Social Health Protection: An ILO Strategy Towards Universal Access To Health Care

Social Health Protection
An ILO strategy towards universal

access to health care
The Social Security Department of the International Labour Office (ILO) is the unit through which the
ILO provides technical assistance and advice to its member countries in the area of social security
policy and governance; develops policies to support the extension of social security to all and social
inclusion; promotes international social security standards and develops and disseminates tools to
support the effective governance of social security schemes.
In 2001, the International Labour Conference (ILC) reached a consensus that high priority should be
given to policies and initiatives to extend social security to those who are not presently covered.
Accordingly, the ILC directed the ILO to launch a major campaign to promote the extension of social
security coverage. The Social Security Policy Briefings series is produced in the framework of the
Campaign; it aims to set out the views of the Social Security Department in areas of particular
importance, and so provide guidance to ILO member countries in the formulation of their social security
policies.
It thus complements the existing Issues in Social Protection Discussion papers series and the Extension
of Social Security series published by the Social Security Department by making available a
comprehensive set of information tools.
International Labour Office

Social Security Department
4, route des Morillons
CH-1211 Geneva 22 – Switzerland
Tel.: (+ 41 22) 799 75 65

Fax: (+ 41 22) 799 79 62
[email protected]
http://www.ilo.org/secsoc
SOCIAL SECURITY POLICY BRIEFINGS
Paper 1
Social Health Protection
An ILO strategy towards universal

access to health care
Global Campaign on Social Security and Coverage for All
Social Security Department

International Labour Office
Copyright © International Labour Organization 2008
First published 2008
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Social health protection. An ILO strategy towards universal access to health care.
Social security policy briefings; Paper 1/
International Labour Office, Social Security Department – Geneva: ILO, 2008
ISBN 978-92-2-121161-7 (print) & 978-92-2-121162-4 (web pdf)
International Labour Office; Social Security Dept
health insurance / medical care / access to care / scope of coverage / social security financing / role of ILO
02.07.1
Soon available in French: La protection sociale de la santé. Stratégie de l’OIT pour un accès universel aux soins de santé; and in Spanish:
Protección Social de la Salud. Una estrategia de la OIT para el acceso universal a la asistencia médica.
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Contents
Page
Foreword ........................................................................................................................................... xi
1. Introduction............................................................................................................................. 1
2. What is social health protection? ............................................................................................ 3
3. Financing social health protection: The current situation ....................................................... 7
4. Coverage of social health protection and access to health services ........................................ 16

a. ILO concepts and definitions of coverage and access .................................................. 16
b. Trends in formal social health protection coverage...................................................... 17
c. The formal and informal economy and the need for social health protection .............. 20
d. The lack of access to health services: An attempt to estimate the dimension............... 23
e. The access deficits and its associations ........................................................................ 26
f. Some observations on recent developments in social health protection....................... 28
5. Rationalizing the use of pluralistic financing mechanisms: An ILO strategy for achieving
universal coverage in social health protection........................................................................ 33
a. Overall concept of the ILO strategy on rationalizing the use of pluralistic financing
mechanisms ................................................................................................................. 33
b. Core elements of the ILO strategy on rationalizing the use of pluralistic financing
mechanisms ................................................................................................................. 34
i. Assessing the coverage gap and the access deficit ............................................. 34
ii. Developing a national coverage plan.................................................................. 34
iii. Strengthening national capacities for implementation ....................................... 47
6. Conclusion .............................................................................................................................. 49
a. Africa.................................................................................................................. 51
b. Asia..................................................................................................................... 59
c. Europe ................................................................................................................ 68
d. Latin America..................................................................................................... 71
References ......................................................................................................................................... 95
ILO Strategy Social Health Protection.Sept v

List of Tables
2.1. Sources of funds for social health protection.......................................................................... 5
3.1. Sources of social health protection financing by country income level.................................. 10
3.2. Percentage of the household financial mechanisms to cope with health care expenses,
South Africa, Kenya and Senegal, 2005 ................................................................................. 12
4.1. Historical development of formal health protection coverage ................................................ 20
4.2. Formal coverage in social health insurance protection in selected countries of Africa
and Asia................................................................................................................................... 22
4.3. Percentage of the population with formal health protection coverage in selected
Latin American countries and selected years within 1995-2004 ............................................ 22
4.4. Estimated accesss deficit in selected countries ....................................................................... 30
5.1. Health care coverage and access map specimen ..................................................................... 36
5.2. Scope of health financing mechanisms ................................................................................... 39
5.3. Overview: Pros and cons of key financing mechanisms for social health protection ............. 40
List of Figures
2.1. Flow of funds .......................................................................................................................... 4
3.1. Income level of countries and death at ages 0-4 and 60+, 2006 ............................................. 7
3.2. Percentage of causes of death in low-,middle- and high-income countries, 2001 .................. 8
3.3. Financing of global health expenditure, 2004......................................................................... 8
3.4. Out-of-pocket expenditure as a percentage of total health expenditure, selected
countries, 2006 ........................................................................................................................ 9
3.5. Percapital health expenditure in US$, by country income level, 2004 ................................... 9
3.6. Total health expenditure as a percentage of GDP and public expenditure on health
as a percentage of total health expenditure by country income level, 2004............................ 10
3.7. Sources of health protection by region, 2001.......................................................................... 11
3.8. Total health expenditure as a percentage of GDP, selected low income countries, 2006....... 11
3.9. Spiralling health and poverty trap ........................................................................................... 12
3.10. Public expenditure on health as a percentage of total health expenditure, selected OECD
countries, 1990, 2000, 2005 .................................................................................................... 13
3.11. Total expenditure on health per capita, US$ purchasing power parity, selected OECD
countries, 1960-2005............................................................................................................... 15
4.1. Achieving universal coverage in social health insurance........................................................ 20
4.2. Out-of-pocket expenditure, selected low-income countries, 2006.......................................... 23
4.3. Regional distribution of poor people in developing countries lacking in access to health
services ................................................................................................................................... 25
4.4. Density of health professionals ............................................................................................... 26
4.5. Regression between access deficit and Human Poverty Index (HPI) ..................................... 28
4.6. Regression between access deficit and Human Development Index (HDI) ........................... 29
A.1. Comparison of selected countries in Africa ............................................................................ 51
A.2. Ghana National Health Insurance sources of funds ................................................................ 55
A.3. Comparison of selected countries in Asia............................................................................... 59
A.4. Comparison of selected countries in Latin America ............................................................... 71
vi ILO Strategy Social Health Protection.Sept

List of Boxes
5.1. Health budget for Thailand ..................................................................................................... 37
5.2. Checklist for key policies on health care financing ................................................................ 42
5.3. Checklist for policies on building rational linkages between different health financing
mechanisms............................................................................................................................. 43
5.4. Checklist for key policies adequate benefit packages and protection from
catastrophic spending.............................................................................................................. 44
5.5. ILO Convention No. 102 / Article 10 ..................................................................................... 45
5.6. Checklist for key policies on creating institutional and organizational efficiency ................. 47
List of Appendix Tables

1. Selected indicators of social health protection in Benin ......................................................... 52
2. Selected indicators of social health protection in Burkina Faso ............................................. 53
3. Selected indicators of social health protection in Egypt ......................................................... 54
4. Selected indicators of social health protection in Ghana ........................................................ 56
5. Selected indicators of social health protection in Kenya ........................................................ 56
6. Selected indicators of social health protection in Senegal ...................................................... 58
7. Selected indicators of social health protection in Tunisia....................................................... 59
8. Selected indicators of social health protection in China ......................................................... 61
9. Selected indicators of social health protection in the Republic of Korea ............................... 62
10. Selected indicators of social health protection in India........................................................... 63
11. Selected indicators of social health protection in Indonesia ................................................... 63
12. Selected indicators of social health protection in Philippines................................................. 64
13. Thailand’s Social Helath Protection Mechanisms .................................................................. 66
14. Selected indicators of social health protection in Thailand..................................................... 67
15. Selected indicators of social health protection in Albania ...................................................... 69
16. Selected indicators of social health protection in Belarus....................................................... 70
17. Selected indicators of social health protection in Georgia...................................................... 71
18. Selected indicators of social health protection in Chile .......................................................... 72
19. Selected indicators of social health protection in Colombia ................................................... 73
20. Selected indicators of social health protection in Costa Rica ................................................. 74
21. Selected indicators of social health protection in Ecuador ..................................................... 75
22. Selected indicators of social health protection in Peru ........................................................... 76
A2.1. Estimated access deficit in social health protection ................................................................ 77
A2.2. Formal coverage in social health protection ........................................................................... 83
ILO Strategy Social Health Protection.Sept vii

