Social health protection in Cambodia: Challenges of policy design and implementation

The Government of Cambodia is implementing ambitious reform initiatives to improve the country's social health protection system. In January 2018, it was announced that the Health Equity Fund (HEF), which is fully subsidized by a joint government‐donor initiative for the reimbursement of user fees for the poor at public health facilities, is to be expanded to some segments of informal workers belonging to associations, as well as to commune and village chiefs. Since 2017, the National Social Security Fund (NSSF) has provided social health insurance for formal economy workers in enterprises with eight employees or more. In January 2018, it was expanded to civil servants and all employees regardless of the size of the enterprise. However, this article highlights that the new ambitious reforms are not accompanied by careful planning as regards funding, service delivery, human resources and institutional design. This article therefore aims to examine key policy issues and challenges for Cambodia's ambitious reform of its social health protection system in terms of resource generation, population coverage, strategic purchasing and governance.     

The evolution of the Georgian social protection system since independence: An unclear future despite recent expansion

In the first decade of transition, the Georgian social protection system experienced a major retrenchment as the government struggled to finance welfare provision in the face of massive economic contraction and the near collapse of public institutions. Since 2004, this trend has been reversed, with the economy returning to a fast growth path and public administration improving considerably. Recent reforms, including the notable introduction of universal public health insurance, are welcome steps towards building a modern welfare state. Major challenges still remain, however, especially in relation to the system's limited effect on widespread poverty. Decelerating growth, the lack of strong pro‐welfare actors, and the absence of positive external pull factors may stall or prevent future growth, but the changing nature of the social contract between the people and government, as well as Georgian politicians' growing recognition of the importance of the welfare system for inclusive growth, leaves ample space for optimism.     

The Brazilian pension model: The pending agenda

To achieve national goals defined by the 1988 Brazilian Federal Constitution, cash benefits alone are insufficient in the absence of more robust social services to reduce inequalities and improve social cohesion. The Constitution, albeit of national importance and international significance, has not addressed many institutional and administrative weaknesses in the design of the national pension system. Although coverage has been increased and inequality reduced, these measures are not sufficient. Brazil's ambitions to further develop social policies (and, indeed, to live up to its accorded international status as a social policy leader) may be constrained by an over‐reliance on conditional cash transfers such as those provided under the Bolsa Família programme. Brazil faces a major political‐economy challenge in addressing all these issues because the policy reform process is difficult, and, more importantly, because of the embedded role of vested interests. Moreover, Brazil must tackle these issues in the face of growing fiscal pressures, which could weaken the current political legitimacy of social policy and undermine important recent successes.     

Introduction: Social security and the digital economy – Managing transformation

This special issue of the International Social Security Review considers the multidisciplinary topic of social security and the digital economy. The selected articles that comprise this issue offer a number of varying perspectives on the changing and increasingly complex environment in which social security institutions operate and critically assess not only how social security institutions are likely to be impacted but also how they may respond to the challenges foreseen. Social security institutions do not have control over external factors that can negatively impact the financing and coverage of social security programmes. Nonetheless, with the shift to the digital economy, the task at hand is to manage an unprecedented process of change. Though ensuring service continuity is the primary concern, also required are improvements in service delivery for all stakeholders and the development of responses to meet new operational challenges and emerging coverage risks. Particularly in more developed economies, the socio‐economic challenges that accompany the labour market changes associated with the transition to the digital economy are often characterized as presenting a risk of growing precarity. Regardless, the global policy goal remains one of ensuring sustainable and adequate social security protection for all.     

Access to social protection among people with disabilities: Evidence from Viet Nam

Although people with disabilities are frequently targeted as key beneficiaries of social protection, little is known on their access to existing programmes. This study uses mixed methods to explore participation in disability‐targeted and non‐targeted social protection programmes in Viet Nam, particularly in the district of Cam Le. In this district, social assistance and health insurance coverage among people with disabilities was 53 per cent and 96 per cent respectively. However, few accessed employment‐linked social insurance and other disability‐targeted benefits (e.g. vocational training, transportation discounts). Factors affecting access included the accessibility of the application process, disability assessment procedures, awareness and the perceived utility of programmes, and attitudes on disability and social protection.     

