Cambodia is a lower-middle income country with a population of 15.64 million in 20182 and a gross domestic product (GDP) per capita of US$1,510.3 in 2018.3 Cambodia has found political stability since 1997. It is a country in economic expansion, particularly through strong production in the garment and tourism industry. The Cambodian economy has maintained an average growth rate of 8 per cent between 1998 and 2018, making it one of the fastest growing economies in the world. While slowing slightly in 2019, growth remained strong, estimated at 7.1 per cent.4
In Cambodia, health remains an important challenge and a development priority. In addition, poverty in Cambodia has declined sharply, from 47.8 per cent in 2007 to 13.5 per cent in 2014 according to official estimates. Cambodia thus reached the Millennium Development Goal of halving poverty in 2009. Cambodia has also made considerable progress in improving maternal and child health, early childhood development and primary education in rural areas.5
Citizens' right to healthcare in Cambodia is ensured by Article 72 of the Constitution of the Kingdom of Cambodia, dated 21 September 1993. Article 72 provides that: 'The health of the people shall be guaranteed. The state shall give full consideration to disease prevention and medical care. Poor people shall receive free medical consultations in public hospitals, infirmaries and maternities. The state shall establish infirmaries and maternities in rural areas.' The Ministry of Health (MOH) is responsible for all healthcare matters and it has worked with several international development agencies to reform the country's healthcare system. Before the Khmer Rouge years, Cambodia's pharmaceutical sector had operated a rudimentary but effective system, which is gradually being rebuilt.6
In the early stages after being reconstituted, the Cambodian government implemented social health programmes such as health equity funds (HEFs), voucher schemes, voluntary community-based health insurance (CBHI) and private insurance. These programmes were well received by the public and yielded positive results. The MOH has continued to invest in these healthcare programmes and is now focused on improving Cambodia's healthcare system.
Cambodia is confronted with both pathologies characteristic of developing countries (tuberculosis, dengue fever, malaria, etc.) and diseases more typical in prosperous societies (diabetes, cardiovascular diseases, cancer, etc.).7 In 2017, total health expenditure represented about 6 per cent of Cambodia's GDP and has been increasing in the context of the country's high-growth economy.8
II THE HEALTHCARE ECONOMY
In Cambodia, health expenditure is divided between public and private sectors. The Health Strategic Plan 2016-2020 reveals that there are approximately 1,000 public healthcare facilities and 8,000 private healthcare facilities or providers across Cambodia.
The MOH is responsible for governing healthcare, the healthcare industry, public health and health-related non-governmental organisations (NGOs) in Cambodia. It governs and regulates the activity of medical professionals, hospitals and clinics in the country. On a local level, the public health service is provided by the 24 provincial health departments, which themselves manage a provincial hospital and govern several operational health districts. Currently, more than half of the government's health expenditure is spent on medical supplies. Despite this decentralisation effort of the public health services, the quality and access to the public health services is not entirely satisfactory. In 2017, the number of hospital beds per 1,000 people was 0.7 (compared to 2.2 hospital beds per 1,000 people in Thailand). In addition, the low remuneration of government health workers, which is US$100 to US$150 a month when the living wage is US$350 per month, and the general shortage of health professionals, remain major problems. As a result, many public health sector employees work for both the public and private sectors.
The public sector in Cambodia therefore remains insufficient, which has caused a considerable increase in private health expenditure in recent years. In 2015, about 60 per cent of patients sought private providers. As a result of the growth of the private healthcare sector, the MOH now aims to regulate the private sector more effectively by putting in place required licences and strengthening law enforcement.9
There are four main forms of social health protection in Cambodia. One, the HEFs, is an assistance scheme for poor people and is the most extensive protection system in terms of the number of individuals covered. In 2011, the Cambodian government considered that between 26 per cent and 30 per cent of its population were poor and that the majority of them were eligible for a HEF or fee exemption. However, owing to discrepancies between official statistics and actual coverage, this represented only around 6 per cent to 9 per cent of the Cambodian population. Disadvantaged people who do not benefit from an equity fund have to finance their own healthcare expenditure (known as out-of-pocket expenditure).
CBHIs constitute the voluntary insurance scheme for the informal sector, and is the second most important of the social health protection schemes. However, currently only 1 per cent of the population is insured by one of the nine CBHIs in Cambodia. A state objective is for the whole informal sector to have access to a CBHI. In practice, the lack of knowledge or understanding of the concept of 'insurance', the low level of trust of legal institutions, the lack of 'willingness to pay' for a hypothetical risk of disease, and the weakness of the medical infrastructure and public care services explain why so few people are covered by a CBHI.
A third form of social protection, a mandatory scheme for the formal sector (social health insurance (SHI)), is still under construction. The intention is for this type of insurance to be obligatory for people working in the formal sector (mainly civil servants) and will be wage-based. The objective is that the SHI will eventually cover approximately 15 per cent of the population.
The last system is a private health insurance scheme that targets the wealthiest section of the Cambodian population, which represents approximately 0.1 per cent of the population. This system is expensive but quite efficient, giving a reasonable level of social health protection to affiliated individuals.
Other types of health financing schemes are also found in Cambodia although these remain minor in terms of coverage, such as maternal health vouchers, global health initiatives and national programmes for patients with tuberculosis, malaria, AIDS and for child vaccination schemes.