Common Acronyms
ILO International Labour Office
ADB Asian Development Bank
GDP Gross Domestic Product
GTZ Deutsche Gesellschaft für Technische Zusammenarbeit/

German Technical Cooperation
HDI Human Development Index
HPI Human Poverty Index
IHPP International Health Policy Programme
NHA National Health Accounts
MDG(s) Millennium Development Goal(s)
MOH Ministry of Health
OECD Organization for Economic Co-operation and Development
OOP Out-of-Pocket Payments
PRSP Poverty Reduction Strategy Papers
SHI Social Health Insurance
STEP Strategies and Tools Against Exclusion and Poverty
THE Total Health Expenditure
UN United Nations
WHO World Health Organization
ILO Strategy Social Health Protection.Sept ix

Foreword
This is the first in a planned series of papers on social health protection, to be published by
the Social Security Department of the ILO. It represents an important contribution to the
Department’s commitment to the International Labour Conference to pursue the Global
Campaign on Social Security Coverage for All.
We hope that it will mark a new departure in the wider debate on ways to provide coverage
to the majority of the world’s population, engaging not only the ILO’s constituents, but
also researchers, practitioners, decision-makers and other stakeholders in social health
protection. . Moreover, we anticipate that it will play a significant role in ensuring that the
human rights to health and social security, both enshrined in the United Nations Universal
Declaration of Human Rights, will become a reality in the shortest possible time. In the
longer term, our approach will of course reflect the outcome of that debate. Nevertheless,
we trust that the basic approach underpinning our thinking, that is, one of rights-based
advocacy for universal coverage of social health protection and access to health care, is
flexible and open enough to achieve a wide consensus focusing on the two central
objectives of social security: poverty alleviation and granting to all people the opportunity
to live their lives free of debilitating insecurity.
This policy paper and the strategy outlined were developed in close consultation with the
ILO’s constituents [including, specifically, a number of members of the ILO Governing
Body]. Representatives from governments, employers’ organizations and trade unions have
given valuable support to this initiative toward the development of our future strategy, and
we would like to express our sincere thanks for their key role. The paper takes full account
of the many comments and overall feedback received following the circulation of an initial
draft, together with [a number of] position papers.. Accordingly, this paper strongly
reflects the values of tripartism and social dialogue, concepts that are fundamental to the
structure and mandate of the ILO. We would like to thank in particular ILO constituents
from the following countries for their valuable inputs: Australia, Austria, Finland, France,
Hungary, Italy, Jamaica, Jordan, Republic of Korea, Latvia, Lebanon, Lithuania, Mexico,
Morocco, Myanmar, New Zealand, Peru, Portugal, Switzerland, Thailand, Tunisia and
Trinidad and Tobago.
Xenia Scheil-Adlung took the overall responsibility for the drafting of this policy paper,
while Jens Holst provided the statistical data and some country information. Charles
Crevier analyzed the statistical data and developed the section on measuring access
deficits. Technical support in compiling the paper was provided by Jennifer Frances de la
Rosa and Veronika Wodsak.
We have benefited greatly from the valuable comments made by colleagues from ILO and
from various international organizations and experts. We wish to thank the following
colleagues from the Social Security Department who have contributed to the paper,
through help in drafting major parts thereof, by providing oral or written comments, or by
providing inputs through their research and technical cooperation activities: Pauline
Barrett-Reid, Alejandro Bonilla-Garcia, Florence Bonnet, Anne Drouin, Krzysztof
Hagemejer, Frank Hempel, Aidi Hu, Christian Jacquier, Ursula Kulke, Florian Léger,
Philippe Marcadent, Tharcisse Nkanagu, Karuna Pal, Vinicius Pinheiro, Emmanuelle
Saint-Pierre Guilbault, Valérie Schmitt-Diabate, Wolfgang Scholz, Carmen Solorio,
Philippe Vanhuynegem, John Woodall. We also would like to thank our colleagues from
the ILO field offices Christina Behrendt, Fabio Bertranou, Christine Bockstal, Fabio
Durán, Ginette Forgues, Kenichi Hirose, Markus Ruck, Marc Socquet, Sergio Velasco, and
Hiroshi Yamabana.. The final editing was carried out by Frances Papazafiropoulos, with
secretarial and administrative support provided by Irene Brown, María José Escriche,
ILO Strategy Social Health Protection.Sept xi

Vicky Giroud Castiella and Diane Vergnaud, and we would like to thank all of them for
their valuable support.
We are grateful to all who commented on the first draft for consultation of Social health
protection: An ILO strategy towards universal access to health care. Their contributions
have been very important for the further development of the ILO’s approach in achieving
universal coverage in social health protection. While the vast majority of these comments
are duly reflected in this final version of the ILO Strategy on Social Health Protection, a
smaller number of readers may find that their perspectives are not directly reflected in the
strategy which is put forward here. Nevertheless, all of the inputs have helped us to
formulate our policy proposals on social health protection. Its central messages have been
discussed in various fora within and outside the ILO, in consultation with ILO constituents,
various international organizations, bilateral institutions, and the academic world.
Michael Cichon, Xenia Scheil-Adlung,

Director Health Policy Coordinator
xii ILO Strategy Social Health Protection.Sept

1. Introduction
The affordability of health care is a key issue in most countries. In high-income countries,
increasing costs, financial constraints of public budgets and economic considerations
regarding international competitiveness have all made social health protection reform a
political priority. In many high-, middle- and low-income countries, providing affordable
health care is high on the development agenda, given the large numbers of people lacking
sufficient financial means to access health services; worldwide, millions of people are
pushed into poverty every year by the need to pay for health care.
The denial of access to medically necessary health care has significant social and economic
repercussions; aside from effects on health and poverty, the close links between health, the
labour market and income generation have an impact on economic growth and
development. This may be attributed to the fact that healthier workers are more productive
- and labour supply increases if morbidity and mortality rates are lower.
Universal social health protection ensures that all people in need have effective access to at
least adequate care and is thus a key mechanism for achieving these objectives. It is
designed to alleviate the burden caused by ill health, including death, disability and loss of
income. Social health protection coverage also reduces the indirect costs of disease and
disability, such as lost years of income due to short and long-term disability, care of family
members, lower productivity, and the impaired education and social development of
children due to sickness. It hence plays a significant role in poverty alleviation.
For many years, it was commonly thought that introducing and extending social health
protection in developing countries was premature because they were not economically
mature enough to shoulder the financial burden associated with social security. It was
argued that attention should first be focused on macroeconomic growth and that
redistribution through social transfers in cash or in kind should be postponed until the
economy has reached a relatively high level of prosperity. This perspective associated
social health protection only with consumption costs.
At present, social health protection is increasingly seen as contributing to building human

capital that yields economic profits through gains in productivity and higher
macroeconomic growth.
Everyone, as a member of society, has the right to

The current debate 1 also focuses on
the links between ill health and
social security and is entitled to realization, through
national effort and international co-operation andpoverty: these links play an
in accordance with the organization and resources important role in Poverty Reduction
Strategy Papers (PRSPs) and have
of each State, of the economic, social and cultural
rights indispensable for his dignity and the free been addressed in the Millennium
development of his personality. Development Goals (MDGs) aimed
[Art. 22, Universal Declaration of Human Rights, at halving extreme poverty and
1948] improving health by the year 2015.
Implementing universal social
health protection might turn out to be a milestone for achieving the MDGs by that target
date.
1
Social health protection has been highlighted at the G8 Summit 2007 in Heiligendamm
(Germany) and will also be an important issue at the G8 Summit in Japan 2008 as well as figuring
prominently in several international health initiatives.
ILO Strategy Social Health Protection.Sept 1

