 1980-2017
Family in rural Cambodia, ©WHO/Yoshi Shimizu

5. 5
Overview of the health system
Mixed health system
1. OOP and Donor funding
2. National & local governments
3. Decentralized system
4. Pro-poor/Social health insurance focus
1. User fees at the point of service
2. Provide majority of curative care
3. Fragmented system – loose regulation
Public
sector
Private
sector
Article 72 of the Constitution of 2008 establishes the obligation of the state to ensure
the health and well-being of all Cambodians, especially the poor and vulnerable.

6. 6
Overview: Service delivery network
Health Coverage Plan:
• Public health infrastructure developed to facilitate
access
Patient pathway:
• Health centres as gatekeepers to higher level of care,
but easily bypassed
Outpatient care:
• Private providers deliver majority of primary health care
• Self-medication often first treatment option
• Staff shortages (often) at health Centres inhibit care
Inpatient and preventive health care:
• The public sector plays a dominant role for inpatient care and preventive health services
Collaboration
• Private not-for-profits mostly work at district and community levels to support public services
• No official cooperation exists between public and private providers
Pharmacy at a social clinic in Phonm Penh
©WHO/Yoshi Shimizu

7. 7
Overview: Governance and administration
• Manages and leads entire health sector
• Public health administration centralized
Central
• Implements Health Strategic Plan, service delivery
Local (Provincial/Operational District)
• Professional associations: Medical Council role and professional
association roles limited in regulation and representing workforce
• Not-for-profits: Often collaborate with government on curative,
education and promotion health activities
Other

8. 8
Overview: Health financing
Selected health finance indicators, 2000-2015
• Out of pocket payments (OOPS) are the main source of financing in health care
• Foreign donors make up almost 50% of total government health spending
Source: WHO, 2018a

9. Scheme Target population Coverage
Tax funding via government budget All population sectors Public health facilities nationwide
User fees / exemptions All populations with capacity to
pay / poor patients
98% of public health facilities nationally / public health
facilities nationally
Global health initiatives Patients with malaria, TB, AIDS
and children needing vaccinations
Nationwide
Health Equity Funds The eligible poor (those below the
national poverty line)
All hospitals and health centres nationally
Voluntary Health Insurance Those with capacity to pay Where available
Community Based Health Insurance Mainly in the informal sector
living above the poverty line
3% of the national population
Vouchers for reproductive health services Poor women In 9 Operational Districts and 4 private clinics
National Social Security Fund (NSSF) Private sector workers and civil
servants
Work injury benefits for private and government
sector workers
Midwifery Incentive Midwives working in public
facilities
Nationwide
9
Overview: Health financing contd.
Source: Ministry of Health
• Basic service coverage of services (supply-side) achieved
• Gradual shift towards upscaling demand side schemes occurring
Sources of government funding for health services and health financing schemes

10. Overview: Infrastructure
10
Number of public health facilities, 2017
• Public health infrastructure steadily increasing but remains vastly outnumbered
by the private sector.
• Hospital bed to population ratio lower than neighbouring Thailand and Viet Nam
• State of the art diagnostic equipment mostly found in the private sector.
Source: WHO, 2018b

11. Overview: Human resources for health
11
Rebuilding the health workforce has largely been a success following Khmer Rouge
rule. There were only 25 doctors in the country in 1979
Health workforce:
 Improvement in staff numbers, quality and responsiveness required
 Current staff numbers: Approximately 21,000; Estimated 36000 health workers
required by 2020
Health Coverage Plan: Heavy reliance on nurses and midwives (70% of workforce)
to achieve national coverage of primary health care services
Health workforce density per 1000 population
Source: WHO, 2018b

12. Overview: Major reforms
12
• 1995: Health Coverage Plan
• 1996: Health Financing Charter
• 2000: Sector-Wide Management (SWiM) and Health Equity
Funds
• 2003: 1st Health Strategic Plan (HSP 2003-07) and Health
Sector Support Plan (HSSP 2003-08)
• 2007: Midwifery Incentive Scheme
• 2008: 2nd HSP (2008-15) and 2nd HSSP (2009-15)
• 2008: Introduction of Special Operating Agencies
• 2010: Fast Track Initiative to reduce maternal and newborn
mortality
• 2016: National Social Security Policy Framework
• 2016-2020: 3rd HSP
Antenatal care, Prey Khmer Health Clinic
©WHO/Yoshi Shimizu

13. Achievements and progress made: Policy and planning
13
Strong record of policy-making and planning
Stewardship with coordination with key
stakeholders at national level
Complete reconstruction of the health system
following Khmer Rouge regime
Effective health financing interventions and
significant poverty reduction

