Cambodia

There is no main strategic purchasing unit in place, but the two social health protection schemes – the Health Equity Fund and the Social Health Insurance – increasingly seek to undertake some strategic purchasing functions.

In Cambodia, a social health protection system is in place, with the two main schemes being the HEF (Health Equity Fund) under the MOH and the Social Health Insurance (SHI) schemes under the NSSF (National Social Security Fund). Overarching policy and governance for these schemes lies under the National Social Protection Council (NSPC), which was established in 2017 as part of the National Social Protection Policy Framework 2016-2025. Subcommittees, or working groups, are convened under the NSPC to give technical advice on strategic purchasing. There are efforts by the NSPC to integrate HEF and NSSF purchasing mechanisms so as to move toward more strategic purchasing.

The Cambodia Health Equity and Quality Improvement Project (H-EQIP) provides technical support to the Cambodian government to improve health coverage and access. In 2017, H-EQIP established a third-party Payment Certification Agency (PCA) to gradually become an independent purchasing verification agency. The PCA already carries out some strategic purchasing functions by verifying HEF benefits provided to patients and monitoring the quality assessments of health centres, hospitals and health administrations at the provincial and district level. The PCA has also taken over the Cambodian Patient Management Registration System (PMRS) to monitor the HEF and other health system data in order to take on an expanded role in strategic purchasing. More broadly, H-EQIP also includes plans for incentive-based systems that reward public health facilities for providing quality care.

Medicines and vaccines
Ministry of Health
Private sector
Development partners

Medical equipment and consumables
Ministry of Health
Some public healthcare facilities
Private sector

Healthcare services
Health Equity Fund (MOH)
Social Health Insurance (NSSF)
Private insurance
Voluntary community-based health insurance

Healthcare support services
Ministry of Health
Private sector

The private healthcare sector provides a greater proportion of healthcare services than does the public healthcare sector. These services are purchased through out-of-pocket (OOP) payments (the largest source of funding in the Cambodian health system) or, increasingly, through insurance/social protection schemes. Private insurers purchase health services through contractual arrangements with public or private providers. The value of Cambodia’s private health insurance premium market is estimated to be over USD 24 million.

The Ministry of Health (MOH)’s public budget is allocated to provinces based on their population size. As part of the Cambodia Health Equity and Quality Improvement Project (H-EQIP), co-funded by the Cambodian government and development partners, the MOH also provides service delivery grants (SDGs) to health facilities to help them improve their services. These SDGs include fixed grants and performance-based grants paid directly to health facilities. Fixed grants are transferred every quarter to help hospitals and health centres maintain equipment/infrastructure or address drug shortages. Performance-based grants are provided as incentives for high-quality health services and staff performance.

Beyond health services, the MOH is also responsible for purchasing healthcare goods (drugs, medical equipment, medical supplies and technologies) for public health facilities. Vaccines are procured through development partners (i.e. UNICEF) and through the private sector.

The MOH and National Social Security Fund (NSSF) also purchase health services through the Health Equity Fund (HEF) and Social Health Insurance (SHI) schemes, respectively. Beneficiaries of the MOH’s Health Equity Fund (HEF) can access public facilities participating in the scheme. The HEF uses case-based payments to providers based on a one-time costing study, with provider payment rates being set by the Ministry of Health. Beneficiaries of the NSSF’s Social Health Insurance (SHI) schemes — the civil servant scheme and the private sector scheme — can access public health facilities and selected private health facilities. The NSSF’s SHIs use case-based and fee-for-service payments to providers. Voluntary, community-based health insurance schemes exist for those in the informal sector but their coverage is limited.

Cambodia’s main purchasers of health services are the Ministry of Health (MOH) and the National Social Security Fund (NSSF). The MOH purchases services for the poor through the Health Equity Fund (HEF) and the NSSF purchases services through Social Health Insurance (SHI). Collectively the MOH estimates that the SHI, the HEF and small voluntary health insurance schemes cover 4.7 million people – 30% of the population. However, these account for only a fraction of total health expenditure: the private health sector accounts for a large share of health spend (approximately 50%), and out-of-pocket expenditure is high (60.4%).

Overall, 90% of Cambodia’s health expenditure is allocated to curative services. Donors are the main source of the 10% of health expenditure dedicated to preventative services such as immunisation.

The MOH is the main purchaser of medical equipment and supplies, and over 50% of the MOH’s budget is spent on procuring drugs and medical supplies. This has left service delivery and staff salaries underfunded. Due to low wages for government health workers, many health staff work both in the public and private health sectors. The MOH is the main purchaser of medical equipment and supplies; currently, over half of the government’s health expenditure is used on medical supplies. 