Although an effort has been made by the government to set up these protection systems, the majority of them have not yet been effectively implemented and the proportion of people covered by these insurance schemes remains very low. The combined coverage of these four social health protection schemes amounts to less than 10 per cent of the population. The majority of Cambodians (89 per cent of women and 92 per cent of men) still do not have health insurance.10 Moreover, social health protection schemes usually cover the costs of primary care and hospitalisation, but this does not always extend to medicines. An effort to ensure the effectiveness of these measures and to communicate the existence and necessity of these measures has yet to be made – and must be – if the Cambodian population is to be effectively covered.
The International Global Fund also finances the treatment of certain diseases, such as tuberculosis, malaria and AIDS. Nevertheless, 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.11
ii The role of health insurance
During the past two decades, Cambodia has made significant progress in economic growth and improvements in key health indicators, particularly through the National Social Security Fund (NSSF) system, and the objective of implementing Universal Health Coverage.
The National Social Security Fund
The NSSF is a public, autonomous and self-financed institute under the Ministry of Labour and Vocational Training (MLVT). Daily operations are supervised by the MLVT while the Ministry of Economy and Finance (MEF) administers all finance-related issues. The NSSF protects everyone who works in Cambodia in an enterprise or establishment, trainees, apprentices and persons who are attending a rehabilitation centre, as well as seasonal and occasional workers. In the past, the NSSF only applied to enterprises and establishments with eight employees or more but this has changed. The Prakas No. 448 on the Registration of enterprise/establishment and worker in the NSSF for the persons defined by the provisions of the Labour Law states in its Provision 4 that: 'The Employer refers to natural or legal persons in the public or private with one worker or more in spite of regular or casual workers.' Further, Article 5 thereof states that: 'The employer or enterprise/establishment under the scope of the Law on Social Security Schemes for persons defined by the provisions of the Labour Law is compulsory to register his or her own enterprise/establishment in the National Social Security Fund (NSSF).' Thus, any employer who has at least one employee must register with and pay the monthly contribution to the NSSF. The NSSF does not apply to public civil servants, diplomatic staff, or officials who are temporarily appointed to public service. Occupational risk started at the end of 2008 and covers companies throughout the Kingdom of Cambodia. Even though there is an authority within each province, companies located in the provinces tend to register in Phnom Penh.
The NSSF currently provides two types of healthcare for people insured.
The first is healthcare for employees relating to accidents at work. It was established by the first Cambodian Social Security Law, currently known as the Law on Social Security Schemes for Persons Defined by the Provisions of the Labour Law, passed by Parliament in September 2002. It protects workers via an employment injury scheme, with a view to mitigating the social burdens and promoting social stability. Currently, 6,868 enterprises are registered with the NSSF system. The services covered are pre-established and are classified as follows:12
- Those who are temporarily disabled are paid a daily allowance equal to 70 per cent of workers' daily average wage until recovery, and a daily allowance for those caring for them equal to 50 per cent of the victim's daily allowance.
- Those who are permanently disabled receive a one-off payment, determined by the NSSF for physical loss of less than 20 per cent incapacity, a monthly allowance for physical loss of 20 per cent or more, a regular physical and medical check every year and rehabilitation services.
- Rehabilitation services are provided based on the description of the disability and extent of permanent damage; either a prosthesis is provided or other benefits. These services are not fully regulated yet.
- The funeral allowance comprises a service for delivery of a person's corpse to his or her home (US$1.5 per kilometre) and US$1,000 for funeral costs. In addition, a benefit is payable to survivors of the deceased (spouse, children, parents or ageing persons).
- A survivor's benefit of around 28 per cent of the daily average wage is paid to the family. A legal marriage certificate is required. If the spouse remarries, the benefit ceases.
Since 2016, coverage by the NSSF has not been limited only to occupational accidents but also has a role in health insurance by covering the personal (non-work related) injuries of registered persons. This social security scheme was established by Phase II of Healthcare, which was issued in the Rectangular Strategy Phase III of the Royal Government and established by Sub-Decree No. 01 SDE, dated 6 January 2016, concerning the Establishment of Social Security Scheme on Healthcare for Persons Defined by the Provisions of the Labour Law. Therefore, currently, there are two complementary mechanisms because health protection of workers is not limited to diseases or injuries directly linked to work but includes the prevention of risk to personal health or non-work injury. Both schemes are linked and sufficiently comprehensive to ensure workers are protected. This system has contributed to promoting health and preventing disease and injury for workers.13 The system ensures and provides benefits and a safe income to members in the event of a contingency such as invalidity, old age, miscellaneous accidents and death.
The NSSF administers schemes of social security protection in accordance with the National Social Security Law and the provisions of the sub-decrees relating to social security. Between 1 January and 31 August 2019, the NSSF provided 19.9 billion riels in postnatal benefits to 49,480 workers.14 This aim of this benefit is to support the livelihood of workers when they have children, to promote social protection and the growth of the Cambodian population, and to relieve the hardship of workers.15 This system now has a central role in the healthcare system in Cambodia. This social insurance is legitimate and compulsory, ensures comprehensive protection and provides long-term social security to the workers and their dependants. The objective is for the NSSF to become the leading organisation that provides social security services.
