Assessing progress towards universal health coverage in Cambodia: Evidence using survey data from 2009 to 2019

Over the past decades, many low-and middle-income countries have implemented health financing and system reforms to progress towards universal health coverage (UHC). In the case of Cambodia, out-of-pocket expendi-ture (OOPE) remains the main source of current health expenditure after several decades of reform, exposing households to financial risks when accessing healthcare and violating UHC's key tenet of financial protection. We use pre-pandemic data from the nationally representative Cambodia Socio-Economic Surveys of 2009 to 2019 to assess progress in financial protection to evaluate the reforms and obtain internationally comparable estimates. We find that following strong improvements in financial protection between 2009 and 2017, there was a reversal in the trend thereafter. The OOPE budget share rose, and the incidence of catastrophic spending and impover-ishment increased in nearly all geographical and socioeconomic strata. For example, 17.7% of households experienced catastrophic health expenditure in 2019 at the threshold of 10% of total household consumption expenditure, and 3.9% of households were pushed into poverty by OOPE. The distribution of all financial pro-tection indicators varied strongly across socioeconomic and geographical strata in all years. Fundamentally, the demonstrated trend reversal may jeopardize Cambodia's ability to progress towards UHC. To improve financial protection in the short term, there is a need to address the burden created by OOPE through targeted in-terventions to household groups that are most affected. In the medium term, our findings emphasize the importance of expanding health pre-payment schemes to currently uncovered vulnerable groups, specifically the near-poor. The government also needs to consider extending the scope of services covered and the range of providers to include the private sector under these schemes to reduce reliance on OOPE.

Automated summary

In low-and middle-income countries, implementing health financing and system reforms is crucial to achieve universal health coverage (UHC). However, in Cambodia, out-of-pocket expenditure (OOPE) remains the main source of healthcare payment, posing financial risks and hindering UHC's goal of financial protection. The study found a reversal in progress towards financial protection after improvements between 2009 and 2017, with increased catastrophic spending and impoverishment. The distribution of financial protection indicators varied across socioeconomic and geographical groups, threatening Cambodia's ability to achieve UHC.