The ILO supports the MDGs through its Decent Work Agenda and in the context of the
debate on a fair globalization. The four pillars of this approach include:
1. Employment - the principal route out of poverty is through work and income.
2. Rights – as a condition for the empowerment of people to escape from poverty.
3. Social protection - a safeguard of income and financial support in case of sickness.
4. Dialogue - the participation of employers’ and workers’ organizations in shaping and

ensuring appropriate and sustainable government policies for poverty reduction.
The ILO approach to social health protection is founded on the human rights to health and
social security - and on the significance of such protection with regard to rights at work
and employment. Since the ILO’s founding in 1919, it has emphasized the role of social
health protection in reducing poverty, generating income and increasing wealth.
The relevance of social health protection for the Organization may be illustrated by the fact
that in the Social Security (Minimum Standards) Convention, 1952 (No. 102), health ranks
first among the contingencies covered.
The importance of strengthening linkages between rights, employment and development

was underlined in the report of the ILO World Commission on the Social Dimension of
Globalization (ILO, 2004a).
In view of the alarming deficit in social health protection coverage in many countries and
ILO's long experience in this field, a new strategy has been developed to contribute
towards achieving universal coverage at a global level. This strategy reinforces the
agreement on social security reached among representatives of governments, workers' and
employers' organizations at the International Labour Conference in 2001 to give highest
priority to "policies and initiatives that can bring social security to those who are not
covered by existing systems". It is part of the Global Campaign on Social Security and
Coverage for All.
The ILO strategy responds to the needs of uncovered population groups in many
developing countries, the informalization of economies and persisting high rate of health
related poverty and unemployment. This strategy explicitly recognizes the contribution of
all existing forms of social health protection and aims to optimize their impact with the
ultimate goal of achieving universal coverage.
This paper aims to set forth some basic notions about the ILO strategy on rationalizing the
use of pluralistic financing mechanisms. It is based on the most recent information on
social health protection coverage. After a brief introduction on the ILO's concept of social
health protection, the paper outlines global patterns of social health protection financing
and coverage. Given the lack of data on social health protection coverage, the paper
proposes a new indicator aimed at providing, for the first time, some assessment of the
global deficit in access to health services. The ILO strategy takes account of the significant
gaps revealed by the ILO access deficit indicator and suggests new pragmatic policies to
close the gaps, based on a rational and coherent approach.
2 ILO Strategy Social Health Protection.Sept

2. What is social health protection?
Based on the core values of equity, solidarity and social justice, the ILO defines social
health protection as a series of public or publicly organized and mandated private
measures against social distress and economic loss caused by the reduction of productivity,
stoppage or reduction of earnings, or the cost of necessary treatment that can result from ill
health.
Equity, solidarity and social justice are understood here as basic characteristics of universal
access to social health protection founded on burden sharing, risk pooling, empowerment
and participation. It is up to national governments and institutions to put these values into
practice.
Achieving universal social health protection coverage - defined as effective access to

affordable quality health care and financial protection in case of sickness - is a central
objective for the ILO. In this context, coverage refers to social protection in health, taking
into account the:
size of the population covered;
financial and geographical accessibility of covered services;
extent to which costs of a benefit package are covered; and
quality and adequacy of services covered.
Social health protection is a series of public or Social health protection consists of

publicly organized and mandated private measures various financing and
against social distress and economic loss caused by the organizational options intended to
reduction of productivity, stoppage or reduction of provide adequate benefit packages
earnings or the cost of necessary treatment that can for protection against the risk of ill
result from ill health. health and related financial burden
and catastrophe.
There are various mechanisms to finance health services. These range from tax-funded
national health services, vouchers and conditional cash benefits, to contribution-based
mandatory social health insurance and mandated or regulated private non-profit health
insurance schemes (with a clearly defined role in a pluralistic national health financing
system comprising a number of different subsystems), as well as mutual and community-
based non-profit health insurance schemes. These mechanisms normally involve the
pooling of risks between covered persons - and many of them explicitly include cross
subsidizations between the rich and the poor. Some form of cross subsidization between
the rich and the poor exists in all social health protection systems, otherwise the goal of
universal access could not be pursued or attained.
Generally, the following main resources may be used for funding:
Taxes: Social health protection may be funded from general government revenue
such as direct or indirect tax from various levels, including national and local tax in
addition to general or earmarked tax. Direct taxes are levied on individuals,
households and enterprises and comprise property taxes, personal income tax and
corporate profit taxes. Indirect taxes, on the other hand, are obtained from goods and
services (e.g. excise / “sin tax” on consumption of tobacco products). Payments
related to indirect tax are based on consumption and not on overall income. General
taxes can be drawn from different sources and therefore have a broad revenue base;
nonetheless, allocation for health care is subject to annual public spending

negotiations. Hypothecated taxes are earmarked for health and may be less
susceptible to political influence. Taxes are often used for various forms of social
health protection funding. Besides financing national health services, vouchers or
conditional cash benefits, taxes are used as subsidies for mixed health protection
schemes such as national health insurances, whereby government revenues are used
to subsidize the poor. In addition, government revenues may be used as subsidies for
social health insurance, community-based and private health insurance, as shown in
figure 2.1. Subsidies might cover costs for the poor, deficits, specific services, start-
up or investment costs.
Figure 2.1. Flow of funds
Social health insurance Providers

National health National health insurance
services Community-based health insurance
Vouchers Private commercial health
Conditional cash insurance
benefits
Contributions or payroll taxes: Contributions are collected to fund social health

insurance schemes. Contributions are usually mandatory and not risk-related but
based on earned income that is collected from the payroll. Employers and employees
share contributions. This usually involves formal labour markets, which translates to
coverage extended to formal economy workers and their families. International
experience shows employee contributions might be as low as 1 per cent of covered
monthly earnings, as in Egypt (International Social Security Association, 2007, p.78),
and 2.5 per cent in Jamaica (International Social Security Association, 2005, p.135).
In the case of employers’ contributions, Egypt provides for 4 per cent of covered
monthly payroll and Jamaica for 8.5 per cent 2 of their employees’ gross income. In
many countries, contributions are based on the ability to pay and access to health
services depends on needs. Contributions may be collected by a single national health
insurance fund – or by one or more social health insurance funds which are often
independent from the government but subject to regulations.
Premiums: Premiums are collected by private insurance schemes, including

community-based health insurance schemes and private commercial funds.
Community-based schemes are usually voluntary and managed by organizations of
informal economy workers, community based and non-government entities,
cooperatives, trade unions and faith-based groups. Premiums are often flat-rate and
services frequently limited. Premiums for private commercial health insurance funds
2
Information provided to ILO by the Jamaica Employers Federation, October 2007.

are usually voluntary and risk-based. People in high-risk groups pay more and those
with lower risks pay less. Benefits and services vary depending on the insurance
company and insured persons.
Out-of-pocket payments (OOP): OOPs are often used as a source of funding.

However, the ILO does not consider them as a means of financing social health
protection. They involve payments made directly to the health care providers at the
point of delivery, based on the services utilized, and may be paid partially or in full.
They may take the form of direct payments, formal cost sharing or informal
payments. Reference is made to direct payments when the consumer pays the full
amount of health services not covered by any form of protection. Formal cost sharing
(user fees), on the other hand, involves expenditures on health services which are
included in the benefit package but are not fully covered, e.g. in order to set
incentives.
Apart from the above-mentioned sources, there are other sometimes significant sources of
health funding such as donations, grants, loans, employers’ funds and savings accounts.
However, these are not further discussed here.
Each mechanism of funding is characterized by specific forms of collecting funds, risk

pooling and purchasing of health services. The collection of funds involves an entity which
pays (e.g. citizens, insured individuals); a specific type or means of payment (taxes,
contributions, and premiums); and an institution which collects the payment - the
government (central, regional or local), a social security institution, private insurance funds
or health providers (table 2.1). Risk pooling refers to the sharing of financial risks and
accumulating funds for health services. The purchasing of health services involves the
shifting of the funds to health service providers for - and on behalf of - the covered
population.
Virtually all countries have established systems based on multiple financing mechanisms
that combine two or more of the mentioned sources of funding - and the ILO explicitly and
pragmatically recognizes the pluralistic nature of national health protection systems. The
ILO advises the promotion of systemic combinations of national financing systems that
provide:
(a) universal and equitable access to health services;
(b) financial protection in case of sickness; and
(c) overall efficient and effective delivery of health services.
Table 2.1. Sources of funds for social health protection
Direct, indirect taxes and other Contributions/ payroll taxes Premiums Direct, indirect taxes
revenues and other revenues
Collected From
Individuals Employers Individuals Individuals
Households Employees Households Households
Enterprises
Collected By
Government authorities Social security institutions or Private insurance funds Providers
public bodies

In this context, it is important to ensure that national health financing systems do not
crowd out other social security benefits.
When striving to achieve universal social health protection, organizing and financing
health protection are not enough in themselves; economic and social factors also play a
pivotal role and attempts must be made to address poverty, support the formalization of the
informal economy and create decent workplaces. Social health protection thus cannot be
pursued in isolation; it is - and should always be seen as – part and parcel of an overall
national social protection strategy.
Furthermore, achieving universal coverage involves developing specific regulations and

arrangements that focus on efficiency of organization including purchasing and provider
payments; distribution of resources and services across different categories of care and
geographic areas; quality; and participation of social partners and civil society. The
concrete nature of these related arrangements significantly impacts on the adequacy and
availability of care, access to health services, and ultimately on the overall cost of the
social health protection system. A key to this goal is to engage in social and national
dialogue.
Social dialogue can play a major role in the development and reform of health services by
providing the social partners with the opportunity of expressing their own interests and
concerns. It allows them to advance together when they have many interests in common
and may also help them to reach compromises about matters on which they have different
views. Social dialogue in improving health services is based on certain values and
principles to which all social partners subscribe (ILO, 2005d, p.6).
The importance of social health protection can be appreciated by looking into its current
situation globally, regionally and nationally. The following chapter highlights recent
developments and gaps in social health protection.