14. 14
Achievements and progress made: Maternal and
child health
Health indicators, 1990-2016
• Maternal, under-5 and infant mortality rate halved between 2005 and 2016
• Strong political backing has facilitated programs to increase skilled birth attendance
and institutional births
Source: World Bank, 2018

15. 15
Achievements and progress made: Special operating
agencies (SOAs)
Contracting arrangements for SOAs
• Internal contracting approach to
deliver greater financial
autonomy at local level
• Better performance recorded in
OD to SOA conversion
• Inadequate incentives have led
2/3 of public health workforce
to take part in dual practice
• More than 1/3 of ODs have
become SOAs

16. 16
Achievements and progress made: Health equity funds
• Principal social protection scheme in
Cambodia
• 3.2 million clients below poverty line
Social
protection
• Covers all hospitals and health
centres nationally for all standard
services provided
National
coverage
• Increases health care utilization,
reduces OOPs, debt and asset sales
• Free services for beneficiaries
Benefits

17. Achievements and progress made: Data and
information management
17
• Health Management Information System: maintained since 2010
• 55 Referral Hospitals, 24 Provincial Hospitals, 8 National Hospitals, Two NGO
hospitals and all OD offices enter data directly via internet
• Upgrade: Consultative and participatory approach in line with WHO requirements
• Accuracy: data reported to be within 5% of household surveys suggesting validity and
reliability
• Utility: Quarterly and annual reviews, SOA performance reviews and annual budgeting
• Health Information System Strategic Plan created to support national health plan
• Electronic Health Records: Piloted and expected expansion

18. Remaining challenges: Epidemiological transition
18
• 58% of mortality resulted from NCDs in 2016
• Infections are still the number 1 cause of disability-adjusted life years (DALYs)
Leading causes of death and loss of DALYs (% of total) 1990-2016
Source: Institute for Health Metrics and Evaluation, 2018

19. Remaining challenges: Risk factors
19
• Behavioural risks now number one risk factor for death
• Child and maternal conditions make up 16% of premature death and loss of DALYs
Leading risk factor for death (all ages, both sexes), 1990 and 2016

20. Remaining challenges: Mental health
20
Household survey found high rates of psychiatric
morbidity: 42% depressed, 7% PTSD, 53% anxiety
MoH integration of mental health into public sector,
limited services in short and long term care
Existing mental health staff concentrated in capital and
large towns decreasing access
Patients turning to informal care arrangements through
monks, traditional healers or family and NGOs

21. 21
Distribution of providers in annual per-capita OOP
spending on health care, 2012
Distribution of annual household OOP spending on
health care by income quintile, 2012
• 77% of OOP payments go to the private
sector
• The richest income quintile spends 16
times more than the lowest quintile in
terms of OOP spending
Remaining challenges: Out of pocket payments
Source: MoH, based on CSES 2012 (NIS, 2013) Source: MoH, based on CSES 2012 (NIS, 2013)

22. 22
Remaining challenges: Inefficiencies in national health
budget
Government health expenditure, 2013 (% of total budget)
• Only 30% of the national
health budget reaches the
provinces with the rest
remaining within MoH
• Drug and medical supply
expenditure is far higher
than the international
average. They are also more
than double wage outlays.
Source: Official budget figures provided by the MoH

23. Remaining challenges: Regulations
23
Health sector laws
• 1996 Law on the management of pharmaceuticals
• 1997 Law on abortion
• 2000 Law on management of private medical,
paramedical and medical aid services
• 2002 Law on prevention and control of HIV/AIDS

24. 24
Remaining challenges: Private sector
•Rapid expansion including in rural areas
1426 public vs 12641 private facilities
Lack of oversight over private sector
2/3 of patients go to private providers for curative services
Private health expenditure makes up 60% of THE

25. 25
Remaining challenges: Quality of care
•Low health sector
quality of care
NCDs strain health
services
No continuum of
care for people
with disabilities
Only one
recognized cancer
centre nationally
Health outcomes
still vary according
to demographics

26. Finance
Education
Programs
26
Remaining challenges: Donor led health system
• The Cambodian health system is
highly dependent on donors for
development assistance
• Roughly 20% of THE comes from
donor contributions
• A number of charitable agencies
and NGOs provide high quality
inpatient and outpatient care,
training, education
• NGOs and international NGOs also
fund and operate local and national
programs including HIV/AIDS and
HEFs
High level of donor dependence

27. Future prospects: Cambodia
27
Single payer
health fund
Strengthening
MoH
leadership
Consolidation
of existing
programs
Public-private
coordination
Key challenges:
• Epidemiological
and
demographic
transition
• Low QoL

28. 28
Based on the Health Systems in Transition
The Kingdom of Cambodia Health System Review, 2015

29. http://www.searo.who.int/entity/asia_pacific_observatory/publications/hits/hit_cambodia/en/
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