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.     

Decision time: Cost estimations and policy implications to advance Universal Health Coverage in Cambodia

Cambodia aims to expand social health protection to move toward Universal Health Coverage. We developed a modeling tool to facilitate the simple, interactive estimation of cost and coverage for three policy alternatives, enabling decision-makers to simultaneously adjust for scenario options currently under consideration. Assuming the adoption of all scenario options, the projected cost of expanding social health protection to all is US$42 million, to vulnerable individuals is US$32.1 million, and to uncovered 1st–3rd wealth quintile people is US$30.4 million. These policy alternatives are projected to increase population coverage to 100%, 89.1%, and 92.5% by 2025, respectively. The results have multiple policy implications. First, given the similar costs and coverage estimates for the targeted approaches, and other considerations, expansion to the 1st–3rd wealth quintiles is recommended. Second, the model quantifies the potential impacts for policy changes relating to each scenario option. The inclusion of dependents under the contributory schemes significantly shifts costs; reversing the policy of non-payment for priority public health services increases public health facility revenue; and, alignment of reimbursement rates leverages demand-side financing which can increase value for money. Finally, the cost estimates provide a basis for economic planning. Revenue raising options include increasing the contribution ceiling for the private employees’ scheme and the progressive adoption of strategic purchasing.     

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.     

Health care as a social security benefit: Institutional approaches to extending coverage

Reaching universal health‐care coverage requires an appropriate mix of compulsory contributory social insurance schemes, with mechanisms to include the informal‐economy population, and tax‐based social assistance for those whose incomes preclude their own contributions. This article urges a reversal of the trend that favours the separate development of social health insurance by separate health authorities and makes the case for the extension of health‐care coverage using existing formal‐sector social security schemes, not least because they have the necessary political backing and institutional structures. The article reviews reasons for the slow pace of coverage extension to date, and stresses the added value of incorporating health care as a social security benefit while also acknowledging the importance of retaining linkages between statutory and well‐regulated community‐based or micro health‐insurance schemes.     

Extension of social insurance coverage to informal economy workers in China: An administrative and institutional perspective

This article reviews administrative issues in the context of decentralized social protection in China. In particular, what are the main obstacles to expanding social insurance coverage for workers in the informal economy? Over the last two decades, China has achieved remarkable progress toward universal social protection when this target was set as a national policy priority. However, the social insurance enrolment of informal economy workers still lags significantly behind. This article reviews the application of the International Labour Organization’s definition of informality in the Chinese context and overviews existing pension and health insurances in China. This article discusses the impact of China’s inter‐governmental fiscal relations and decentralized social protection in the multilevel government system. The article highlights that under a system of decentralized managed social insurance many informal economy workers choose to opt out of the system because of low benefits and high compliance costs. This result in deficits in social insurance coverage amongst informal economy workers.     

The Associations between income,informal social networks,and health among older adults in South Korea: A multi‐group analysis based on the level of age‐friendly environments

The aim of the present study was to empirically investigate the role of age‐friendly environments (AFE) on the associations between income, informal social networks, and health among South Korean older adults. We used data from the “2017 Age Integration Survey” collected nationally and ultimately analyzed 615 older adults over 50 years of age. Structural equation modeling and multi‐group analysis were used to test the hypothesis. Specifically, two groups of perceived levels of AFE (top 25%, bottom 25%) were compared in order to examine the moderating effects. The results indicated that poor income and scarce informal social networks each had a significantly adverse impact on health. However, the effect of income on health was no longer significant for older adults living in environments that were more age‐friendly. In both groups, the presence of fewer informal social networks adversely impacted health, although the sizes of the effects decreased when the level of AFE perceived by older adults was improved. Finally, several implications of the study findings were discussed.     

