GRET - SKY Health Insurance Project Cambodia
Briefing Note March 2007
Acronyms used in this document :
GRET = Groupe de Recherche et d'Echanges Technologiques
HIS = Health Insurance Scheme
SKY = acronym for “Insurance for our Families” in khmer
MoH = Ministry of Health
OD and PHD = Operational Health District and Provincial Health Department
GRET has been active in Cambodia since the late 1980s in several fields of economic
development (agriculture, micro-finance, water sanitation, etc.). GRET launched in particular
a micro-finance program in 1991 that progressively turned into a financially viable, legally
recognized micro-finance institution called AMRET (formerly EMT). AMRET now covers
over 150 000 clients in 12 provinces of rural Cambodia.
In 1998, GRET found out that a health insurance product would be relevant to protect poor
rural households against severe health expenses, as a complement to micro-credit. GRET
therefore launched an experimental rural health insurance project covering two Cambodian
provinces (Kandal and Takeo) the same year.
Micro-insurance is an innovative approach, in Cambodia and worldwide; there are very few
international references on health insurance for poor populations. For this reason GRET
health insurance project in Cambodia received the "Pro-Poor Innovation Award" from CGAP1
The project is currently supported by AFD (French development Agency) and GTZ. SKY also
receives strong institutional support from the Cambodian Ministry of Health via a formal
2. Health Insurance Project rationale
Several studies have confirmed that health risks are a crucial factor in the impoverishment
of households in Cambodia:
- Cambodia is one of the countries of the world where health conditions are among the
worst and where families invest the most in care (health care expenditures represent a
high percentage of household income in Cambodia; and a caesarian section costs close
to 100 USD while the annual income of a poor farming family does not exceed 400
- Health problems pull households into situations of heavy indebtedness or
decapitalisation, in the face of which micro-credit is no longer adapted as a solution;
1 Consultative Group to Assist the Poorest (donor consortium specializing in micro-finance, founded in 1995)
GRET SKY Briefing Note 1
Developing health insurance to reduce the impact of health problems on households is
therefore a considerable stake in poverty prevention. 3. Key objectives of GRET Health Insurance Scheme
The project‟s objectives can be summarized as follows:
? Secure the incomes of Cambodian households by limiting the economic consequences of
large health expenditures (illness, accidents);
? Facilitate and encourage these households' access to appropriate quality health care.
4. These objectives are in line with the general Strategic Plan of the Ministry of
Health for 2003-2007
Cambodian Ministry of Health has set a strong pro-poor approach in all the working areas of
its strategic plan for 2003-2007. The objective is to limit the impoverishing effect of health
care expenditures for catastrophic risks while ensuring poorest people's access to quality
Considering this strategy and priority action, GRET believes that private/ community based/
voluntary health insurance scheme is part of the alternative health financial schemes that can
be piloted at an appropriate scale, in line with the Strategic plan 's goal, given that the scheme
(i) A local "safety net" to prevent households falling into deeper poverty when facing
(ii) A tool to channel households from inappropriate and expensive care delivered by
private practitioners to public health facilities (iii) An external/independent body between users and public providers, that can enhance
quality in partnering public health facilities by "voicing" users, but at the same time
promote existing public health services in rural areas and encourage households to
change their way of assessing quality of care
(iv) A complementary mechanism to reinforce public health providers' utilization and
secure a part of their financial resources through capitation mechanism. Piloting health insurance scheme fits into 4 of the 6 priority working areas that have been set
in the Cambodian MoH‟s strategic plan. It should locally contribute to achieve the general
expected outcomes in the following working areas:
- Health service access and delivery
- Health care quality improvement
- Behavioral change and communication
- Health financing
Besides, through planning and sharing health expenditures, GRET health insurance services
are expected to limit the impoverishing effect of health expenditures but will be harmless to
improve access to care for households who are already into the poverty trap: It is obvious that
the poorest of the poor will not access insurance services that require to pay a premium even if
Since MoH plans to implement pilot Equity Funds to improve access to care for the poorest,
GRET is working on building efficient complementarities between Equity Funds and the
community based Health Insurance Scheme when active in the same area. In specific
conditions, the Equity Fund could purchase the insurance premium for the pre-identified
poorest instead of covering the whole cost of care, which would considerably enhance its
In order to ensure a regular dialogue with major stakeholders in the health and social health
insurance sectors, GRET has therefore initiated together with MoH a Social Health
Insurance Consultative Group (HICG). This Group aims to be a platform for discussions on
health insurance in Cambodia, contributing to reflections on health financing in the country,
and favoring experience sharing from GRET Health Insurance Project and other on-going
GRET also strongly contributed to the redaction of the Community Base Health Insurance
guidelines, published by ministry of Health at the end of 2006. GRET is part of the
stakeholders involved in discussions regarding the preparation of a sub-decree defining the
conditions for microinsurance operations.