3. Financing social health protection:
The current situation
It has been argued that high and sustained economic growth increases demand for
employment. By the same token, improvement in earning capacity can lead to increases in
labour productivity and growth. Furthermore, economic development has the potential to
reduce poverty and promote economic productivity (ADB, 2004) – and a prerequisite for
labour productivity is health. It is estimated that an increase of 10 per cent in average life
expectancy leads to an increase in annual economic growth of 0.3 to 0.4 per cent (WHO,
2002). Although investment in health through social health protection is vital, it is also
fraught with complexities. Challenges in financing social health protection are
multidimensional and may be related to socio-economic, demographic and health trends
within countries and around the globe.
As far as indicators in health are concerned, the significant difference in child mortality
between high- and low-income countries reflects the strong link between poverty, access to
affordable health services and death (figure 3.1). Low-income countries record 30.2 per
cent of all deaths in the 0-4-age bracket, as compared to 0.9 per cent in high-income
countries. On the other hand, the share of deaths at age 60 and over exceeds 75 per cent in
high-income countries but stands at about 34 per cent in low-income ones (Deaton, 2006).
Figure 3.1. Income level of countries and death at ages 0 – 4 and 60 +, 2006
80
70
60
50
High income countries
40
30
Low and middle income
20
countries
10
0
0-4 years old 60 years old and
above
Source: Deaton (2006).
Deaths due to communicable diseases, pregnancy and nutrition are more likely to occur in
low- and middle-income countries (36.4 per cent) than in high-income ones (7 per cent),
while non-communicable diseases account for the majority of deaths (86.5 per cent) in
high-income countries (figure 3.2).

Figure 3.2. Percentage of causes of death in low-, middle- and high-income countries, 2001
100
50
0
Non Communicable
Injuries
communicable diseases
High income countries 5.9 86.5 7.0

Low and middle income 9.8 53.8 36.4
countries
Source: World Bank (2006b).
The financing of health-care costs is shared between governments, which contribute 35 per
cent to global health expenditure; social insurance (covering 26 per cent); private insurance
(20 per cent); and out-of-pocket expenditure and other private expenditure which account
for 19 per cent of worldwide expenditure on health(figure 3.3).
Figure 3.3. Financing of global expenditure on health, 2004
General
Government
Out-of-Pocket
Revenues
19%
(excluding Social
Insurance)
35%
Social Insurance
26%
Private insurance
20%
Note: 2004 world health expenditure: US$4.1 trillion.

Source: WHO, National Health Accounts (2007).
Global expenditure on health, as shown in figure 3.3, reveals a large amount of out-of-
pocket expenditure paid at the point of service delivery. A high share of OOP indicates
global inequity and lack of coverage for social health protection. OOP is the most
inefficient way of financing health-care spending. It weighs most heavily on the poor and
is associated with a high risk of household impoverishment through catastrophic costs
(WHO, 2000, pp. 35, 113).

Figure 3.4. Out-of-pocket expenditure as a percentage of total health expenditure,
selected countries, 2006
Bangladesh
80
Cambodia
70 Ghana
India
60
Pakistan
50 Yemen, Rep.
40
Malaysia
30 Slovak Republic
South Africa
20
10 Belgium
0 Luxembourg
Netherlands
Low, Upper-Middle and High Income
Countries
Source: Appendix II, table A2.1.
Figure 3.4 shows the range of OOP within and among low-, upper-middle- and high-
income countries. People in low-income countries such as Cambodia, India and Pakistan
shoulder more than 50 per cent of their health expenditures compared to upper-middle- and
high-income countries. Such a situation can lead to further inequities, increased poverty,
catastrophic health expenditures and impact on income generation due to sale of assets and
borrowing. It also reflects that public expenditure seems to increase in tandem with an
increase in country income levels. Other country examples of OOP expenditure are shown
in Appendix II, table A2.2.
The level of per capita health expenditure also varies significantly among low-, middle-
and high-income countries. As shown in figure 3.5, it ranges between US$1,527, US$176
and US$25 in high-, middle- and low-income countries, respectively. This includes funds
from various public, private and other sources.
Figure 3.5. Per capita health expenditure in US$, by country income level, 2004
1600
1400
1200
1000
800
600
400
200
0
High Income 1527

Middle Income 176
Low income 25

The share of total health expenditure as a percentage of GDP amounts to 7.7 per cent in
high-income countries, 5.8 per cent in middle-income countries and 4.7 per cent in low-
income countries. Public expenditure on health as a percentage of total health expenditure
amounts to 70.1 per cent in high-income countries, 61.7 per cent in middle-income
countries and 51.7 in low-income countries (figure 3.6).
Figure 3.6. Total health expenditure as a percentage of GDP and public expenditure on health
as a percentage of total health expenditure by country income level, 2004
80
70
60
50
40
30
20
10
0 High income Middle income Low income
Total Health Expenditure as a % of GDP 7.7 5.8 4.7
Public Expenditure on Health as % of Total Health 70.1 61.7 51.7

Expenditure
In the global picture, the growing share of public expenditure on health with rising income
levels indicates the increased risk pooling through taxes and e.g. contributions for
mandatory social health insurance. This share is usually linked to the overall social and
economic development of countries with regard to labour markets, financial markets,
enforcement of legislation, infrastructure, capacity to collect taxes etc.
Table 3.1. Sources of social health protection financing by country income level
Countries Tax revenues for social health Social security contributions

protection in % of GDP in health in % of GDP
Low-income 14.5 0.7
Low / middle-income 16.3 1.4
Upper-middle income 21.9 4.3
High-income 26.5 7.2
Source: IMF (2004) , World Bank (2004).
As shown in table 3.1, trends in the use of tax revenues for social health protection range
from 14.5 per cent of GDP in low-income countries to 26.5 per cent in high-income
countries. Contributions to mandatory social health insurance are significantly lower and
range from 0.7 per cent in low-income countries to 7.2 per cent in high-income countries.
Globally, the share of tax revenues is higher than the share of contributions - and both are
positively correlated to income.
At the regional level, the share of different forms of social health protection in overall
health spending varies significantly (figure 3.7). In 2001, tax spending was - at 40 per cent

- relatively high in Africa, Eastern Mediterranean countries and Europe; social health
insurance ranked particularly high in OECD and transition countries in the European
region, in Western Pacific and in Eastern Mediterranean countries; while in the Americas
private health insurance played a key role.
Figure 3.7. Sources of health protection by region, 2001
Government
South Asia
Social insurance East Asia and the Pacific
Private insurance Eastern Europe and Central Asia

Latin America and the Caribbean
Out-of-Pocket
Middle East and North Africa
Other Sub-Saharan Africa
0% 20% 40% 60% 80% 100%
Source: WHO, National Health Accounts Data (2003).
Specific experiences of groups of countries (low-, middle- and high-income countries)

reflect more closely the trends in financing social health protection.
Current concerns in low-income countries often relate to the fact that key health policy
targets, such as those formulated in the Millennium Development Goals (MDGs), cannot
be achieved with the limited funds available. Some Low-income Countries like Burundi,
Pakistan and the Democratic Republic of Congo spend as little as about 2% of GDP on
health (figure 3.8). The impact of this inadequate or low funding in poor countries is
enormous, given that people lack access to health services and are more likely to die from
diseases that are curable in richer countries – for instance, respiratory infections which
account for 2.9 per cent of all deaths in low-income countries, but for relatively few deaths
in high-income countries (Deaton, 2006).
Figure 3.8. Total health expenditure as a percentage of GDP, selected low-income countries, 2006
Cambodia
12 Benin
10 Malawi
Percentage
8 Zimbabwe
6 Bangladesh
4
Yemen, Rep.
India
2
Burundi
0
Pakistan
Low Income Countries
Congo, Dem. Rep.
The relationship between ill health and poverty has been clearly shown in quantitative
ILO/WHO/OECD studies. In countries such as Kenya, Senegal and South Africa, the
impoverishment level due to health payments amounts to between 1.5 and 5.4 per cent of
households – implying that in 2005 alone, over 100,000 households in Kenya and Senegal,
and about 290,000 households in South Africa fell below the poverty line as a direct result
of paying for health services. Table 3.2 shows how catastrophic expenses burden the

uninsured. In addition, out-of-pocket health payments deepen the level of poverty of
people that are already poor (up to 10 per cent of households in Senegal, for example) in
all three countries (Scheil-Adlung et al., 2006).
Table 3.2. Percentage of household financial mechanisms to cope with health care expenses,
South Africa, Kenya and Senegal, 2005
South Africa Kenya Senegal
Uninsured Insured Uninsured Insured Uninsured Insured