Ageing in “Poor Household” or Ageing into Poverty? Tackling the Policy Dilemma of Redistribution

The policy issue of how to target poor households rather than provide universal coverage takes the primary place in the question of redistribution where resources are limited. The Government of India's social protection programs, particularly the old age pension for the informal sector of the economy, has taken a targeting approach. In this article we show that there is a case for universal coverage since ageing households experience greater exclusion from market-based protection as well as from informal (household-based) protection. We make the argument for universal coverage on two grounds: first, a targeted approach has resulted in leakage, indicating that non-poor elderly individuals in the unorganized sector also require some sort of support. Though they are valid, we do not resort to traditional arguments against targeting, such as that it creates institutional lock-in mechanisms and stigmatizes the recipients. Second, the loss of income on age-related matters (e.g. hospitalization) or the ability of elderly individuals to gain credit is not particularly class-specific, although the targeting policy implies it is. The article is based on the secondary data source of the National Sample Survey, primary data sources, particularly those conducted by the authors in Kerala and Maharashtra and specifically designed for the ageing population, and ethnographic observations from fieldwork.     

Extending health care coverage: Potential linkages between statutory social security and community-based social protection

Abstract   The extension of social health protection in developing countries is widely recognized as a priority. Various financing and institutional methods can be used in pursuing this objective, but none of them can achieve universal coverage in the short term. Based on an analysis of the respective strengths and weaknesses of social health insurance and community-based health care schemes, this article demonstrates the high potential of coverage extension strategies that use a pluralistic institutional approach to establish linkages and exploit complementarities optimally. A typology of potential linkages among different methods is presented and their value added illustrated using country examples.     

Social protection systems and the future of work: Ensuring social security for digital platform workers

Digitalization is transforming societies and economies worldwide at an unprecedented scale and pace. In the wake of automation and digitalization, new forms of employment have been emerging in various occupations and sectors, such as the digital platform economy. The emergence of new forms of employment, such as work on digital platforms, requires that existing social protection systems adapt to the specific situation and needs of such workers, as to realize the human right to social security for all. Current social protection coverage for workers on digital crowdwork platforms reveals significant gaps in social security coverage. Where such coverage exists, it is often provided through the workers’ previous or additional jobs, or indirectly through their spouses or other family members. This raises questions about digital platforms free riding on the traditional economy with regard to the financing of social security. How can social protection systems adapt to changing forms of work to ensure full and effective coverage for workers in all forms of employment, including those in “new” forms of employment? How can workers in all types of employment, including those on digital platforms, be protected in an adequate and comprehensive way, combining contributory and non‐contributory mechanisms and based on equitable and sustainable financing mechanisms, so as to ensure adequate social protection to all?     

The coverage of social protection in the Global South

About 73% of the global population is not, or is only partly, covered by social protection. Particularly across low‐ and middle‐income countries (LMICs), social protection coverage is highly heterogeneous. What explains the large differences in the inclusiveness of social protection across LMICs? By analysing 100 LMICs using retirement schemes as an example, this study shows that non‐contributory schemes in LMICs are, by far, more inclusive than contributory ones. Surprisingly, democratic institutions characterised by low levels of political corruption only promote the inclusiveness of non‐contributory social protection while reducing the coverage of contributory schemes.     

Gaps in social protection for health care and long‐term care in Europe: Are the elderly faced with financial ruin?

While public expenditure on health care and long‐term care (LTC) has been monitored for many years in European countries, far less attention has been paid to the financial consequences for older people of private out‐of‐pocket (OOP) expenditure necessary to access such care. Employing representative cross‐sectional data on the elderly populations of 11 European countries in 2004 from the Survey of Health, Ageing and Retirement in Europe (SHARE), we find that OOP payments for health care and LTC are very common among the elderly across European countries and such expenditures impact significantly on disposable income: up to 95 per cent of the elderly make OOP payments for health care and 5 per cent for LTC, resulting in income reductions of between 5 and 10 per cent, respectively. Failure to prevent financial ruin, as a consequence of excessive OOP payments, is evident in 0.7 per cent of elderly households utilizing health care and 0.5 per cent of elderly households utilizing LTC. Those particularly concerned are the poor, women and the very old.     

