Public Health in Practice 4 (2022) 100306

Contents lists available at ScienceDirect

Public Health in Practicejournal homepage: www.sciencedirect.com/journal/public-health-in-practiceDiscrepancy of financial burden among elderly visiting a private general
hospital in Phnom Penh, Cambodia: A three-year cross-sectional study
Yurie Kobashi a, *, Khemvitou Sok b, Yoshifumi Hayashi c, d, Hong Chhay a, Masaharu Tsubokura e,
Kimhab Chou f, Nobukazu Hokamura g, Akihiko Ozaki h, Yoshitaka Nishikawa i,
Manabu Okawada jaDepartment of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia
Department of Radiology, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia
Department of Neurosurgery, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, CambodiadDepartment of Neurosurgery, Kitahara International Hospital, Owadamachi, Hachioji, Tokyo, 192-0045, Japane
Department of Internal Medicine, Soma Central Hospital, Soma, Fukushima, 976-0016, Japanf
Department of Medicine, University of Puthisastra, Sangkat Boeung Raing, Phnom Penh, CambodiagDepartment of Gastroenterology, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, CambodiahDepartment of Breast and Thyroid Surgery, Jyoban Hospital of Tokiwa Foundation, Jyobankamiyunagaya, Iwaki, Fukushima, 972-8322, Japani
Department of Health Informatics, Kyoto University School of Public Health, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japanj
Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodiabc

A R T I C L E I N F O

A B S T R A C T

Keywords:
Disparity
Aging
Out-of-pocket payment
Cambodia

Objectives: This study aims to clarify the financial burden of health on the elderly. Out-of-pocket payment (OOPP)
in a major private general hospital in Phnom Penh was considered an indicator of financial burden.
Study design: This study is a three-year cross-sectional study.
Methods: To investigate the characteristics of patients who visited the Sunrise Japan Hospital (SJH), their data
were obtained from the electronic reception database.
Results: A total of 119,938 patients who visited SJH from January 2017 to September 2019 were included. The
median age (25th, 75th centiles) was 52 years (36, 66) and 38.31% of patients were aged over 60 years. The
OOPP median (25th, 75th centiles was 73.78 USD (32, 161.89). The median OOPP was the lowest in the 20s andhighest in the 90s. The OOPP of an emergency patient was the highest in the consultation classifications.
Conclusions: The need to raise public awareness regarding the financial burden on the elderly is becoming
increasingly urgent. It is vital to establish a social system to prevent the medical catastrophes.

1. Introduction
Health equity is crucial on ethical grounds and to prevent negativesocial and economic consequences on a national scale [1]. Healthcare
disparity is thought to emerge due to a weak health system and indi­vidual factors: race, sex, sexual identity, age, disability, socioeconomic
status, geographic location, environmental barriers, and stigmatization;[1,2]. Notably, increasing the disease burden among the elderly is a
crucial result of increasing health disparity [3]. World Health Organi­zation (WHO) promotes the development of health policies and thedelivery of quality health services covering the elderly of all economic
statuses without them having to face a financial catastrophe [3].

Nonetheless, there is a need to fill the current gap, specifically regarding
the financial burden of the elderly. Thus, reducing it to decrease
healthcare disparity is a vital public health issue.
The social environment and security system of the elderly have been
fostered in a developed country that has extensively experienced pop­
ulation aging to reduce their medical care burden. Specifically, medicalcare requires affordable access to integrated services as the elderly’s
health needs tend to become more chronic and complex [4]. Gaining
insights from population developed countries is useful; however, healthdisparities are different across populations [5]. Therefore, regional andlocal information is needed. Specifically, the aging population is also
severely high in developing countries. It is estimated that one in five

* Corresponding author.
E-mail address: yurie-s@umin.ac.jp (Y. Kobashi).
https://doi.org/10.1016/j.puhip.2022.100306
Received 8 January 2022; Received in revised form 13 July 2022; Accepted 28 July 2022
Available online 4 August 2022
2666-5352/© 2022 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Y. Kobashi et al.