(%) (%) (%) (%) (%) (%)
Sales of assets 5.9 10.6 1.0 0.2 15.4 4.4
Borrowing from family 10.5 7.0 4.1 4.3 27.9 12.3
or friends
Borrowing from outside 11.5 3.0 3.2 6.1
Source: Scheil-Adlung et al (2006).
For people experiencing extreme poverty, health is a crucially important economic asset
(OECD, 2003; WHO, 2003). Loss of health and productivity pose major problems for a
socially vulnerable person and his or her family. When a poor individual or any member of
the family falls ill, the entire household may be forced to address the health needs of the
sick by skipping school, missing opportunities to gain income and selling prized livelihood
assets.
Figure 3.9. Spiraling health and poverty trap
Source: Adapted from ILO (2005c).
These health and health-related events can be catastrophic and further plunge people into
poverty due to income loss and high health-care costs. This situation might lead to vicious
cycles of poverty and ill health that can continue from one generation to the next if left
unattended (figure 3.9). Social health protection is vital to address the health and financial
risks to which vulnerable people are exposed.
As for high-income countries, developments in social health protection show the

increasing share of public expenditure and rising levels of income, indicating a growing
proportion of risk pooling through taxes and other forms of social health protection. This is
linked to the overall social and economic development of countries: the labour markets,
financial markets, legislation, institutional infrastructure, and capacity to collect taxes.
In almost all OECD countries, public spending on health is by far the most relevant source
of funding which provides citizens with social health protection (figure 3.10). In Europe,
government and social security spending together account for an average of about 70 per
cent of total expenditure for health care. The population covered by public social
protection mechanisms is close to 100 per cent, except in those countries where private

health insurance is mandatory for some population groups (OECD, 2006). 3 Germany and
the United Kingdom are examples of countries with different health protection
mechanisms, but they both achieve the same goal of universal or near-universal coverage.
Germany has established social health insurance schemes to provide for sickness,
maternity and long-term care coverage for its population. Data from 2006 shows that it
covers all wage and salary workers earning up to €47, 250 a year, including the insured
person’s spouse or partner and children up to age 18, if they are not insured through a
sickness or long-term care fund; pensioners, students, persons with disabilities under
certain conditions; apprentices and beneficiaries of unemployment benefits. The
contributions of the employee and employer vary according to the fund. The average
contribution of an employee is 7.55 per cent of covered earnings up to a ceiling, and 6.65
per cent for the employer (SSA, 2006).
The United Kingdom, on the other hand, has a National Health Service that provides
medical benefits to all persons residing in the country, irrespective of nationality or the
payment of contributions or income tax. It likewise includes short-term incapacity benefit,
statutory sick pay, maternity allowance, statutory maternity, paternity and adoption pay.
Through this tax-funded mechanism, the government covers 92 per cent of statutory
maternity and paternity pay, a part of the statutory sick pay and most of the medical
benefits under the National Health Service (SSA, 2006).
Figure 3.10. Public expenditure on health as a percentage of total health expenditure,

selected OECD countries, 1990, 2000, 2005
100.0
80.0
60.0 1990
2000
40.0 2005
20.0
0.0 Unit ed Unit ed

Aust ria Canada Finland France Iceland Norway Spain
Kingdom St ates
1990 73.5 74.5 80.9 76.6 86.6 82.8 78.7 83.6 39.4
2000 75.9 70.4 75.1 78.3 82.0 82.5 71.6 80.9 43.7
2005 75.7 70.3 77.8 79.8 82.5 83.6 71.4 87.1 45.1
Data as of October 2007.

Source: OECD Health Data, 2007 (United Kingdom 2005 data, difference in methodology).
In many Western European countries, universal rights are translated into access to health
care through the above-mentioned social protection mechanisms; however, they do not
always achieve universal access and there are still inequalities which must be addressed.
These include lack of insurance coverage, inadequate coverage for certain types of care,
increased individual costs of care, exclusion of certain population groups and geographical
disparities of supply of health providers. Long waiting periods for medical treatments, as
3
This refers to the Netherlands where health insurance is mandatory. People can choose between
various insurance providers, and flat-rate contributions are independent of their ability to pay.

well as lack of information and complex administrative procedures, are further
shortcomings. Although increased efforts have been made to cover excluded groups, some
gaps remain, e.g. for persons lacking permanent residence status or citizenship (European
Commission, 2007, pp. 84-85).
Other challenges faced by populations in high-income countries include demographic

ageing, shortage of health professionals (e.g. nurses) and changes in disease trends - which
include an increasing prevalence of lifestyle-related diseases, such as obesity 4 - and
disability patterns. Disability due to chronic diseases is partly linked to ageing and often
requires expensive and labour-intensive long-term care. Data from Germany indicates that
in 2002 about 2.5 per cent of the total population was dependent on long-term care, and the
figure is expected to rise to 3.4 per cent by 2020 (Federal Statistical Office, 2003). While
most high-income countries provide for some kind of professional long-term care services,
these often cover only a small percentage of the nursing care required. Given the cost of
long-term care, many elderly dependents are unable to access services considered
necessary.
Figure 3.11 shows increasing per capita health expenditure in OECD countries from 1960
to 2005. The average health expenditure per capita for persons 65 and older in OECD
countries is estimated to be about three times higher than that for younger persons (OECD,
2005a). It is projected that due to demographic ageing, total health spending in OECD
countries might increase by about 3 per cent of GDP over the period 2000-50 (OECD,
2004). Total expenditure for long-term care ranges between 0.2 per cent and 3 per cent of
GDP in OECD countries (OECD, 2005c). Public revenues are the main source of funding
for these expenditures. Nursing care in institutions accounts for 82.8 per cent of total
expenditure on long-term care in Canada and for 54.7 per cent in Germany.
Figure 3.11. Total expenditure on health per capita, US $ purchasing power parity,
selected OECD countries, 1960-2005
7000
6000
Austria
5000 Canada
Finland
4000 France
Iceland
3000 Norway
Spain
2000 United Kingdom
United States
1000
0
1960 1970 1980 1990 2000 2005
Data as of Oct. 2007.

Source: OECD Health Data, 2007 (United Kingdom 2005 data, difference in methodology).
The expected development of health-care costs for higher age-groups and long-term care
pose a formidable challenge to the health systems of industrialized countries. New ways to
invest in preventing long-term dependency on chronic care and financing of care need to
be devised to avoid the re-emergence of old-age poverty or the dependency on charity in
industrialized countries.
4
As in Finland, specified in the document containing comments on the ILO strategy paper provided
by the Finnish Ministry of Labour.

Access to adequate and affordable health care for all remains a key problem for many poor
countries; however, it is also becoming an increasing challenge for high-income countries,
where demographic trends, rising costs, financial constraints of public budgets and
economic considerations concerning international competitiveness are making social
health protection reform a political priority.
During the past decade, there has been a growing tendency, in most countries, to use
various sources of funding simultaneously for health protection mechanisms. This has
coincided with the widely held view that universal access to health services should be
achieved as quickly as possible. The corresponding financing mechanisms are considered
complementary at all stages of development.
In summary, the above findings indicate that national patterns of health financing not only
have an impact on the health status of the population but also on their income levels and
income security. The global profile of financing social health protection for many low-
and middle-income countries is as follows:
tax funding is significantly higher than contribution funding and both are positively
correlated to income;
there is a close relation between income levels of countries, access to health services
and mortality;
the share of public financing of total health expenditure is low;
limited financial protection leads to high levels of OOP and ensuing health-related
poverty;
solidarity in financing, expressed by risk pooling, is limited;
share of social health protection expenditure of GDP and of total health expenditure is
low; and
a large private share of health financing shifts the burden of health expenditure to
households.
The experience of many industrialized countries shows that social health protection can
raise enough funds to achieve universal access, while protecting the individual against the
risk of high health-care costs in case of sickness.