This system considerably facilitates the regulation of social and health services for all workers. In addition, the government of Cambodia is in charge of cooperating with the competent organisations to disseminate strategies to prevent injuries at work. The NSSF must operate efficiently and transparently.
It is important to note that the NSSF covers only the medical services sought at its panel hospitals or medical institutions and may only cover services sought at private hospitals in an emergency. Therefore, a patient will only have his or her medical expenses reimbursed if the NSSF considers that the medical care was provided in response to an emergency.
In addition, there is often little incentive for public medical institutions to receive patients registered with the NSSF because:
- the cost of the medical services being sought is not very high; and
- the medical institutions may not be reimbursed by the NSSF until long after the treatment is completed, creating a cash flow problem for them.
For these reasons, some medical institutions try to limit the number of patients registered with the NSSF, for example, by receiving them only in the mornings or by claiming that there are not sufficient beds to receive them. Therefore, companies that have employees registered with the NSSF may also subscribe to private group medical insurance for their employees, especially through micro-insurance.
The universal health coverage project
In March 2016, the government committed to achieving universal health coverage (UHC). UHC means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need while also ensuring that use of these services does not cause financial hardship.16
The National Social Protection Working Group led by the MEF has been tasked with advancing the development of a social health protection (SHP) strategy that will help Cambodia achieve its UHC goals. A comprehensive social health protection reform requires multiple decisions to be made relating to health financing. For Cambodia to sustainably finance its ambitious SHP strategy, the MEF will need to identify ways to generate new revenue and improve the efficiency of health spending. Furthermore, international experiences with UHC, particularly those of Cambodia's neighbours, stand to provide useful lessons for the various aspects of social health protection reform that Cambodia will need to consider.17
On 12 December 2018, Cambodia celebrated its annual International Universal Health Coverage Day. The government convened the Second Cambodia UHC Forum to present and discuss new data on health spending and financial risk protection and the way forward for UHC.18 The Minister of Health, Dr Mam Bun Heng, opened the gathering, encouraging the assembled officials to expand financial risk protection coverage to cover more people, focus on service expansion and quality, increase equity in service delivery, especially in primary care, and tackle the rising challenge of noncommunicable diseases. Two reports were presented: National Health Accounts 2012–2016, providing information on health expenditure in Cambodia; and Financial Health Protection 2009–2016, providing information on how much people are paying for health services out of their own pocket, to enable inequities to be addressed. A study on people forced to finance healthcare by borrowing money, which is significant in Cambodia, was also presented.
This ambitious project is carried out in collaboration with Result For Development (R4D), through the USAID-funded Health Finance and Governance Project, and with Abt Associates. R4D conducted a fiscal space analysis to assess where and to what extent new resources can be generated for health in Cambodia. R4D's work will help Cambodia to structure its social health protection initiatives to achieve its goal of UHC in the long term.19
The World Health Organization (WHO) also works closely with the government, particularly the MOH, and other development partners to achieve health for all in Cambodia.
However, within the health system, out-of-pocket expenditure remains high (60 per cent of total health expenditure). Although the country has initiatives to provide financial protection to particular population groups, there is not a national system that provides universal health protection to the entire population. Despite efforts to improve public health services and to establish universal social security, Cambodia's social protection system faces structural difficulties that affect the quality of care provided.20
Micro-insurance21 is a system that uses the insurance mechanism, among other things, and whose beneficiaries are (at least partly) excluded from formal social protection systems, in particular informal economy workers and their families. It differs from systems created to provide legal social protection for workers in the formal economy. Membership is not compulsory (but may be automatic) and members contribute, at least partially, to the financing of benefits.
There are several micro-insurance organisations in Cambodia, which allows the most disadvantaged populations, who do not have recourse to traditional insurance systems, to have access to basic healthcare.
From 2002 to 2011, the GRET (an international development NGO under French law)22 developed a health micro-insurance offer in Cambodia. It was aimed at the informal sector (SKY project) and offered female workers in the textile sector (HIP project) compulsory health insurance. In 2011, the SKY project covered nearly 73,000 vulnerable rural and urban families for US$5 per year.23 Following a change in the institutional context and in consultation with the MOH, the GRET transferred the SKY and HIP schemes in 2011 to local operators subsidised by the state.
These experiences enabled micro-insurers and, since 2012, general insurance companies to propose group personal accident insurance, including healthcare benefits, to employers for their employees. The low level of premium and a very efficient network of hospitals and clinics, both private and public, made this very popular, even with the extension of the NSSF. There have been other attempts to target the lower middle class through new technology, including telecommunications and the internet.
