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.     

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.     

Exit from and re‐entry into social assistance benefit in Belgium among people with migration background and the native‐born

Whereas several studies have examined the timing of exit from social assistance, little is known about the exit destinations after social assistance and whether these entail different risks of re‐entry into social assistance. Using administrative data, we studied 13,552 people with various migration backgrounds who entered social assistance in Belgium in 2004 or 2005. We tracked their social assistance spell(s) and the income source(s) after exit on a quarterly basis over 4 years, using random‐effects hazard models. We found that one‐third of the beneficiaries exited from first‐spells to work, whereas 14% left to active labour market programmes (ALMPs) and 16% to social insurance benefits. About a third re‐entered social assistance, in particular after short work exits. Participation in ALMPs and social insurance benefit receipt was less common among beneficiaries with migration background compared with native‐born and these exits led less frequently to re‐entry than did exits to paid employment.     

How unemployment duration affects social assistance receipt: evidence from Finland

This article reports on a study of the impact of unemployment duration on the probability of becoming a social assistance recipient and on the time spent on social assistance. The data are taken from a local Finnish labour market consisting of the cohort of unemployed people at a given date (n = 2,274). The data are linked to information about the number of months recipients received social assistance during the subsequent year. Count data regression models of the hurdle type are estimated. The results of the analysis suggest that the impact of unemployment duration on the probability of becoming a social assistance recipient is explained to a large extent by changes in the distribution of types of unemployment benefits between people with different lengths of time spent in unemployment. Unemployment assistance recipients are more likely to become social assistance recipients and to spend longer periods on social assistance than are recipients of unemployment insurance because the unemployment benefits for the latter are higher. Among social assistance recipients, time spent on the transfer increases with unemployment duration only for those who are in frequent need of assistance.     

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.     

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.     

Economic support in old age: The role of social insurance in developing countries

The origins of social insurance in industrialized and developing countries are discussed. In recent years social insurance programmes in many developing countries have come under sharp attack. Major issues have been raised with regard to how these programmes are operating, especially with regard to problems of inadequate coverage, adequacy and equity, shortfalls in financing, and administrative mismanagement. In addition to discussing these problem areas, the article reviews the major social insurance options: the family, social assistance, employer sponsored pensions, and savings plans encouraged or operated by governments.     

The impact of tax-financed pensions on poverty reduction in Latin America: Evidence from Argentina, Brazil, Chile, Costa Rica and Uruguay

In many Latin American countries, tax-financed pensions (TFPs) have expanded, mainly resulting from growing informalization of employment and stagnating or declining pension insurance coverage. In the five countries examined in this article, TFPs have generally been effective in reducing poverty and indigence. In Brazil rural social assistance pensions cut the incidence of destitution among poor older people by 95 per cent. In Chile TFPs considerably improved their poverty reduction effectiveness between 1990 and 2000. Tax-financed pensions have therefore been seen as an instrument to supplement contributory pension coverage and boost overall social security coverage. A key challenge is to increase pension insurance coverage through existing statutory pension insurance or special contributory schemes targeted on workers in the informal economy. Otherwise, TFPs could become financially and socially unsustainable in the future. There are also various ways to improve the financing, administration and eligibility criteria of TFPs, particularly because it is necessary to define consistent structure and benefit policies between these and contributory schemes.     

Social Security for the Informal Sector: A New Challenge for the Developing Countries

Informal sector workers constitute a large and increasing part of the labour force in most developing countries. Many of them are not able or willing to contribute a significant percentage of their incomes to finance formal sector social insurance benefits that do not meet their priority needs. Therefore, informal sector workers themselves need to (and have) set up health and other social insurance schemes that better meet their needs and contributory capacity. In addition, special social assistance schemes are necessary to protect the most vulnerable groups outside the labour force. This article also assesses some key implications of these developments for formal social insurance schemes.     

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.     

Rural population and social security in Brazil: An analysis with emphasis on constitutional changes

This paper analyses the situation of the Brazilian rural population with respect to social insurance and social assistance at two points in time: 1988 and 1998. The 1988 Constitution defined new rules with regard to eligibility conditions and benefit values for the rural population. But it was only in July 1991, with Law 8213, that these changes were implemented. We compare — by gender and individual age — activity rates and probability of receiving benefits, before and after the changes in legislation. We also compare, at these two points in time, family structure and the importance of the income of older people in the family budget. The analysis makes clear the positive impact brought by the legislation on the coverage and per capita family income of those families with older members in rural Brazil, bringing about some degree of poverty alleviation, as well as bridging the gender gap with respect to access to benefits. In contrast to what occurs in other Latin American countries, nowadays the Brazilian rural population has almost universal access to social security benefits, not only at family level but also in individual terms.     

The decomposition of social policy in Sweden

The traditionally strong dominance of the state in social security in Sweden has been replaced by a more mixed structure. Individuals are increasingly covered by a mix of private welfare, employment-based corporate welfare and state programmes. There are several reasons behind this development: shifts in the economic and political conditions, strong tax incentives for the individual to buy private insurance, increasing problems for the public system in covering the loss of income for middle and high income earners, repeated media reports that the public welfare system will go bankrupt in the near future and increasing reports on free-riding and cheating in the area of public insurance. The advantage of the more mixed system may be its similarities to social insurance in some of the European Community Member States. However, from a social policy point of view there are also some dangers. There will be increasing tendencies towards inequality. In particular, the difference in social security conditions between the skilfully employed and marginal groups will be even more marked. The unemployed, the young and people with physical or mental handicaps will be left outside the private and corporate structures. There is also a marked risk that some individuals be reach a level of coverage well above the loss of income, and this will be a disincentive to work. Private and corporate welfare systems are also largely invisible in the sense that individuals may not even know under what conditions they are covered. Another problem is that public attitudes towards the public welfare system will increasingly become more negative and different in various parts of the population. The effect of this may be a vicious circle: public social policy becomes increasingly inefficient and unpopular among the working population and remains only as a marginal system for small marginal groups.     