4. Coverage of social health protection
and access to health services
a. ILO concepts and definitions of coverage

and access
The ILO’s ultimate objective in the field of social health protection is:
To achieve universal social health protection coverage defined as effective access to

affordable health care of adequate quality and financial protection in case of sickness. 5
The concepts and definitions of terminologies related to social health protection advocated
by the ILO are introduced in this chapter and will be used in describing the ILO approach.
Concept of Coverage
The definition of coverage refers to the extension of social health protection with respect
to the size of the population that, in case of need, can access health services that are
financed through a risk pooling mechanism in such a way that the amount of health-care
costs borne out of pocket does not pose a barrier to access or result in service of limited
quality. Social health protection coverage is coverage where the third party payer is a
social protection system.
To be effective, universal coverage needs to ensure access to care for all residents of a
country, regardless of the financing subsystem to which they belong. This does not
preclude national health policies from focusing at least temporarily on priority groups such
as women or the poor when setting up or extending social health protection.
Definition of Access
For the ILO, coverage relates to effective access to health services that medically match the
morbidity structure and needs of the covered population. Compared to legal coverage that
describes rights and formal entitlements, effective access refers to the physical, financial
and geographical availability of services.
Benefit packages (i.e. packages of health services that are made available to the covered
population) should be defined with a view to maintaining, restoring or improving health,
guaranteeing the ability to work and meeting personal health-care needs. Key criteria for
5
This was first formulated in the Medical Care Recommendation, 1944 (No. 69), which in its
paragraph 8 provides that “[t]he medical care service should cover all members of the community,
whether or not they are gainfully occupied”. The universality of the right to health care is also
formulated in the Declaration concerning the aims and purposes of the International Labour
Organization (Declaration of Philadelphia), 1944, which states as follows: “The Conference
recognizes the solemn obligation of the International Labour Organization to further among the
nations of the world programmes which will achieve: …. (f) the extension of social security
measures to provide a basic income to all in need of such protection and comprehensive medical
care;…”. In addition, the 1948 Universal Declaration of Human Rights provides in its Article 25 (1)
that “[e]veryone has the right to a standard of living adequate for the health and well-being of
himself and of his family, including food, clothing, housing and medical care and necessary social
service ser services, and the right to security in the event of unemployment, sickness, disability,
widowhood, old age or other lack of livelihood in circumstances beyond his control”.

establishing benefit packages include the structure and volume of the burden of disease,
the effectiveness of interventions, the demand and capacity to pay.
Effective access includes both access to health services and financial protection. Financial
protection is crucial to avoid health-related impoverishment. Financial protection includes
the avoidance of out-of-pocket payments that reduce the affordability of services and –
ideally – some compensation for productivity loss due to illness.
Dimensions of Affordability
Affordability of services is defined as the absence of financial barriers of access to health

services for individuals, groups of individuals and societies as a whole.
Affordability first of all aims at avoiding health-related poverty. Affordability refers to the
maximum share of cost for necessary health care at total household income net of the cost
of subsistence; for example, health-care costs could be considered affordable if they
amount to less than 40 per cent of the household income remaining after subsistence needs
have been met. 6 In line with the WHO, the ILO considers health-care costs below that
share to be non-catastrophic for households. Universal coverage is thus associated with
equity in financing, implying that households should only be asked to contribute in relation
to their ability to pay (Evans, 2007, p.9).
Fiscal affordability relates to the fiscal space that can be made available to finance a level
of expenditure that ensures universal access to services of adequate quality without
jeopardizing economic performance or crowding out other essential national services (such
as social cash transfers or education, internal security, etc.). Necessary expenditure levels
depend on a population’s health status, the availability of infrastructure, the price level of
services, the efficiency of service delivery and the ability of a country to mobilise
resources. The ILO therefore does not advocate global benchmarks on public spending on
health.
Notion of Quality
Quality of care has various dimensions. These include quality of medical interventions, e.g.
compliance with medical guidelines or protocols as developed by WHO or other
institutions. The quality of services also includes ethical dimensions such as dignity,
confidentiality, respect of gender and culture, and issues such as choice of provider and
waiting times.
b. Trends in formal social health protection

coverage
The history of social health protection is characterized by a gradual increase in risk

pooling: some two hundred years ago, private – out-of-pocket – spending was the only
financing mechanism available. Smaller risk pools were subsequently developed, but a
robust notion of social protection in health did not emerge before Bismarck and Beveridge
respectively put the concepts of social health insurance and National Health Service into
practice.
6
This definition refers to the WHO definition of "catastrophic health expenditure".

Today, the pioneer countries of social health protection, such as Germany, Luxembourg,
Belgium, France and the United Kingdom, are high-income countries with universal
formal coverage and effective access to health services. The main health financing
mechanisms still being used are contribution-based social health insurance and the tax-
based National Health Service. In these countries, private for profit insurance makes up
only a small share of health expenditure and the OOP share is about 10 per cent of total
health expenditure (Appendix II, table A2.2).
The trends in formal social health protection coverage, suggest a link (World Bank,
2006b) between rising income levels of countries and the use of health financing
mechanisms based on risk pooling and prepayment. However, it is important to note that
levels of health expenditure and formal social health protection coverage vary greatly
based on the national level of income. This indicates that there is considerable policy space
for countries wishing to introduce social protection financing to cover health-care risks.
While there may be a link between increasing national income and the use of risk pooling
mechanisms, there seems to be a number of countries where this correlation is not
apparent. Data presented in Appendix II, table A2.1, suggest that the extension of social
health protection is not necessarily directly linked to a country's income level:
Burundi and the United Republic of Tanzania, countries with GDP per capita of
US$100 and US$290, respectively, formally cover about 13 and 14.5 per cent of their
population. The Democratic Republic of the Congo, on the other hand, with a similar
GDP per capita, provides coverage at a rate of only 0.2 per cent.
In Ghana with a per capita GDP of US$320, 18.7 per cent of the population is
formally covered by a health protection scheme, while corresponding rates are
significantly lower in Togo with 0.4 per cent coverage (GDP per capita US$310,) and
Burkina Faso with 0.2 per cent coverage (GDP per capita US$300).
A country with a slightly higher GDP per capita like Kenya (US$390) offers formal
social health protection to a quarter of its population, and Haiti with no more than
US$380 per capita to as much as 60 per cent. Countries with a higher level of GDP
like Bolivia (US$890, coverage rate 66 per cent) and Guinea-Bissau (US$920,
coverage rate 1.6 per cent) also show very different rates of formal coverage.
A country's specific situation, including a strong political will to set priorities, can
therefore have an impact on the level of social health protection it provides to its
constituents. Social health protection is an option for low-income countries, and the extent
of population coverage is, to some extent, independent of income levels. The composition
and design of the benefit packages are, however, different when comparing countries based
on their income level - as, for instance, in the case of Germany and the Republic of Korea.
The historical developments of national coverage rates also corroborate this trend. Some
countries have taken many decades to achieve high levels of coverage; whereas others,
starting from similarly low levels of GDP per capita, achieved full coverage within only a
few decades or even years (figure 4.1).

Figure 4.1. Achieving universal coverage in social health insurance
120
Germany
100
France
80 Korea
Coverage
Thailand
60
Luxembourg
40 Canada
20 Mexico
Austria
0
Ghana
1920 1950 1980/1990 2007 (estimate)
Year
Sources: ILO: Compulsory sickness insurance, Geneva, 1927 (for years 1920 to 1925); OECD Health Data 2005 (for years 1970
to 2000).
Table 4.1 compares the cases of Austria, Canada, France, Germany, the United Kingdom,
Japan, the Republic of Korea, Luxembourg and Norway. In the 1920s, countries such as
Austria and Germany formally covered some 30 per cent of their total population while
others (e.g. France and Norway) had formal coverage rates of around 20 per cent, and
Japan only 3.3 per cent. By 1970, the situation had changed considerably: all countries –
except the Republic of Korea – had achieved between 90 per cent and 100 per cent
coverage. The related GDP per capita ranged between US$1,997 in Austria and US$3,985
in Canada. In 1980, the Republic of Korea covered some 30 per cent of the total
population, based on a GDP per capita of US$1,632; in 1989, it had achieved 100 per cent
formal coverage, with a GDP per capita of US$5,429. This coverage rate was thus
achieved with a per capita GDP of less than one-fourth of the other countries compared.
Table 4.1. Historical development of formal health protection coverage
Country Year Total number of insured GDP per capita /

as percentage US$ exchange rate
of total population
1920 18.3
1923 32.7
1924 34
Austria
1925 34.3
1970 91 1 997
1980 99 10 530
2000 99 23167
- -
1970 100 3 985
Canada
1980 100 10 843
2000 100 22 708

Country Year Total number of insured GDP per capita /
as percentage US$ exchange rate
of total population
France / Alsace-Lorraine
1921 22.9
France 1970 95.7 2 884
1980 99.3 12 742
2000 99.8 21 884
1920 31.7
1925 32
Germany 1970 88 3 044
1980 91 13 145
2000 - 22 814
1921 35.2
1922 35
Great Britain / 1925 35
United Kingdom 1970 100 2 205
1980 100 9 524
2000 100 23 954
1927 3.3
Japan 1970 100 1 971
1980 100 9 164
2000 100 37 544
Republic of Korea 1970 - 272

1980 29.8 1 632
2000 100 5,429
3 728
1922 16,6 14 433
Luxembourg 1970 100 43 083
1980 100
2000 -
1920 21.3
1925 21.6
Norway
1970 100 3 285
1980 100 15 519
2000 100 36 028
Sources: ILO: Compulsory sickness insurance, Geneva, 1927 (for years 1920 to 1925); OECD Health Data 2005 (for years 1970
to 2000).
c. The formal and informal economy and the need

for social health protection
In Tables 4.2 and 4.3, coverage is measured in terms of the population formally covered by
social health protection, e.g. under legislation, without reference being made to effective
access to health services, quality of services or other dimensions of coverage discussed
later in the section. The data in table 4.3 shows the various social protection schemes in
these countries.