Public Health in Practice 4 (2022) 100306

people will be aged 60 years or older in 2050 [6,7]. Nonetheless, it wasreported that data about the older adults’ health from low-income
countries are sparse [7]. Moreover, blindsided by battling diseases inyouth and middle age, many developing countries are unprepared forthe developments in the next two decades [6]. Regarding the first step, it
is important to acknowledge the widening disparity of financial burden
related to health among the elderly compared with the youth in adeveloping country. Thus, there is an urgent need to gather information
on indicators of the medical financial burden. However, only a few
studies have been conducted in this area [7,8].
Cambodia is classified as a low and middle-income country (LMIC)
by the World Bank [9,10]. However, 16.3 million nationals have wit­
nessed considerable improvements in public health over the last 20
years, with the country achieving most of the health-related Millennium
Development Goals by 2015 [11]. The proportion of the elderly is esti­
mated to increase from 6.5% in 2010 to 11.0% in 2030 [12]. In
Cambodia, a social system called the “equity fund” supports people whohave financial problems; however, there is no social system that caters to
the elderly As in many other developing countries, care and support for
the elderly are left to their families, with 97% relying on their children
for financial support [13]. However, the proportion of elderly who are ina position to receive family support is declining due to the decrease in
the number of children and households living with the children, and theconcentration of young people in urban areas [12]. Besides, a previous
survey reported that 70.1% of the elderly answered that self-assessed
health status was poor or significantly poor indicating that the healthproblems are becoming severe. Therefore, Cambodia is an advantageousarea for conducting studies on the health-related financial burden of theaging population, which would provide vital information to foster theenvironment for aging individuals in other developing countries.
This study aims to clarify the financial burden of health among theelderly to prevent an increase in Cambodia’s health inequality, where
the elderly’s health problems are becoming severe. OOPP in a private
general hospital in Phnom Penh was considered an indicator of healthrelated financial burden.

2.2. Site detail
The Sunrise Japan Hospital (SJH) is an international private general
hospital, which provides various types of medical facilities, including
emergency care, surgery, outpatient treatment, and others, in Phnom
Penh, the capital city of Cambodia. It consists of 14 medical de­partments, including an intensive care unit, and is equipped beds for
inpatients, and various treatment facilities, such as endovascular. SJH,
which opened in 2016, aims to provide Japanese-standard quality
medical care in Cambodia. SJH offers the original three membershipplans: (1) Bronze members are required to pay a $10 annual member­ship fee and are provided with health seminars; (2) Silver members are
required to pay a $120 annual membership fee, are given a discount of
10% of their medical expenditure, and get free health checkup packages;and (3) Gold members require to pay a $320 annual membership fee, aregiven a discount of 20% of their medical expenditure and can avail offree advanced health checkup packages. The total amount includes all
expenditures in SJH such as tests, drugs, and others; however, theannual membership fee is not included in the OOPP in this study.
Most patients are local Cambodian residents whose economic statusranges from middle-income to high-income. The majority are from
Phnom Penh; however, some are from rural areas. SJH is a major private
general hospital in Phnom Penh, run with foreign capital, and widely
visited by residents in Cambodia. Therefore, patients have various
backgrounds, including those with mild to severe diseases, and withaverage-to high-income economic status, making it suitable forresearching OOPP as an indicator of the medical financial burden toclarify the health disparities in each aging group in Cambodia.
2.3. Data used
The data of patients who visited SJH, which is a major general
hospital in Phnom Penh, was investigated from January 2017 to
September 2019. The patient data were obtained from an electronic
reception database comprising essential characteristics, such as age,gender, consultation classification, next plan classification, doctor’sorder amount, patient’s total OOPP, first language, and insurance
availability (Table 1).

2. Method
This study was a retrospective observational study.

2.4. Primary outcome

2.1. Healthcare systems in Cambodia

The primary outcome was set as OOPP, which was used as an indi­cator of the medical financial burden to investigate the disparities be­
tween participants. This study discussed OOPP for outpatients andinpatients. OOPP is part of the health financing landscape in all coun­tries [17]. There is a robust correlation between OOPP levels and thetwo indicators: the incidence of catastrophic and impoverishing healthexpenditures currently used to monitor how well a health system isperforming regarding financial protection [17]. Moreover, OOPP wasused for the research on the inequality of financial burden among theelderly [18]. We defined the aging population as over 59 years.