Economic crisis and social policy reform in Korea

The economic crisis that broke out in Korea in December 1997 has had a chilling impact on social development in the country. Today unemployment is the highest that Korea has experienced in the past thirty years. This paper aims to examine the impact of the economic crisis on social development and the role of public policy to mitigate the problems caused by the crisis. The economic crisis has hit vulnerable groups harder, increased the proportion of part-time and daily workers, and reversed the trend of steady improvement of income distribution. The economic crisis along with the trend of aging population, globalization, and competition calls for an expanded role of social policy, which the Korean government has neglected for a long time. The main targets of social policy reform in Korea include the expansion of government programs and safety nets for the unemployed and redesigning the national pension and health insurance scheme to provide adequate income security as well as to improve the system sustainability.     

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.     

An Analysis of Selected Pension and Health Care Initiatives for Informal Sector Workers in India

India's demographic trends portend moderately rapid ageing of the population. This, combined with the limited coverage of pension and health care programmes in terms of population, types of risks covered, and benefit levels has led to greater urgency in extending the coverage and reform directions of the current pension and health care programmes. This article analyses three pension and health care initiatives in India directed at the workers and their families engaged in the informal sector. The first initiative, India's National Social Assistance Programme (NSAP), undertaken in 1995 provides budget‐financed transfers targeted at older persons. It is funded by the Union government but implemented by the state governments. The second initiative, called Swavalamban, was started in 2010, but has been subsumed under Atal Pension Yojana (APY), in the 2015–16 budget. Both are voluntary co‐contributory initiatives aimed at providing access to retirement income to low‐income individuals (government co‐contributing with the individual). Unlike Swavalamban, the APY initiative has provisions for minimum guaranteed pension benefits, with contributions required by the members adjusted accordingly. Effectiveness in increasing enrollment and in sustaining contributions over a longer period will impact on the extent of retirement income security obtained by the members. The third initiative, Rashtriya Swasthya Bima Yojana (RSBY), is insurance‐based and aims to provide hospital care to low‐income households. The article argues that for improving outcomes of these initiatives, more effective implementation, greater fiscal resources, and an integrated and systemic approach which is aided by technology‐enabled platforms such as Aadhaar, will be needed.     

Beyond legal coverage: Assessing the performance of social health protection

A frequently used indicator to measure social health protection performance is the extent of population coverage as stipulated in national legislation. However, this indicator does not provide meaningful information on performance in terms of effective access to benefits that are available, affordable and of acceptable quality, not least for the poor and workers in informal economies. This article proposes a new approach to measuring performance by applying a set of relevant indicators in an analytical framework for assessing the performance of social health protection. The approach allows policy‐makers to conclude from comparisons among groups of countries facing similar challenges. Preliminary results include comprehensive information on deficits that need to be addressed when striving for effective universal coverage. With further refinement, the suggested approach could become a standard assessment tool for measuring performance.     

Social Insurance and Older Adults in China: Effect of Education and Household Income on Coverage Following the 2009 Health Reform

Abstract

Education and income have been considered two primary determinants to affect individuals’ health outcomes. China initiated a comprehensive health reform in 2009, with the goals to provide equal access yet sufficient healthcare to all residents. However, social disparities continue to persist following this large reform. This research hypothesized that older adults’ years of education and income are determinants of participation in each social insurance scheme following the 2009 health reform. Multilevel logistic regression models were used with a nationally representative sample (n?=?5,274) to investigate the education and income disparities in each social insurance scheme for older adults, with random effects among provinces at the national level. The analyses show that years of education was not associated with enrollment in three social insurances, with the exception of the association between 11?years of formal education or above and the rural coverage. Participants with higher levels of household income had greater odds of having urban social insurances, but had lower odds of having the rural scheme. Further research should continue to investigate the disparities of enrollment of each social insurance. Chinese policy makers should consider these social factors carefully to reach a true universal coverage.     