Table 4.2. Formal coverage in social health insurance protection in selected countries
of Africa and Asia
Country Insurance schemes Estimated formal coverage

in % of total population
– Urban workers
China – Basic insurance 10
– RCMS (new)
– EISIS
India – CGHS 20
– CBHI
– ASKES
Indonesia – JAMSOSTEK 20
– CBHI
Kenya – NHIF 7
– CCS
Lao People's Democratic Republic – SSO 5
– CBHI
Mongolia – National scheme 78
– Phil Health
Philippines 55
– CBHI
– IMPs
Senegal 11.4
– MOH
Source: WHO (2005); Scheil-Adlung et al. (2006).
Formal social health insurance coverage, including community-based schemes in

low-income countries of Africa and Asia, ranges from the exceptional coverage rate of 78
per cent of the total population in Mongolia to 5 per cent of the total population in the Lao
People's Democratic Republic and 7 per cent in Kenya (table 4.2).
In low- and middle-income countries, formal social health protection coverage often
remains a challenge. In Latin America, for example, many countries are far from attaining
universal coverage, even decades after they first introduced their first public insurance
scheme. Formal coverage of public and private schemes together is afforded to only an
average of 60 per cent of the population in Bolivia, El Salvador and Honduras (table 4.3).
Table 4.3. Percentage of the population with formal health protection coverage in selected
Latin American countries and selected years within 1995-2004
Country Public scheme Social insurance Private insurance Other Total (%)
Argentina 37.4 57.6 4.6 1.4 100
Bolivia 30.0 25.8 10.5 0.0 66.3
Colombia 46.7 53.3 100
Ecuador 28.0 18.0 20.0 7.0 73
El Salvador 40.0 15.8 1.5 57.3
Haiti 21.0 38.0 60.0
Honduras 52.0 11.7 1.5 65.2
Nicaragua 60.0 7.9 0.5 68.4
Source: Mesa-Lago (2007).

Out-of-pocket payment, on the other hand, serves as the key financing mechanism for
health care in many low-income countries – up to 80 per cent of total health expenditure in
countries such as Myanmar, the Democratic Republic of the Congo, Guinea and Tajikistan.
These values are above the average OOP expenditure (49.2 per cent) of 45 low-income
countries. Remaining expenditures are usually financed by taxes and, to a limited extent,
by social and community-based health insurance schemes (figure 4.2).
Figure 4.2. Out-of-pocket expenditure, selected low-income countries, 2006
100.0
80.0
60.0
40.0
20.0
0.0
Average Congo,
Guinea Tajikistan Myanmar
OOP Dem.
OOP 49.2 81.7 82.9 79.2 80.4
In middle-income countries, such as Lebanon and Guatemala, private for-profit insurance

is reducing the share of OOP. However, OOP often remains the principal financing
mechanism, followed by government budgets and social health insurance. In at least 22
countries (China and India among them, see Appendix II, table A2.2), 50 per cent and
more of the total health expenditure is borne out of pocket.
Health care is imperative for all workers and their families, regardless of their employment
status in the formal or informal economy. However, in low- and middle- income countries,
many workers and their families do not have suitable health coverage. This is especially
true for people in the informal economy (Unni et al., 2002). Informal economy refers to
economic activities not covered by government regulations and laws, including those
pertaining to labour protection and social security (ILO, 2004c, p.1).
The ILO report ‘Decent Work and the Informal Economy’ (ILO, 2002d) states that
determining the size, composition and development of the informal economy is
exceedingly difficult. It may be composed of informal employment within and outside
informal and formal enterprises. Those within informal (e.g. small unregistered or
unincorporated) enterprises include employers, employees, own account operators and
unpaid family workers. There are also various types of informal wage workers who work
for formal enterprises, households, or who have no fixed employer. These include causal
day labourers, domestic workers, industrial outworkers (notably homeworkers) and
undeclared workers (ILO, 2002c). Informal enterprises are likely to function with low
levels of capital, skills and technology and limited access to markets; they provide low and
unstable incomes and poor working conditions (ILO, 2004, p.1).
Globalization might contribute to the growth of the informal economy. Competition drives
employers to cut costs by resorting to outsourcing to informal enterprises or home-based
workers, or to engage temporary workers who do not have social protection. National
labour policies do not commonly include temporary and seasonal workers (ILO, 2005,
p.20). These workers do not have job security or benefits. At the same time, they are more

frequently exposed to dangerous and unhealthy working conditions, and are insufficiently
informed to change their circumstances (ILO, 2002, p. 21).
People in developing countries who engage in informal employment are often

characterized as those with extensive manual/physical labour, prolonged working hours,
poor/unhygienic living conditions, deprived benefits, poor bargaining power and voice and
deficient capital and assets (Sinha, 2002). Some migrants, especially illegal migrants, are
also part of the informal economy and share the same challenges - particularly with respect
to limited access to health care and services. Information about their health is usually
scanty on account of their socio-economic conditions and legal status.
Most workers in the informal economy are vulnerable. High health-care costs and serious
illnesses often force them to sell their assets and/or borrow money, leaving them heavily
indebted and predisposing them to vicious cycle of poverty and ill health. Social health
protection is a vital option to shield members of the informal economy from health and
financial risks. Although covering informal economy workers and their families constitutes
a major challenge, a number of initiatives have been launched to capture these workers by
pursuing universal coverage and/or extending social health insurance.
An example of an organization covering the informal economy is the community-based

scheme in India, the Yeshasvini Co-Operative Farmers Health Scheme (Karnataka). A
member’s annual premium amounts to US$ 3 per person, which is supplemented by a
Government subsidy of US$ 2.5 per person. About 2 million people are covered by the
scheme. The benefit package includes surgical procedures and outpatient diagnosis.
Maximum benefit per insured individual per procedure is US$ 2,300 - or US$ 4,600 per
year. Recently, medical emergencies (dog bites, accidental poisoning, road traffic
accidents, etc.), normal deliveries and paediatric care within the first five days after birth
have been included in the package (ILO, 2007, p.2).
The ILO-GTZ-WHO Consortium recently sponsored an international conference to

examine ongoing country interventions to extend financial protection through social health
insurance to workers in the informal economy. 7 The Consortium, forged in 2004, aims to
address the low coverage in social health protection resulting in poor access to health
services and catastrophic health expenditures. It endeavours to extend coverage in
developing countries through various options of health financing such as tax-based
financing, national or social health insurance or community based micro insurance or a
combination of various options (e.g. national health insurance).
d. The lack of access to health services:

An attempt to estimate the dimension
Available data indicates that, worldwide, about 1.3 billion people are unable to access
effective and affordable health care when they need it, while 170 million people are forced
to spend more than 40 per cent of their household income on medical treatment (WHO,
2004b, p.2).
The 1997 Human Development Report (UNDP, 1997) estimates that the majority of the
poor without access to health services live in developing countries: 34 per cent in South
Asia, 27 per cent in sub-Saharan Africa and 19 per cent in South-East Asia and the Pacific
(figure 4.3).
7
See http://www.socialhealthprotection.org/conference2006.php

