Cambodia's Ministry of Health (MoH) is in the process of assessing an official "user-pays" system for the Cambodian health sector according to Director General of Health Eng Huot.
The MoH is considering a World Health Organization (WHO) funded evaluation report on the results of a four-year pilot project on user fees.
"We would like to promote and increase [a user fees system]," Huot said, emphasizing that the contents and recommendations of the report were still under official consideration. "In all the countries of the world hospitals are not free so I think we need to have some participation from the people in [paying for] their own health".
Huot added that any user fee system introduced by the government would provide a built-in mechanism to give access to the poor.
Under-the-table 'service fees' have long been a condition of treatment by staff at hospitals and health clinics throughout Cambodia. The system of staff gratuities is so endemic that patients often find themselves negotiating fees while on the operating table or mid-way through childbirth while others flee hospital under the cover of darkness to avoid high fees.
The experience of Lay Kimly, 27, at Phnom Penh's Calmette Hospital is all too familiar for many Cambodians.
In the early hours of Jan 12 Kimly arrived in the Emergency ward of Calmette to find her husband bloody but unattended on the floor after a traffic accident had left him with two broken legs. Over the next few hours she was repeatedly pressured for money to facilitate her husband's treatment.
"A health worker asked me for $30 and about half an hour later they asked me for $30 more," she said. "An hour after they asked for an additional $30, then 50,000 riels, then $15 and finally 8,000 riels in 'bonuses' to hospital staff so I'd get their attention."
When hospital staff demanded $1,500 for the operation Kimly took her husband home.
Despite the fact that Article 72 of the Cambodian Constitution guarantees free health care for the poor, health costs remain a major source of landlessness and impoverishment in Cambodia with 46% of landlessness caused by health cost indebtedness according to a recently-released survey by Oxfam UK.
"People will pay for health care but we don't necessarily know where that money is coming from", said Dr Aye Aye Thwin of WHO.
Individuals pay 82% of health costs in Cambodia, compared with 14% and 4% borne by donors/NGOS and the government respectively.
But for the poorest of the poor, that money all too often comes from selling property or livestock essential to a family's survival.
Recognizing the existence of unofficial fees, WHO and the MoH have taken an 'if you can't beat them join them' approach by piloting the introduction of official fees in approximately 140 health facilities nationwide.
Dr Thwin said the pilot was created in 1997 to control what she described as "rampant" unofficial fees.
"What we have found is that [official fees] contributed a bit to management improvement within the facilities because for the first time they have had to become more customer-focused," she said.
Thwin concedes that the introduction of official fees has yet to eliminate the practice of charging usuriously high unofficial fees in hospitals and clinics and won't do so without adequate regulation.
"In the better case scenarios it has [reduced unofficial fees] because the management has been good... but in other cases they've continued" said Thwin.
Laurent Ponta, Country Program Manager for Save the Children France (SCF) and member of Medicam's Health Sector Reform think-tank, agrees that patients find a single up-front payment far preferable to the range of hidden charges that now typifies the service in Cambodia.
"It's been proven that when you introduce fees you get a greater rate of utilization," Ponta said.
But Ponta warns that the attraction of the MoH to the program is a perception that it allows the government to shed its own financial responsibilities to national health care.
According to Ponta, raising more money for the national health budget is not as vital as seeing that the money reaches the appropriate destination in the first place.
"The [current] volume of the national health budget is enough to run basic health services in Cambodia" he said. "The problem is that the money doesn't reach the peripheral health structures and the health centers".
As an example Ponta points to the SCF's Kirrivong Operational Health District, which he says has received just 6% of its allocated budget.
In spite of the problem of resource allocation, it appears the MoH sees the fees recovery system as a panacea and has been lobbying NGOs contracted to run medical facilities in the Kingdom to introduce fee systems.
Thwin also highlighted the problem of the gap between the official government health budget and the amount of funds that are actually dispersed, and argues that it won't be possible for the MoH to ever make the system entirely user-funded.
"Even the most successful places are only able to recover 35% to 38% of their operational costs, so you can't expect that it will be a substitute for either government or donor financing" she said.
However, Beat Richner, whose three Kantha Bopha hospitals care for 80% of all hospitalized Cambodian children without charging fees, criticizes the fee paying policy as unrealistic.
"Eighty-five per cent of people from the provinces aren't able to pay one single dollar for health care," he said.
According to Richner Kantha Bopha has neither official nor unofficial fees, something he puts down mainly to staff salaries.
"The first point is with the salary, because with $20 a month no-one can survive. People have to work outside, sell the hospital's medicine's in the market, or take money under the table," he said.
At Kantha Bopha even the cleaners are paid well above the levels of medical staff employed by other MoH facilities. Kantha Bopha doctors receive salaries of $500 a month, more than 20 times what MoH doctors are typically paid.
Under the piloted model, half the revenue raised went to supplement the staff's meager salaries as an incentive to make the fee system work.
While salaries are critical simply paying more will not necessarily improve service according to Dr Thwin, who said the greatest improvements came with community involvement and improved management.
Kimly's husband endured two weeks of ineffective treatment from a kru-Khmer traditional healer before they eventually discovered Takeo Hospital.
"They took care of us first and asked for money later", she said. "[Takeo Hospital] charged 190,000 riel for the operation [less than $50] and gave us free treatment and service."