Health Care in Asia and the Pacific: Increasing the focus on social health insurance

This paper focuses on health insurance reform within the broader frameworks of both social security and health services system development. In most countries in Asia and the Pacific, it is indeed the reform of the health services system, through policy changes in health care financing, that has led to an increased focus on health insurance. The underlying issue in this reform is the shift in responsibility that has taken place in most countries in the region over recent years. In the past, governments were responsible for financing health care for their populations. This shifted to defining, legislating and implementing an appropriate health care financing mechanism, presenting several challenges: to reach universal health insurance coverage through new initiatives for new populations, mainly the informal sector accounting for the majority of the population in almost all these countries; to apply provider payment systems that enable control over costs and the volume of utilization; and to strengthen primary health care as a foundation for rational utilization and more resources for prevention, including prevention of chronic diseases among the ageing population. This approach will require an active partnership between health insurance schemes and government that should reflect the new division of responsibilities to guarantee access to high-quality health care for all.     

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.     

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?     

Reaching universal coverage by means of social health insurance in Lesotho? Results and implications from a financial feasibility assessment

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesotho's exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing.     

The Fiscal Crisis of National Health Insurance in the Republic of Korea: In Search of a New Paradigm

In 2001, National Health Insurance (NHI) in Korea, the social insurance system for health care with universal population coverage, experienced a serious fiscal crisis as its accumulated surplus was depleted. This fiscal crisis is attributed to its chronic imbalance: health care expenditure has increased more rapidly than have insurance contributions. The recent failure in implementing pharmaceutical reform was a further blow to the deteriorating fiscal status of the NHI. Although the NHI has since recovered from the immediate fiscal crisis, this has mainly been because of a temporary increase in government subsidy into the NHI. The strong influence of the medical profession in health policy‐making remains a major barrier to the introduction of policy changes, such as a reform of the payment system to strengthen the fiscal foundations of the NHI. Korea also has to restructure its national health insurance in an era of very rapid population ageing. A new paradigm is called for in the governance of the NHI: to empower groups of consumers and payers in the policy and major decision‐making process of the NHI. The fiscal crisis in Korean national health insurance sheds light on the vulnerability of the social health insurance system to financial instability, the crucial role of provider payment schemes in health cost containment, the importance of governance in health policy, and the unintended burdens of health care reform on health care financing systems.     

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.     

Changing the development policy paradigm: Investing in Social security floor for all

The Paper briefly reviews social security coverage that the world has achieved and summarizes economic and social benefits of a national social security system. It then goes on to argue that social security systems are a necessary part of the institutional framework of any effective market economy, creating—among other things—societal cohesion that is needed for long-term economic development. It makes the case that the introduction of basic social protection in developing countries is both a desirable and an affordable investment in their social and economic development. It estimates the global minimum investment cost to provide basic social security and finally suggests international instruments to introduce a global social security floor.     

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.     

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.     

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.     

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.     

Global–regional interaction to extend access to social protection for migrant workers: Insights from ASEAN and MERCOSUR

Universal access to social protection for migrant workers is emerging as a problematic issue in the implementation of free movement regimes at a regional level. This article focuses on the concept of regional governance as a possible mechanism to address the unsolved challenges of social security regimes to extend coverage. To this end, the article looks at current legal developments in two regional projects (ASEAN and MERCOSUR) to identify a creative approach to strengthen the development of national floors of social protection. The interest of using these case studies lies in exploring whether the regional integration process can play a major role in the progressive extension of social protection rights to migrant workers by facilitating the adoption of social security agreements.     

构建适应市场经济的中国社会保障制度

社会保障制度作为市场经济运行的"安全阀"和"减震器",担负着保证社会成员的基本生活水平、保持社会稳定、协调公平与效率的使命。鉴于目前城乡社会保障的巨大反差、保障范围覆盖不全、保障基金利用效率低下的实际,构建适应市场经济的中国社会保障制度,应建立和发展多元化、多层次的社会保障体系;拓宽社会保障覆盖面,采用新的社会保障筹资比例和筹资方式;大力推进社会保障的法制建设,调节财富,以建立中国的社会保障安全网;解决好城市化进程中新型城镇人口和农村的社会保障问题。     

Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage

Mongolia achieved high population coverage under mandatory health insurance relatively quickly. This fact was viewed by policy‐ and decision‐makers as a central issue for health financing reform in Mongolia. Health insurance brought many new features for health service planning, provision, funding and resource management. Based on initial achievements, health insurance came to be strategically considered as the vehicle for achieving universal coverage. The article analyses developments in Mongolia's health insurance over the last decade along with the core policy dimensions of Universal Health Coverage. It examines various reform approaches and the numerous amendments to laws that have been implemented during this period and discusses new opportunities as well as challenges. The analytical review and findings discussed suggest that Mongolia has a need for evidence‐based policy decisions and informed political support, with health insurance backed by robust institutional and administrative capacities. More generally, it also emphasizes that health policy goals and objectives can be attained by strengthening and making transparent and publicly‐accountable all health system financing functions and arrangements. The policy analysis, experiences, lessons and proposed strategies presented with regard to Mongolia intend to stimulate wider discussions on health insurance development as well as promote continuing focused research on specific aspects of health insurance and public financing reform.     

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.     

Divergence in the development of public health insurance in Japan and the Republic of Korea: A multiple‐payer versus a single‐payer system

Japan and the Republic of Korea achieved universal health insurance coverage for their populations in 1961 and 1989, respectively. At present, Japan continues to operate a multiple‐payer social health insurance system, while the Republic of Korea has moved to an integrated single‐payer national health insurance structure. This article analyzes the influence of political economy in shaping the policy divergence found between these two Bismarckian health insurance systems. Issues addressed include differences in political power, the policy influence of business, the extent to which regional autonomy has developed and regional traits have been preserved, the level of political democratization, the form of political leadership, and the scale of development of the health insurance system. The article offers policy lessons derived from the two countries' experiences.     

Social protection for the family in the Maghreb

This article is based on a study of the protection afforded to the family under the social insurance schemes of the five Member States of the Arab Maghreb Union, and considers the usefulness of family benefits in economically poor countries gripped by the great problems of population growth and unemployment. This type of social protection is conditional upon the individual being actively employed and covers only a very small part of the working population, leaving out the majority. Should not priority be given to coverage against real occupational risks that threaten employment? This is not an easy question to answer in an increasingly unfavourable economic climate, but it should be possible, in the name of those social and human ethics founded on Maghrebi sentiments of family, local, national and regional solidarity, to mobilize particularly the political will to find better solutions or alternatives. It will, however, be necessary first to reconsider family benefit systems in relation to other, more urgent forms of protection in accordance with a social choice based on the rights and cultural values of Maghrebi citizens. By showing the common features of the Maghrebi schemes at the same time as some of their differences, the article will also present useful elements for their harmonization and even their unification into a regional social security system.     

Work Accident Insurance and Prevention in Southern Africa: The Case of Zimbabwe

The paper uses Zimbabwe as a case study to depict the situation in southern Africa with respect to work accident insurance and prevention, provided by workers' compensation schemes which are among the earliest forms of social security to be introduced in the region. There has been an unfortunate tendency to concentrate on compensation issues at the expense of prevention initiatives. Zimbabwe, however, has attempted to integrate the two, notwithstanding the fact that the coverage of the scheme is narrow and the benefits inadequate.     

Income security for older people: An Asian perspective

In Asia and the Pacific, as in other developing regions, the continuing growth of the aged population has a great impact on social security programmes generally and, in particular, on the income security of older persons. In societies where traditional support systems are breaking up, their need for social security protection is increasingly important. A system of social security for the elderly population exists in most countries of the region. Many are provident fund schemes, which are basically saving schemes, and their coverage is low. Where social insurance pension schemes exist, the levels of benefits provided are also low. The focus for future development, therefore, lies in converting the savings schemes into multitiered pension schemes, extending their coverage and raising the level of benefits. In this context the critical question concerns the role of the State and the type of schemes used. The need for public pension schemes is great in Asia and the Pacific, where the level of poverty is comparatively high. Building pension schemes, whether public or private, involves a set of issues that need to be addressed. This article considers the systems currently in place and the challenges and limitations faced when considering the future development of social security in this area.