Funding and payment for specific services
In general terms, the Cambodian government funds only 10 per cent of national health expenditure, while international donors contribute more than 20 per cent. The remaining 70 per cent of the total cost must be borne by users. This represents a considerable burden for poor and middle-income households, especially in rural areas. Total health expenditure was estimated at about US$1 billion in 2014 (roughly US$68 per capita).24
The NSSF is funded by contributions from employers. The registration of employees and workers is done by employers at the NSSF office of the MLVT. Employers have 45 days to register with the NSSF after completing their MLVT registration. Registration is mandatory but free of charge. Contributions are borne fully by the employer; they cannot be deducted from an employee's net salary.25 At present, the scheme covers the occupational risk scheme for work-related accidents, and the healthcare scheme for preventative healthcare and medical services. The applicable rate for the occupational risk scheme is 0.8 per cent of the employee's salary, subject to a cap of 8,000 riels per employee. The applicable rate for the healthcare scheme is 2.6 per cent of the employee's salary, subject to a cap of 40,800 riels per employee.26
III PRIMARY/FAMILY MEDICINE, HOSPITALS AND SOCIAL CARE
i Diversity of healthcare providers
A section of the population frequently consults private doctors and traditional therapists, who have widely varying degrees of training. At present, this lucrative private sector is not regulated by the government. At the same time, public facilities are underused: according to a Demographic and Health Survey in 2010, only a quarter of the population sought initial treatment in the public sector. Public personnel are poorly paid, which often encourages doctors and nurses to seek work in the private sector. Lack of regulation leads to gross abuses in the pricing of services and the quality of prescriptions; informal fees are often added to the formal costs of care. Regarding the quality of care, public hospitals have uneven standards whereas private hospitals provide a better level of care. Dr Kee Park, a US-trained neurosurgeon and Senior Consultant in Neurosurgery at the Preah Kossamak Hospital in Phnom Penh,27 said: 'A distinction should be made between private versus public facilities where quality and ability are in stark contrast. In the best private facilities, diagnostic capabilities are sufficient for most common conditions. For example, multiple private CT and MRI scanners are available in Phnom Penh.'28
ii Healthcare insurance provided by the NSSF
As mentioned above, since the issuance of Sub-Decree No.01 SDE, dated 6 January 2016,29 the NSSF has provided health insurance to all workers for injuries and illnesses that occur outside work. These healthcare services include both comprehensive healthcare and preventive health services.
Healthcare delivery refers to medical care, patient referral, transportation of the injured, and daily allowances. It includes medical treatment and hospitalisation (diagnostic, laboratory, medical imaging, surgical, treatment, prescription of drugs and costs of a patient's hospital room if it is necessary to stay in hospital) as well as outpatient and emergency services. The patient has the right to access medical care services in the nearest healthcare institution. Also covered by the NSSF are childbirth; antenatal and postnatal care; rehabilitation services, which are medical care services aimed at helping patients to restore and rehabilitate their abilities, skills and functions for daily life, as well as communication skills lost or damaged as a result of illness, injury or disability; patient or victim referral services; patient referral service; transportation of patients who are terminally ill and the deceased. Kinesitherapy and physical therapy are considered as assistance services.30 A daily allowance is granted during a period of absence from work due to sickness, maternity leave, or accident, and medical care services are free of charge.
The NSSF has established reimbursement rates for different categories of patient care. The insurance provided covers healthcare in the following categories:31
- inpatient and outpatient cover includes:
- treatment and care services provided by medical professionals;
- diagnosis, laboratory, medical imagery and screening services;
- surgical apparatus and other medical equipment;
- prescribed medicines and patient rooms;
- treatment in hospital, free of charge, up to a maximum of 180 days;
- treatment of chronic diseases (cancer and other diseases as defined by the law);
- a daily allowance, for 180 days, which amounts to 70 per cent of the patient's daily wage; and
- health prevention (including vaccinations under certain conditions);
- emergency services cover includes:
- referral services for patients;
- all emergency treatment services;
- all treatments and care until recovery;
- patient and victim referral services and transporting cadavers; and
- kinesitherapy, physiotherapy and rehabilitation services after illness;
- maternity support cover includes:
- delivery and prenatal and postnatal care;
- a daily allowance, for 90 days, which amounts to 70 per cent of the patient's daily wage;
- a free monthly health check-up; and
- other forms of support from the government: US$100 for a child, US$200 for twins, US$300 for triplets. Triplets will be considered as the Prime Minister's adopted children, and will receive an allowance of 5 million Khmer riels (US$1,250).32
Four main categories that are not covered are free services under public health policy, expensive treatments (such as dental care, organ transplantation, heart surgery, hemodialysis, eye laser therapy), non-primary care (such as sexual surgery, plastic surgery, fertility treatment, treatment of alcoholism and drug abuse) and self-treatment.
Health prevention refers to punctual diagnosis, persons identified as having health risks or ill-health, consultation, and other necessary interventions with a view to preventing health problems, such as screening, health education and vaccination programmes. These health prevention services shall be provided by the NSSF, national programmes, institutions and relevant organisations involved with healthcare.
IV THE LICENSING OF HEALTHCARE PROVIDERS AND PROFESSIONALS
The Department of Hospital Services of the MOH is responsible for approving the establishment of medical institutions in Cambodia.
The Department of Drugs, Food, Medical Devices and Cosmetics under the MOH is the main regulatory body for pharmaceuticals in Cambodia. It is responsible for protecting public health by preparing and executing national policies and legal regulations on pharmaceuticals, traditional medicines, health supplement drugs and products, food, medical devices and cosmetics.33
ii Institutional healthcare providers
Institutional healthcare providers in Cambodia are public and private hospitals, clinics, polyclinics and consultation rooms (also known as cabinets).
