Assessing the determinants of out-of-pocket health expenditures among Cambodian households in informal employment using survey data
Kaiser, Andrea Hannah LU ; Mao, Sovathiro ; Sundewall, Jesper LU ; Ross, Marlaina ; Koy, Sokunthea ; Vorn, Searivoth ; Koeut, Pichenda and Ekman, Bjoern LU
(2025)
In International Journal for Equity in Health
24(1).
- Abstract
Background: As the deadline for the Sustainable Development Goals approaches, financial protection in Cambodia remains inadequate, especially for nonpoor informal workers lacking formal social health protection coverage or access to other prepayment schemes. This exposes them to high out-of-pocket health expenditures (OOPE) and related financial hardship. To better understand the drivers behind these expenditures, our study aims to model their healthcare, health, and social determinants and to assess their relative importance. Methods: In 2023, we conducted a cross-sectional multistage clustered sampling survey across seven Cambodian provinces, surveying 3,254 households engaged in informal employment and not covered by any formal... (More)
Background: As the deadline for the Sustainable Development Goals approaches, financial protection in Cambodia remains inadequate, especially for nonpoor informal workers lacking formal social health protection coverage or access to other prepayment schemes. This exposes them to high out-of-pocket health expenditures (OOPE) and related financial hardship. To better understand the drivers behind these expenditures, our study aims to model their healthcare, health, and social determinants and to assess their relative importance. Methods: In 2023, we conducted a cross-sectional multistage clustered sampling survey across seven Cambodian provinces, surveying 3,254 households engaged in informal employment and not covered by any formal social health protection scheme. The survey gathered information on households’ use of outpatient and inpatient care and associated OOPE. We employed generalized linear models (GLMs) to analyse the healthcare, health, and social determinants of OOPE and the OOPE budget share (the proportion of total annual household consumption expenditure spent on OOPE) and applied Shapley decomposition analysis to quantify the relative contributions of these determinants to the explained variance in our outcomes. Results: Healthcare variables were the dominant contributors to the explained variance in all outcomes (41.36–50.73%), followed by health factors. While several social variables were significant, only the wealth quintile made notable contributions to explaining variance in our outcomes. The key healthcare contributors included the sector type and level of care, and the number of outpatient medications. Important health contributors included illness severity and the presence of chronic illnesses or noncommunicable diseases. Conclusions: Our findings emphasize the necessity of integrating nonpoor informal workers and their dependents into formal prepayment schemes to reduce OOPE and enhance financial protection on Cambodia’s path toward universal health coverage. Strategically engaging with private providers and pharmacies to improve access to essential services and medicines, coupled with the implementation of an effective referral system are important policy considerations to this end. Further research is needed on how health determinants are modifiable with policy interventions. Our findings can assist the Cambodian government in advancing its universal health coverage goals and offer insights for other countries aiming to extend coverage to similar population groups.
(Less)
- author
- Kaiser, Andrea Hannah
LU
; Mao, Sovathiro
; Sundewall, Jesper
LU
; Ross, Marlaina
; Koy, Sokunthea
; Vorn, Searivoth
; Koeut, Pichenda
and Ekman, Bjoern
LU
- organization
- publishing date
- 2025
- type
- Contribution to journal
- publication status
- published
- subject
- keywords
- Cambodia, Financial protection, Informal employment, Low- and middle-income countries, Out-of-pocket budget share, Out-of-pocket health expenditures, Population coverage, Universal health coverage
- in
- International Journal for Equity in Health
- volume
- 24
- issue
- 1
- article number
- 33
- publisher
- BioMed Central (BMC)
- external identifiers
-
- pmid:39891289
- scopus:85217531200
- ISSN
- 1475-9276
- DOI
- 10.1186/s12939-025-02394-6
- language
- English
- LU publication?
- yes
- id
- aa4a559f-f4c0-4326-bd91-a27c1e0d0e08
- date added to LUP
- 2025-03-21 08:41:50
- date last changed
- 2025-07-11 17:37:14
@article{aa4a559f-f4c0-4326-bd91-a27c1e0d0e08,
abstract = {{<p>Background: As the deadline for the Sustainable Development Goals approaches, financial protection in Cambodia remains inadequate, especially for nonpoor informal workers lacking formal social health protection coverage or access to other prepayment schemes. This exposes them to high out-of-pocket health expenditures (OOPE) and related financial hardship. To better understand the drivers behind these expenditures, our study aims to model their healthcare, health, and social determinants and to assess their relative importance. Methods: In 2023, we conducted a cross-sectional multistage clustered sampling survey across seven Cambodian provinces, surveying 3,254 households engaged in informal employment and not covered by any formal social health protection scheme. The survey gathered information on households’ use of outpatient and inpatient care and associated OOPE. We employed generalized linear models (GLMs) to analyse the healthcare, health, and social determinants of OOPE and the OOPE budget share (the proportion of total annual household consumption expenditure spent on OOPE) and applied Shapley decomposition analysis to quantify the relative contributions of these determinants to the explained variance in our outcomes. Results: Healthcare variables were the dominant contributors to the explained variance in all outcomes (41.36–50.73%), followed by health factors. While several social variables were significant, only the wealth quintile made notable contributions to explaining variance in our outcomes. The key healthcare contributors included the sector type and level of care, and the number of outpatient medications. Important health contributors included illness severity and the presence of chronic illnesses or noncommunicable diseases. Conclusions: Our findings emphasize the necessity of integrating nonpoor informal workers and their dependents into formal prepayment schemes to reduce OOPE and enhance financial protection on Cambodia’s path toward universal health coverage. Strategically engaging with private providers and pharmacies to improve access to essential services and medicines, coupled with the implementation of an effective referral system are important policy considerations to this end. Further research is needed on how health determinants are modifiable with policy interventions. Our findings can assist the Cambodian government in advancing its universal health coverage goals and offer insights for other countries aiming to extend coverage to similar population groups.</p>}},
author = {{Kaiser, Andrea Hannah and Mao, Sovathiro and Sundewall, Jesper and Ross, Marlaina and Koy, Sokunthea and Vorn, Searivoth and Koeut, Pichenda and Ekman, Bjoern}},
issn = {{1475-9276}},
keywords = {{Cambodia; Financial protection; Informal employment; Low- and middle-income countries; Out-of-pocket budget share; Out-of-pocket health expenditures; Population coverage; Universal health coverage}},
language = {{eng}},
number = {{1}},
publisher = {{BioMed Central (BMC)}},
series = {{International Journal for Equity in Health}},
title = {{Assessing the determinants of out-of-pocket health expenditures among Cambodian households in informal employment using survey data}},
url = {{http://dx.doi.org/10.1186/s12939-025-02394-6}},
doi = {{10.1186/s12939-025-02394-6}},
volume = {{24}},
year = {{2025}},
}