Cambodia has a regulated public and an unregulated private healthsector. A referral system has been developed among public hospitals andfacilities (e.g., provincial hospitals and health centers), but it has notbeen adopted in private hospitals [14]. Public hospitals and healthcenters are required for each district and are dependent on the numberof residents, while private hospitals are concentrated in urban areas[15]. Recently, the government focused on improving the public sector
to enhance residents’ health and reduce health disparity. Specifically,
health equity funds (HEFs) cover health costs for poor people. The poor
living below the national poverty line are protected by HEFs; the HEFs
coverage was approximately 90% in 2014 [10]. Moreover, employees
are widely covered by health insurance. While these systems work for
public hospitals, the health expenditure in private hospitals is not
generally covered by insurance. However, due to the high quality of
medical care in private hospitals, people—specifically wealthier indi­viduals—tend to prefer to go to these hospitals even though medical
costs are higher. Therefore, it is essential to investigate OOPP in private
hospitals. The OOPP per person in Cambodia in 2017 was 49.60 USD[16]. The ratio of individual health expenditure to total health expen­
diture in the private sector is 61.13%, considerably higher than 23.80%
in the public sector [16].

2.5. Analysis
First, the age distribution was shown to clarify the patients’ char­acteristics. Next, OOPP in each group was descriptively analyzed toclarify the differences. After a Kruskal-Wallis H test, the Steel-Dwass test
was performed to statistically analyze the difference in the mean valueof OOPP for each group to determine which group had a significant
difference.
The OOPP by gender was figured for each of the three age groups (19years and under, 20 to 59, 60 and over), and the Wilcoxon rank-sum test
was performed for statistical analysis of the mean value of OOPP bygender. Next, OOPP by the consultation and the next plan classifications
for each age group (19 years and under, 20 to 59, 60 and over) were
described using figures, and the Steel-Dwass test after a Kruskal-Wallis H
2

Y. Kobashi et al.

Public Health in Practice 4 (2022) 100306

test was performed for the statistical analysis of the difference in themean value of OOPP by consultation classification for each group to
examine which had a significant difference.
A statistically significant p-value was set at 0.05. STATA IC (Light­
stone, Texas USA, version 15) was used for statistical analysis. As
numeric data was not normally distributed, we used median to sum­
marize the data. All procedures were conducted according to the
STROBE guidelines. The National Ethics Committee for Health Researchin Cambodia approved all the experimental protocols (Ethics Commit­
tee, ID: 079NECHR). Individual informed consent was waived by theCommittee because the opt-out consent process was used.

Table 1
Participants’ characteristics (N = 119,877).
Gender (n [%])
Male
Age (median [25th, 75th centiles]) (years)
Consultation classification (n [%])First visit
Health check up
Emergency
RevisitExam only
Rehabilitation
Vaccination
Medicine only
Other and Unknown
Language (n [%])
Cambodia
Japanese
EnglishChineseUnknown
Member ship status
BronzeSilverGold
Staff
Staff family
Unknown
Insurance (n [%])
Yes
No
Order amount by doctor (median [25th, 75th centiles])(USD)
Out of pocket payment (median [25th, 75th centiles])(USD)
Next plan classification (n [%])
Consultation finish
Revisit for medicine
Revisit for consultation
Admission
Transfer
Unknown

57,683 (48.12)
52.00 (36.00,
66.00)
28,178 (23.51)
13,473 (11.24)
7517 (6.27)
45,366 (37.84)
2568 (2.14)
8667 (7.23)
1538 (1.28)
6520 (5.44)
6050 (5.05)

