Extending social security to the poor Wouter van Ginneken Antwerp, 18 December 2003

Outline of presentation 1. Social security shortfalls: Extent and reasons 2. Social security and poverty 3. Extending health insurance 4. Global campaign on social security and coverage for all 5. Conclusions

1. Social security shortfalls: Extent and reasons Definition of social security: ensure access to health care and guarantee income security (contributory and tax-financed systems) 5-10% coverage in low-income countries. Rising informal economy employment. Adjustment, governance and decentralization. Workers in the informal economy have different priority needs and low contributory capacity.

2.1 Poverty, social security and other social policies Needs and capabilitiesSocial securityOther social policies Risks related to employment capacity and family cohesion UnemploymentUnemployment (insurance) benefits Regulatory and other labour market policies Sickness, disability and survivors Social (insurance) pensionsCare, rehabilitation and reintegration; safety & health Old-ageSocial (insurance) pensionsHome help; old people’s homes Family cohesionMaternity, child and family benefits Child care; parental leave Basic needs and capabilities SubsistenceTax-financed benefitsSocial work; anti-poverty policies HealthHealth insuranceNational health service; health policy EducationFee waiversSchool meals and books; education policy HousingRent and energy subsidiesSocial housing FoodFood stamps and subsidiesFood aid

2.2 Social security: micro and macro impact Micro-impact: Supports employment capacity and family cohesion (f.e. health & maternity protection) Income security in case of lack of employment capacity Macro-impact: Social cohesion (through security and social dialogue), leading to predictable economic situation (investment climate and acceptance of structural change).

3.1 Extending health insurance: middle-income countries The achievers: South Korea and Costa Rica (political commitment, public expenditure and formal labour force). Striving for universal coverage: Colombia and Tunisia (fast-track versus gradualist; effective design and organization; constitutional commitment). Policy issues: (i) when to go for universal compulsory coverage? (ii) how to deal with the self-employed? (iii) impact of voluntary associations.

3.2 Low-income countries: The emergence of micro-insurance Efficient solution to immediate needs Coordination network (« la concertation ») between mutual health organizations in 11 West African countries. How to up-scale: training in design and management; monitoring and regulation; co-financing arrangements; re-insurance.

3.3 The potential of district- based schemes Actors: district government, civil society, social partners, health care providers Advantages of district-level approach: Greater social control More effective management options Greater chance to achieve universal coverage Developing district-based schemes: Establish unsatisfied demand for health care Design an overall system that covers everyone, in a process of social dialogue Experiment with various extension mechanisms.

4. The global campaign on social security and coverage for all Knowledge development Research (best practice, ESS Papers) New mechanisms (experimenting with community - and district - based HI schemes) Technical cooperation Extension through social dialogue (Mali, Honduras and Sri Lanka) Basic social pension (Global Social Trust). Partnerships African initiative for Health care coverage in Latin America

5. Conclusions Social security and poverty Extending Health insurance: combination of top-down and bottom-up approaches Global Campaign on Social Security and Coverage for All