Health Care for Expatriates in Cambodia

Published in AsiaLIFE Phnom Penh April 2007

A thriving health industry in Phnom Penh no longer warrants an urgent plane ticket out of the country for routine care. To boot, medical care is easy on the pocket. But while most practitioners aspire to the western model of care, the system is far from user-friendly and choosing a practitioner is not a simple task. On top of the usual precautions are considerations to a developing country’s medical environment. This is a brief guide to navigating the (western medicine) landscape in Cambodia, with tips for routine and emergency care, and a short look at medical insurance.

Where to find a good doctor?
• Go public or private? The public sector is much maligned, for good reason (though to give them credit if alternatives aren't available, such as in the provinces, their capacity has much improved for simple procedures). The national hospitals and programmes (HIV/AIDS, TB, malaria, immunisation) receives dedicated funding and so has better services than in the rest of the sector. In response to market demand given the weak public health infrastructure, the private sector is booming, offering much better care.

• Go local or foreign? With medical (and other) degrees an easy purchase in Cambodia, the natural reaction is to avoid all Khmer facilities. But this is a dangerous yardstick. There are many excellent Khmer clinicians, charging significantly less than foreign colleagues for equal or even better quality care. Likewise are some Western practitioners causing more harm than good. A foreign doctor / foreign-run facility is not assurance of quality care.

• Seek endorsements from friends and check for medical certificates during the visit. The accreditation system is at infancy; enforcement capacity of the Ministry of Health (MOH) is inadequate, with cases of illegal practices simply referred to the police (--uhm, well, uhm....). In absence of a functioning regulatory mechanism, patients need to conduct their own quality survey. With views on health care vast and varied don’t stop at one person's professed experiences. And keep in mind that information from embassies and government websites may be biased in favor of that country's interests over the patients’. Listed below are personal recommendations based on positive outcomes after consultations.

• Obtain referrals to competent technicians and labs from a reliable practitioner. Having sophisticated equipment is not a guarantee that it is operated properly or that results are accurately interpreted. Patients have left consultations where technicians did not catch broken bones! The same holds true for laboratories.

• Medicines should be purchased at facilities known to dispense legitimate drugs procured from reliable suppliers. On the national level is the problem of quality control. With the increasingly sophisticated counterfeit industry small measures such as checking for proper storage, expiration dates and packaging (don’t buy drugs in unmarked plastic bags!) only go so far. Even holograms can be counterfeited— and testing is only done at laboratories through the MOH. At the pharmacy level, be aware that even in licensed facilities bearing the green cross, it is not necessarily a trained pharmacist at the counter. This is not the place to seek medication advice!

• See the specialist and not the temp. In some clinics the higher the qualifications the higher the fees. Similarly, higher consultation fees are charged to see Westerners and foreign-trained doctors.

• Fee structures should be disclosed before beginning any consultation to avoid surprises.

• Language presents a challenge and patients should be able to communicate with the practitioner. Multi-lingual skills is good, but technical jargon is another level of competency altogether. (French is the language of the medical profession here.)

Tips for medical emergencies
As far as accidents go, technically victims are taken to one of the national hospitals specialising in trauma care, such as Calmette or Kossamak hospitals. But as a matter of practicality it’s anyone’s guess what the emergency response will be. Some private clinics make arrangements with the police so that ambulances take accident victims to that facility, where treatment is of low quality and expensive. One Khmer insurance agent’s advice is to stay conscious long enough to ensure being taken to the facility of choice, to prevent theft of personal effects, and to summon a friend or colleague. While this certainly is not reassuring, there’s a lesson to be had: prepare for the possibility of an accident.

• Identify in-country healthcare resources in advance of a medical emergency. Having these numbers handy will shave precious time in seeking advice and referral during a crisis.

• Exchange contacts lists with a trusted circle of friends familiar with each other’s routines and schedule. This list should contain your general practitioner and preferred hospital for emergencies, special medical conditions, insurance information and the Embassy/Consulate numbers. (speaking of emergencies, is there an internationally agreed system for labeling priority contacts on mobile phones??)

• Carry this list on a small card in Khmer in your wallet/pocketbook.

• Identify potential donors with compatible blood types in case of emergency. The blood bank has procedures in place to keep the blood supply safe, but it being in perpetual short supply it is not fail-safe. Without a local medical advocate minding your care, foreigners are better off at the following four facilities with regard to blood supply.