The two key social protection schemes — Social Health Insurance (SHI) and HEF (Health Equity Fund) — purchase health services separately, though the same public facilities may participate in both the HEF and SHI.

Employees in the public and private sector receive health insurance for occupational and personal health from the NSSF as a single payer. The NSSF, which historically only managed SHI for the private sector, expanded in scope to also manage public sector SHI from 2018. The HEF covers about 2.5 million poor Cambodians. Beneficiaries are identified through a nationwide exercise under the Ministry of Planning (MOP), and can access public health facilities contracted by the HEF.

The MOH is the primary central purchaser of medical equipment and pharmaceuticals for the public healthcare sector.

The National Social Protection Council (NSPC) was established by the government in 2017 as the key agency responsible for the coordination of various social protection policies. Thus, policy responsibility for both the HEF (Health Equity Fund) and NSSF (National Social Security Fund) lies under the NSPC. There are ongoing efforts to align operations between the HEF and NSSF in terms of benefit packages, provider payment mechanisms and amount, IT systems, provider selection criteria and referral mechanisms. However, concrete plans for integration have yet to be implemented. The National Social Protection Policy Framework 2016-2025 proposes the NSSF as the single institute to manage both schemes. However, the NSSF currently lacks the capacity to concurrently manage both schemes and strategically purchase services.

While the Ministry of Health (MOH) remains the primary purchaser of healthcare supplies and pharmaceuticals, some purchasing functions are gradually being transferred to the 25 provincial-administrations (i.e. the management of financial resources, properties and human resources in health). The government has recently released funds to public hospitals to directly purchase medical devices in order to close the gap between public and private care.

• Health Equity Fund / MOH (for healthcare services)

• Ministry of Health – Prequalification, Evaluation and Award Committee (for healthcare goods, pharmaceuticals)

• National Social Security Fund (for healthcare services)

• Private medical facilities

• Development partners

There are pre-contracting processes in place to assess the Health Equity Fund (HEF)’s purchasing of health services from public health facilities. In order to contract with the HEF, public facilities must fulfil three criteria:

1) Prove that they can implement appropriate user fees as directed by the MOH;

2) Register and submit health information through the national Health Management Information System;

3) Use the Patient Management Registration System operated by the Payment Certification Agency (PCA).

The MOH decides which healthcare goods to purchase based on requests from public health facilities, public health priorities and on their available fiscal space. Cambodia’s Essential Medicine List (EML) is used as the basis to ensure that necessary medicines are purchased and distributed to facilities. A centralised supply system is used: an annual list of required medicines, consumables, reagents and lab materials is produced based on the EML, and procurement is conducted once a year by the MOH’s procurement unit: the Prequalification, Evaluation and Award Committee (PEAC). Goods are stored at the MOH’s Central Medical Store (CMS) and delivered to public health facilities on a quarterly basis. Little analysis is done on international reference prices, leading to inefficient drug purchasing decisions.

The National Social Protection Council (NSPC) provides overarching governance for social health insurance and mandates the role of the National Social Security Fund (NSSF) as a single purchaser, also covering the Health Equity Fund (HEF), though this has not yet been implemented. There is no official governance mechanism for the private sector.

The Ministry of Health’s Bureau of Health Economics makes decisions on setting user fees for public health facilities in Cambodia. Every health facility in Cambodia implementing the user fee scheme must submit required documents to the Bureau. The Bureau also coordinates all health financing initiatives (including from development partners).

The Health Equity Fund (HEF) and National Social Security Fund (NSSF) have different decision-making and governance mechanisms. The NSSF is governed by a Governing Board comprising representatives from employer federations, trade unions, the government ministries (Ministry of Economy and Finance, Ministry of Health) and more. Major budget decisions are made by the NSSF Executive Director and the Board, whereas technical matters are handled by various NSSF divisions; accordingly, decisions on Social Health Insurance are primarily made by the director of the NSSF’s Healthcare division.

The HEF operates under the MOH, where authority is shared between the Department of Planning and Health Information (DPHI) – in charge of the benefit package and provider payment mechanisms – and the Department of Budget and Finance which handles financial matters. Governance of the HEF lies with Health Financing Steering Committees (HFSC) established at the provincial and district levels, chaired by the vice-governors of the respective areas.

There is no clear decision-making body on strategic purchasing. The National Social Protection Council (NSPC) oversees coordination efforts between the Health Equality Fund (HEF) and National Social Security Fund (NSSF) which could make purchasing more strategic. Various stakeholders part of the HEF, NSSF and Payment Certification Agency (PCA) are involved in making decisions on different functions of strategic health purchasing.

