P4HC+ taking shape

Apr 2016

Source: P4H Country Focal Point in Cambodia

The new coordination mechanism called P4H Cambodia+ (P4HC+) bringing 12 organizations to the table is taking off. The update below provides some context and info on upcoming activities.

Context:  With the onset of 2016 a new breeze went through the Cambodian health (financing) scene. 

  • The third Health Strategic Plan is nearing completion but the health financing section is already outlined.
  • The Ministry of Economy and Finance drafted its Framework on Social Protection and will invite development partners for critical reflections. The document is welcome as it sets direction for the country towards universal health coverage. As such it endorses the launching of social health insurance for formal private sector employees, to be followed by insurance for civil servants. Dependents will be included at a later stage. The ministry projects health equity funds for the poor to be entirely funded and managed by the government from 2020 onwards and anticipates expansion of the eligible population towards vulnerable groups such as people with disabilities and older people. The non-poor informal sector population will be covered by mandatory health insurance following an intermediate period of voluntary enrolment. In common with the previous consultation process of development partners, feedback will be provided as a joint effort.
  • Selected development partners are set to embark on pooled funding arrangements from July onwards. Associated changes include a reconsideration of the health equity fund operations, the only functional social health protection scheme to date. Changes include a reconfiguration of the roles of the health equity fundoperators, the NGOs that administer the funds at health facilities and operational health districts. As such they will do less administrative work and focus more on ensuring uptake of entitlements by the beneficiaries.


P4HC+: concurrent with the new developments and many new faces amongst the partners, P4H’s operations and approach were reconsidered. A modus operandi was drafted and is nearing completion following two meetings. Partners include all bi- and multilateral organisations engaged in health financing in Cambodia or recognised as members at global level. The collaboration, coordination, cooperation and alignment arrangements for health financing and social health protection toward universal coverage in Cambodia are named P4HC+ and 12 organisations participate.  

·      An initial overview of activities, technically and financially supported by these organisations, was drafted. It indicates a considerable enthusiasm for support, up to the point of congestion, to the Ministry of Health, but little activities directed to other main players such as Ministry of Economy and Finance (overall guidance) and Ministry of Labour and Vocational Training (social health insurance for formal sector employees and civil servants).


·      Following extensive discussions and preparations invitations for the Leadership for Universal Health Coverage Programme were sent to the Ministers of Health, Economy and Finance, and Labour with the request for participation of senior officials. Twelve representatives were identified, including three vice-ministers and one deputy-vice-minister, three director generals, and three departmental directors.


Previous Updates

Jan 2016 – Process update – Jan 2016

Process update – Jan 2016

Jan 2016Source: GIZ / P4H Country Focal Point

  • The formulation of the third Health Strategic Plan (2016-20) is not yet completed although the section on health financing was finalised. The related strategies will focus on the national budget for health, targeting of available resources according to population needs, increasing financial risk protection and efficiencies in the use of the available resources, aligning objectives and funding of development partners and the Ministry of Health together with improved coordination practices.
  • The pooled funding arrangements scheduled to start in July 2016 are taking shape and the endeavour is called H-EQIP to highlight the programme’s emphasis on health equity and quality of care improvement. Major partners include the World Bank, KfW, Australian DFAT and KOICA. USAID will provide additional financial support for technical inputs.
  • The Ministry of Economy and Finance contracted a private firm to assist them with the formulation of the country’s Framework for Social Protection, including social health insurance for formal sector employees (private and civil) and social health protection for the informal sector population. Development Partners engaged in the sector were invited to comment on the first draft report whereby GIZ, USAID, ILO and UNICEF joined forces –with support by JICA- to formulate a joint response. The Ministry of Economy and Finance suggested the Development Partners to improve the framework’s section on social health protection whereby the opportunity was taken to incorporate main aspects of the Health Financing Policy. The Minister of Health later endorsed the concerned section. These actions increase the likelihood for approval of the policy although sections will have to be rewritten, especially concerning institutional arrangements.
  • The partners engaged in formulating the response to the draft Framework for Social Protection by the Ministry of Economy and Finance grouped themselves under the Social Protection Exchange Group.
  • Major progress was made with the recent issuing (last week) of a sub-decree by the Council of Ministers concerning the start of Social Health Insurance for private formal sector employees under the National Social Security Fund.
  • USAID introduced the Health Finance and Governance Project while JICA is scheduled to formally engage in social health protection for the informal sector population. In a real P4H spirit, both agencies consult(ed) extensively with government officials and development partners how to maximise optimal collaboration and to avoid overlap with other initiatives. JICA held a study tour to Japan –to be followed by Thailand early February- with decision-makers of various ministries in preparation of the project formulation exercise. USAID in turn facilitates informative sessions at the Ministry of Economy and Finance concerning strategies to include the missing middle –the non-poor informal sector population- and means to achieve universal health coverage.