• Emergency medicine options are narrowed to the national hospitals specializing in trauma (ie. semi-private Calmette and government-run Kossamak) and foreign-run clinics (ie. French/Khmer-run Naga Clinic and American-run SOS). An adequate comparison is beyond scope of this article—even those in health and medicine have conflicting views. Recent assessments of the national hospitals by expert evaluators report that Calmette and Kossamak both receive intensive foreign technical assistance and mentoring, and are both equipped with excellent trauma surgeons and equipment. Their capacity to administer appropriate care has significantly improved in the past decade.

Options for medical coverage
Given the low cost of medical care, many don't find health insurance necessary. For those seeking peace of mind given that emergency evacuation and hospitalization can run into the tens or even hundred thousand dollars, the Cambodian market has several private brokers such as Asia Insurance, Forte Insurance and Infinity Financial Solutions.

They represent the more popular insurance companies such as Bupa, Goodhealth, April, William Russell, Aviva. Plans range from coverage of only accident/trauma care to the gamut of long-term medical needs. Other sources of info are credit cards, professional societies, alumni associations and travel guide websites, who often partner with insurance companies to offer reduced rates to clients.

These sample quotes include hospitalization, emergency medical evacuation and repatriation services for a 33-year-old female. You aren't limited to brokers in Cambodia. To avoid paying premiums higher than the official published rates, contact insurance companies directly for a quote and they will refer you to a local broker.

• Both Asia Ins. and Infinity represent Goodhealth. The range of plans start at $477 annually with no co-payment with Asia Ins., compared to $1,254 for the same package with Infinity.

• BUPA plans start at $821 annually ($1600 deductible annually) with Asia Ins., with comparatively higher rates for the same packages from Infinity.

• Forte’s Fig Tree Blue plans start at $448 per annum with no co-payment.

Another option are travel assistance packages with 24-hour access to full service coordination of legal, medical or billing issues related to emergencies. For an annual fee, services at affiliated clinics are also provided at the membership rate. American-based companies are listed below.

And for coverage of household staff, the community-based health insurance scheme at the Phnom Penh Municipal Referral Hospital, SKY (Health for Our Families), costs $4.50/person/month.

Everyday precautions
• Have an emergency plan: identify a physician and donor, keep contacts lists updated.

• Keep vaccinations up-to-date. Hepatitis B is a particular worry.

• Road accidents are increasing in Cambodia. It’s a good habit to use seatbelts in the car, or a helmet on the motorbike, both of which will soon be law. Many employers require it, and many insurance plans will be void if the accident victim is not in compliance. Be alert. A useful phrase is "Som, chee yeut yeut" (Please, drive slowly).

• Check for front brakes on motorbikes before using them (are there brake handles in front of the right handlebar, and a brake line down to the brake pads on the front wheel?).

• Using familiar and reliable drivers and motodops can also decrease the probability of accidents.

• Bear in mind that medicine is a business, dangerously more so in a climate lacking a regulatory infrastructure and patient protection mechanisms.

• Do not self-diagnose or self-medicate. The fact that a Cambodian medical office may not resemble those back home in no way makes you more competent than an MD.

And for those unwilling to traverse the medical landscape here, Thailand’s excellent facilities are just a day trip away. Bangkok and Thai Airways both occasionally launch specials in conjunction with the larger medical facilities.

Useful numbers in emergencies by no deliberate order:
Your Embassy: _________

Police hotline (from land line): 117
Foreigner Police: 023-366-841 or 023-720-235 or 012-942484

Fire service (from land line): 118
Fire: 023-722-555 or 012-786693

Ambulance 24 hours (from land line): 119
Ambulance 023-724891

Clinics in Phnom Penh:
Ly Srey Vyna Clinics 023 982 003 or 12-9090988
Liudmila Health Clinic 023-302868 or 012-813318
Somary Clinic 023 99 18 68 ext.8081, 023 99 11 66
Samphop Sophea 012 883 661
Visal Sok Clinic 012 817 794
Tropical and Travellers Medical Clinic 012 898 981
Naga Clinic emergency hotline: 011-811-175 or 023-211-300
SOS emergency hotline: 023-216-911

Laboratories:
Institut Pasteur du Cambodge 023 725 606
NIPH 023 88 29 41
Biomed Lab 023 88 48 89

Pharmacies:
Pharmacie de la Gare: 012-805-908
Naga Pharmacy: 023-212-324
U-Care 023-222399

Insurance brokers:
Asia Insurance Ravuth L. Phann 012 239 222
Forte Insurance Maak Vuthy
Infinity Financial Ouk Sameath 012 644 111
SKY Insurance 092 74 60 04

Travel medical and emergency assistance
International SOS: www.internationalsos.com.
MEDEX travel assistance services: www.medexassist.com
International Association for Medical Assistance to Travelers: www.iamat.org.