Tim Kelsall and Seiha Heng

This working paper explores and seeks to explain some of the deep-seated problems of the Cambodian health system, such as under-resourced facilities, underpaid, poorly qualified staff, and a burgeoning private sector.

​Over the past 15 years, Cambodia has made significant strides in expanding effective access to free healthcare for poor people, thanks largely to ‘Health Equity Funds’ (HEFs), a multi-stakeholder health-financing mechanism. HEF operators have helped expand access, incentivise health staff, and lobby on behalf of poor patients.

However, despite their successes, they have been unable convincingly to address some of the deeper-seated problems of the Cambodian health system, such as under-resourced facilities, underpaid, poorly qualified staff, and a burgeoning private sector. This paper explains this state of affairs as a product of Cambodia’s ‘political settlement’, in which relatively successful multi-stakeholder initiatives exist as ‘islands of effectiveness’ in a sea of rent-seeking and patronage. While such islands may currently be the best solution available for poor people, the deeper problems are unlikely to be solved without a shift in the political settlement itself.