As at December 2019, public health facilities comprised 1,221 health centres, 127 health posts, nine national hospitals, 25 municipal or provincial referral hospitals and 92 operational district referral hospitals.34
Establishment of medical institutions
Medical practice may only be performed in Cambodia in medical institutions that are categorised as hospitals (having more than 80 beds for inpatients), polyclinics (having between 20 and 80 beds for inpatients), clinics (having between 10 and 20 beds for inpatients), and consultation rooms or cabinets (for outpatient consultation only).37
Prakas (ministerial order) No. 034 dated 4 July 2011 on the Modification of Procedures and Technical Conditions of the Request to Open, Close, Transform or Relocate Medical, Paramedical and Medical Aid Services sets out the permit requirements for the above-mentioned medical institutions.
Penalties for medical institution violations
Monitoring is carried out to ensure compliance with the conditions for the opening of establishments for the manufacture of pharmaceutical products. In the event of non-compliance with the conditions, penalties are applied.
The main legislation regulating pharmaceuticals in Cambodia is the Law on the Management of Pharmaceuticals (17 June 1996) (the Pharmaceutical Law), as amended by the Law on the Amendment of the Law on the Management of Pharmaceuticals (28 December 2007), with other relevant ministerial regulations and notifications. The MOH has the authority to instruct on and control any activities relating to pharmaceuticals, and may appoint health agents to conduct monitoring at a pharmaceutical establishment (Pharmaceutical Law, Article 9). Any person who fails to obtain an authorisation when opening, closing or relocating any pharmaceutical manufacturing establishment is subject to a fine ranging from US$2,500 to US$5,000. The MOH takes any violations that cause serious damage to public health, or human and animal lives to court. Any person who obstructs the implementation of the Pharmaceutical Law is subject to imprisonment for between one and six months or a fine ranging from US$500 to US$2,500, or both.38 The applicant must first register the foreign manufacturer to register and import any medicinal products that are manufactured overseas. This process is subject to a different registration regime.39
Likewise, in cases of non-compliance with the permit requirements for establishing a medical institution, the Law on Management of Private Medical, Paramedical, and Medical Aid Profession, promulgated by the Royal Kram No. NS/RKM/1100/10 dated 3 November 2000, imposes a fine ranging from US$250 to US$1,250, suspension of the medical institution's operations from one to three months,or both. Any case of recidivism is subject to a double fine and suspension or termination of the operation.40
iii Healthcare professionals
Healthcare providers and professionals are governed by several regulations including the Law on Management of Private Medical, Paramedical and Medical Aid Profession mentioned above. In addition, there are five professional councils, namely, the Medical Council of Cambodia,41 the Pharmaceutical Council of Cambodia, the Dental Council of Cambodia,42 the Cambodian Council of Nurses43 and the Cambodian Midwives Council.44 These councils assist the MOH in supervising and monitoring the practice of health professionals.
In accordance with the Law on Management of Private Medical, Paramedical and Medical Aid Profession, medical professionals and paramedical professionals refer to physicians, pharmacists, dentists and midwives, whereas the medical aid professionals are nurses, laboratory specialists, physical therapists, dental specialists and similar professional practitioners.
To be entitled to practise as a medical, paramedical or medical aid professional, some common requirements are set out in the Law on Management of Private Medical, Paramedical and Medical Aid Profession, such as:
- being a Cambodian national;
- holding a diploma accredited by the MOH;
- being registered with the medical council, pharmacist council, dentist council, midwife council or nursing council;
- never having been convicted of any crime; and
- being physically fit to practise.
In addition, the Law on Regulation of Health Practitioners, dated 22 November 2016, further determines the rules and procedures for regulating health practitioners and the practice of their profession. The purpose of this Law is to protect the health and safety of members of the public by providing the mechanisms for ensuring that all health practitioners are qualified, competent and fit to safely practise their profession. According to this Law, a health professional refers to a physician, dentist, midwife, nurse, pharmacist, laboratory specialist, physical therapist, dental specialist, radiologist or other health professional who is registered with the relevant health professional council. Article 6 of this Law sets out the access conditions for health professions. Any person who wishes to practise in the health profession shall be registered with a health professional council and hold a valid health practitioner licence. He or she must also maintain professional codes, standards and norms, and work within the scope of practice of the health profession. A health practitioner may be considered unfit to practise by the health professional council if he or she fails to meet the licensing requirements; is guilty of professional misconduct leading to the suspension or revocation of a health practitioner licence; has a health condition (mental or physical) that impairs the person's ability to practise; or has been convicted of a crime in Cambodia or any other country. Disciplinary sanctions and complaints may occur if the health professional council has found a practitioner guilty of professional misconduct or to be unfit to practise. The following sanctions can be imposed: warnings, registrations in the personal file, temporary or permanent imposition of conditions on their practice, temporary suspension of the practitioner's licence or revocation of the licence, or removal of the practitioner's name from the register of the relevant health professional council.45
Foreign medical professionals, paramedical professionals and medical aid professionals are authorised to practise their profession in the Kingdom of Cambodia in accordance with the procedures and conditions set out in Sub-Decree No. 094 on Procedure and Conditions authorising Foreign Medical, Paramedical and Medical Aid Professionals to Perform Private Professional Practices in the Kingdom of Cambodia dated 11 November 2002.
Criminal sentences for fraudulent practice of the medical professions may be found under Articles 639 to 644 of the Criminal Code, including any bribery of a member of a health professional council, doctor, or any person seeking to bribe a member of a health professional council or doctor. In addition, any issuance of a false medical certificate or false medical statement engages the criminal liability of the authors.