The sustainability of China’s Urban Employees’ Pension Programme: A case of getting old before getting rich?

This article examines the sustainability of China’s Urban Employees’ Pension Programme – the main component in China’s overall old‐age support system. It looks at the sustainability of the programme generally and, in particular, at case studies of two areas (Tianjin municipality and Guangxi province) to highlight both the extent of regional variations and the common challenges facing Chinese policy‐makers. It discusses a number of key issues that should assist policy‐makers to address the challenge of population ageing. It concludes that the challenge facing China is no more severe than that already faced by other countries in Europe and Asia. Moreover, the ageing of the population is not uniform across the regions of China. Consequently, those areas where the demographic shift is more advanced will provide some opportunity for policy experimentation. Given the experience to date of slow progress on various aspects of pension policy reform, the article suggests that it seems unlikely that paradigmatic change will be significant. Nonetheless, the study suggests a range of parametric policy measures that China should consider. The challenge facing China’s policy‐makers is to ensure that China gets old and rich at the same time.     

Financing social security out of contributions: About origins,present discussions and prospects of a success story

In writing the overture to an issue on contribution financed social security one cannot but speak of Bismarck; it must also address Beveridge who saw contributions, although in their design and role clearly differently from Bismarck, as one core revenue tool to finance his vision. Beveridge attributed to the private financial sector a prominent role in securing people against the negative effects on income of shocks and crises, while Bismarck did not. Beveridge's concept, when first published, had, and still has today, the most attractive charm of rigorously satisfying peoples' striving for equitable and inclusive societal solutions. Bismarck's concept intrinsically offers income security only to those who contribute, while the level of protection depends on the level of contributions paid (with the exception of health insurance). In reality, both concepts, where implemented, had to face the realities of socio‐economic and political developments: Beveridge's vision was achieved in respect of access to health services where his proposal, in its predominantly tax‐financed version, has since turned into a worldwide blueprint for health schemes; in its other components, it was not resilient enough to achieve the intended standards and now is replete with means‐tested (poor relief) elements. Bismarck's scheme has proven its potential to achieve “universality”, not necessarily by theoretical design but as a matter of fact, i.e. covering people from cradle to grave (like Beveridgean schemes). With globalization, schemes of both origins have had to face massive neoliberal attacks over the last three decades. Which of the approaches is best able to survive must be left an open question: in the current worldwide context of rapid change, both have weak and strong points, and whether a symbiosis of the two offers the answer to future challenges remains to be seen.     

The regulatory challenge of occupational safety and health in the online platform economy

The online platform economy raises a range of intricate legal questions connected to labour law and social security protection. In particular, the atypical forms of labour relationships used by many online platforms (e.g. multilateral, hyper‐temporary, off‐site, autonomous), often contractually defined as independent contracting, have challenged the application of labour and occupational health and safety law in many countries across the world, as the application of these norms tends to be dependent on the existence of an “employment relationship”. These developments are compounding the general increase in atypical employment, especially as a result of the 2007–08 financial and economic crisis. It has mostly fallen to courts to resolve the disputes between online platforms and their online platform workers, but some European Union (EU) Member States (such as France) have taken specific legal measures in response to these difficulties. Also, the EU‐level as such is becoming increasingly involved, with the Court of Justice’s ruling in the case of Uber providing some guidance on the “employment question”, and a pending legislative initiative on a Directive for Transparent and Predictable Working Conditions which may provide minimum labour protection for online platform workers in the EU. This article analyzes the problem of labour law in the online platform economy and surveys the various responses by courts and policy‐makers across the EU, which may furthermore set the tone for developments outside the EU in this area.     

Expanding economic protection to the elderly in Latin America

This article addresses the reforms introduced in Latin American pension systems that had the aim of increasing coverage beyond formal‐sector workers. For this purpose, fourteen representative regional experiences are analysed using a taxonomy based on features of the cases examined in terms of design, implementation and results. The findings show that, although the reforms share the goal of expanding coverage, there are significant differences deriving from the context in which they were originally designed, their goals, and the capacity available to implement them. The results are not homogeneous, and it is possible to identify some aspects in which policy decisions can lead to better or worse results.     

Social security reforms in Kenya: Towards a workerist or a citizenship‐based system?

