Implementing a sustainable health insurance system in Cambodia: a study protocol for developing and validating an efficient household income-level assessment model for equitable premium collection

Haruyo Nakamura,Tomoya Yoshida,Sovannary Tuot,Shuhei Nomura,Siyan Yi,Floriano Amimo,Makoto Tobe

doi:10.1186/s12939-020-1126-8

Abstract

BackgroundAs elsewhere in low- and middle-income countries, due to limited fiscal resources, universal health coverage (UHC) remains a challenge in Cambodia. Since 2016, the National Social Security Fund (NSSF) has implemented a social health insurance scheme with a contributory approach for formal sector workers. However, informal sector workers and dependents of formal sector workers are still not covered by this insurance because it is difficult to set an optimal amount of contribution for such individuals as their income levels are inestimable. The present study aims to develop and validate an efficient household income-level assessment model for Cambodia. We aim to help the country implement a financially sustainable social health insurance system in which the insured can pay contributions according to their ability.MethodsThis study will use nationally representative data collected by the Cambodia Socio-Economic Survey (CSES), covering the period from 2009 to 2019, and involving a total of 50,016 households. We will employ elastic net regression analysis, with per capita disposable income based on purchasing power parity as the dependent variable, and individual and community-level socioeconomic and demographic characteristics as independent variables. These analyses aim to create efficient income-level assessment models for health insurance contribution estimation. To fully capture socioeconomic heterogeneity, sub-group analyses will be conducted to develop separate income-level assessment models for urban and rural areas, as well as for each province.DiscussionThis research will help Cambodia implement a sustainable social health insurance system by collecting optimal amount of contributions from each socioeconomic group of the society. Incorporation of this approach into existing NSSF schemes will enhance the country’s current efforts to prevent impoverishing health expenditure and to achieve UHC.

Highlights

As elsewhere in low- and middle-income countries, due to limited fiscal resources, universal health coverage (UHC) remains a challenge in Cambodia
At the General Assembly held in December 2012, the United Nations set the achievement of universal health coverage (UHC) as a new common agenda for the global community [2]
A contributory health insurance is typically introduced for the population employed in the formal sector, such as civil servants and private sector workers, since insurance contributions can be deducted from their salaries

Summary

Introduction

As elsewhere in low- and middle-income countries, due to limited fiscal resources, universal health coverage (UHC) remains a challenge in Cambodia. Countries that adopt a contributory health insurance system to cover the general population usually collect a fixed amount of contribution, which is set at a level that the lowestincome group can afford. Such a practice, endangers the financial sustainability of the insurance fund or imposes heavy burden of subsidy on the government, whose fiscal resources are already limited [3]. There is an urgent need to develop a mechanism to assess household income level to collect contributions according to one’s ability to pay, while ensuring financial sustainability of the insurance fund and placing minimum burden on the governments of LMICs

Objectives

Methods

Findings

Conclusion