V NEGLIGENCE LIABILITY
There is no specific regulation governing liability in cases of medical malpractice or injury to the health of others. Therefore, such instances shall fall under the Civil Code of Cambodia.46 Normally, the relationship between a healthcare professional or institution and a patient is a contractual one. Hence, in the event of breach, malpractice or misconduct by a healthcare professional or institution, the latter's liability may be engaged in accordance with Article 398 et seq. of the Civil Code.
There is no administrative court in Cambodia, meaning that a malpractice or misconduct case involving a public health professional or institution would also be treated by a civil court or criminal court, as the case may be.
Further, Cambodian laws and regulations do not impose any insurance requirements on health professionals. Consequently, not all health professionals subscribe to any liability insurance for their practice.
ii Notable cases
There is no publication of precedents but court cases against clinics and doctors do exist in Cambodia.
Apart from possible professional malpractice or misconduct, certain cases concerning unethical behaviour by health professionals have been disclosed in the press.
In a recent case, a doctor (a private practitioner) charged a farmer US$5,000 for treating his two children who had contracted dengue fever. This extortionate practice sparked public anger. This case highlighted the rise of certain dishonest practices by private practitioners in taking advantage of their profession by overbilling or misleading patients.
Another case in 2016 reinforced Cambodians' loss of confidence in the healthcare provided by the country. In this case, a man suddenly died after receiving injections for back pain at a private clinic and the clinic subsequently closed.
These cases are rapidly publicised through social media. This is significantly shaping the popular perception of national health facilities in the country in an extremely negative way. Cambodians appear to be gradually losing confidence in their healthcare services, which directly increases the demand for and use of healthcare services abroad.47
VI OWNERSHIP OF HEALTHCARE BUSINESSES
Cambodia allows 100 per cent foreign ownership of businesses, allowing market entrants to set up their own companies locally.48 There has been significant growth in the number of modern health facilities, developed by foreign firms (such as the Royal Phnom Penh Hospital, Sunrise Hospital, Bangkok Hospital, Raffles Medical Cambodia, among others). These are equipped with advanced equipment that meets international standards, and have highly skilled medical staff from Thailand, the United States, France and Japan.49
Many US companies have found it advantageous to work with local partners who have strong local experience and networks as well as knowledge of the local market, rules and regulations.
Consistent with Cambodia's rapidly growing economy and demand for medical services, a number of new private hospitals and clinics have opened throughout the country during the past few years, and more are expected in the future. The dental market is also gaining increased interest from medical tourists from developed countries such as Japan, Australia and those in the Middle East. Approximately 20 dental clinics in Phnom Penh are operating in accordance with international standards, appropriate certification from the International Organization for Standardization and staff trained in the West.
Concerning the production of pharmaceutical products, foreign applicants can also apply to be local pharmaceutical manufacturers, provided they have fulfilled all conditions, including incorporation of a company at the Ministry of Commerce and having a qualified pharmacist. The local company may, therefore, be 100 per cent foreign owned.50
There has been a tremendous increase in the consumption of pharmaceutical products in Cambodia, with an annual growth rate averaging around 10 per cent. Private pharmacies are first visited in urban areas. During the past decade, the Cambodian population has become more knowledgeable about the importance of healthcare and health supplements, and nutrition products are becoming more popular as people are more commonly taking a preventive approach to their health. The areas of greatest demand include Phnom Penh and the larger provincial towns.51 US importers face competition from pharmaceuticals imported from lower-cost countries, including Thailand, Indonesia, Malaysia, Pakistan and India. Products from these countries are very competitive in targeting the lower end of the market. The main competitors of US medical devices companies are in Japan and European countries, primarily Germany. Consumable healthcare products from China are also very popular in the market because of their competitive prices.
Medical importers need to send their products to the MOH for testing to determine whether they are subject to any specific restrictions.52
Thus, there are no specific barriers on foreign firms in Cambodia importing medical products. However, three specific types of products are restricted in Cambodia: narcotic drugs, psychotropic substances and precursors.
VII COMMISSIONING AND PROCUREMENT
As has been mentioned, the Cambodian healthcare market is comprised of a wide variety of providers, including public health facilities, pharmacies, private hospitals and professional medical service providers. Apart from formal healthcare services, informal healthcare providers are common throughout the country: these include vendors selling drugs from shops or markets and traditional birth attendants, as well as traditional healers. Approximately half of the Cambodian population rely on traditional medicine, but the rapidly growing pharmaceutical industry indicates a trend away from these treatments.53 Health facilities lack sufficient human capital and resources, which prevents them from meeting the needs and expectations of the population. The 2019 budget only allocated US$455 million to healthcare, a decrease of US$30 million from 2018.
