Cambodia Socio-Economic Survey Research Articles

Hardship financing, productivity loss, and the economic cost of illness and injury in Cambodia

BackgroundFinancial risk protection is a core dimension of universal health coverage. Hardship financing, defined as borrowing and selling land or assets to pay for healthcare, is a measure of last recourse. Increasing indebtedness and high interest rates, particularly among unregulated money lenders, can lead to a vicious cycle of poverty and exacerbate inequity.MethodsTo inform efforts to improve Cambodia’s social health protection system we analyze 2019–2020 Cambodia Socio-economic Survey data to assess hardship financing, illness and injury related productivity loss, and estimate related economic impacts. We apply two-stage Instrumental Variable multiple regression to address endogeneity relating to net income. In addition, we calculate a direct economic measure to facilitate the regular monitoring and reporting on the devastating burden of excessive out-of-pocket expenditure for policy makers.ResultsMore than 98,500 households or 2.7% of the total population resorted to hardship financing over the past year. Factors significantly increasing risk are higher out-of-pocket healthcare expenditures, illness or injury related productivity loss, and spending of savings. The economic burden from annual lost productivity from illness or injury amounts to US$ 459.9 million or 1.7% of GDP. The estimated household economic cost related to hardship financing is US$ 250.8 million or 0.9% of GDP.ConclusionsSuch losses can be mitigated with policy measures such as linking a catastrophic health coverage mechanism to the Health Equity Funds, capping interest rates on health-related loans, and using loan guarantees to incentivize microfinance institutions and banks to refinance health-related, high-interest loans from money lenders. These measures could strengthen social health protection by enhancing financial risk protection, mitigating vulnerability to the devastating economic effects of health shocks, and reducing inequities.

Does Land Titling Improve Agricultural Productivity?: Evidence from Rural Cambodia

This study verifies whether the hypothesis of the positive causal relationship between land titling and agricultural productivity works in rural Cambodia. The effects of land titling may suffer from simultaneous causality bias, which can be partly solved by instrumental variable estimation. It uses the Cambodia Socio-Economic Survey (CSES) parcel-level data surveyed from January 2014 until December 2014. The findings show that the effects of land titling on agricultural productivity are insignificant when village and household fixed effects control it. Land titling does not lead to increased use of inputs for agricultural production. But, it only slightly impacts total debt, not monthly interest rates. The conjecturable reason is that the land title itself affects slightly their debts but those are not invested in their land through agricultural inputs due to lack of credit accessibility. Furthermore, social customs and norms in rural Cambodia may replace the role of land titling.

The Exclusionary Power of Microfinance

In recent years, international banks, investment agencies, and development institutions have created new markets for capital accumulation by rapidly expanding the commercial microfinance industry in the global South. In Cambodia, which has one of the largest microfinance industries in the world, the typical loan amount now exceeds the average annual household income and requires land-based collateral. Cambodian borrowers are increasingly over-indebted, compelling families to reduce their food consumption, take out new loans to service prior debts, migrate, and/or sell their land in distress. In this paper, we investigate this last effect of over-indebtedness, distress land sales. We argue that the exclusionary power of microfinance debt—constituted by collateralized legal contracts, discourses of moral responsibility, and public shame—is driving land dispossession among the country’s most vulnerable people. To make our argument, we draw on ethnographic fieldwork, supplemented by quantitative data from the Cambodia Socio-Economic Survey, MIX Market, and two industry-sponsored large-scale quantitative surveys of over-indebtedness. We trace the rise of the commercial microfinance industry, show how it has contributed to over-indebtedness, and consider how household debts can lead to distress land sales. These land sales have largely gone unacknowledged in the industry because they take place through informal channels rather than the court system. We conclude that microfinance-debt-induced land dispossession in Cambodia is a product of an overly commercialized international microfinance industry that now values profits over people.

Effects of remittances on household poverty and inequality in Cambodia

The author uses data from the Cambodia Socio-Economic Survey in 2014 to investigate the impact of remittances on poverty and inequality. Unlike other studies that use income to measure poverty, we employ monthly per capita consumption. We also consider remittances as a substitute income rather than an exogenous transfer. Therefore, imputing counterfactual expenditure in a scenario of no migration no remittances is necessary. To test for selection, a Heckman model is required under the null hypothesis that non-recipient households are randomly drawn from the population. Contrary to some previous studies, we find significant effect of selection bias and evidence that remittances reduce the poverty rate by 2 percent on the national level or 5 percent for recipient households. Furthermore, remittances decrease the poverty gap by 2.5 percent or 6.6 percent for a sub-sample of recipient households, but they also increase inequality by 1 percent, as measured by the GINI coefficient.

