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The Health and Economic Impact of a Government Health Insurance Program in Cambodia

Development Challenge

Despite shouldering 90% of the global disease burden, developing countries currently have far lower rates of health insurance coverage than industrialized nations. The economic and health consequences of such coverage deficiencies for poor households can be severe. The high cost of care can cause poor households to forgo preventive measures and early detection of illnesses, leading to the increased likelihood of later encountering serious health problems. Moreover, there are negative economic effects associated with poor care. For example, injury and incapacitation can lead to lost income, which can further lead to persistent poverty if households are forced to sell their productive assets, such as livestock. Perhaps even worse, health shocks can lead to a cycle of poverty if they reduce investments in children's health or education.


The need to address how to increase health insurance coverage in an effort to improve health and economic outcomes is an issue of significant concern to policymakers in poor nations. In 1998, Cambodia implemented the SKY Health Insurance Program in an attempt to increase health care coverage to rural families without risking further impoverishment. For a fixed monthly premium, the program offers households unlimited primary and emergency care, as well as other health services. In addition to providing affordable and quality health care, SKY aims to mitigate the economic consequences of large health expenditures to households, thus eliminating the potentially devastating spiral of health shocks and economic distress at the source.

Evaluation Strategy

This project will examine the impact of the SKY program on both health and economic outcomes using a randomized trial. The health outcomes of interest include primary care utilization, health-seeking behavior, and measured health status. The economic outcomes to be examined will include families' vulnerability to health shocks due to high medical costs, loss of income while ill or incapacitated, sales of productive assets, and reductions in investments. 
Data will be gathered from a sample consisting of approximately 3,000 households with over 15,000 individuals. A pre-intervention baseline survey and follow-up surveys of the same households will be conducted over the 4 year experimental period. The survey will provide data on the variables of interest, which include health status, health-seeking behavior, asset vulnerability, investment and saving decisions, and risk management. The randomized design will enable estimation of the causal effect of health insurance through comparison of the changes in outcomes over time across insured and non-insured households.