As at July 2020, there were 3,087 registered pharmacies, 541 drug import and export companies and branches, 14 medical manufacturing institutions, 16 medical device manufacturing institutions, one health supporting products manufacturing institution, 789 cosmetic import and export companies, and 83 cosmetics centres and branches of cosmetics centres in Cambodia. Imported drugs account for more than 60 per cent of the pharmaceutical market. Local people generally prefer Western drugs and devices owing to their better quality. Currently, the MOH is the single largest purchaser of drugs, medical supplies and medical equipment in the country.54
VIII MARKETING AND PROMOTION OF SERVICES
The marketing and promotion of healthcare services and products are regulated by:
- the Law on Management of Private Medical, Paramedical, and Medical Aide Profession;
- the Law on Management of Pharmaceuticals promulgated by Royal Kram No. NS/RKM/0696/02 dated 17 June 1996;
- the Law on Amendment of the Law on Management of Pharmaceuticals promulgated by Royal Kram No. NS/RKM/1207/037 dated 28 December 2007;
- Prakas No. 028 on Private Practice Advertisement in Medical, Paramedical and Medical Aid Practices dated 23 August 2004;
- Prakas No. 0053 dated 6 February 2009 amending Prakas No. 083 on Conditions of Advertisement of Pharmaceutical, Curative and Preventive Products dated 31 March 1999; and
- Joint-Prakas No. 007 between the Ministry of Health and the Ministry of Information on Conditions of Advertisement of Modern Medicines, Traditional Medicines, Cosmetics, Feeding Products for Infants and Children, Tobacco and Private Medical, Paramedical and Medical Aid Services dated 21 February 2006.
ii Medical services advertising
Commercial advertising of private medical services is prohibited by Prakas No. 028.55 In addition, medical, paramedical and medical aid services may not be used for personal gain or business. However, advertisements within the professional framework not affecting the ethics of health professionals is possible with authorisation from the MOH. Owners of private medical services intending to advertise must submit to the MOH the content of the advertisement, video spot, audiovisual recordings and other images relating to the advertisement, for examination by the relevant municipal or provincial health professional councils.
iii Pharmaceuticals and medical devices advertising
Any advertising of modern medicines, traditional medicines, cosmetics, feeding products for infants, and tobacco through television, radio, newspapers, magazines, journals and other means is possible only when the owners of the services that seek advertisement services receive a licence from the MOH following approval of the contents of the advertisement, video spot, audiovisual recording and other images relating to the advertisement. However, no enterprise, private sector or individual is allowed to advertise, through any means, modern medicines or traditional medicines containing dangerous substances such as addictive drugs, psychotropic drugs, abortifacient drugs, any drugs used in the treatment of sexually transmitted diseases, HIV/AIDS, cancer, sexual performance, and drugs for infants, among others.56
IX FUTURE OUTLOOK AND NEW OPPORTUNITIES
Certain medical devices have significant sales potential in Cambodia. These include diagnostic devices and imaging equipment such as ultrasound machines, X-ray machines and CT scanners. The challenge in this market is the high degree of competition from medical device companies in other countries in the region. Moreover, while many Cambodians travel abroad for medical reasons, Cambodia has become something of a regional dental hub, attracting people from across South-East Asia and beyond to receive treatment. Dental care in Cambodia often costs up to 70 per cent less than in neighbouring countries and the country has earned a reputation as a major tourist destination in the dental field.57
One potential future healthcare initiative in Cambodia would provide insurance to tuk-tuk drivers and to domestic workers. Tuk-tuk drivers often work in conditions that fall far beneath international labour standards. Most drivers are not covered by any social protection and, in the event of hospitalisation, they must pay for their own care (especially following a road accident). Before the July 2018 legislative elections, Prime Minister Hun Sen promised health cover for these workers. This welcome initiative would allow this category of workers to receive basic, sometimes inaccessible medical care. This initiative would also cover household employees. Thibault Van Langenhove, project manager at Agence Française de Développement (AFD), stated that 'for the moment, this is done on a voluntary basis, but in the long term, to ensure the sustainability of the system, it should become compulsory'. The AFD project will provide around €690,000 to finance a telephone platform for tuk-tuk drivers and domestic staff.58
Another challenge for the coming years, according to neurosurgeon Dr Kee Park, concerns the establishment of good quality regulation for healthcare workers. He said that 'one area that requires urgent attention is a system to regulate quality of healthcare workers, as well as the wide availability of unregulated medicine'. For example, there was an HIV epidemic close to Battambang province in 2015 resulting from an unlicensed healthcare worker using improper sterilising techniques for injections.59
Impact of covid-19 on the healthcare industry and organisation of the authority
Cambodia had its first confirmed positive case of covid-19 on 27 January 2020 and, as at 11 August 2020, the MOH has reported 268 confirmed cases – 53 females and 215 males.
In accordance with the Health Strategic Plan 2016–2020 of Cambodia, challenges to the country's healthcare system include the 'limited capacity of public health services to deal with diseases and health problems relating to chronic diseases, non-communicable diseases, and public health emergencies such as pandemics of emerging/re-emerging infectious diseases, as well as disaster preparedness and response'. There are also challenges in effective health service delivery owing to the shortage of competent health personnel in health facilities within the health system.60
To manage the covid-19 situation, three hospitals in Phnom Penh – Khmer-Soviet Friendship Hospital, National Pediatric Hospital and Kantha Bopha Hospital – were designated as dedicated medical facilities to carry out testing and treat covid-19 patients. The Pasteur Institute in Cambodia was selected as the WHO International Reference Laboratory for covid-19 testing. Twenty-five provincial referral hospitals are also identified by the MOH for covid-19 cases outside the capital.61
The Royal Government of Cambodia has also established a National Commission and an Inter-Ministerial Commission on Combating Covid-19. The National Commission is led by the Prime Minister while the Inter-Ministerial Commission is led by the Minister of Health, Dr Mam Bun Heng. The National Commission is tasked with determining national policies and strategies to combat covid-19; implementing strategic plans to prevent and manage covid-19; managing the effects on political, economic and social aspects both at national and international levels; and leading and facilitating the implementation of measures applicable to industries and institutions both at national and sub-national levels.