3. Result
The demographic characteristics of the participants are shown in
Table 1. A total of 119,938 patients who visited SJH from January 2017
to September 2019 were included Of these, 48.12% were male, and the
median age (25th, 75th centiles) was 52 years (36, 66). The most sub­stantial proportion in consultation classification was “Revisit” (37.84%),
and that in the next plan classification was “Consultation finish”(37.69%). Approximately 90% spoke the Khmer (Cambodian) language;
this proportion was similar to the fact that approximately 90% of
Cambodian residents and approximately 10% of foreigners comprise thetotal population. Only 2% of the patients used insurance, and the OOPP
median (25th, 75th centiles] was 73.78 USD.
Fig. 1 shows the patients’ age distribution. The line shows the pop­
ulation pyramid in Cambodia in 2018. The proportions of 0–19 years,
20–59 years old, and 60 years and above were 8.22%, 53.47%, and38.31%, respectively. The population decreasing Notch was admitted
around the 40s, affected by the severe war under the Khmer Rouge.
Supplemental Fig. 1 shows the age distribution of each consultation
classification, and Supplemental Fig. 2 shows the age distribution ofeach next plan classification.
Fig. 2 shows the sequential change in the number of participants ineach age group. The median age in years (median [25th, 75th centiles])in each three-month period is 57 (41, 69), 59 (45, 70), 58 (41,70), and58 (42, 69) in 2017; 53 (38, 67), 52 (36, 66), 51 (36, 66), and 51 (35, 66)
in 2018; and 51 (34, 65), 48 (31, 64), and 49 (32, 64) in 2019. The
proportion of elderly people aged 60 years and above was 45.66% for
the first three months of 2017. However, this decreased to 32.41% in thelast three months of 2019. Supplemental Fig. 3 shows the sequential

108,439 (90.46)3236 (2.70)
2077 (1.73)
1174 (0.98)
4951 (4.13)
74,580 (62.21)
15,072 (12.57)
21,797 (18.18)
3491 (2.91)
3953 (3.30)
984 (0.82)
2395 (2.00)
117,482 (98.00)
107.93 (52.04,
196.3)
73.78 (32.00,
161.89)45,178 (37.69)
6128 (5.11)
36,319 (30.30)
2081 (1.74)
117 (0.10)
30,054 (25.07)

Fig. 1. Age distribution of patients in Sunrise Japan Hospital Phnom Penh (%) and population pyramid in Cambodia in 2018.
The blue and pink lines showed the distribution of the entier population in Cambodia in 2018. The Notch showed the decrease in population under the Khmer Rouge
between 1974 and 1979.
3

Y. Kobashi et al.

Public Health in Practice 4 (2022) 100306

Fig. 2. The number of patients in each age group every three months.

change in the number of participants in each consultation classification.
OOPP for each age, gender, consultation classification, and next planclassification is shown in Table 2. OOPP of those aged over 60 years washigher. The OOPP of an emergency patient was the highest of all con­sultations. OOPP of those who needed admission was the highest of allnext plan classifications.
Fig. 3 shows the OOPP for every 10-year age group. A Kruskal-Wallis
H test confirmed a statistically significant difference in the average valueof OOPP (USD) in each classification (p < 0.01). There were no signif­
icant differences between the teens and the 50s age group (p = 0.3716)
and between the 80s and the 90s age groups (p = 0.0920) with the SteelDwass test. In contrast, a significant difference was observed between allother age groups (p < 0.01) with the Steel-Dwass test. The median OOPP
was the lowest in the 20s age group and highest in the 90s.
Fig. 4-a shows the OOPP by gender for each of the three age groups(19 years and under, 20 to 59, and 60 and over). A significant difference
was observed in the 20–59 years age group with the Wilcoxson rank-sum
test (p < 0.01, higher in males). No significant difference was observedin the other age groups.
Fig. 4-b shows the OOPP by consultation classification for the threeFig. 3. Out-of-pocket payment (USD) by every age group (10-year intervals).

age groups (19 years and under, 20 to 59, 60 and over). A significant
difference was observed in all age groups with the Steel-Dwass test (p <0.001).
Fig. 4-c shows the OOPP by the next plan classification for each of theage groups (19 years and under, 20 to 59, 60 and over). A significant
difference was observed among all age groups with the Steel-Dwass test
(p < 0.001).
Moreover, the median ages were higher in the revisit population,
emergency department, rehabilitation department, and admission
department (S Fig. 1, S Fig. 2).