With social security provisions in Kenya remaining under‐reported in the more recent literature, this overview covers recent reforms in key areas of the country's social security system. In the health sector and in old‐age pension provision social security is still mainly workerist (biased toward those in formal employment), and attempts to expand coverage have had limited effect only – cash transfer programmes, for instance, have been expanded but in practice they do not universally cover the entitled categories. Thus, although the Kenyan social security system now has a considerable pro‐poor social assistance component it remains biased toward those in formal employment, to the benefit of the highest income quintile.     

The challenge of pension reform in Georgia: Non‐contributory pensions and elderly poverty

Georgia's national social security system offers almost universal non‐contributory basic pension coverage. The basic pension has, to date, proved effective in dealing with old‐age poverty. But Georgia's fiscal constraints and ageing population also highlight the importance of improving the pension system, in order to ensure its sustainability. This article presents policy reform choices, which suggest that, in Georgia, pension reform might include increasing the statutory retirement ages and reducing the generosity of benefits through means testing. The case of the Georgian non‐contributory basic pension might hold value for some low‐ and middle‐income countries that are considering the implementation of, or expanding coverage under, a non‐contributory pension programme.     

Microinsurance: A short history

Twenty years ago, the International Social Security Review published an article that introduced a new term to the vocabulary of development and social protection: Microinsurance. Now, twenty years later, it is suitable to take stock of the contribution of microinsurance towards promoting coverage and social security. The article reviews the main insights gained from 20 years of implementation, including a clear expression of the value proposition of health microinsurance, understanding the demand for microinsurance, the business process for successful implementation, and conditions that must be satisfied for scaling and sustainable operations. It also explains the context that led to a considerable divergence in the microinsurance space. The article offers a discussion of unresolved issues and thoughts about the future of microinsurance. The conclusion of this article is that microinsurance can flourish when the necessary four pillars for its implementation exist, namely mainstreaming through political support, enhanced insurance literacy of the customers, technical assistance to self‐administer the schemes, and availability of seed capital. The sufficient additional condition is that customers perceive microinsurance as offering welfare gains that cannot be obtained by other means.     

Lessons from China on different approaches to pension coverage extension

Achieving universal pension coverage is both an aspiration and a challenge for many developing economies. Traditional contributory schemes are less effective in extending pension coverage to workers who are not in the formal sectors of the economy. As an alternative, non‐contributory schemes have gained popularity in recent years. China’s pension reforms mirror this global trend. The introduction of a contribution‐based pension scheme for urban employees (Employees’ Pension) was followed by a scheme for rural and urban residents (Residents’ Pension), which is partly government financed and partly contributory, with multiple options for premium payment. This study uses nationally representative survey data collected in 2016 to compare the inclusiveness of the two schemes. It finds that access to the Residents’ Pension scheme is more equal than the Employees’ Pension. Lower status workers in terms of education, employment, income and hukou‐migration are more likely to participate in the Residents’ Pension as opposed to the Employees’ Pension, compared with higher status workers. The Chinese experience suggests that a workable solution for pension extension in low‐ and middle‐income countries is to have a scheme that is flexible, affordable and responsive to the diverse needs of the population.     

Including informal economy workers in contributory social protection: Current challenges in Latin America

Owing to a favourable economic situation and to national labour market and social protection policy reforms, Latin America has witnessed significant progress in social protection coverage. Some countries, however, have seen weaker progress, with stagnant coverage levels. Several factors underlie the extension of pensions and health care coverage and the formalization of the labour market: substantial improvements in the quality of employment, more flexible eligibility criteria for contributory coverage, and the strengthening of the supervisory and regulatory roles of the State. This article first addresses the link between social protection and informality in Latin America to show the relationship between informal labour markets, the lack of social protection and the scale of unpaid contributions. Also highlighted is regional progress in extending social protection as a result of labour market formalization. Countries in the region have used various policies to encourage formalization and these have also helped to reduce wage inequalities, since formalization has had especially beneficial effects on low‐income sectors. Finally, we discuss dichotomous views on social protection financing in the region that tend to place contributory and non‐contributory financing in opposition to one another but do so in favour of the latter, tend to support proposals for limited coverage, and which do not challenge the stratification of access to social protection. The move towards a convergence of benefits is deemed essential: strategies to universalize social protection in the region should not focus exclusively on increasing resources, but must address institutional change as a crucial part of the locus of innovation.     

