Social health insurance in developing countries: A continuing challenge

This paper addresses the issue of the feasibility of "social" health insurance (SHI) in developing countries. SHI aims at protecting all population groups against financial risks due to illness. There are substantial difficulties in implementation, however, due to lack of debate and consensus about the extent of financial solidarity, problems with health service delivery, and insufficient managerial capacity. The transition to universal coverage is likely to take many years, but it can be speeded up. Adopting a "family" approach to financial protection, sustained financial support from governments and donors, and deconcentrating the development of SHI may slash several years from the time needed to achieve full universal protection against healthcare costs.     

Development of Social Health Insurance in Mongolia: Successes, Challenges and Lessons

This paper examines the process of developing social health insurance in Mongolia, and its successes, challenges and lessons. The government of Mongolia introduced social health insurance in 1994, which is compulsory for all public and private sector employees and low-income and vulnerable population groups. The scheme also provided voluntary insurance for unemployed people of working age. About 95 per cent of the population was covered by health insurance within the first two years thanks to a high level of government subsidy for vulnerable population groups. The insurance benefit initially covered nearly all inpatient services except the treatment of some specified chronic and infectious diseases, which were directly funded by the government. The scheme not only had many successes but also faced challenges in maintaining universal coverage. The new financing arrangement has provided little financial incentive for healthcare providers to contain health expenditure, contributing to rapid health cost inflation. In addition to reforming the payment system for providers, there has been an increasing need to expand benefits into ambulatory care. The development of compulsory health insurance in Mongolia shows that a prepaid health insurance mechanism based on risk sharing and fund pooling is feasible in low-income countries given political commitment and government financial support for vulnerable population groups.     

透过"橱窗"看到的福利国家--一个基于瑞典的案例分析

瑞典福利国家制度的显著特征是覆盖面广、设计项目多、保障水平高,注重"公平"胜于注重"效率"。20世纪70年代后,这一制度的实施出现了财政危机,然而更深层次的危机,则是高福利所要求的高税率对人们工作积极性和国际竞争力的打击。因此使之成为改革的重点。瑞典改革案例给予中国重要启示:建设完善的社会保障制度,是实现经济发展与社会进步的必然选择,这既是政府的责任,也是人民的企盼;但制度设计要避免重蹈瑞典福利国家制度"过度"福利供给的覆辙。     

Informal Economic and Social Security in Sub-Saharan Africa

Most people think that there is no social security in sub-Saharan Africa, whereas a theoretical statutory social security is foreseen in quite a few African States. Since the 1960s, the first formal social security provision in French-speaking sub-Saharan Africa was established mainly in the field of health services. Nevertheless, the situation is different in reality. The coverage rate is less than 10 per cent of the workforce. The majority of the population are excluded because they work in the informal sector. Formal social security systems are usually based on a labour-centred view, which is founded on formal employment and thus employment contracts. Legal restrictions, such as the exclusion of several categories of employees, and administrative and financial problems are primarily responsible for the low coverage rate. This situation has induced informal sector workers to create their own "safety nets". The integration of these existing informal social security schemes in a broader, pluralist approach to sub-Saharan social security seems necessary.     

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 performance of the income protection system for older adults in Ecuador and future challenges

The objective of this article is to analyse the performance of Ecuador’s pension system and the challenges it will face in the future. Over the last 13 years, the pension system has made significant advances in terms of coverage and adequacy. However, demographic ageing is straining the financial sustainability of the contributory scheme. In this context, a number of public policy areas are identified, in terms of parameters and structures, which, together with the expansion of non-contributory coverage, could provide a more equitable and sustainable scheme.     

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.     

Protecting the ageing poor or strengthening the market economy: the case of the Hong Kong Mandatory Provident Fund

The Mandatory Provident Fund (MPF) launched by the Hong Kong government seems to be a residual welfare state's strategy to cope with an ageing population and, at the same time, preserve a minimal welfare state and further enhance economic development. The MPF can only provide limited protection for a limited number of employees; many older people still have to depend on financial support from their families or have to work. On the other hand, the MPF immediately boosts the economy by creating more jobs for the financial services sector and by providing more business opportunities for banks and insurance companies. Thus, the MPF has consolidated the foundation of Hong Kong's capitalism by socialising and incorporating the whole working population in the market economy but has provided little protection for their old age.     