Table 2Out of pocket payment of each group.
Out of pocket payment (median [25th, 75th centiles])(USD)
GenderMale
75.30 (32.00, 168.64)
Female73.04 (32.00, 157.50)
Age (years)
0–19
70.54 (44.17, 117.61)
20–59
65.00 (10.00, 144.66)
60+
96.66 (40.00, 197.48)
Consultation classification
First visit
121.94 (71.16, 198.09)
Health-check up
10.00 (0.00, 50.00)
Emergency
206.16 (92.00, 349.52)
Revisit101.16 (54.88, 184.70)
Exam only
21.58 (0.00, 80.00)
Rehabilitation
40.00 (32.00, 40.00)
Vaccination
17.24 (0.00, 50.7)
Medicine only
23.19 (8.34, 54.04)
Next plan classification
Consultation finish
76.70 (37.70, 147.88)
Revisit for medicine
115.36 (73.43, 184.10)
Revisit for125.72 (64.95, 213.00)
consultation
Admission
342.19 (202.70, 494.68)
Transfer
274.04 (149.25, 427.90)

4. Discussion
To clarify the health disparity in developing countries, it is crucial toresearch OOPP as an indicator of the financial burden related to health.
This study’s novelty is the provision of detailed OOPP information ofpatients visiting a private general hospital in Cambodia.
In Cambodia, the median age of the national population was 25.7
years in 2019, and the proportion of elderly, that is over 60 years, wasapproximately 10%, which is relatively low. Nonetheless, 38.31% of
patients who visited SJH were over 60 years. In Japan, one of thedeveloped countries in East Asia, approximately half of the outpatientsin 2017 were elderly people aged over 64 years [19]. The proportion of
the elderly visiting SJH is low compared to their proportion in Japan.
4

Y. Kobashi et al.

Public Health in Practice 4 (2022) 100306

patients over 60 years. A 2007 survey showed that health expenditure
per year of people aged over 65 years was more than double that of otherage groups in Cambodia [8]. The OOPP per capita per year was 224
rieles among those aged over 64 years and 103 rieles among those aged
between 45 and 64 years in 2007 [8]. The same trend was observed inthis study. Moreover, it is reported that the proportion of OOPP of theelderly tends to be higher in the low economic status group. To prevent
personal catastrophe caused by OOPP for aging people and improvehealth disparities, further field research is required to identify the in­dividual problems among aging people. It is vital to foster a social sys­
tem that guarantees that the medical expenses of the elderly is shared by
the individuals and the social system.
The fact that OOPP is associated with the consultation classificationor the next plan classification is notable in discussing the prevention of
personal catastrophe due to medical expenses. In this study, it wasparticularly high among emergency patients and those who needed to be
admitted. In Cambodia, the incidence of medical catastrophes caused by
OOPP in health expenditure was approximately 12% in 2007 and 6% in
2013, higher than in other Southeast Asian countries [8].
Medical-related financial catastrophes are a crucial problem even indeveloped countries. For instance, to prevent such catastrophes, ahigh-cost medical expense benefit system (eligibility certificate forceiling-amount application) has been put in place in Japan. It is crucial
to discuss social support for medical expenses, when medical expenses
become extremely high, not only considering age and income, but alsoeach individual situation.
SJH, a private general hospital in the capital of Cambodia, is favoredby residents. The number of patients increased approximately 3.5 times
between the first three months in 2017 and the last three months in
2019, and the area coverage expanded to rural areas, specifically in thefirst year after the opening (data not shown). Approximately 90% of
patients’ first language is the Khmer language. This could be because thequality of medical care, the education level of staff, and the degree of
hospitality are high. According to previous research, the growth ofprivate sectors negatively impacted universal health coverage (UHC)and increased health disparities in Cambodia [22]. However, to achieve
UHC and improve health disparity, it is necessary to reduce the gap in an
efficient way, such as by building a cooperative relationship for sharing
knowledge and technology between private and public hospitals, andbuilding a system that allows residents of all economic statuses to see
doctors in private hospitals if necessary rather than restricting to theprivate sector.
When interpreting the findings, several limitations should beconsidered. First, this study is a private single-center study; hence,
consultation bias should be considered. According to previous studies,
the poor elderly in rural areas are mainly directed to the Health Center,
which covers poor residents [13], while SJH mainly caters to thewealthy elderly. Therefore, this study might not reflect the actual situ­
ation in Cambodia. Moreover, information about social status, economic
status, and family status was not obtained. In Cambodia, the majority ofthe elderly rely on their children for at least some financial support [13];thus, family status has a great influence on patient consultations.
Moreover, we could not capture expenditure beyond the SJH system. In
addition, we did not have the data of individual expenditure in a year.
We consider to accumulate suggested data to assess the representative of
actual health expenditure. Finally, we included only SJH’s data; thus,
further study is required including data on public hospitals as well. The
information on the private hospital was limited compared to that of the
public hospital in Cambodia. Despite these limitations, this study, for the
first time, could provide detailed information on OOPP in a private
hospital in Cambodia and will be useful for the discussion on reducing
the gap in health inequality. Furthermore, to clarify the disparity of the
population in Cambodia, the OOPP survey of public hospitals and thecomparison between public hospitals and private hospitals should beconsidered in the future.