Pension reforms in EU11 countries: An evaluation of post‐socialist pension policies

This article evaluates the pension policy pathways of the 11 former state socialist nations that have joined the European Union since 2004. Focusing primarily on the post‐2004 period, the analysis discusses the most important measurable outcomes of these countries’ pension reforms, in terms of poverty alleviation, pension adequacy and fiscal sustainability. Going beyond the quantifiable concepts, we also investigate the quality of the 11 countries’ pension systems in terms of equity as well as efficiency, emphasizing the less conspicuous design errors present in these systems. Although these errors have received little attention to date, they may harm pension schemes along several dimensions, including their fiscal sustainability.     

The old‐age pension law in Mexico: The promise of poverty in old age?

In 1997, Mexico replaced its main old‐age pension system with an individual capitalization system. In 2021, the first people subject to the new system will retire. Using a model that projects demographic and labour variables and using Monte Carlo simulations, the findings of this study show that in 2051 the percentage of men not having a pension will increase from 38 per cent to 59 per cent, and that of women from 44 per cent to 66 per cent. The replacement rate for the average Mexican worker will fall from 70 per cent to 30 per cent. The numbers of people in extreme poverty will increase by almost 2.8 million, representing 9.44 per cent of the population. Alternative scenarios are proposed that involve increasing the contribution rate and raising the retirement age.     

Developing countries and systemic pension reforms: Reflections on some emerging problems

Since 1981 close to forty countries have introduced systemic pension reforms that have replaced all or part of prior pay‐as‐you‐go (PAYG) schemes with privately managed funded defined contribution (FDC) pillars or systems. However, over the past decade about half of these countries have subsequently cutback on, or entirely eliminated, these FDC schemes. In this article we explore some of the reasons why this reversal is often taking place in developing countries. As part of our analysis we propose a new pension reform typology that goes beyond the commonly used dichotomy between PAYG and pension privatization. We identify and discuss four factors that are of particular relevance to those seeking to understand the pension policy reversals that have been taking place in many developing countries: low pension coverage and incentive incompatibility, triple burden costs, tradeoffs between pension reforms and social pensions, and difficulties with annuitization.     

The role of mutuals and community-based insurance in social health protection systems: International experience on delegated functions

The institutional architecture for the provision of social health protection varies across countries, as do the actors and organizations involved. In some countries, mutual benefit societies and community-based health insurance organizations (CBHI) play a role in this area. In the 1990s, these were promoted particularly as a means of extending social security coverage, especially in sub-Saharan Africa. In the current context, the adoption of the 2030 Agenda for sustainable development, as well as renewed political will to realize universal coverage, has led to a questioning of the role of mutuals/CBHI. However, the literature on the roles they play in national social security systems remains limited. For this scoping review, 49 documents were analysed, covering 18 countries worldwide, focused on the delegation of functions to mutuals/CBHI in national social health protection systems. The results reveal the dynamics of the delegation of functions within social protection systems over time and their implementation processes. These provide areas for reflection that can inform policy processes.     

Extending social security coverage to the rural sector in China

In late 2009 China launched an innovative, voluntary programme that by 2011 had extended pension coverage to 326.4 million people in the rural sector, including contributors and beneficiaries. It requires one contribution per year and provides a flat‐rate benefit and a contributions‐related benefit through a contributory individual account, with a government guarantee that the benefit will continue for life. The programme encourages participation of persons who do not pay income taxes, and thus have no tax incentive to participate, by providing substantial government subsidies. As a further incentive, old‐age benefits are provided to older parents when all their adult children participate in the contributory programme.     

The social security number: A small device underpinning big systems

The possession and use of a personal social security number helps to structure people's daily lives. However, despite its fundamental normative importance, the social security number remains a little‐known entity. Increasingly universal and yet diverse in form, it is a legal and technical norm which is as much a mechanism for surveillance and monitoring as it is a necessary instrument for giving effect to social rights. Analysis of this constituent element of social security systems permits as assessment of some of the technical difficulties presented by the ever‐increasing movement of people and data. Overcoming these technical difficulties should permit to envisage a first technical step towards realizing a universal and global social security system.