Home > Laws > In Brief: The extension of social security in Cambodia

In Brief: The extension of social security in Cambodia


After decades of civil war that have hampered its development, Cambodia is now living a period of fast economic growth and is at a turning point of its economic and social development. There is a hope that growth will reduce inequality in this country, where 35% of the population is living under the poverty line, and where the economic gap is increasing between people living in rural areas – representing the 80% of the whole population – and those living in urban areas (especially those living in Phnom Penh).

Cambodia is also dealing with several health diseases (tuberculosis, dengue fever, malaria, HIV/AIDS, diabetes, hypertension, cancer, etc.). The response to HIV/AIDS has been remarkable due to a strong and very independent national program and funding by the Global Fund. However, donor funding is mainly focused on communicable diseases, misaligned with Cambodian top priority of maternal and child health (MCH).

A shift in investments is certainly needed from abundantly funded programs on communicable diseases control (CDC) towards more neglected areas like non communicable diseases (NCD) and MCH. For a more detailed analysis of the most recent achievements and priorities of health policy in Cambodia, see the Health Strategic Plan for 2008-2015.

I) Social protection : A right enshrined in the Constitution
II) Social security in Cambodia (except on health): Legal framework and main programmes
III) Social health protection: Facts and figures
IV) Conclusion: The challenge of health insurance

I) SOCIAL PROTECTION: A RIGHT ENSHRINED IN THE CONSTITUTION OF CAMBODIA

Some articles of the 1993 Constitution of Cambodia refer directly to social security:

  • Article 36: “Every Khmer should have the right to obtain social security and other social benefits as determined by law.”
  • Article 72: “The health of the people shall be guaranteed. Poor citizens shall receive free medical consultation in public hospitals, infirmaries and maternity wards.”
  • Article 75: “The State shall organize social security schemes for workers and employers.”

Unfortunately, the complete fulfillment of those principles is still a long way ahead.

II)SOCIAL SECURITY IN CAMBODIA (except on health): LAWS AND PROGRAMMES

1) Legal framework

The Labour Law, adopted by the Government of Cambodia in 1998, was the first law on social protection to enter into force in the country. It introduced the ILO standards on labour into the national legal system, e.g. fixing work hours at 48h per week and providing for a minimum age for work (15 or even 18 years old in some cases).
In 2002, the Law on Social Securitywas enacted. This law gives private sector’s workers a right to social benefits for working accidents, disability, old age and retirement (for war veterans). According to this law, its provisions cannot be implemented until the National Social Security Fund (NSSF) takes action, before all by signing the corresponding applicatory decrees.
The NSSF was established in March 2007, by

2) Social security programmes: Facts and figures

The Government made an important step towards alleviating poverty through social protection by enacting the National Strategic Development Plan (NSDP) for 2006-2010. Among other things, this Plan aims at ensuring that the poorest households have access to health services and education. Moreover, since 2005 the Government has put in place a number of programmes related to social protection that are being managed by the three Ministries that are most concerned with social protection [the Ministry of Social Affairs, Veterans and Youth Rehabilitation (MoSVY), the Ministry of Labour and Vocational Training (MoLVT) and the Ministry of Women’s and Veteran’s Affairs (MoVA).] Through these programs, several systems of protection were created to cover different parts of the population (e.g. retired, disabled, poor and sick people).
In 2005, according to the Asian Development Bank (source: ADB), the total expenses for social protection programmes not related to health amounted to 1,4% of the GDP, that is 78 millions US $, of which:

  • 47% assigned to micro finance (a)
  • 24%assigned to old age pensions (b)
  • 29% assigned to programs related to the work market (e.g. training), to social assistance and to the protection of childhood (c, d, e).

These balance sheet items are further detailed in the following paragraphs.

  1. Since the early Nineties, micro finance programs target the poorest people, in order to help them to face some financial burdens and to improve their overall conditions of life. In 2005, the 41% of the poor was benefiting from one of these programs (source: ADB).
  2. In 2005, 8% of Cambodians with more than 60 years of age (120.000 people) perceived an old age pension from the Government (source: ADB). The main beneficiaries were:
  • Dependants of deceased militaries (54. 895 beneficiaries)
  • Disabled persons (31. 121 beneficiaries)
  • Retired civil servants (19. 489 beneficiaries)
  • Retired militaries (5. 151 beneficiaries)
  • Disabled civil servants (5. 151 beneficiaries)

The total amount of expenses for pensions was estimated to be 16.4 million US $ in 2005.

  1. 5% of unemployed and underemployed people benefit from programs aimed at facilitating access to training and to the labor market.
  2. 16% of individuals considered poor benefit from some forms of social assistance. This consists mainly of food aid, access to health care for children and pregnant women and assistance to people affected by HIV. Allowances are paid either by the Government, or by religious groups, NGOs and the World Food Program. Besides, 9% of disabled people also benefit from social assistance.
  3. Finally, 45% of 5 to 14 years old Cambodians benefit from education and food programs targeting poor children and adolescents.