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

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.

Household-level analysis of the impacts of electricity consumption on welfare and the environment in Cambodia: Empirical evidence and policy implications

Cambodia’s biomass consumption is the most dominant energy source at residential sector, and its use is mainly for cooking and heating which could affect health due to indoor air pollution. The biomass is mainly sourced from wood cutting and forest-encroachment that could impact the environment due to reduction of forest at considerable scale. By using the data 2015 of Cambodia Socio-Economic Survey, the study investigates the impacts of electricity consumption on household welfare, such as earnings and the school performance of children in the households, and further to investigate its impacts on the environment. The study found that household’s access to electricity with ability to spend on electricity consumption contributes to the positive household welfare effects and environment via a reduction of biomass consumption, and the more household spends on biomass, the more they are prone to sickness of lung problem. The study also confirmed the important role of human capital formation for the positive impact on the welfare and the environment. These findings lead to policy implications that would improve affordable access to electricity to ensure that all households can use electricity for their basic needs and productivity, and also to reduce the negative effects on environment.

Migration and investments in the health of children left behind: the role of remittances in children's healthcare utilization in Cambodia.

Remittances, financial support from family members who have migrated for work, are an increasingly important source of income for households left behind in many lower- and middle-income countries. While remittances have been shown to affect the health status of children left behind, evidence is very limited as to whether and how they affect children's healthcare utilization. Yet, this is an important consideration for policymakers seeking to improve equitable access to quality care in settings where migration is common. I examine whether children under age five whose household receives remittances are more likely to utilize higher quality healthcare providers than those without remittances in Cambodia, a country with high rates of migration and a pluralistic health system. The analysis includes 2230 children reporting recent illness in three waves of the Cambodia Socio-Economic Survey with data on migration, remittances and children's health expenditures. I use mixed-effects and fixed-effects regression analysis to estimate the effect of remittances on children's likelihood of entering care with a formally trained provider, and among those attending a formally trained provider, likelihood of using a public-sector facility. Treatment expenditures are lower among households with remittances, while transportation expenditures do not vary significantly by remittance status. In mixed-effects and fixed-effect regression models, children who receive remittances have a lower likelihood of utilizing qualified providers (adjusted OR = 0.66, 95% confidence interval 0.44-0.98), though this effect is attenuated in fixed-effects models, and there is no association between remittances and attending a public-sector facility. These findings underscore that remittances alone are not sufficient to increase children's utilization of qualified providers in migrant-sending areas, and suggest that policymakers should to address barriers to care beyond cost to promote utilization and equity of access to higher quality care where remittances are a common source of income.

The impacts of energy insecurity on household welfare in Cambodia: Empirical evidence and policy implications

This study investigates the impacts of energy insecurity on household welfare in Cambodia. The notion of energy insecurity is not well understood in the literature as well as in local contexts. This study defines household energy insecurity as the status quo derived from the interplay of inadequate and insufficient energy consumption that prevents households from meeting basic energy needs. The notion of energy insecurity can only be well understood by investigation in the local context as it varies from place to place. Households facing insufficient energy consumption may forgo many other opportunities. Once energy security has been defined in the Cambodian context, the study employs multiple regression models using the Cambodia Socio-Economic Survey Data (2015) to investigate the impacts of household energy insecurity. The study confirmed that energy insecurity has enormous negative impact on welfare of the households, with a further negative impact on the human capital formation of the children. The findings will lead to policy implications to improve household energy security, and thus impact economic, social, and environmental development.

Cambodia's energy poverty and its effects on social wellbeing: Empirical evidence and policy implications

This study aims to quantify the incidence of energy poverty in Cambodia and its potential impact on the social wellbeing of the people of Cambodia. The notion of energy poverty of a household is not well understood in the context of literature as it may refer to either ‘energy poor’ or ‘economically poor’ condition of the household. This study defines energy poverty in terms of lack of accessibility and/ or affordability of energy, which may cause the deprivation of a household and affect its wellbeing. The study uses the latest Cambodia Socio-Economic Survey Data 2015 (CSES 2015) to investigate the impacts of energy poverty on the health, education and earning opportunities of the households. The findings of the study suggest that energy poverty of a household is strongly associated with the type of fuel used and low consumption of unaffordable clean energy by the household. The resulting impacts of energy poverty on the wellbeing of households are enormous. Energy poor households have a higher probability of its members suffering from respiratory problems, spending more on medical care, having a higher dropout rate from schools and lower earning opportunities than the households without energy poverty. Based on its findings, the study suggests an urgent need of policy measures focusing on provision of clean and affordable energy to poor households to reduce / eliminate energy poverty in Cambodia.