Inequity in access to the Argentinian pension system (1994–2017)

Pension coverage in Argentina is inequitably distributed between different income levels, both during working years and during retirement. The objective of the article is to study the evolution of inequity in access to the Argentinian pension system in terms of its association with the socio‐economic status of individuals during the period 1994–2017. An evaluation is offered of how variables such as sex, age, and educational attainment influence such inequity. It is concluded that, although the level of average coverage increased, inequity in access increased significantly in the years following the 1994 reform, both among the active and the inactive population. However, inequity in access among active persons did not improve substantially with the return to the pay‐as‐you‐go pension system, while it was considerably reduced among the inactive population. While the former are found to be affected to a greater extent in terms of coverage as a result of the pro‐educated bias among the active population, the latter outcome is thought to be a direct result of the transitory plan (Pension Inclusion Plan) for pension inclusion, after which inequity was to resume its upward course.     

The Role of Insurance in Social Protection in Latin America

Social protection schemes in Latin America face serious short falls in the financial resources available to meet their needs. New types of insurance envisaged in reforms should help to contain costs and increase coverage. However, in strengthening schemes' coverage it is highly probable that considerable demand for additional financial resources will arise to address the need to introduce the principle of solidarity into the system. This article examines reforms in the financing of social security for healthcare and pensions, highlighting the implications of various public-private combinations for financial management and coverage.     

The "Papy-boom": A historical opportunity for French public hospitals

Abstract   The French public hospital system represents a major element in overall social security expenditure and ongoing reforms are having a significant impact on its financial equilibrium and the internal management of its activities. Nonetheless, the system has been unable to achieve the productivity objectives imposed on it. Significantly, staffing costs account for three quarters of its expenditure, yet most employees are civil servants who cannot be laid off easily. The only possibility for meaningful change in the size of its workforce may lie in the demographic revolution now affecting the French population, which will see half the present staff of public hospitals reaching retirement age within the next decade.     

From reform to crisis: Argentina's pension system

Argentina underwent economic and social collapse in December 2001. The crisis brought the worst socioeconomic indicators in its history, and the pension system was not immune from this disaster, which was unparalleled in any middle-income developing country. In 1994 the pension system had been restructured, and was regarded as a viable model for other reforms elsewhere. This article discusses in general terms the features of the current pension scheme, the structural problems that were not resolved in the reform of 1994, the relation between that reform and the government's financial crisis, and the impact of the economic collapse on the pension system. Finally, it discusses some aspects of the challenges faced in building a system that is financially viable and has the potential to close the major gaps in coverage affecting both the working population and older persons.     

The construction of the medical insurance system in the Republic of Korea, 1963–1989

The task of bringing a whole population into medical insurance coverage is a challenging one for a country's health policy makers. The outcomes of health policy differ significantly from one country to another depending on each state's socio-economic and political background. Health policy in Korea is to a great extent incremental in character and the consequence of a variety of causal events. This is why it has been difficult to apply the established social welfare theories to the Korean case. In any event, the Korean national medical insurance system, constructed between 1963 and 1989, reveals some similarity to that in Japan, i.e., compartmentalization of financial and administrative units as well as inequality in contributions and benefits. The system also reflects Korea's traditional Confucian value which emphasizes mutual dependence between family members.     

Providing social security in a context of change: Experience and challenges in Latin America

Over the past two decades Latin America has experienced major demographic, economic and social changes. The trend towards accelerated ageing of the population in most countries, together with the financial restrictions faced by social protection systems, has brought sweeping changes in pension programmes. The new demographic and labour context presents challenges for these new programmes which, unless they make the necessary adaptations, will definitely be unable to attain their stated objective of providing universal coverage and eliminating poverty in old age. This article offers a general discussion of the processes that the region is undergoing, as well as the limitations and challenges imposed by existing welfare systems. Finally, it examines the options available to retain the objective of universal coverage and thus ensure the economic needs of the elderly population.     