5. Project Stages & Outputs
5.1 The experimentation process (1997-2001) went through the following stages:
1997: studies, reflection on the model, market research;
1998-1999: first intervention zone (Kandal): evolution of the insurance product from a simple
service limited to a few major risks (death, amputation, surgery in the trunk) towards
proximity primary health care (provider model; recruiting a doctor to the team);
2000-2001: opening of a second zone (Takeo), using a different, 'insurance only' models (no
longer including the primary health care offer) and seeking to establish partnerships with pilot
health care structures (hospital).
Until the end of 2001, implementation was therefore limited to a reduced and progressive
scale to ensure validation of the lessons learnt before expanding the system.
At the end of 2001, the health insurance system covered 389 insured in two communes in
Kandal province (14% of the population) and 81 (9%) in the new zone in Takeo.
5.2 In the second phase (2002-2005), the project developed the following activities in
order to consolidate the scheme and increase membership:
- Developing partnerships with health care structures (2002-2004), to closely manage
quality and payment of care for insured:
- Kandal province : partnership signed in July 2002 with Roluos primary health care
center (capitation payment mechanism). (See Annex: description of insurance
- Takeo province:
- Zone 2: partnership signed in July 2002 with Prey Sbat health care center and Ang
Roka district hospital previously supported by AMDA and now by Swiss Red
Cross (capitation payment mechanism);
- Zone 3: Opening of a new insurance pilot scheme, with a partnership signed in
March 2003 with Prey Rumdeng health care center and Kirivong hospital, both
supported by Swiss red Cross (capitation payment mechanism);
- Partnership with Takeo hospital (Fee-based - See Annex as well); third-party
- Implementing a more performing registration system (2004), allowing families to join
the scheme more easily:
- Registration is now opened throughout the year still for 6-month period while before
people could only join twice a year for a six-month period.
- Payment of premium on a monthly basis (versus 6 months), with premium based on
family size: increase of permanent sales force on the field, and further development of
Information System in Head Office needed to ensure good follow-up of activity.
- New system implemented and experimented in Takeo Province‟s Zone 2 since January
2004; rolled out in Zone 1 and 3 in March 2004
5.3 Mid - 2005, the scheme starts its scaling up phase:
Extending into rural areas: Takeo province
- April 2005: Extension to the whole Ang Roka district (coverage of the nine Health centers)
- June 2006: reorganization of SKY field management. A regional coordinator is appointed for
Ang Roka district. Three insurance agents are assigned to health care centers (3 centers per
agent), one part-time representative per center is hired for facilitating relationships between
care providers and members, collecting premiums and promoting SKY. Village chiefs also
receive financial incentives when they help register new families.
Since the beginning of the rollout in Takeo in June 2005, SKY has gone from 1 417 insured to
6 110 insured in April 2007. Growth has been particularly strong since the methodological
modifications of June 2006, thus validating the current model.
Starting with the urban scheme
SKY began to operate in Phnom Phen at the end of 2005, in partnership with the Municipal
Hospital of Phnom Penh. After one year of activity, the pilot is currently being revised and
adjusted to enable roll out in 2007. A new partnership is about to be signed with Prey
Kossamak Hospital to extend SKY offer.
5.4 Results as of December 2006
31/12/05 31/12/06 Growth rate
Insured people 4392 8926 103%
Insured households 917 1780 94%
Average family size 4,75 5,01 5%
Average premium/year/capita $3,1 $4,57 47%
At the end of December 2006, the health insurance system covered 8 926 insured, 1 780
households, i.e. a growth rate of more than 103% since last year.
6. First lessons learnt
(a) Developing Adequate Insurance Services Cambodian households are usually not familiar with insurance services. To develop
appropriate insurance products, GRET believes that specific communication methods must be
developed to explain basic insurance principles and define insurance products with members.
To ensure the participation of the members in the definition of the insurance system, the
project has developed the following methods:
- It uses surveys (Exit Patients, Wealth Ranking, Drop out questionnaire, …) and other
participatory methods (user groups) to assess the situation of members, understand their
needs, and improve the services proposed;
- Insurance relies on trust between the scheme and its members; full-time insurance agents
are living in the rural villages covered by the system. They ensure a daily presence at local
health centers; insurance must be a service close to the people;
- „ICC‟ (Insurance Consultative Committees) are set-up in villages. Such committees allow
insured people to be informed on the project, provide feedback on insurance products and
contribute to improving the overall system. Those ICC meetings will be adapted for urban
context in Phnom Penh.