Decades of war have seriously affected the health care system. No health training has been done for years and the number of doctors has decreased. In 1979, there were not more than 50 doctors and this figure didn’t rose up to over 2000 until the Nineties.
In the early Nineties, the will to develop social protection in the field of health began to emerge, first through a training program funded by France and then through a reformatory policy launched by the Government of Cambodia since 1992. The turning point of this policy was in 1996, when the National Charter on the Financing of Health Care came into force, introducing official rate bases in the public sector.
As of the private sector, the 2000 Law on Social Security provided a legal basis for establishing a private health insurance system. Actually, such a system was mainly put in place for the textile sector’s workers.
In 2005, the Master Plan adopted by the Ministry of Health made another important step towards the extension of health protection. This Plan aimed at favouring access to health care and had the long term goal of ensuring universal coverage through three major pillars:

  • A compulsory health insurance for employees of both the private and the public sector;
  • A community based voluntary health insurance linked to the social protection system;
  • A social assistance program financed through Health Equity Funds, extending coverage to the poorest.

In spite of all these plans, there is still no real health insurance system in Cambodia and a second master plan is currently being considered to finally create such a system. In 2006, the expenses for health care amounted to 6% of the GDP (source: WHO). The main figures are resumed in the table below.

Indicators Value
General government expenditure on health as % of total government expenditure 10.7 % (WHO, 2006)
General government expenditure on health as % of total expenditure on health 26.1% (WHO, 2006)
Private expenditure on health as % of total expenditures on health 73.9 % (WHO, 2006)
External resources for health as % of total expenditure on health 22.3% (WHO, 2006)
Out-of-pocket expenditure on health as % of private expenditure on health 84,4% (WHO, 2006)
Per capita total expenditure on health (PPP int. $) 167.0 (WHO, 2006)

So far, the role of the Government in the field of health protection has been limited and consisted mainly of developing infrastructures and training tools, rather than of a real extension of access to health care. According to GRET, in 2006 there were 9 national hospitals and 965 public care centers, corresponding to about 7,000 beds. This supply is insufficient to cover the needs of families, which therefore often turn to private care. According to the Ministry of Health, there were in 2004 more than 2,300 private providers, of which 66% operating without a license.
Cambodia has the highest percentage of out-of-pocket expenditures in Asia, which is one of the reasons why many households enter the vicious circle of indebtedness, loss of capital and impoverishment. A strong part of families practice self-care or seeks health care very late, whilst other families make debts to pay their health care. This may lead to make poor even poorer and to bring the “not so poor” into poverty.
To face these issues, a number of community based social insurance schemes (CBHI) were introduced in various parts of the country by a range of international and local NGOs and still play a major role in the country. CBHI is a non-profit, voluntary insurance mechanism based on the sale of low cost insurance premiums that provide the purchaser and his/her family with coverage for health charges for a stated list of medical services delivered at contracted public health facilities. CBHI is based on the principle of risk pooling and pre-payment for health care. The following table shows the number of beneficiaries of some insurance systems.

Systems Insured people
GRET 32, 800 (CBHI Report ,2009)
CAAFW 20,500 (CBHI Report, 2009)
RACHA 8,400 (CBHI Report, 2009)
PBHI 5,200 (CBHI Report,2009)
CHHRA 3,500 (CBHI Report, 2009)

The results of these programmes are remarkable: in the areas of the country where a CBHI scheme was put in place, the average number of outpatient visits per member was 1.93, that is almost double the national average in 2008, demonstrating a regained trust of the target population in the public health facilities in their areas as well as in the CBHI services. For more information on CBHI programmes in Cambodia:
– Power Point presentation on CBHI implementation in Cambodia
– CBHI section of the 2008 National health financing report of Cambodia

A new Health Insurance Project (HIP) co-managed by the textile employers’ association (GMAC) and a French NGO (GRET) is being launched and may bring considerable progress towards social security in the field of health in Cambodia. This is a three-year program financed by AFD and covering work-related health risks of textile workers and their families (10,000 workers should be covered the first year, 100,000 the second year), thus involving about a third of the Cambodian population. The HIP is an experimental programme aimed at creating the health branch of social security in Cambodia. Some staff members of the National Social Security Fund are to be integrated in the programme and the Ministry of Employment agreed to give its cooperation.

IV) CONCLUSION:THE CHALLENGE OF HEALTH INSURANCE

Since some years, the health care system of Cambodia has been improving, either as for its quality, its accessibility and available resources. The main motors of change have been the will of the Cambodian Government and the development of community based health insurance systems.
This notwithstanding, there are still several obstacles to overcome, as the needs of the population are numerous and diverse, while resources are very limited. In order to ensure the development of a health insurance system, Cambodia needs to elaborate a consistent strategy supported by different actors. The country should overcome the vicious circle still characterizing the access to health care and adopt a long-term perspective.
Cambodia should mainly:

  • Show a strong political engagement and favour the confidence of citizens in public institutions;
  • Increase the sensibility of the population for social protection issues;
  • Mobilize additional resources to fund the system.

Mutual insurance companies, community based schemes, health insurance systems, linked schemes and all other actors may play a major role in the extension of social security in Cambodia, by contributing to increase and improve the quality and availability of healthcare.

Source: ILO http://www.ilo.org/gimi/gess/ShowCountryProfile.do?cid=376&aid=2

  1. 25/10/2011 at 1:15 pm

    Labor Law was enacted in 1997 but in your article referred to Labor Law was enacted in 1998 is wrong.

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