Aug 2015 – Process update – Aug 2015

Process update – Aug 2015

Aug 2015

Source: P4H Country Focal Point (GIZ)

  •  A major activity was the formulation of the third Health Strategic Plan 2016-20, a consultative process that commenced at the start of this calendar year. Attention was paid to carefully integrate elements of the Health Financing Policy that can be realised during the concerned period. The Strategy is 90% complete and ready for consideration by civil society and public and private health care providers.
  • In parallel and complementary to the formulation of the third Health Strategic Plan, several development partners consider to financially support the implementation of this Strategy by use of pooled funding. Reflecting Cambodian peculiarities, this pooled funding approach isn’t termed SWAp (Sector-Wide Approach) as in other countries but SWiM –Sector Wide Implementation- due to a considerable degree of earmarked funding. The Health Financing Policy is to be an important guide for the SWiM approach.
  • Despite prominently featuring in the design of the SWiM approach, the Health Financing Policy remains stuck in the Ministry of Economy and Finance due to two events. The first is the requirement to provide a cost estimation concerning the implementation of the interventions specified in the document. To this end, a P4H-funded a costing exercise was conducted for the informal sector population. The exercise takes a five-year perspective and happened in collaboration with ILO. The respective document is expected for the end of August.      Second, the Ministry of Economy and Finance is developing a framework outlining the institutional arrangements and legal and financial requirements for the country’s social security system.


  • It appears that social health insurance may commence soon for formal private sector employees (companies with at least 8 employees) and that such arrangements may also be instigated for civil servants and military and police forces. Although the draft Health Financing Policy foresees three institutions to manage an equal number of schemes (for civil servants; private formal sector employees; and informal sector population) preference seems to go to one institute due to limited financial resources and available technical capacity in the country. This requires an adjustment of the draft Policy.

  • However, prior to embarking on a revision of the document more clarity concerning preferred directions by the new stakeholders is required. This group of stakeholders has recently been enlarged by members of Commission VIII of the National Assembly, in charge of Health Care, Work, Social Affairs, and Women Affairs. For sure,  universal health coverage is on many agendas.


Oct 2014 – Cambodian Ministry of Economics and Finance largely approves Health Financing Policy

Cambodian Ministry of Economics and Finance largely approves Health Financing Policy

Oct 2014 – Formulation of the Cambodian Health Financing Policy started in July 2012. It was a consultative process that involved a range of stakeholders for wider strategic issues while technical details were addressed by a smaller core group of experts.

The result is a technically sound document that gives due considerations to the country’s historical and political developments that shaped the health system and associated arrangements for social health protection. The policy also tries to anticipate politically sensitive issues, especially those by the Ministry of Economics and Finance.

Potentially contentious issues are those requiring additional finances. The Policy therefore promotes efficiencies –technical, allocative and administrative – and makes reference to additional sources of money for health in the form of sin taxes. These taxes do not exist yet in Cambodia, resulting in a considerable proportion of the population indulging in tobacco products.

In August, two years after the start of the Policy formulation, the Minister of Health sent the draft Policy to five ministries for feedback:

• Ministry of Planning, which is, amongst others, responsible for the IDPoor programme –a nationwide community-based pre-identification of the poor using proxy means testing
• Ministry of Labour and Vocational Training: houses the National Social Health Protection Fund that in turn will start operating Social Health Insurance for the formal private sector
• Ministry of Social Affairs, Veterans and Youth Rehabilitation: is responsible for the National Social Security Fund and –to be developed and started- respective Social Health Insurance for civil servants
• Council for Agriculture and Rural Development: the inter-ministerial body under the Council of Ministers responsible for coordinating the implementation and monitoring of the National Social Protection Strategy
• Ministry of Economics and Finance: responsible for the administration of financial and economic policies of Cambodia, including allocation of budget for social affairs.

