Expanding social health protection in Cambodia: An assessment of the current coverage potential and gaps,and social equity considerations

The Royal Government of Cambodia recently launched its National Social Protection Policy framework to strengthen and expand social security and assistance. To inform social health protection policy, we examine socio-economic survey data and administrative coverage data to assess the coverage potential of existing coverage mechanisms and current gaps; and compare equitable contribution rates. Over 53 per cent of the population currently has no social health protection coverage mechanism, and about 16 per cent of the population who do have access to a mechanism are not yet enrolled. Current expansion efforts focus on the formal employee scheme, primarily benefiting individuals from higher income households. In addition, recent coverage expansion to some informal workers leaves significant gaps, particularly among the informal sector. We find out-of-pocket health care expenditure to be an excessive share of income among lower wealth quintile individuals and conclude they are financially vulnerable. Finally, we illustrate that an equitable approach to individual, monthly health care contributions among the lower three quintiles has a severely limited potential for revenue generation, and collection costs could exceed the amount collected. Therefore, we recommend that vulnerable groups should be exempted from contribution payments as social health protection is expanded.     

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.     

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 pension coverage in Cambodia: The governance and investment challenges of the Social Security Investment Fund

Rapid economic growth, declining fertility and changes in family structures have encouraged the Kingdom of Cambodia to reform its old-age pension system. The Government of Cambodia reached an important milestone in 2019, when the Law on Social Security was promulgated. The Law includes provisions for a compulsory defined benefit pension scheme, establishing a sound framework for extending compulsory pension coverage beyond the public sector to formal private-sector workers. As a future step, the compulsory pension scheme should be extended to informal workers. To accompany the reform, the investment policy for the pension scheme’s reserve funds, including the supervisory regime and investment strategy, will be essential for the modernization of the Cambodian social security system. In this regard, Cambodia has successfully sought policy advice. However, the country should continue to seek further advice, and to act on this. Otherwise, the necessary and increasingly pressing policy ambitions of Cambodia to develop an adequate and sustainable social protection system may not be fully realized.     

Analysis of the implementation of a social protection initiative to admit the poorest of the poor to mutual health funds in Burkina Faso

To enable mutual health funds to extend coverage to poor people, the Mutual Health Support Network (Réseau d’appui aux mutuelles de santé – RAMS) in 2012 launched an initiative in collaboration with the Ministry of Social Action and Solidarity (ministère de l’Action sociale et de la Solidarité nationale – MASSN) in Burkina Faso. This article reveals difficulties in the initiative's implementation, which resulted in the continued exclusion of poor people from health services. Poor people were required not only to make co‐payments, but also to accept a limitation of coverage to three episodes of illness per year. Additional challenges to service takeup were the geographical distance of the homes of some beneficiaries covered by a mutual fund agreement from a health centre and the failure by some health workers and managers of pharmacies to recognize the mutual membership card. A formal framework was lacking that brought together all the actors involved in planning and implementing the initiative. Those involved did not all have the same information. Each structure performed the tasks within its scope, according to its own interests, but without consulting the other parties, and there was no platform for discussing implementation difficulties.     

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.     

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.     

Social protection assessment‐based national dialogue exercises: Cambodia,Indonesia, Thailand,Viet Nam

Between 2011 and 2013, the International Labour Organization, in collaboration with governments and several United Nations agencies working as part of the Social Protection Floor Initiative, conducted social protection assessment‐based national dialogue (ABND) exercises in Cambodia, Indonesia, Thailand and Viet Nam. The exercises were carried out in order to take stock of existing social protection realities in the respective countries, including social insurance, social assistance and anti‐poverty programmes. These inventories present a comprehensive picture of what elements of national social protection floors (SPFs) are in place, where “holes” in national floors exist, and provide a framework within which to propose recommendations for the further design and implementation of social protection provisions that guarantee at least the SPF to the entire population. This article describes the methodology for conducting ABND exercises, the situational analysis of the SPF in four countries, and the policy recommendations that were formulated for achieving basic health care and income security for children, the working‐age population and the elderly. The results of preliminary calculations of the cost of implementing proposed policy options are also outlined.     

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.     

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?     

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.     