Fig. 4. Out-of-pocket payment (USD) for three age groups (0–19 age group,
20–59 age group, and over 60 age group). (a) by gender (b) by consultation
classification (c) by next plan classification.

There is no public social security system specialized for the elderly,
however, population aging has increased dramatically in recent years[20]. A previous survey reported that approximately 50% of individuals
over 60 years and approximately 80% over 70 years depend on theirchildren for financial support. Therefore, many elderly people withfinancial problems do not visit doctors [21]. Their financial burden isincreasing, and there is an urgent need to raise public awarenessregarding this.
The OOPP of patients who visit private general hospitals in
Cambodia has increased with age. The OOPP of each consultation
classification and next plan classification were significantly high among5

Y. Kobashi et al.

Public Health in Practice 4 (2022) 100306

5. Conclusion

equity, Gerontol. 56 (Suppl 2) (2016) S178–S193, https://doi.org/10.1093/
geront/gnw034.
[4] World Health Organization Department of Ageing and Life Course, Global strategy
and action plan on ageing and health (2016 - 2020). https://www.who.int/publi
cations/i/item/9789241513500, 2016. (Accessed 10 December 2020).
[5] World Health Organizations, 10 facts on health inequities and their causes.
https://www.who.int/features/factfiles/health_inequities/en/, 2017. (Accessed 10
December 2020).
[6] P. Shetty, Grey matter: ageing in developing countries, Lancet 379 (2012)
1285–1287, https://doi.org/10.1016/s0140-6736(12)60541-8.
[7] S. Chatterji, J. Byles, D. Cutler, T. Seeman, E. Verdes, Health, functioning, anddisability in older adults present status and future implications, Lancet 385 (2015)
563–575, https://doi.org/10.1016/s0140-6736(14)61462-8.
[8] A.I.D. Australian, ADB, Impact of out-of-pocket expenditures on families andbarriers to use of maternal and child health services in Cambodia. https://www.
adb.org/sites/default/files/publication/30151/impact-out-pocket-spending-cam
bodia.pdf, 2007. (Accessed 10 December 2020).
[9] Ministry of Planning and Ministry of Health, Demographic and health survey 2014.
https://dhsprogram.com/pubs/pdf/fr312/fr312.pdf, 2014. (Accessed 10
December 2020).
[10] Bureau of Health Economics and Financing, Annual health financing report 2015.
https://www.dfat.gov.au/sites/default/files/cambodia-ministry-of-health-annualhealth-financing-report-2014.pdf, 2015. (Accessed 10 December 2020).
[11] World Health Organization, Cambodia–WHO, country cooperation strategy
2016–2020. https://apps.who.int/iris/bitstream/handle/10665/246102/WPRO_2016_DPM_004_eng.pdf?sequence=1&isAllowed=y;
2016, 2016. (Accessed 10 December 2020).
[12] Royal Government of Cambodia, National ageing policy 2017-2030. https://cambodia.unfpa.org/sites/default/files/pub-pdf/NAP%202017-2030_%20Fin
al_English-Printed.pdf, 2017. (Accessed 10 December 2020).
[13] National Institute of Social Affars, Needs & challenges of older people, 2019.
https://voice.global/publications/needs-challenges-of-older-people-in-cambodia-a-research-report/, 2019. (Accessed 10 December 2020).
[14] Y. Kobashi, Slaiman N. ChouK, P. Neun, HayashiY, M. Tsubokura, M. Okawada,
Improving the rural-urban balance in Cambodia’s health services, Int. J. HealthPol. Manag. (2020), https://doi.org/10.34172/ijhpm.2020.136.