Since the outbreak of covid-19, neighbouring countries such as Thailand and Vietnam have imposed travel restrictions and the closure of borders to foreigners with strict limitations. Consequently, this has affected Cambodians seeking medical treatment in those countries. Hence, despite the economic slowdown, it is necessary to strengthen Cambodia's healthcare system and improve its capacity to encourage Cambodians to regain trust and confidence in the local healthcare system.
Cambodia is in a state of transition when it comes to healthcare. The country is beginning to acquire the capability to handle advanced medical treatment and specialist cases. A number of international-standard hospitals and clinics have opened in the past few years, filling critical gaps in emergency and trauma care, surgery and neurology. Major achievements for Cambodia have been the establishment of the NSSF for workers and the UHC projects.
Concerning the cost of medical insurance in Cambodia,62 in accordance with market statistics for general insurance for 2019 issued by the Insurance Association of Cambodia, an increase in gross premiums of 22.1 per cent63 was noted between 2014 and 2019. Gross premiums for medical insurance rose from US$5.13 million in Q1 2019 to US$7.13 million in Q1 2020, representing a 36.4 per cent increase, while gross claims for medical insurance increased from US$1.84 million in Q1 2019 to US$2.17 million in Q1 2020.64
However, some households are still unfamiliar with the concept of insurance. Better dissemination of information is needed and more effective health protection systems must be put in place to make the social protection system more widely available in terms of location and for all social classes.65
In addition, owing to the lack of confidence in healthcare in Cambodia, a large part of the middle-class population opt to go abroad to access healthcare services. Middle-income families generally go to Vietnam for treatment, while those on higher incomes go to Thailand and the very rich families go to Singapore. There are also those who seek treatment in China, including the royal family. According to the marketing director of the Heart Centre at Phyathai2 Hospital in Bangkok, Cambodians have been the number one nationality among foreign patients receiving medical treatment at the hospital in recent years. This is a concern, given the negative implications for the national healthcare system.66
1 Antoine Fontaine is founding partner at Bun & Associates.
2 Asian Development Bank, Basic Statistics 2019.
3 World Bank national accounts data and OECD national accounts data files, last updated 1 July 2020.
6 Chris Hilleary, Managing Director of PharmASEAN.
8 PacificBridgeMedical, Healthcare in Cambodia, 11 July 2017.
23 https://www.coordinationsud.org/actualite/le-gret-transfert-ses-activites-de-microassurance-sante-au- cambodge/; http://www.reportersdespoirs.org/sky-la-micro-assurance-sante-pour-tous-au-cambodge/.
29 Sub-Decree No. 01 SDE, dated 6 January 2016, concerning the Establishment of Social Security Scheme on Healthcare for Persons Defined by the Provisions of the Labour Law; Sub-Decree No. 140 SDE, dated 26 August 2017, concerning the Revision of Article 7 of Sub-Decree No. 01 SDE; Inter-Ministerial Prakas No. 173 LV/PrK, dated 25 July 2016, on Provider Payment Methods for Health Care; Inter-Ministerial Prakas No. 327 LV/PrK, 17 August 2017, on the Revision of Annex 1 of Inter-Ministerial Prakas No. 173 LV/PrK; Press Release No. Special, dated 1 September 2017, on Service Provision of Health Facility Signed the Agreement with the National Social Security Fund (NSSF) to Workers; Prakas No. 093/16 LV/PrK, dated 7 March 2016, on the Determination of Phases and Date of the Implementation of Social Security Schemes; Prakas No. 109 LV/PrK, dated 17 March 2016, on Healthcare Benefits; Prakas No. 220 LV/PrK, dated 13 June 2016, on the Determination of Contribution Rate and the Formalities of Contribution Payment; Prakas No. 238 LV/PrK, dated 21 June 2016, on the List of Chronic Disease in the Social Security Schemes; Prakas No. 049/17 LV/PrK NSSF, dated 8 February 2017, on the Inclusion of Health Prevention Services in Social Security Scheme on Healthcare; Notification No. 127 LV/N, dated 2 May 2016, on the Registration of Workers in the National Social Security Schemes; Notification No. 014/17 LV/N, dated 3 February 2017, on the Provision of Wage and Daily Wage to the Female Workers for Maternity Leave.
34 Ministry of Health of the Kingdom of Cambodia, 2019 Health Performance Report and 2020 Work Directions, January 2020, p. 120.
35 id., at p. 121.
36 id., at p. 138.
37 Prakas No. 034 dated 4 July 2011 on the Modification of Procedures and Technical Conditions of the Request to Open, or Close, Transform or Relocated Medical, Paramedical and Medical Aid Services.
38 Articles 10 and 11 of the Pharmaceutical Law.
40 Royal Kram No. NS/RKM/1100/10, Article 13.
55 Provision 1.
56 Provisions 1 and 2 of Joint-Prakas No. 007 dated 21 February 2006.