论社会转型期政府在城市社区建设中的角色

改革开放以来,我国社会结构、社会运行机制和价值观念体系加速变化,整个社会处于加速转型之中。经过二十多年的改革发展,城市社区建设在社会体制的加速转型之中兴起,并且取得了巨大的成就。然而,在社会转型期却存在许多问题,政府在城市社区建设中存在着角色定位不准确,在城市社区管理中存在“越位”、“缺位”和“错位”等问题。本文结合城市社区建设的发展过程分析,认为政府在城市社区建设中的角色应该由主导性向公共服务性转变。     

Extending coverage under the Argentinian pension system: Distribution of access and prospects for universal coverage

One of the main challenges facing social policy in Latin American is to guarantee social security coverage for the entire population in the presence of a large informal sector. In Argentina, a regional pioneer in terms of the development of its pension system, more than one third of those of retirement age were without benefits in 2005. Since then, considerable progress has been made in extending coverage thanks to the introduction of a programme that has reduced contribution requirements and allocated benefits to a large number of seniors previously excluded from the system. This article analyzes the impact of this process in Argentina on the level and distribution of coverage, identifies changes in socio‐demographic factors which affect inclusion/exclusion in the social security system, and discusses remaining obstacles to the provision of universal coverage in the medium and long term.     

The "X component" in Shanghai's social security reforms

In 2003, the Shanghai Bureau of Labour and Social Security launched the zhenbao (town insurance) programme, now widely known as 25 plus X. This scheme is regarded as an important experiment in social security reform and has been lauded for extending social security to areas where previously only segments of the population had mandatory coverage. Using data from 103,000 individuals enrolled in 25 plus X, we examine the extent to which the scheme represents an extension in social security coverage. Our analysis suggests that while it does represent an extension of benefits for some, for many it represents a considerable dilution in benefits.     

Pensions in Nigeria: The performance of the new system of personal accounts

In 2004, Nigeria copied the 1981 Chilean pension reform and established a funded system based upon personal accounts. The new system was neither appropriate for a country such as Nigeria, nor did it meet aspirations of improving pension coverage or helping economic growth. The current financial and economic crisis hit the scheme in so far as it hit stock values. However, more important has been the negative real interest rates that can be earned on government bonds and on bank deposits — where the majority of contributions are invested. Bank scandals and rising fiscal deficits do not breed confidence in the system or the government's ability to deliver meaningful benefits in old age.     

The difficulties of extending social security in Tunisia's agricultural sector

The development of social security in the agricultural sector in Tunisia faces obstacles due to the particular social and economic conditions that apply. The desire of the public authorities to extend social protection to the rural population as a whole runs up against both technical and financial problems. The exact number of people employed in the agricultural sector is not known and it is difficult to define precisely the range of persons to be protected. The changes that have been made in the legal framework in order to adapt social security to the composition and the working conditions of the agricultural population have not achieved their objective. The lack of a coherent system is reflected in particular in the variety of legal provisions and schemes which may be applicable to employees engaged in the same work or working in the same firm. The precarious nature of agricultural employment, the low incomes and thus the low contributory capacity of the workers, the level of benefits offered — in the agricultural schemes sometimes very much below those in the general scheme — all these make social security appear impossible to achieve or not worth while. The resistance encountered by the social security institution may also be due in part to the failure of the Social Security Fund to make people sufficiently aware of the position in the face of some of the traditional structures of solidarity.     

The public pension system in Taiwan: Equity issues within and between systems

This article analyses the challenges facing the New Public Service Pension Fund System in Taiwan, China. After less than two decades of operation, this young system is facing financial imbalance and is embroiled in controversy regarding the generosity of its benefits provisions. The article first introduces Taiwan's different systems for old‐age security, with a focus on that for general public‐sector employees. It then addresses the financial challenges facing the general public‐sector pension system, including the rising cost of its benefits for all taxpayers. Finally, a number of possible reform directions are suggested, including lowering benefit levels, making qualifying criteria more stringent, or establishing a new system. With regards to the latter, any proposed new system must seek to satisfy the goal of longer‐term financial soundness while realizing optimal fairness among all stakeholders including taxpayers.