(b) An Innovative Model for a Viable and Reproducible Insurance System
The early stages of the experiment made it possible to verify the existence of a strong
demand among households for primary health care coverage beyond hospital care alone.
Indeed, primary care is a daily preoccupation for households; with very limited resources;
occurrences are higher, it is also a way for households to understand how insurance works.
Given the population‟s limited ability to contribute, insurance systems in theory target rare
care (hospital risks) first and not primary care (a high frequency risk) in order to be financially
viable. It is therefore necessary to reconcile the demand with the insurance system‟s financial viability. This project shows that it is possible is to build a two-tiered system:
- linked to primary health care providers (using a „capitation‟ provider payment mechanism
to ensure costs containment and enhance appropriate quality of care); here, the insurance
favours use of the partner provider;
- partnership with hospitals for more serious and more expensive risks that the insurance
system can manage; here, the idea is to lift financial obstacles for users.
- with the necessity of a clear and functioning referral system between the primary and
secondary health facilities.
(c) The Need for Strong Partnerships with Public Health Care Structures
Quality of care and more generally the quality of service (proximity, welcoming of staff,…)
are essential. To guarantee this quality as well as transparent user fees, it is necessary to sign
clear agreements with local health structures. GRET decision has been to work with public health care providers.
- The Government made the policy choice of creating health operational districts
throughout the country, with subsidized local health centers and a pricing system that
is clear and consequently limited.
- Some public facilities also receive support from medical NGOs, thus guaranteeing the
minimum quality necessary for insurance to be launched
- The challenge for the public sector is balancing access to care for the largest number at
accessible rates while paying health staff attractive salaries. Developing an insurance
system can contribute to financing health care structures. Regular ‘Monitoring
Meetings with current health care partners, aim to discuss impacts of HIS on health
care structures and to contribute to improving overall health care quality through the
feedback of insured members (cf. Exit Patients Survey).
(d) The major design features of the pilot health insurance scheme under test in the four
geographic zones are as follows.
The health insurance scheme:
- follows a community based and voluntary membership's approach;
- covers the whole members of the family (family membership required);
- has a clear social mission / must be affordable for all rural households including large and
- follows a pragmatic membership‟s approach, taking into account rural households
situation and enabling them to join the scheme easily;
- incites to stable / long term memberships (waiting periods, dropouts penalties, …) in order
to limit anti-selection and enhance outreach of coverage for households;
- is designed in consultation with the direct beneficiaries in the villages;
- covers both primary health care and hospital care with mandatory referral mechanism;
- works in partnership with public health facilities through capitation payment mechanism
and close monitoring (to enhance quality assurance and costs containment);
- is transparent / health insurance scheme's financial statements are shown in villages Health
Insurance Consultative Committee (including elected insured representatives);
- works in partnership with Health authorities (MoH central and provincial level) to fit into
national health policy and guidelines;
- is private and independent from health authorities or health providers / aims to be
managed by Cambodian managers with local insurance agents based in the village;
- is non-profit but must reach financial sustainability in the long run after a subsidized
period by external donors' funding.
7. Next steps
The challenge for the coming years is to continue the extension of the scheme and reach
- Geographical extension: in 2007, SKY started to operate in Kampong Thom province, and
in 2008, to the whole Takeo Province (70 health centers). Kampot and Sieam Reap are
also future potential SKY zone.
- Targeted population diversification: New target group will be approached ( garment
workers, students ….) and specific marketing tools have to be designed.