Social security coverage extension: A review of recent evidence

This article reports the findings of 13 studies undertaken as part of the International Social Security Association (ISSA) project on “Examining the existing knowledge on coverage extension”. It reviews recent evidence that highlights how cash benefits and health‐care coverage, financed on the basis of contributions or tax revenue or both, can be extended and maintained in low‐, middle‐ and high‐income countries. The article also highlights a number of priority areas and issues for coverage extension, including realizing improved protection for informal‐economy and migrant workers.     

Reinvigorating the social contract and strengthening social cohesion: Social protection responses to COVID-19

The COVID-19 pandemic has exposed the vulnerability of those who are inadequately covered by social protection in more and less developed countries alike, and has exacerbated the fragility of a social contract that was already under strain in many countries. A weak social contract in the context of an exceptional crisis poses a very real risk to social cohesion. Nevertheless, many States have reasserted themselves as the guarantor of rights by protecting public health and incomes. By sustaining these measures, economic recovery will be supported which will help minimize risks that may weaken social cohesion. However, this is a fast-moving, inherently unstable and protracted crisis. Social protection stands at a critical juncture. Decisive policy action will be required to strengthen social protection systems, including floors, as one of the cornerstones of a reinvigorated social contract.     

The extension of healthcare coverage and protection in relation to the labour market: Problems and policies in Latin America

In the past 25 years almost all 20 countries of Latin America have reformed their healthcare systems, but coverage by social insurance averages 53 per cent of the total population (less than the ILO minimum standard), ranges from 7 to 26 per cent in ten countries and has stagnated or decreased in at least eight, and access is insufficient. This article (1) analyses the transformation of the labour market and its impact on social insurance coverage; describes legal coverage of various groups; estimates statistical coverage/access and its trends in the three typical sectors (public, social insurance and private); documents the differences in coverage by income, geographical area and ethnic group; examines the difficulties in the incorporation of the informal economy, the rural population, indigenous peoples and the poor, as well as the causes of low coverage, and touches problems of access;(2) summarizes recommendations from international organizations on coverage and access; suggests specific policies to expand protection in general and to vulnerable groups, and identifies themes that require more statistics and research; and (3) summarizes findings and recommendations. A preliminary version of this article was presented at the ISSA Regional Conference for the Americas held in Belize City, 28‐31 May 2006. Based on the author's book Las Reformas de Saluden América Latina y el Caribe: Su Impacto en los Principios de la Seguridad Social (Santiago, ECLAC/GTZ, 2006), the article summarizes and restructures all pertinent sections of that book, with numerous changes and new data. Useful comments were provided by two anonymous referees.     

A Study of a Total Social Services Care Population and its Inter-Agency Shared Care Populations

There are very few large population studies and little informationabout the characteristics of social services populations andthe inter-agency populations that social services departmentsshare with other agencies. This study fills this gap. It examinesa total social services adult care population, excluding residentialcare homes (N = 19,461) in the context of its general co-terminoushealth authority population (N = 646,239). Approximately two-thirds(61 per cent) of the social services population were women,compared to the health authority population of 51 per cent.Sixty-two per cent were over sixty-five years compared to 23per cent of the health authority. Age groupings and genderedpatterns of service use are then identified for different caregroups. The study then examines care populations shared betweensocial services and other agencies, identifying the amount ofshared care and the characteristics of specific shared caresubgroups. Forty-two per cent of the social services populationwere shared with the community health trust and 19 per centwith the mental health trust. The proportion of the social servicespopulation in contact with Criminal Justice and accident andemergency was nearly twice that in the overall health authoritypopulation. The limitations of these data are examined and thepotential of this method to inform inter-agency planning andshared care is discussed.