Informal workers and Kenya’s National Hospital Insurance Fund: Identifying barriers to voluntary participation

This article investigates the barriers to informal workers’ voluntary participation in Kenya’s national health insurance scheme – the National Hospital Insurance Fund. Based on primary data from both qualitative and quantitative methods, we find that the key determinants of enrolment include social factors, such as marital status, which create demand for insurance, and the role of informal workers’ associations that promote the voluntary uptake of health insurance and prevent default through contribution support. Participation barriers and reasons for inactiveness stem from the nature of informal work characterized by irregular earnings, which combine with apprehension about having to pay penalty charges for the late payment of premiums, inadequate levels of knowledge about health insurance schemes, institutional constraints such as complex registration procedures, as well as premium costs and poor-quality services, all of which discourage enrolment or the reactivation of lapsed membership. There is thus a need for health insurance schemes, such as Kenya’s National Hospital Insurance Fund, to educate informal workers on insurance services and protocols and to improve services to encourage uptake and reduce default behaviour.     

Health care privatization processes in Europe: Theoretical justifications and empirical classification

This article analyses the health care system reform process in Europe based on the concept of privatization. This notion is understood from two perspectives. First, privatization may concern the health care financing or the provision of health services. Second, privatization can be “imposed” on individuals or be “internalized” and then introduced by individuals (patients and doctors). So we emphasize the diversity that privatization can assume. We classify privatization mechanisms used by different countries and identify which of the perspectives presented are more common in 14 European Union countries since the 1980s. The article shows that even if privatization processes are widespread, they assume different patterns in each country.     

Social protection and revenue collection: How they can jointly contribute to strengthening social cohesion

Social protection and revenue collection are often regarded as potential drivers of social cohesion. The article joins this debate, providing three main contributions. First, we carefully discuss the concept of social cohesion and endorse one specific definition. Second, we propose using the concept of the “fiscal contract” as the key theoretical lens to understand the often neglected potential joint effects of social protection and revenue collection policies on social cohesion. Third, we illustrate three main mechanisms through which these policies can have positive or negative impacts on the different components of social cohesion and highlight the relevance of these for policy-makers deliberations.     

Linking taxation and social protection: Evidence on redistribution and poverty reduction in Ethiopia

Although redistribution results from the simultaneous effects of taxes and transfers, analyses of their distributional effects in low‐income countries have largely been undertaken from singular perspectives. This article jointly assesses the distributional effect of taxes and transfers (through social protection) using Ethiopia as a case study. We find that Ethiopia's flagship social protection programme is more effective than income taxation in achieving poverty reduction, while neither policy achieves a sizeable reduction in overall inequality. We also find that Ethiopia does not currently have the capacity to close the poverty gap or to fully fund its main safety net programme using domestic income sources alone.     

Youth‐oriented active labour market policies and economic crisis: Explaining policy effort in Greece and Portugal

The starting point of this study is the implementation of seemingly similar youth‐oriented labour market policies in Greece and Portugal. Both countries have suffered high youth unemployment rates and have been pressured to restructure their labour market as part of the rescue programmes adopted during the European sovereign debt crisis. Despite convergence in terms of policy trajectories, there is a significant divergence in employment outcomes. In Portugal, youth‐oriented policies were better‐targeted and structured. Their implementation has been more effective and has involved the social partners from the outset of the crisis. In Greece, policy design failures, administrative weaknesses and unfavourable macroeconomic conditions have limited the dynamics of youth‐oriented policies thus increasing youth insecurity. Τhe analysis suggests that convergence in policy content can be compatible with divergence in terms of outcomes.     

India's Mahatma Gandhi National Rural Employment Act: Assessing the quality of access and adequacy of benefits in MGNREGS public works

The extension of social protection to all has become a central policy objective, both nationally and internationally. A considerable number of middle‐ and low‐income countries have undertaken substantial efforts to extend social protection, while the international community reaffirmed its commitment to the extension of social protection through the adoption of the ILO Recommendation concerning National Floors of Social Protection, No. 202 (2012). This article reviews the legal provisions and the implementation of the Indian Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), legislated in 2005, and does so in the light of the more recent provisions of ILO Recommendation No. 202. Since its introduction ten years ago, MGNREGA has provided a source of income to rural workers, increased wage rates, achieved high female participation rates and created durable assets. India's local governance bodies, Panchayati Raj Institutions (PRI), have been empowered and involved in the processes of planning and monitoring. However, despite successes, there have been considerable shortcomings in implementation. This article highlights two central themes: first, the innovative policy framework of the Act, which brings together rights‐based entitlements, demand‐driven employment, and citizen‐centred monitoring. Second, it assesses the accessibility and adequacy of benefits in the implementation of MGNREGA. We conclude that MGNREGA offers potential for South‐South learning, both in terms of policy‐design and implementation.