[15] World Health Organization, Success factors for women’s and children’s health.
https://apps.who.int/iris/bitstream/handle/10665/254481/9789241509008-eng.
pdf?sequence=1&isAllowed=y; 2015, 2015. (Accessed 10 December 2020).
[16] K. Dalal, O. Aremu, Fairness of utilizing health care facilities and out-of-pocket
payment burden: evidence from Cambodia, J. Biosoc. Sci. 45 (2013) 345–357,
https://doi.org/10.1017/s0021932012000521.
[17] World Health Organization, Out-of-pocket payments, user fees and catastrophic
expenditure. https://www.who.int/health_financing/topics/financial-protection/out-of-pocket-payments/en/, 2020.
[18] R. Strasser, S.M. Kam, S.M. Regalado, Rural health care access and policy indeveloping countries, Annu. Rev. Publ. Health 37 (2016) 395–412, https://doi.
org/10.1146/annurev-publhealth-032315-021507.
[19] K. Dalal, O. Aremu, G. Ussatayeva, A. Biswas, Out-of-pocket health expenditureand fairness in utilization of health care facilities in Cambodia in 2005 and 2010,
F1000Research 6 (2017) 2066, https://doi.org/10.12688/f1000research.12801.1.
[20] Ministry of Planning, Aging and migration in Cambodia. 2013. https://cambodia.
unfpa.org/en/node/11126, 2013.
[21] J. Knodel, K.S. Kim, Z. Zimmer, S. Puch, Older persons in Cambodia: a profile fromthe 2004 survey of elderly. http://globalag.igc.org/elderrights/world/cambodiael
derly.pdf, 2005. (Accessed 10 December 2020).
[22] A.D. Asante, P. Ir, B. Jacobs, L. Supon, M. Liverani, A. Hayen, et al., Who benefits
from healthcare spending in Cambodia? Evidence for a universal health coveragepolicy, Health policy Plan 34 (2019) i4–i13, https://doi.org/10.1093/heapol/
czz011.

The OOPP, an indicator of the financial burden among patients, ishigher among the elderly in SJH—a major private general hospital
located in the capital of Cambodia. To improve the health disparity andachieve UHC in Cambodia, it is crucial to establish a social security
system to support the extremely high OOPP for health by the society sothat the burden does not solely fall on the individuals.
Funding
This research did not receive any specific grant from any funding
agency in the public, commercial, or non-profit sector.
Author contributions
YK had full access to the data and had final responsibility for anal­
ysis. All the authors made a substantial contribution to this research. YK,MT, OA, YN contributed to the writing the paper, while all members
contributed to the study design, data collection, and coordination withlocal stakeholders.
Declaration of interest
The authors did not declare any competing interest and persocal
relationships which influenced on the present work.
Acknowledgement
We would like to thank Mr. Keiya Kamata and Mr. Takahiro Yoshimi
and all staff members the Sunrise Japan Hospital, Phnom Penh forproviding important data for this research.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.puhip.2022.100306.
References[1] T.C. Veinot, H. Mitchell, J.S. Ancker, Good intentions are not enough: how
informatics interventions can worsen inequality, JAMIA 25 (2018) 1080–1088,
https://doi.org/10.1093/jamia/ocy052.
[2] The U.S. Department of Health and Human Services, Healthy People.gov. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities,
2018. (Accessed 10 December 2020).
[3] R. Sadana, E. Blas, S. Budhwani, T. Koller, G. Paraje, Healthy ageing: raisingawareness of inequalities, determinants, and what could be done to improve health6