Child Labor and Mother's Labor Market Participation: Evidence from Cambodia

This paper analyzes child labor participation decision and how it affects intra-household, especially mother’s, labor market participation through the mother-child relationship in the market work. Using Cambodia Socio-Economic Survey 2014, it shows that a higher probability of child labor increases the incidence of mother’s work. However, it also demonstrates that a mother is less likely to get involved in the market work if the eldest child is a son. This suggests the substitutability between a mother and her eldest son in market work, whereas the eldest daughter tends to do domestic work instead of her working mother.

Healthcare Access Among Cambodia’s Poor: An Econometric Examination of Rural Care-seeking and Out-of-Pocket Expenditure

To inform efforts to improve Cambodia’s social health protection system and advance universal health coverage, health care-seeking and out-of-pocket expenditure (OOPE) were assessed using the 2016 Cambodia Socioeconomic Survey data. This study focuses on the poorest wealth quintile who reside in rural areas- the primary target population of Cambodia’s largest social health protection scheme, the Health Equity Fund (HEF). The study also estimates the proportion of poor with an Equity card which provides access to HEF benefits at public facilities. Overall, 76% of people who sought healthcare in the past 30 days went to private providers, paying, on average, US$39.43 for treatment. About 18% of patients first sought care from public facilities, paying, on average, US$38.15. Though HEF aims to provide free healthcare for the rural poor, this analysis found that 67.2% of such patients seeking first care at public health facilities pay, on average, US$11.61 after controlling for confounding factors. However, treatment expenditure among the rural poor is about 52% less compared to third wealth quintile patients (p<0.01). About 36% of people under the national poverty line do not hold an Equity card to access HEF benefits. Thus, we conclude that HEF is not yet fully reaching its intended impact of removing OOPE as a barrier to access among the poor. Finally, free access to healthcare should incentivize utilization of public services; however, this study was unable to isolate such an effect among patients from the poorest wealth quintile. Access to healthcare can be strengthened with policy directives focused on further reducing OOPE and addressing other challenges to improve patient demand for public services such as quality of care. Enrollment exclusion errors should be corrected by relaxing the eligibility criteria with population coverage expansion. In addition, health service access should be systematically monitored by integrating service utilization, OOPE, and quality indicators into national monitoring and evaluation systems.

Can labor provisions in trade agreements promote gender equality? Empirical evidence from Cambodia

AbstractIn recent years, an increasing number of regional and bilateral trade agreements have emerged that include provisions on labor standards. The claimed purpose of these labor provisions is to improve working conditions in developing and emerging economies. However, little is known about whether such provisions actually do impact working conditions. This paper conducts an econometric study on the effectiveness of labor provisions in trade agreements. In particular, we evaluate the impact of the 1999 Bilateral Textile Agreement between Cambodia and the United States (CUSBTA) on both the gender wage gap and discrimination. The agreement combined the incentive of higher exports with the obligation of textile manufacturers to comply with international core labor standards, which include the elimination of discrimination in respect of employment and occupation. Using data from the Cambodia Socioeconomic Survey and applying a difference‐in‐difference estimation, we find a statistically significant reduction of the gender wage gap in the textile sector that can be attributed to the CUSBTA.

Long-term consequences of armed conflicts on poverty: the case of Cambodia

Using the Cambodia Socio-Economic Survey 2011, this study is to quantify the impacts of disabilities induced by armed conflicts on poverty. Two main empirical findings emerge: First, disabilities aggravate poverty by 12–15%. Especially, disabilities caused by war and land mines exacerbate poverty significantly by 26–27%. In contrast, congenital disabilities or disabilities caused by accidents and diseases do not generate significant impact on poverty. Second, household characteristics, such as the number of household members, residential area, education, and marriage status of household head, are systematically correlated with poverty.

Rural Electrification in Cambodia: Does It Improve Welfare of Household?

We use subsamples of Cambodia Socio-Economic Survey (CSES) 2004 and 2011 to examine the impact of rural electrification on household consumption, tobacco consumption, and children's education in Cambodia. Dierence-in-Dierences was used to find that rural electrification increased household consumption by about 17 percent and reduced probability of tobacco consumption of household head by 23 percent. We also find that richer households benefitted more than poorer households. Additionally, electrification increased boys' years of schooling completed by 0.68 and girls' years of schooling completed by 0.65. It also increased probability of enrolling in primary school for boys, but not for girls. And it increased probability of completing primary education by 12 percent for boys and 8 percent for girls.

