Social Protection for agricultural workers in Senegal Aly CISSE ILO/STEP Sénégal

Outline Context of MIS Development Evolution of the extension of social security Positive contribution and limits of micro insurance National Strategy of Social Protection Social Protection for agricultural workers

Reminder: Some data GDP / capita: less than 700 US $ Life expectancy: 50 years Child infant mortality: + 150 / 1000 Maternal mortality: + 510 / 100 000 On average, more than 40% of population is poor Poverty in worse in rural areas (57,5%)

Context Let’s go back in time: In the 60s (following independance) government was the only garantee for health care access: free access for all was the principe; Two major events changed the situation: Structural adjustment policies; Bamako Initiative. Policies reinforces by international organizations such as world bank and MFI to improve what they called macroeconomics agregats:

Structural adjustment policies Public health expenditures reduction; Bad public health care supply; Difficulties for government to ensure health care access and quality.

Bamako Initiative Health care services recovery with a tarification policy End of free access to health care: communities should participate to the health cost. Participation of the population to health care services management Policy

MIS a credible alternative Democratization process in Africa Development of a strong civil society Presence of NGOs and international organizations Government involvment Encourages the development of a strong civil society

Evolution of the extension of social security in Senegal 10 years ago Formal sector employees (10%) Covered through social security and other mechanisms (private insurance) Rural and informal sector (80%) Excluded from social security Isolated beneficiairies from social assistance funds Very Poor (10%)

Evolution of the extension of social security in Senegal Development of micro-insurance (bottom-up) : 1995-2003 Complementary mutuals Civil servants / corporation / trade unions Formal sector employees (10%) M Micro- Insurance developed by a MFI Pamecas in Senegal M M M IMF Rural and informal sector (80%) Insurance managed by a federative structure ASSURCAD in Senegal M Health Micro-Insurance Schemes « mutuelles » Wer Werlé Thiès Oyofal Paj in Senegal, Very poor (10%)

Evolution of the extension of social security in Senegal Development of linkages : since 2000 Linkages formal / informal SP schemes Unions des Mutuelles de Santé de Dakar, UMSD Formal sector employees (10%) Contracting with HC providers - mutualized agreements in Thiès M M M IMF M Rural and informal sector (80%) M Linkages of MI schemes Cadre local de développe- ment des mutuelles de Kaffrine in Senegal M M M Ind. « Sponsorship », solidarity and equity funds - Wer Werlé Thies Very poor (10%)

Positive contribution of micro-insurance Improved comprehension of social protection Improved conditions of access to health care and reduced insecurity Increased transparency in billing / fee setting and management of healthcare thanks to the contracting process with HC providers

Current limits of MIS Weaknesses of the schemes Size of membership limited  reduced pools 64% of the schemes have less than 1 000 persons covered in 2003 Some reasons: Voluntary membership When membership is automatic, the size is increased; Ex: Mutuelle des volontaires de l’éducation (Senegal), 135 000 persons covered Inadequacy of health care  the system is less attractive Limited financial capacity of the members + no subsidies  limited benefits packages

Current limits of MIS Weaknesses of the schemes Poor management skills and information systems Voluntary management staff; little number of schemes with computerized MIS (Progressive installation of MAS gestion in Senegal, Benin and Burkina Faso) Premium collection mechanisms Per month & direct payment  low collection rates Weak capacity to negotiate with healthcare providers

Current limits of MIS Limitations at a higher level Lack of coherence at the national level Poor redistribution Between +/ - rich members (flat rate premiums) With other segments of the population (formal sector) No functional linkages with statutory SS schemes Weakness of the environment for the development of these schemes

National Strategy of Social Protection in Senegal In that context, the government of senegal decided to move forward in order to boost social security coverage The formalization of the NSSP began in 2005 with

Context of NSSP elaboration Absence of Social Protection in PRSP I Correlation between absence of social protection and household poverty Households ( particularly poor households) are vulnerable face to risks such as accident, illness, etc. Participatory approach Key actors: government, civil society, international organizations Big ILO involvment The NSSP became one pilar of the PRSP II (2006-2010)

Objectives of the SPSN Increase the social protection coverage level, specially for health care Sensitize populations on the importance of social protection as poverty reduction strategy Train human resources necessary for social protection systems planning and management More specifically: extend the health insurance level of coverage from less than 20% to 50 % by 2015

Nationwide micro-insurance schemes based on socio-occupational groups Transport operators (400 000 persons to be covered) SCHEME Agricultural workers (5 million persons to be covered) SCHEME Trade unions Groups Groups of farmers Federations The groups include cooperatives, GIE, groups of producers, federations of GIEs …

Social Protection for agricultural workers in Senegal

Context Level of poverty of agricultural workers Experiences of social protection in rural areas Government comittment to support social protection of agricultural workers Law in 2004 (Loi d’orientation agro-sylvo-pastorale)

Principes Automatic enrollment Diversity of financing sources (beneficiaries, taxation, budget allocation) Innovative financing mechanisms (indirect premium collection ) Outsourcing of technical management and use of computerized MIS Progressivity in the implementation

Services covered Health insurance first step: a priority for all Coverage system Health care in the public sector Primary level (health post, health centre) Secondary and tertiary level (regional and national hospitals) Quasi-totality of health care are covered Level of coverage 70% at the primary level 90% at secondary and tertiary level

Cost of coverage The cost of coverage is estimated to 13 000 FCFA per person and per year (20 USD) Beneficiaries will pay 23% (7 USD) Government will pay 67% (21 USD)

Legal framework The implementation of nationwide HMIS such as the agricultural workers social protection system should help improve access to health care and quality. It goes with the restructuration of the HMIS environment(laws and regulations, relationships with health care providers) …………………………

Legal framework The structuration is based on: A legislation on health micro insurance schemes; A coherent framework for the contracting process with healthcare sector Since 2004, ILO works with 8 WAEMU (West African Economic and Monetary Union) to elaborate legal framework on HMIS Health care providers, HMIS and other partners were involved in the process. Legal framework (rules and regulations) in an adoption procedure at WAEMU. HMIS will be reinforced in terms of access and quality of care in partnership with health care providers. A contracting framework aims to improve quality of care and relationships between HMIS and providers. This will allow: Health care providers face an organized demand; HMIS to alleviate difficulties such as cautions asked by health care providers or fee setting not adapted to their members. The contracting framework contains key elements: Quality of care, Fee setting and billing modalities, Information, follow up, control mechanims of the contracting framework

Social Protection for agricultural workers in Senegal Thank you fo your attention