Cambodia’s path toward universal health coverage: Strengthening strategic purchasing through capacity building

Universal health coverage (UHC) means that all people can access the quality health services they need without suffering financial hardship. Health financing is fundamental to achieving this goal: it determines how much public resources can fund the health sector, what services are available and who can access them, without families facing catastrophic costs.

Cambodia has made significant progress in expanding social health protection. Between 2018 and 2023, coverage increased from 27% to nearly 50% of the population through schemes including the National Social Security Fund (NSSF), which covers registered employees (public and private) and voluntary contributors, and the Health Equity Fund (HEF), which supports poor and vulnerable households.

However, major gaps remain. Half the population is still not covered by the national social health protection schemes, and over 60% of the health spending in the country comes directly from households’ out-of-pocket payments. This high out-of-pocket spending leaves many families vulnerable to financial challenges from preventable illnesses.   

Cambodia’s roadmap to UHC 

The Royal Government of Cambodia has reaffirmed its commitment to expanding access to healthcare through the Roadmap Towards Universal Health Coverage in Cambodia (2024-2035).

The roadmap sets out the country’s ambitious targets to expand population coverage under the social health protection system to 80%, and to reduce out-of-pocket health spending to no more than 35% of total health expenditure. As the key health financing function linking public funds to service delivery, strategic purchasing – the active process of deciding which services to buy, from whom, and how to pay for them – is recognized in the plan as a critical policy driver for advancing these health financing reforms by making resource allocation more efficiently and equitably.

Building capacity for strategic purchasing 

To support Cambodia’s UHC Roadmap implementation, WHO Cambodia, with support from BACKUP Health, a global programme of the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH and the Providing for Health (P4H) network, developed a capacity building programme: “Strengthening Strategic Purchasing Capacity to Accelerate Universal Health Coverage in Cambodia.” In doing so, BACKUP Health worked closely with the bilateral GIZ programme Improving Social Protection and Health II in Cambodia. Both programmes are commissioned by the German German Federal Ministry for Economic Cooperation and Development, while ISPH II is also co-funded by the Australian Government.

Tailored to Cambodia’s context, the programme started with a series of health financing trainings to equip participants with up-to-date knowledge and analytical skills for health financing policy development. The focus was on applying strategic purchasing policy design,  based on global evidence and local situation, to enhance the efficiency, equity and sustainability in financing service health delivery across the country.

^{Over two months, participants in the training series engaged in learning health financing frameworks, simulations, and virtual knowledge exchange sessions with other countries in the Western Pacific region. © WHO / Monika Mey & Puthealin Sok}

“The collaboration provides an opportunity for Cambodian decision-makers to take a strategic view of the country’s health financing landscape and align resource allocation for greater impact on health outcomes,” said Dr Marianna Trias, WHO Representative to Cambodia. “The programme offers an in-depth analysis of Cambodia’s health financing situation, complemented by selected lessons from other countries in the Western Pacific region and beyond. These examples serve as signposts that highlight what has been achieved, what works, and what can be adapted to Cambodia’s context,” she added.

The training brought together Cambodia’s health financing institutions through a whole-of-government approach, including the General Secretariat of the National Social Protection Council (GS-NSPC), Ministry of Health, Ministry of Economy and Finance, National Social Security Fund (NSSF), National Payment Certification Agency, Social Security Regulator, and other relevant ministries and health partners involved in health sector planning and financing.

“Cambodia’s journey towards Universal Health Coverage depends not only on mobilizing resources, but on how those resources are used. By strengthening purchasing mechanisms, aligning provider incentives with performance and quality, and improving the efficient use of public and external resources, we directly influence service delivery and accelerate progress toward Universal Health Coverage. Our aim was to enable our partner to use existing resources as efficiently as possible, says Nina Siegert, component lead at BACKUP Health.

Dr Vanny Peng, component lead for health at ISPH II adds “Strategic purchasing is not only a technical reform, but also a governance reform. It requires coordination, trust and shared ownership across ministries. Supporting this cross-sectoral collaboration is at the heart of GIZ’s engagement.” 

Bridging health, social health protection and finance perspectives

The training helped participants develop a comprehensive understanding of health financing systems from multiple view points across government sectors.

“The knowledge that I had earlier was fragmented because I didn't have a health background, but more of a social policy background,” said Reach Mony, Senior Analyst at GS-NSPC. “Now I’ve learned about the fundamental framework to think about health financing in terms of revenue raising, pooling, strategic purchasing and benefit package design.” 

This integration of health, social health protection and finance perspectives enables policymakers to see connections between funding mechanisms and health outcomes, supporting decisions that are both sustainable and cost-effective.

“One thing I learned is that to achieve universal health coverage, we need stakeholders working together,” said Nita Noy, Officer at the Department of Planning and Health Information, MoH. “The stronger the cooperation between ministries, the more effective and sustainable health financing becomes.

Reach Mony echoed this sentiment: “For policy analysts like me, it’s really beneficial because it helps you think about the strengths and weaknesses of a particular tool or decision.”

Kakrona Keout, Chief Bureau of the Department of Health Services at NSSF, emphasized learning from international experience: “I learned a lot from the experiences of other countries around the world and in Southeast Asian contexts. The most important thing I learned from this course that I can apply in my job is how to design health benefit packages for social health protection.”

^{(Left to right) Group photo of the first training session. Training participants: Ms Reach Mony, Senior Analyst at GS-NSPC; Ms Nita Noy, Officer at the Department of Planning and Health Information, MoH; Mr Kakrona Keout, Chief Bureau of the Department of Health Services at NSSF. © WHO / Monika Mey & Rocel Ann Junio}

As the principal lecturer of the health financing training course, Ding Wang, Health Economist at the WHO Cambodia Office, stated: “Global experience has shown that the development and effective implementation of health financing policies depend on building consensus and fostering close collaboration across the health, finance, and social protection sectors. The participants in this training represented key actors from all three sectors, and the course has laid a strong foundation for continued dialogue and cooperation in the future.”

The path ahead 

With rapid socio-economic growth, Cambodia is expected to graduate from least developed country status in 2029. This significant milestone will also bring changes, including rising expectations for health services and social health protection amid a gradual phase-out of development assistance. Strengthening domestic health spending and health system financing will therefore be essential to sustain progress.

Building on the capacity developed through the training, the next phase of WHO’s support will focus on translating knowledge into concrete policy and implementation actions. This includes supporting the relevant government departments to clarify strategic purchasing policy directions, strengthen institutional arrangements and governance, and develop practical purchasing instruments such as benefit package definitions, provider payment methods, and contracting mechanisms. WHO, along with support from GIZ and P4H, stands ready to support the government in ensuring that strategic purchasing is effectively implemented for better value for money and improved health outcomes in Cambodia.