Rethinking the Effects of Microcredit on Household Welfare in Cambodia

This article analyses the effects of microcredit on household welfare in terms of household expenditure per capita in Cambodia, with data from the Cambodia Socio-Economic Survey carried out in 2014. The analysis describes the effects via formal and informal lending sectors, accounting for endogenous selection bias arising from unobserved factors and for structural differences between borrowers and non-borrowers in terms of expenditure functions. The findings suggest that microcredit in both sectors reduces household expenditure.

Impact of health financing policies in Cambodia: A 20 year experience

Improving financial access to services is an essential part of extending universal health coverage in low resource settings. In Cambodia, high out of pocket spending and low levels of utilisation have impeded the expansion of coverage and improvement in health outcomes. For twenty years a series of health financing policies have focused on mitigating costs to increase access particularly by vulnerable groups. Demand side financing policies including health equity funds, vouchers and community health insurance have been complemented by supply side measures to improve service delivery incentives through contracting.Multiple rounds of the Cambodia Socio-Economic Survey are used to investigate the impact of financing policies on health service utilisation and out of pocket payments both over time using commune panel data from 1997 to 2011 and across groups using individual data from 2004 and 2009. Policy combinations including areas with multiple interventions were examined against controls using difference-in-difference and panel estimation.Widespread roll-out of financing policies combined with user charge formalisation has led to a general reduction in health spending by the poor. Equity funds are associated with a reduction in out of pocket payments although the effect of donor schemes is larger than those financed by government. Vouchers, which are aimed only at reproductive health services, has a more modest impact that is enhanced when combined with other schemes. At the aggregate level changes are less pronounced although there is evidence that policies take a number of years to have substantial effect.Health financing policies and the supportive systems that they require provide a foundation for more radical extension of coverage already envisaged by a proposed social insurance system. A policy challenge is how disparate mechanisms can be integrated to ensure that vulnerable groups remain protected.

Estimating the Economic Effects of Remittances on the Left-Behind in Cambodia

Using propensity score matching with the 2009 Cambodia Socio-Economic Survey of households, this study examines the effects of remittances on indicators of household well-being: poverty, consumption and labour participation of non-migrant members. The theoretical framework is built upon a “new economics of labour migration”, hypothesising that the emigration decision is jointly determined by households and individual migrants and that remittances basically represent a form of contractual arrangements between them. The results indicate that households with at least one migrant member and which receive remittances could reduce their poverty headcount rate by 3-7 percentage points vis-a-vis their matched controls. Remittances also reduce depth and severity of poverty of treated households. On the contrary, remittances generate a 5-9 percent “dependency effect” on working age adults who are employed due to reduced weekly hours worked. The impact of remittances on labour participation and salary income is, however, vulnerable to unobservable factors.

The Effects of nonfarm activities on farm households’ food consumption in rural Cambodia

This article analyzes the effects of participation in nonfarm activities on farm households’ food consumption in rural Cambodia. An endogenous switching model is built on data from the Cambodia Socio-Economic Survey conducted in 2009 to evaluate whether rural farm households make food consumption gains from participation in such activities. This model accounts for selection bias resulting from unobserved factors that potentially affect both farm households’ decision to participate in nonfarm activities and food consumption. The model also controls for structural differences between participants in nonfarm activities and nonparticipants that most previous studies do not account for. The results suggest that by engaging in nonfarm activities, rural farm households make positive gains in per capita food consumption, thus confirming the hypothesis that engagement in nonfarm activities exerts positive effects on household food consumption.

Simulating the Impacts of Cash Transfers on Poverty and School Attendance: The Case of Cambodia

Using the Cambodia Socioeconomic Survey 2004 and employing micro-static simulation techniques, we measure the potential impacts of cash transfer programs for children to identify targeted groups that will have the most effect on poverty and school attendance. We conclude that the largest impacts occur by targeting poor children. If this proves to be too administratively costly, then targeting children in rural areas or targeting all children living in the ten poorest provinces will also yield significant poverty reduction. With regard to improving school attendance, the same targeted groups generally provide the biggest impacts as well, although the impacts on school attendance tend to be smaller than on poverty reduction.

Tobacco expenditure and its implications for household resource allocation in Cambodia

ObjectivesTo assess the determinants of smoking behaviour and to estimate the impact of tobacco consumption on the consumption of other commodities by Cambodian households.MethodsTo assess the determinants of smoking in...