Considerable upscale of the scheme, together with the consolidation of the scheme’s
structure and organization, should finally allow for:
- better identification of the conditions of viability,
- proper design of the optimal financial model based on the most appropriate
type and level of premium and capitation;
- full validation of the hypothesis of risk. This last item remains crucial to
establish an health insurance model in Cambodia
The expected result of current expansion phase is therefore the validation of a health insurance
? that is viable in the long term ;
? that contributes to poverty prevention in Cambodia, since insurance will secure the
income of fragile households;
? that improve the overall health conditions of its members; ? and that favours the improvement of the Cambodian health care system by
encouraging the population to make use of it in optimal conditions (quality of care, clear
GRET Š SKY Health Insurance Schemes Š February 2007
Takmau ODAng Roka DOKirivong DOK‰mpong Thom ODEntire city1999200120031/01/20072005 (starts in december)Specific groups targeted working in informal and formal Full OD, 9 health centers (starts in June 2005) 1 health Center, 16 villages (1224 households)1 Health Center10 villages (1648 households)3 Health Centers (7 700 households)sector (mototaxi, garnment workers, beer girls, market 23 250 householdsvendors)1 114 households (6 189 persons) - 6,2% of 78 households (410 persons) - 1,18% of 140 households (612 persons) - 11,4% of membership248 households (1 123 persons)509 households (2 059 persons) membershipmembership
1 person family: 0,50$ / family / month 2-1 person family: 0,98$ / family / month 3 categories of prices adjusted to group revenues . 6 Months minimum, with automatic roll-over. Registration period opened throughout the year.4 persons family: 1,08$ / family / month 2-4 persons family: 1,83$ / family / month Approximatly 3% of the estimated revenue. For formal 5-7 persons family: 1,50$ / family / month 5-7 persons family: 2,32$ / family / month sector, minimum 50% co-payment from employer>8 persons family: 1,83$ / family / month >8 persons family: 2,68$ / family / month 1 person family: 0,78$ / family / month 2-4 persons family: 1,34$ / family / month 5-7 persons family: 1,82$ / family / month >8 persons family: 2,19$ / family / month 2 Months reserve fund collected at registration. Refundable at the end of the contract.Roluos Health Centre9 Health Centres of the ODPrey Rumdeng Health Centre3 Health Centres of the ODChey Chumneas - Takmau referral hospitalAng Roka HospitalKirivong HospitalK‰mpong Thom Provincial Hospital
Municipal Hospital of Phnom Penh
Takeo hospitalTakeo hospitalFree access to Prey Rumdeng Health Centre services Free access Roluos Health Centre services (MPA) Free access to all 9 Health Centre services (MPA) Free access to all 3 Health Centre services (MPA) Free access to SKY primary health care within Municipal (MPA) including prescribed drugs.including prescribed drugs.including prescribed drugs.including prescribed drugs.Hospital
Free access to OPD and IPD services in Takmau Free access to OPD and IPD services in Ang Roka Free access to OPD and IPD services in Kirivong Free access to OPD and IPD services in Free access to OPD and IPD services in Municipal Chey Chumneas hospital.hospital after referralhospitalK‰mpong Thom hospital after referralhospital
Possible referral to other Phnom Penh national Free access to OPD and IPD care in Takeo Hospital after referral.hospital in case of complex pathologies
Safe Motherhood program incuding a cash Safe Motherhood program incuding a cash benefit benefit (45$) for deliveries in health facilities.(45$) for deliveries at PPMRH.
Grant for funerals (50,000 Riels) + transportation of the Grant for funerals (50,000 Riels) + transportation of Grant for funerals (50,000 Riels) + transportation Grant for funerals (60 USD) + transportation of the body Grant for funerals (50,000 Riels).body + mortuary band.the body. of the body. back home (in Phnom Penh). Emergency transportation grant 20,000 Riels.Emergency transportation grant 20,000 Riels.Emergency transportation grant 20,000 Riels.Family registration: to join the insurance scheme all family members must be insured. Monthly Payment of the premium. Advance payement strongly encouraged (free additional month of coverage for 6 month advance payment).
Capitation contract with health centers and referral hospital. Third party payment with Takeo hospitalCapitation** contract with health centers and referral Capitation contract with health centers and Capitation payment with Municipal Hospitalhospital. referral hospital.
Long term treatments of chronic diseases, glasses, basic dental care, prothesis. Waiting period of six month for non urgent surgery. Waiting period of 3 to 6 months for delivery matters.
Local insurance agents living in villages of the health centreÕs catchment area. Part time "member's facilitators" working in health facilities, Insurance Consultative Committee in each commune to ensure community involvement and a good adaptation of the health insurance services to the needs of the families. It is composed of elected representatives of the insured members, one representative of the commune authorities, one representative of the pagoda, and the insurance agent as secretary of the committee. Local authorities (village chiefs, distrcit and commune gouvernor) 1 Full time Insurance Agent, 1 hostess at Municipal Hospital, partnering NGO for promotion and commercialisation.
* Since health insurance is a new concept in rural area, in a first step the premium is subsidised to encourage rural households to test insurance servicesÕ impact.** Capitation mechanism: a fixed amount is paid in advance by the health insurance scheme to health providers per insured person for the defined set of health services over the defined period, regardless the actual utilization of any or all of the benefits.
GRET SKY Briefing Note 8