Social policy and health: transition countries in a comparative perspective

T. Ferrarini, O. Sjöberg. Social policy and health: transition countries in a comparative perspective Int J Soc Welfare 2010: ??: ??–??© 2010 The Author(s), Journal compilation © 2010 Blackwell Publishing Ltd and International Journal of Social Welfare. This article analyses the development and design of unemployment insurance and family policy benefits and their links to health outcomes in Estonia, Poland, the Slovak Republic, Slovenia, the Czech Republic and Hungary from the mid‐1990s. Comparing these six transition countries with long‐standing welfare democracies reveals important similarities and differences in policy and health. Unemployment benefit schemes resemble corporatist schemes in important respects, however, with lower coverage and average benefits. Subjective wellbeing is also comparatively low among both employed and unemployed in the transition countries. Several transition countries have mixed family policy strategies that simultaneously support dual‐earner families and traditional gender roles. One clear exception is Slovenia, which has a highly developed dual‐earner support. Family policy generosity is related to lower rates of poverty, infant mortality and child injuries. The article demonstrates the fruitfulness of institutional analyses of the link between social policy and population health in a broader welfare state context.     

社会医疗保险对老年人健康水平的影响：基于浙江省的实证研究

本研究根据2010年浙江省城乡老年人口生活状况调查的数据认为,对于老年人的社会医疗保险问题,不仅要关注保险覆盖面的扩大,更应关注不同保险项目参保老人之间的健康平等。在揭示医疗服务使用与健康水平负向关系这一主效应的基础上,研究发现,职工医保作为moderator可以改善使用较多医疗服务老人的健康水平,新农合的作用则相反。研究希望对医疗保险的改革思路进行反思,全民医保的改革思路不仅是医疗服务可及性的提高,更应该是不同社群享有平等的医疗福利,并最终促进健康结果的平等。     

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。     

Comparing unemployment protection and social assistance in 14 European countries. Four worlds of protection for people of working age

Pfeifer, M. Comparing unemployment protection and social assistance in 14 European countries. Four worlds of protection for people of working age This article aims to show which policy responses 14 Western European countries have adopted to deal with rising unemployment levels and increased need for benefits during working age. In contrast to earlier studies, both components of unemployment benefits (UB), i.e. unemployment insurance and unemployment assistance, were taken into account in a social rights indicator that depicts the legal entitlements of the unemployed. In total, there were eight indicators of both UB and social assistance representing expenditure, generosity, problem pressure and benefit entitlements. The following cluster analysis groups countries using these indicators. The resulting typology consisted of four ways of protecting the working‐aged: an extensive safety nets type operating well with functioning labour markets; a liberal protection type dealing with low levels of unemployment; a targeted protection type combined with an insider–outsider divide on the labour market; and lastly, a patchy safety nets type facing high unemployment levels.     

Smaller net or just fewer to catch? Disentangling the causes for the varying sizes of minimum income schemes

The number of social assistance recipients varies significantly between welfare states. Social assistance is a last-resort residual benefit, so a high number of receipts may be related to policies for first-tier benefits, social assistance and their implementation, as well as need factors (unemployment rate and low income). Considering the strong political will to diminish the receipt of last-resort benefits, we demonstrated a way to decompose the reasons for eligibility in a cross-national analysis of two Nordic countries, namely Finland and Sweden. By using administrative register microdata, eligibility simulations and policy swaps, we found that the legislative features of social assistance, such as more extensive benefit norms and earning disregard, contribute to Finland's higher eligibility rate and likely explain some of the reasons for its higher number of recipients. Finland also exhibited lower non-take-up rates among those eligible, which implies better access to benefits than in Sweden.     

Multi‐pillared social insurance systems: The post‐reform picture in Chile,Uruguay and Brazil

This article focuses on an analysis of social insurance models and reforms in Chile, Uruguay and Brazil. Noting that these three countries are following different reform trajectories, the article explores trends in the restructuring of each of these insurance systems across the course of successive reforms. In the systems, different trends are supporting a closer link between contributions and benefits, according growing importance to private individual accounts and favouring the expansion of the role played by social assistance. These trends all suggest a move towards various forms of multi‐pillared social insurance, but with uncertain results in terms of redistribution and the dynamics of the fundamental objectives of social insurance.     

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.     

Labour market integration of unemployed youth from a life course perspective: the case of Norway

The aim of this article is to analyse the labour market integration of previously unemployed youth in a life course perspective. 'Work, Lifestyle and Health' is a longitudinal panel survey following a sample of nearly 2,000 individuals who are representative of the Norwegian cohorts born between 1965 and 1968. The survey was first conducted in 1985 with follow-ups in 1987, 1989, 1993 and again in 2003. Unemployment among young people does not necessarily lead to marginalisation and social exclusion. Long-term effects will be dependent upon how the youths cope with unemployment, the duration of the unemployment period, their mental health status and educational qualifications. Many young unemployed people are not entitled to unemployment benefits because they lack work experience. Consequently, they are dependent on support from their family and/or social assistance. However, there is still much to learn about the long-term consequences of youth unemployment, e.g. whether or not the youths have received social assistance and what are the long-term consequences for their future labour market career and labour market integration.