Download this and other articles about the state of social protections in the global South compiled in our latest DAWN Informs here
Context and Background
Looking at its history, Cambodia, like other less developed countries, receives overseas development aid and financial assistance from international financial institutions such as the International Monetary Fund (IMF) and the World Bank (WB) in order to restore and build its economy and to enhance development. This financial assistance comes with conditions which require Cambodia to reform many areas, including economic policy and public administration. Privatization was introduced and adopted under a Structural Adjustment Program and other policy frameworks and strategy plans including the Medium-Term Economic and Financial Policy Framework Paper 1999–2002 and Poverty Reduction Strategy Paper. Thus, privatization becomes one of the main strategies for economic development in Cambodia.
Privatization of essential services including education, water, electricity, housing and public healthcare has become a major concern for Cambodian people especially the poor: 71%[1] of the total population (who have an income less than USD 3 per day); and women, since privatization prevents these groups from accessing essential services. The promotion of the private sector’s role in providing services and the introduction of user-fees at public health facilities have become critical barriers for people to access free and quality healthcare. The spending on healthcare per capita in Cambodia is high. For instance, in 2014, out-of-pocket per capita expenditure on health per year accounted for 63% of total expenditure on health, whilst government expenditure accounted for only 18.5%[2].
Social Protection in Cambodia and Its Coverage
Privatization, a key policy imposed by IMF, World Bank and other financial institutions via aid and concessional loans and made through free trade agreements, has posed a serious threat and impoverished people in Cambodia, as it has elsewhere in the world. Social Protection/Social Security, coined and introduced by various actors including the World Bank and implemented through key international laws, has emerged as a critical social policy to alleviate poverty and as a shield to protect people from disaster caused by such impoverishing neo-liberalized economic policy.
According to the Universal Declaration of Human Rights (UDHR), “all members of a society have the right to social security, and everyone has the right to a standard of living adequate for the health and well-being of himself/his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control”[3]. Through the International Covenant on Economic, Social, and Cultural Rights, “States recognize the right of everyone to social security including social insurance”[4]. Similarly, as articulated by the International Labor Organization (ILO), Social Protection or Social Security is a “human right and is defined as the set of policies and programs designed to reduce and prevent poverty and vulnerability throughout the life cycle. Social protection includes benefits for children and families, maternity, unemployment, employment injury, sickness, old age, disability and disaster survivors, as well as health protection. Social protection systems address all these policy areas by a mix of contributory schemes (social insurance) and non-contributory (tax-based financing) including social assistance”[5].
In Cambodia, the term and concept of “Social Protection” has become popular since the promulgation of the National Social Protection Strategy (NSPS) 2011-2015. This strategy defines social protection and determines the scope of policy and implementation activities. In March 2017, the National Social Protection Policy Framework 2016-2025 was made with the goal to develop a strategic plan for the Royal Government of Cambodia to guarantee income security and reduce economic and financial vulnerability of its citizens by focusing on two main pillars, namely Social Assistance (non-contributory) and Social Security (contributory).
Social Assistance is mainly financed by the Cambodian government’s budget with the aim to ensure decent living standards for poor and vulnerable citizens, including individuals living close to or under the poverty line, pregnant women, infants, children, elders, people with disabilities and families with no food security. Currently, the Cambodian government has been implementing some programs including the Health Equity Fund (HEF) for holders of poor identification cards (IDpoor) and families who cannot afford to pay for health care, food reserves for disasters, scholarship programs for poor primary school students, vocational trainings and other benefits.
Social Security, being a contributory system, encourages citizens to seek protection in the face of unforeseen social and economic crisis which can negatively affect their income security and increase their vulnerability to illness, maternity, employment injuries, unemployment, disability, old age or death. As stated in the Social Protection Policy Framework 2016-2025, this program is composed of five components including pensions, health insurance, work injury insurance, unemployment insurance, and disability insurance. However, to date, the government has only implemented two components, namely health and work injury insurance for formal sector workers who are covered under social insurance, a pre-paid system that depends largely on the contributions which are compulsory payments made by employers.
