First published in 1948, the International Social Security Review is the principal international quarterly publication in the field of social security.
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.
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 is 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.
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.
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.
Processes of public policy formation and implementation in the Middle East and North Africa are underexplored. This article presents a case study in public policy reform, focusing on efforts to expand health insurance coverage in Egypt. The account draws on a thematic analysis of peer and non-peer reviewed literature and print media between 2005 and 2015, with a particular focus on the period to 2011. This analysis shows that reform initiatives failed for much of this period because of fundamental disagreements between key actors over the goals, proposals and the political process for change. The success of planned reforms in Egypt may well depend on the extent to which account is taken of the varied agendas and evolving power relations of these actors, especially given the profound political, social and economic challenges the Egyptian health system now faces.
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.
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.
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 extension. Some countries, however, have seen weaker progress, with stagnant coverage levels. Several factors underlie the extension of pensions and health care coverage and the increased 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 controversial and diverging views on social protection financing in the region. These views tend to favour non-contributory over contributory financing mechanisms and support proposals for limited coverage, but do not address the stratification of access to social protection. The move towards the alignment of benefits is deemed essential: strategies to universalize social protection in the region should not focus exclusively on increasing resources, but must address their form given that institutional change is a crucial part of the locus of innovation
In the absence of a bilateral agreement for the portability and totalization of social security contributions between the United States and Mexico, this article examines the access to pension and health insurance benefits and employment status of older Mexican return migrants. We find that return migrants who have spent less than a year in the United States have a similar level of access to social security benefits as non‐migrants. Return migrants who have spent at least a year in the United States are less likely to have public health insurance or social security benefits, and could be more vulnerable to poverty in old age. These results inform the debate on a bilateral social security agreement between the United States and Mexico to improve return migrants' social security.
Chinese health care policy has undergone numerous reforms in recent years that have often led to new challenges, inciting the need for further reform. The most recent reforms attempt to find a middle path between public health care provision and commercial private insurance. In this way, China is following in the footsteps of countries that initially increased the role of privatization in the 1990s and at the beginning of the 21st century, but are now gearing towards public health care. However, this process of constant reform has led to a lack of transparency in the functioning of the health care system, provoking a loss in public trust. There remains an important degree of uncertainty about the future direction of developments in China. Nonetheless, a dual financing approach to health care using tax finance and social insurance might yet crystallize, offering a potential model to inform developments in other countries.
This article assesses the effectiveness of pension provision and health insurance in preventing ill health among older people in developing countries. It argues that, until recently, social protection agendas devoted insufficient attention to health risk prevention, instead focusing on the reduction of income poverty through cash transfers. The article shows that there is little reliable evidence to indicate that providing older people with pension benefits enhances their health status and that these effects should not be taken for granted by policy‐makers. The article then focuses on the effect of inclusion in health insurance schemes on health outcomes for older people, with specific reference to outcomes related to hypertension. Drawing on newly‐available data from the World Health Organization for Ghana, Mexico and South Africa, it shows that older people with health insurance are marginally more likely to be aware of health conditions such as hypertension and more likely to have them under control. Nevertheless, the great majority of hypertensive older people, insured or uninsured, are not effectively treated. The chief barriers to treatment are shown to be mainly related to awareness and service provision, rather than financial ones. Consequently, the capacity of pensions or health insurance to enhance health outcomes for older people in such countries, including in rural areas, is heavily contingent upon health education, health screening and adequate health service provision. These interventions should be viewed as an integral element of mainstream social protection strategies, rather than adjuncts to them. Yet, in practice, social protection and health promotion continue to be treated as almost entirely separate spheres, thus presenting substantial institutional barriers to developing combined interventions.
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.
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.
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.