Request for Proposal (RFP): Individual consultant to develop a framework for the evaluation of the voluntary social health insurance scheme of the NSSF

The Government of the Kingdom of Cambodia’s 7th legislature of the National Assembly has prioritized progressing towards universal health coverage. This commitment is reflected in key national strategic documents and policies, including the Pentagonal Strategy Phase I, the National Strategic Development Plan 2019-2023, the Health Strategic Plans for 2008-2015 and 2016-2020, the National Social Protection Policy Framework, and with the launch of the “Roadmap Towards Universal Health Coverage in Cambodia 2024-2035” in May 2024. Achieving UHC is a significant policy goal for the Royal Government of Cambodia, necessitating innovation in both public and private health sectors, institutional development among the public operators, and significant collaboration across the government.
The Cambodian public healthcare system has two main pillars, the Health Equity Fund, and the National Social Security Fund (NSSF). Within the contributory pillar, two main groups are legally covered by the social health protection through the NSSF, namely the employees of the public and private sector.
Public officials, former civil servants, and veterans have had access to the medical services since early 2018. As of December 2023, approximately 400 thousand civil servants and veterans actively contribute to this scheme. Workers under the Labour Law are entitled to medical services and non-medical benefits. As of December 2023, around 1.5 million employees actively contribute to this scheme. Medical services for both groups are available at all public and private health facilities that have agreements with NSSF.
2023 Extension: voluntary contributions for self-employed workers and NSSF dependents
The NSSF implemented – in 2021-2023 a pilot project to provide social security to Phnom Penh’s self-employed tuk-tuk drivers. The pilot project was called Social Protection: Innovation for the Informal Sector and known as SPIN Project. The NSSF was assisted technically by GRET, supported by the French development agency AFD. Following a financial capacity assessment of tuk-tuk drivers, and consultations with the informal workers association IDEA, the monthly contribution rate was set at 15,600 Cambodian riels (about 3.9 US Dollars) and granted access to medical services through the NSSF clinics network. At the end of its implementation, SPIN had seen the enrolment of about 3,000 workers as the 2023 enrolment was open to any self-employed occupation in view of the expected development into a national scheme.
The legal establishment of a voluntary health insurance scheme happened in a rapidly evolving legislative and executive environment following the July 2023 Cambodian general-election and the appointment of succeeding prime minister in August 2023. In the first address to the National Assembly, the new prime minister, Hun Manet, highlighted six priority goals for his five-year term, including the expansion of healthcare services towards universal health coverage and accelerating the implementation of the National Strategy for the Development of Informal Economy 2023-2028 to enable the workers in the informal economy to transition into the formal economy and be covered by the social security system. Against this backdrop, the
SPIN pilot project evolved into a national scheme with the enactment of Sub-Decree No. 280/2023 in August 2023.1
Voluntary scheme parameters
Following Sub-Decree No. 280, the NSSF began scaling up its operations. The new scheme was established with a voluntary regime, targeted at the self-employed and the dependents of NSSF members including non-working spouses and children below 18. As of January 2024, more than 134,600 self-employed workers were covered under the voluntary health care system.
Sub-Decree No. 280 defines the self-employed as workers younger than 60 years old who conduct their own income generating activity, without receiving a wage or a salary by a private employer or the State and without an employment contract, and that do not employ workers for their income generating activities.
The monthly contribution rate of the scheme was fixed at the 2.6 per cent of the contributory wage and the contributory wage was determined to be 600,000 Cambodian riels for both dependents and self-employed. Effectively, this maintained a nominal contribution fee of 15,600 Cambodian riels as from the pilot project. Additionally, the rate of 2.6 per cent corresponds to the rate paid by employers within the mandatory healthcare scheme for private sector employees – de facto aligning the rates although maintaining a different contributory wage.2
In the public sector, the monthly contribution rate for the dependents was fixed at the 1.4 per cent of the contributory wage and the contributory wage was determined to be 870,000 Cambodian riels for both dependents and self-employed. Effectively, this rate consists in a nominal contribution fee of 12,180 Cambodian riels.3
As a buffering period to avoid health consumption immediately upon registration, there is a contributing waiting period of 2 months before gaining access to the medical services through the NSSF contracted public and private health facilities.
Contributing self-employed members are entitled to maternity benefits from the 26th week of pregnancy, conditionally on having paid contributions for 9 months within the 12 preceding the expected childbirth. The maternity benefit consists in an income replacement transfer for a 90-day period at 70 per cent of the contributory wage. The funeral grant corresponds to a one-off payment of 2,000,000 Cambodian riels (500 US Dollars).