Decisions on provider payment rates are made by the NSSF’s Provider Payment Mechanism Committee (comprising members from the NSSF, the National Institute of Public Health, the MOH Department of Hospital Services and representatives from public hospitals). The committee agrees on provider payment rates and submits these to the NSSF Board of Directors for approval. As the committee members are also purchasers and providers, they may not always be free from conflicts of interest.

The MOH’s Health Equity Fund makes decisions on contracting with public health providers alongside the Ministry of Economy and Finance. The MOH’s Department of Planning and Healthcare Information (DPHI) is primarily responsible for setting benefit packages and provider payment mechanisms. A semi-autonomous Payment Certification Agency (PCA) is responsible for verifying and auditing all HEF claims received from public healthcare facilities.

The Ministry of Health has outlined the implementation of the Health Equity Fund (HEF) in its Health Equity Fund Operation Manual. The manual describes the organisation, administration, financing and monitoring of the HEF.

The National Social Security Fund (NSSF)’s website lists legislation relevant to social protection and health insurance, including Sub-Decree No. 01 SD.E (2016) which outlines compulsory employer/employee contributions for public and private sector health insurance. This Sub-Decree and various associated legal instruments outline contribution rates, provider payment mechanisms, healthcare benefits and quality assurance principles.

In accordance with the 2008 Law on Public Finance Systems, the management of public revenue, expenditure, and lending is delegated to the Ministry of Economy and Finance (MoEF). The MoEF is responsible for drafting the Law on Finance, preparing medium term (3-5 years) expenditure frameworks and overseeing budget management. Public budget negotiations are carried out between the Ministry of Health (MOH) and the MoEF yearly.

Since 2004, the Royal Government of Cambodia has been carrying out a Public Financial Management Reform Program (PFMRP) to reform its public financial management system and practices. The goal is for Cambodian public financial management systems to meet international standards and best practice over time. There are also regular Public Accountability and Performance Assessments, with the last being conducted in 2021.

The 2011 Law on Public Procurement outlines guidelines for public procurement, ensuring that this is conducted in “a transparent, accountable, fair, effective, distinguished, equal, economical, and timely manner”.

The Ministry of Economy and Finance governs public procurement and tendering processes. Public Competitive Bidding is the preferred method of selecting suppliers, contractors or service providers for public procurement; this includes International Competitive Bidding and Domestic Competitive Bidding. Different procurement methods are used in the selection of suppliers, contractors or service providers without bidding; these include Direct Contracting, Repeat Order, Force Account and Contracting with Communities, depending on the circumstance. Competitive tendering selections are based on criteria including price, quality and fairness.

The following methods are used for the procurement of consulting services: Quality Based Selection, Quality and Cost Based Selection, Budget Based Selection, Least Cost Based Selection, Direct Negotiation Based Selection, and Qualifications Based Selection.

Procuring entities (e.g. public ministries such as the Ministry of Health) must develop annual procurement plans which are approved by the Ministry of Economy and Finance. Internal procurement units execute procurement activities according to the approved procurement plan.

Public procurement for medical supplies, equipment, technologies and pharmaceuticals conducted by the Ministry of Health (MOH) is governed by the general 2011 Law on Public Procurement. Tenders for medical supplies, infrastructure and devices are published by the government/MOH with the financial/technical assistance of development partners such as the WOrld Bank and the Asian Development Bank.

Oversight of pharmaceutical sale, export and import falls under the MOH’s Department of Drugs and Food (DDF). Companies that wish to sell or import drugs in Cambodia must register on the Cambodia Pharmaceutical Online Registration System (CamPORS) launched in 2019 and obtain a license from MOH valid for three years. The Law on Pharmaceuticals Management (1996), amended in 2007, outlines authorisation processes to run a pharmaceutical business. Only pharmacists with qualifications stipulated in the Law may trade, import or export pharmaceuticals.

Medical equipment is regulated by the MOH’s DDF under prakas no. 1258, 2012. Medical devices are classed according to level of risk (A to D), following ASEAN guidelines on medical devices.

The Ministry of Health (MOH) is responsible for enforcing contracts with Health Equity Fund (HEF)-participating facilities. The third-party Payment Certification Agency (PCA) audits claims and has the authority to block HEF reimbursement to facilities if these do not meet contracting requirements. Similarly, for performance-based Service Delivery Grant funds, the PCA is responsible for assessing the performance of health providers against set benchmarks to determine the release of funds. The National Social Security Fund (NSSF) oversees internal claims processes and grievance management for its private and public sector Social Health Insurance (SHI) schemes.