The response appears positive. As such, the Ministry of Economics and Finance welcomes the initiative for universal health coverage. It appreciates the long-term vision of the Health Financing Policy and recommends three sources of financing to be considered: out-of-pocket, insurance and government budget. The response reiterates the government’s commitment to enable the poor financial access to health care but stresses the need for the Ministry of Health to ensure quality health care.

Following this response the Policy is now with the Minster of Health for his signature. The Health Financing Policy will be an essential input for the formulation of the third Health Strategic Plan (2016-20) and features high on the agenda of development partners as a means to channel their financial assistance.


Please find below a working paper: toward UHC: the Cambodian experience formulating a health financing policy and various related briefing notes.


Briefing Note – Catastrophic Expenditure

Briefing Note – HEF non-utilisation

Briefing Note – Lessons from Ghana

Briefing Note – Voluntary enrolment in HEF



Relevant Files:

Dec 2013 – Functional analysis for establishing the National Social Health Protection Fund in Cambodia

Functional analysis for establishing the National Social Health Protection Fund in Cambodia

Dec 2013 – This assessment was conducted in October of 2013 with the aim of elaborating the organisational structure and determining the staffing requirements for establishing the National Social Health Protection Fund. This Fund is one of the three envisaged social health protection institutions and will cater for the informal sector population.


Relevant Files:

Jul 2013 – First meeting of the ‘health financing contact group’ since 2011

First meeting of the ‘health financing contact group’ since 2011

Jul 2013 – Following inactivity during a prolonged period for a variety of reasons the contact group for health financing was revived on the 3rd of July 2013.
The meeting was well attended by a variety of representatives. Because considerable time had elapsed since the last such meeting an introductory round was necessary to get to known the new faces around the table.

The opportunity was taken to update on each agency’s activities concerning health financing and social health protection. Topics discussed included an update of P4H Network’s recent developments.
An overview was provided concerning the latest adjustments of the draft health financing policy, particularly regarding risk and fund pooling of the three social health protection schemes in the long term, measures to promote enforcement of regulation and co-payments. This was followed by a discussion on the need to maintain user fees or not to motivate service delivery by health staff.
The best way to supplement the contact group that currently consists solely of development partners would by a forum in which the government participates and ideally leads, was the last point of discussion.
The next meeting is scheduled for early September.


May 2012 – Regional forum on health-care financing

Regional forum on health-care financing

May 2012Several P4H partners are involved in a regional forum which takes places in May 2012 in Phnom Penh. The objectives of the forum are to bring together stakeholders active in health financing in the Mekong area in order to share country experiences, to stimulate research and knowledge-sharing and to establish a regional community of health financing practice.


Nov 2011 – Workshop on CBHI and HEF in Cambodia

Workshop on CBHI and HEF in Cambodia

Nov 2011A joint AFD/GIZ workshop on social health protection for the poor and near-poor focused on the implementation of Community Based Health Insurance (CBHI) and Health Equity Funds (HEF) in the same geographic areas takes place in Phnom Penh.


Apr 2011 – Adoption of National Social Protection Strategy

Adoption of National Social Protection Strategy

Apr 2011Under the leadership of the Prime Minister and with active coordination from the Council for Agricultural and Rural Development (CARD), a national Social Protection Strategy is adopted. The document is the overarching reference for all future documents related to specific pillars of social protection such as health, education, pension, etc. Thus future social health protection policy and health financing strategy will have to align with the national Social Protection Strategy.

Relevant Files:


Mar 2010 – First P4H joint action plan for Cambodia

First P4H joint action plan for Cambodia

Mar 2010In line with the Memorandum of Understanding signed in 2009, the local P4H network prepares its first P4H joint action plan. Scheduled activities and financial gaps are listed according to the main areas of work of both the Ministry of Health and Ministry of Labour and Vocational Training. One of the key joint activities scheduled is a catastrophic expenditures survey.

Relevant Files:


Jun 2009 – P4H partners sign MoU

P4H partners sign MoU

Jun 2009WHO, ILO, AFD and GIZ country representatives sign a Memorandum of Understanding (MoU). In signing the MoU, the P4H network’s goal is to support the Royal Government of Cambodia in its efforts to ensure equitable access to quality health care for all people of Cambodia.

Relevant Files: