The literature indicates that a large proportion of Cambodians borrow to meet the costs of health care. Access to formal credit suppliers, especially for the poor, is limited. Hence, they rely on loans with high interest rates from informal creditors. Consequently, many become heavily indebted with considerable potential for further impoverishment. A major reason for these borrowing practices is the limited cash flow in the Cambodian society. Prasso
 pointed out that in 2000 the amount of money in circulation in the country stood at US$28 per person only. Historical reference is also made to the fact that French colonisers tried to tackle perverse borrowing practices by money lenders to peasants at annual interest rates of 200–300%. Current interest rates are lower though still enormous. In neighbouring Vietnam by contrast, monthly interest rates by private money lenders were found to be only 1.8% on average
Many authors such as McIntyre et al. and Storeng et al. report on perverse effects of borrowing from money lenders to pay for health care related costs but do not mention interest rates associated with such loans. Since interest rates increase the amount of debt to be repaid, effects of such loans will last longer than for interest-free credit. Loans from money lenders are taken out because of the limited time frame during which health providers have to be paid. Borrowing from money lenders is also mostly practiced by people with limited social resources such as reciprocity between households or support from community organizations
[2, 31]. Social resources were reported to be one of the most important sources for quickly mobilising money although the poor tend to be the least likely to have access to them
. In Cambodia, the poorest have the least assets that can be quickly liquidated in tandem with limited social resources. As a result they will have to resort to money lenders and pay the highest interest rates because of lack of collateral.
As pointed out by Storeng and colleagues
, a vicious cycle is created whereby loans are obtained to pay off interest of previous loans and assets are sold to pay off debt, which in turn further reduces productivity and thus income and ability to pay. But few studies have been done to assess the long term effects of loans for paying for health care on household livelihood
. The negative consequences of financial stress on mental health in low-income countries are increasingly being documented
[33, 34]. In India, for example, indebtedness is a major cause of suicide amongst farmers
. It is thus not unreasonable to advocate for longitudinal studies on coping strategies resulting from borrowing, especially with interest, to assess the long-term effects on household economies but also on health itself. Such studies could be done per type of informal credit and participants should be carefully selected since many resort to more than one credit source.
Strategies should be developed to limit borrowing with interest to pay for health care. One option could be to attract the population, especially the poor, to public health providers where costs are considerably lower than in the private sector
. A common strategy to attract patients to public health providers is to extend exemptions from user fees for certain population groups such as women and children, or for prevalent diseases of which control is a public good, such as tuberculosis
. Several authors have pointed out that free health care alone is not sufficient and that it also requires exemption initiatives to subsidise transport costs
[37, 38]. In Cambodia, HEF have been developed to attract the poor to exempted health services. They are extended nationwide as they greatly improve financial access
. However, the vast majority of beneficiaries of such schemes still first seek health care in the private sector where they incur most expenses for treating the condition
[12, 13]. Accordingly, at least in Cambodia, HEF unaccompanied by additional interventions are not the panacea to overcoming excessive borrowing costs from money lenders due to treatment seeking. Although HEF were not found to reduce the likelihood of incurring health-related debt, coverage by a HEF did reduce the amount of health-related debt by 25-28%
. More information is thus required on the determinants of care seeking to be able to attract people to the public sector when sick.
A more comprehensive approach than fee waivers or user fee exemptions is required, including interventions outside the health sector
[31, 41]. As such there was a call for more research on alternative health care financing strategies and mechanisms to enable improved coping with the costs of illness through reinforcement of existing social networks
. However, as seen above, the poor are least likely to access such networks. Nevertheless, with the emergence of chronic diseases and associated requirements for lifelong treatments in a financially constrained environment like Cambodia
, the need for such community financing becomes more prominent
. Studies are therefore required to elicit existing barriers to social inclusion and means to overcome them.
Microfinance institutions have been advanced as a potential solution and they often go hand in hand with health interventions
 to mitigate health problems and the need to spend money on related treatments. However, it has been reported from Bangladesh that the poorest women refused to participate in programs based on microcredit because of their aversion for the stress associated with loan repayments
[45, 46]. Others consider microfinance an effective risk mitigation strategy that enables borrowers to cope with sudden costs such as those associated with health care seeking
. The figures cited above indicate that the MFIs insufficiently penetrate rural Cambodia. Therefore, further research is needed to investigate whether extending microcredit to the poor can be used as a means to avert borrowing from informal creditors for health care expenses, and how this might be done.
If MFIs would be pursued as an option outside the health sector, additional interventions for the poorest should be implemented, similar to the experience in Bangladesh, including: provision of income generating asset grants, subsistence allowance until asset grants generate income, skills development training, social awareness development
[41, 45]. Alternatively, a potentially more powerful intervention for the poorest may be the provision of non-conditional cash transfers
[30, 34]. Meaningful research in Cambodia would then relate to identifying the most comprehensive approach to avoid or reduce the extent of borrowing from money lenders for health related expenses by the poor. This could consist of a combination of HEF and non-health sector interventions.
However, it is imperative that countries like Cambodia progress towards the development of regulatory interventions for the credit market. A package of basic consumer protection rights tailored to the problems faced by the poor in accessing money should be implemented