The prakas on The Determination of Roles and Duties of the Control Agent in Private Medical Paramedical and Medical Aid Services outlines the role of MOH control agents to monitor and enforce the activities of the private medical sector, ensuring minimum quality and technical standards. However, no official accreditation and accountability system exists for the private sector.
The MOH also has the authority to monitor pharmaceutical establishments and take action on any violations of Cambodia’s Pharmaceutical Law.

Every public health facility except for the national hospital receives an annual envelope/global budget ceiling. The amount of funds received from this envelope depends on their performance assessment score.

Service delivery grants (SDGs) given to healthcare facilities, co-funded by the Cambodian government and development partners, include an element of performance-based financing. Performance-based SDG grants are given to facilities based on assessments of financial management, infection control, hygiene, medical waste disposal, client satisfaction and Health Equity Fund (HEF) management. Implemented from 2017 onward, these SGD assessments have already incentivised participating health centres to improve across various indicators measured.

The Government Midwifery Incentive Scheme (GMIS) was introduced in 2007 to encourage facility deliveries. Midwives and other health professionals are paid with cash incentives based on the number of live births they attend to in public healthcare institutions (USD15 for a live birth in a health centre, USD10 for a live birth in a referral hospital). The higher incentives for health centres are meant to encourage deliveries at primary care health centres as the recommended location for normal deliveries.

The MOH conducts regular evaluations of healthcare providers as well as provincial and district-level health systems. These evaluations assess competency across medical care, management, service delivery, information systems, human resources, financing and governance. However, these evaluations are currently only done for public facilities as there is no accreditation system for private facilities.

No information was found on feedback mechanisms.

The Ministry of Health (MOH)’s Bureau of Health Economics collects health financing information from all public health facilities in a regular health financing report and analyses this information.

The Social Protection Monitoring and Evaluation Mechanism, established in 2020, is a tool used to measure different indicators and goals in social protection. This evaluation mechanism is intended to track the cost-effectiveness, efficiency and financial sustainability of Cambodia’s social and health protection. Various ministries and agencies are responsible for reporting accurate, complete annual data on certain indicators to the General Secretariat for the National Social Protection Council (NSPC) . These indicators include (non-exhaustive list):

For the National Institute of Public Health: Percentage of population with OOP health spending >10%, 25% and 40% of HH income; UHC index score; number of TB cases detected and treated

For the NSSF: Actual expenditure vs planned budget; fund balance; number of new people registered to receive benefits; number of health consultations; total value of benefits transferred; number of days to reimburse

For the MoEF: approved budget for health services; disbursed budget for health services; percentage of the government budget spending on essential services (education, health and social protection)

For the MOH: percentage of eligible claims processed within 15 days; patient satisfaction score; health facility management quality score; number of people receiving benefits.

There are currently two main information management systems: the Health Management Information System (HMIS) and the Patient Management and Registration System (PMRS).

The HMIS was launched in 1993 and covers information on routine health services and health problems across all facilities in the national health system. The aim of the HMIS is to provide the Ministry of Health (MOH) with data on health needs, service delivery and resource utilisation in order to assist with planning and decision-making. The HMIS is managed by the Health Information System Bureau at the Department of Planning and Health Information, MOH. While hospitals are nationally covered, only 47% of health centers could submit their data as of 2017. A majority of health centres still lack electronic data collection systems.

The PMRS, managed by the Payment Certification Agency (PCA), is Cambodia’s early electronic medical record (EMR). It is used by public health facilities to manage individual patient data by creating a system of unique patient identifiers. The system collects data on patient details, service utilisation and service fee and allows for aggregate reporting of financial data by facilities. The PMRS is used at the point of care in most facilities part of the Health Equity Fund (HEF) to manage both poor and non-poor patients. While its primary aim is to streamline patient management processes, the PMRS can give the MOH financial and utilisation information useful in monitoring the HEF.

Private facilities, which make up a majority of Cambodia’s health spending, are not integrated in national data management systems and do not report patient nor financial data to the MOH.

The Ministry of Health (MOH) makes use of Health Management Information System (HMIS) data to monitor the performance of health services and to prepare regular reports on Cambodia’s health system. Sub-nationally, the HIMS is used for performance reviews, disease-specific program reviews, Health Financing Steering Committee meetings and annual budgeting by facilities. However, the data does not directly inform national or sub-national financing decisions and it is unclear to what extent the data is used to guide purchasing decisions.

Some ad-hoc costing studies have been conducted to explore provider payment mechanisms in Cambodia, using indicators on utilisation, financing etc. as inputs. However, these costing studies take place vertically (e.g. for specific symptoms/disease areas) to secure funding from development partners and/or to develop provider payment rates. These are not conducted regularly, and are not used to track health system performance or to systematically inform purchasing decisions. Routine health costing systems could help optimise the use of financial resources.

No specific indicators are used.