Social Protection Coverage and Freelance Sex Workers
As informal sector workers, freelance sex workers are not yet covered by the social security scheme though the government has plans to expand Social Protection for all. With irregular incomes ranging anywhere between 3.75-7.50 USD per day[6], freelance sex workers live precariously and are unable to save, often unable to cope with income insecurity, health and occupational hazards and accidents.
Under the Health Equity Fund (HEF) scheme of the Social Assistance System, sex workers who hold IDpoor cards can access treatment at public health facilities. However, not every sex worker has an IDpoor card. According to a research report conducted by the Women’s Network for Unity[7] on “Health and Life, Experiences of Sex Workers and Entertainment Workers”, only 17.6% out of 131 sex workers interviewed in the study have a Health Equity Card. Mobile freelance sex workers can’t fulfil the criteria to be assessed by the Ministry of Planning in order to get an IDpoor card. Some freelance sex workers are mobile and don’t have specific shelter. Recently, with advocacy efforts of sex workers facilitated by the Women’s Network for Unity, the Ministry of Planning expressed a commitment to support mobile sex workers to access IDpoor cards.
However, accessing healthcare through the IDpoor cards does not fully respond to the needs of the poor including sex workers, and is not sustainable. The Health Equity Fund scheme still largely depends on financial support from development partners, though the government is increasing its budget. More concerning is that Cambodia is on the way to becoming an upper-middle income country, and as a result, the financial support from external development partners will gradually reduce and Cambodia will face a budget shortfall for covering healthcare. As stated in the 2016-2020 Health Strategic Plan, there is an expectation of a budget deficit of USD 1,104 million for healthcare which urgently needs the political will of and commitment from the government in order to increase the national budget for the health sector. Aside from these concerns, some freelance sex workers (38.2% of 131 interviewed women) experience discrimination and poor service from health staff when they are seeking health treatment by using IDpoor card[8]. Questions raised regarding these concerns include: What is next for freelance sex workers? Will they be covered under social insurance, and if so, will the state pay for them? What of other informal sector workers, the poor, elderly, people with disabilities, children, women and those who have irregular income? How will effective healthcare be delivered to them?
Social Protection and the Gap
The adoption and implementation of Social Protection can only address some of the people’s needs.
However, there are a number of concerns regarding the current system. Firstly, it still lacks a comprehensive and clear measure and procedure to ensure
that groups of people such as informal sector workers (including sex workers
and farmers), people with irregular income, youth, elders, and all the poor access
to free and/or affordable basic social services, as well as social security such as pensions, and other
necessary support/subsidies. Informal sector and irregular income groups are
still excluded from the scheme, though some have access to social
assistance. Secondly, the
contributory social security system, though currently compulsory and paid
for by employers (for work injury and health insurance) through social
insurance schemes, will add more burden to citizens in addition to tax duties. Finally,
the current social protection framework excludes the provision for free and/or
affordable access to other essential services such as housing, water,
electricity and transportation etc. These essential services are crucial for
ensuring that the basic needs of people are met, especially for poor migrant
workers and women workers, and must be included in Social Protection programs.
[1] Cambodia, Addressing the Skills Gap, Employment Diagnostic Study by ILO & ADB, 2015
[2] Health Financing Profile (May 2016)
[3] The Universal Declaration of Human Rights (UDHR), Articles 22 and 25.
[4] The International Covenant on Economic, Social and Cultural Rights, Article 9.
[5] World Social Protection Report 2017-2019, Universal Social Protection to Achieve Sustainable Development Goals, ILO 2017. Retrieved from: https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/—publ/documents/publication/wcms_604882.pdf
[6] Health and Life, Experiences of Sex Workers and Entertainment Workers, by Women’s Network for Unity, April 2018.
[7] Women’s Network for Unity (WNU), a sex worker’s association based in Cambodia, was founded at the end of 2002, having mission to strengthen sex workers network to advocate for the greater participation in program, policy and law development related to sex work that will give them greater access to social services, and freedom from violence and discrimination.
[8] Health and Life, Experiences of Sex Workers and Entertainment Workers, by Women’s Network for Unity, April 2018.