Figure 4.3. Regional distribution of poor people in developing countries lacking access to health
services
19% 7%
Latin America and Carribean
4% 27% Sub-Saharan Africa
South Asia
South East Asia and Pacific
9% Arab States
Oriental Asia
34%
Source: UNDP (1997).
Data helping to determine the access deficit at the global level is limited. To date,
comparable data on access to health services are somewhat scarce and incomplete for the
purpose of international comparisons. Despite the significant efforts of many national and
international institutions to develop and provide data on access to health services,
particularly by the poor, information gaps still exist. Often only very specific and
non-comparable data is available at national and international levels that do not allow
assessments of effective coverage and access. Nevertheless, given the close link between
access to health services and lack of coverage in social health protection, the availability of
such data is vital when developing and advocating strategies for universal coverage.
Due to these limitations, numerous conceptual and methodological issues come into play in
the provision of data on coverage and access. Ideally, the most useful approach to measure
social health protection coverage would be a combination of key indicators reflecting the
situation in a country, including the following:
number of people formally/legally covered by social health protection;
costs borne by legally covered individuals to obtain the care they need, e.g. out-of-
pocket payments;
cost of public and private health expenditure not financed by private households' out-
of-pocket payments;
total public expenditure on health benefits as a percentage of GDP; and
physical access to health services.
Unfortunately, national data is fragmented and more research is required to combine them
in a meaningful way. Among the indicators mentioned above, physical access to health
services is relatively difficult to measure; yet, it is the factual basis for all concepts of
coverage. Legal coverage, for example, is meaningless if the necessary physical
health-care infrastructure and health-care staff are not available. Access to health services
not only varies among countries and regions, but also within countries. Attempts to
describe and quantify access to health care often refer to access to hospital beds. However,
this indicator tends to overweigh hospital care if used as a co-indicator for social health
protection coverage.
Indicators on the outcomes of maternal and child health care services might provide a first
approach to measure effective access to health services. Until more reliable data becomes

available, the following indicators can be used to estimate access to health care, even if
they exhibit some inconsistencies:
births attended by skilled health personnel based on the WHO definition: percentage
of live births attended by skilled health personnel in a given period of time, and
density of health professionals, i.e. the number of population per health professional,
i.e. physicians, nurses and midwives.
The birth attendance access (BAA) deficit was obtained using the difference between 100
and the percentage of live births attended by skilled personnel at a given time – thus
revealing the percentage of live births not cared for by a qualified health professional. The
health professional density-based access deficit indicator (i.e. the staff related access
(SRA) deficit), on the other hand, was measured using the relative difference of the
national density levels of health professionals and the Thailand benchmark8. Thailand was
used as a normative benchmark because it achieves good health outcomes with a staffing
ratio of one health professional for 313 population (2004 data). However, this is a
conservative minimum estimate. If, for example, health professionals are very unevenly
spread in a country, the de facto deficit may be much greater than the estimate based on
national averages. But if this rather “optimistic” indicator signals a national or regional
problem, it might be safely assumed that the real problem is even bigger than the one
indicated by national averages.
Figure 4.4 shows the density of health professionals in selected countries. High-income
countries (e.g. United Kingdom with 66 individuals per health professional) have a much
higher health professional to population ratio than low- and middle-income countries (e.g.
Chad with 3,113 individuals per health professional). Such ratios reflect huge global
inequalities in access to health care. The situation is compounded by the migration of
health professionals from low- and middle- income to high-income countries.
Figure 4.4. Density of health professionals in selected countries
3500
3000
2500
2000
1500
1000
500
0 Burkina
UK France Bolivia Algeria Mexico Egypt Ghana Chad
Faso
Population per health professional 66 92 129 262 297 348 388 932 3113
Source: ILO calculations (2007) based on WHO data for health professionals and UN population data.
Tables A2.1 and A2.2 of Appendix II present the two above deficit indicators on a country-
by-country basis, with further information such as population size, GDP, Human Poverty
Index (HPI), Gini coefficient, formal coverage, OOP, and total expenditure on health. It
8
The actual formula for the SRA for a country X with a population POPx and a number of
professionals PROFx is : SRAx = (POPx – PROFx * DENSt)/POPx whereby DENSt denotes the
professional density in the benchmark country t (here Thailand)

should be emphasized that the suggested indicators only estimate the dimensions of the
overall national access deficit.
In Table A2.1 the SRA Deficit Indicator was

The ILO Global Staff Related Access calculated for the first time for a significant
Deficit Indicator shows that one third of number of countries which then permitted a
the population has no access to health careglobal estimate. The results yielded an
using Thailand as a benchmark estimated global SRA deficit of 30 to 36 per
cent, based on Thailand as a benchmark. This
means that more than one-third of the global population is not receiving the quality of
health care that could be provided to them by an adequately staffed network of health
professionals. If countries such as Ireland would be used as a reference, then the global
SRA deficit increases to more than two-thirds of the global population.
But even the Thailand anchored SRA deficits reveal high national access gaps. In China,
the estimated staff-related access deficit indicates that 34 per cent of the population does
not have access to adequate health services - and this figure rises to 40 per cent in
Colombia. This is comparable to the staff-related access deficit of 42 per cent in Peru.
Table 4.4 lists both the SRA deficit and BAA deficit, showing that birth attendance access
deficits tend to be structurally lower than the staff related access deficits.
Table 4.4. Estimated access deficit in selected countries
Estimated access deficit

Staff-related Births attended
(in % of population) (in % of live births)
Burkina Faso 85 43
China 34 17
Colombia 40 9
Ghana 66 53
Peru 42 29
Philippines 29 40
Uganda 78 61
e. The access deficits and its associations
Access deficits and indicators of social and economic developments are generally assumed
to be associated. The results of regression analyses conducted to investigate the correlation
between the staff-related access deficit and the Human Poverty Index (HPI) 1 and 2, the
Human Development Index (HDI) the GDP per capita and Gini coefficient, are described
here-below.
Figure 4.5 shows the correlation between SRA access deficits and the Human Poverty
Index (HPI). HPI is a composite index that measures deprivation in the areas of long and
healthy life, knowledge and decent standard of living. The index HPI-1 is the human
poverty index for developing countries and is based on the probability at birth of not
surviving to age 40; the adult illiteracy rate; and unweighted data on the average of
population without sustainable access to an improved water source and children below
normal weight for their age. HPI-2 is for selected OECD countries and based on four
components, namely: the probability at birth of not surviving to age 60; people lacking

functional literacy skills; long-term unemployment; and population below 50 per cent of
median adjusted household disposable income. 9
According to figure 4.5, there seems to be a correlation between HPI levels and staff-
related national access deficits. It is noteworthy that most of the developed countries with
low HPI are also those with low levels of staff-related national access deficit. Conversely,
countries on the upper right-hand side of the figure have both high HPI and access deficit
levels; these include Chad, Ethiopia and Bangladesh.
However, some countries show significant variation from the general trend. Botswana, for
instance, has a relatively low access deficit, given its poverty level. Assuming the data is
accurate, it may be observed that Botswana, like other countries in the upper left-hand side
of the figure, enjoys low levels of SRA deficit - despite what its poverty level might
suggest. The opposite statement is true for countries in the lower right-hand side of the
figure. Correlation between the access deficit and HPI does not prove that low national
access deficit reduces poverty but rather illustrates that they usually coexist.
Figure 4.5. Regression between access deficit and Human Poverty Index (HPI)
70
60 M ali
Chad
y = 0 . 0 0 4 3 x 2 + 0 . 0 0 11x + 13 . 4 4 9 Nig er
Et hio pia
R 2 = 0 .6 6 6 1
Guinea Sierra Leone
50
M o zamb ique
B o t swana B enin Lesot ho
Zambia Zimb ab we
Gamb ia
Human poverty index
Bang ladesh
M alawi
A ngo la Côt e d'Ivo ire Burund i
40 Nig eria Y emen
Camb od ia To g o Hait i
Rwand a
Pakist an Ugand a Unit ed Repub lic of Tanzania
Camero o n Kenya
M oro cco Ghana
Namibia
So ut h A f rica Ind ia
30
Cong o
Gabo n
Guat emala
A lg eria M yanmar
20 Eg yp t
Tunisia Cape
Nicarag ua V erd e Ind onesia
Sri Lanka Ho nduras
Unit ed St at es of A merica Jamaica Philip p ines El Salvad o r V iet Nam
B o livia
Do minican Republic China Peru
Canada
10 Turkey
Net herlands Parag uay M alaysia
Colomb ia
No rway M exico
Cuba Cost a Rica
Urug uay Chile
-
- 10 20 30 40 50 60 70 80 90 10 0
Staff-related national access deficit (% of population)
The Human Development Index (HDI) is a composite index and measure of human
development based on life expectancy, adult literacy, education, GDP per capita and the
Gini coefficient (as indictors of the economic standard of living) of countries worldwide.
HDI provides a larger view of human progress in the light of income and well-being. The
HDI covers many components of the HPI and thus shows comparable trends. Nevertheless,
the HDI correlation shown in figure 4.6 is somewhat stronger than with the HPI, showing
9
HPI definition obtained from www.undp.org

that the level of development is a better predictor for declining SRA deficits than the
poverty level.
The regression of GDP per capita and SRA deficit shows that a high GDP per capita level
is highly correlated with a low health-care deficit. The correlation between Gini coefficient
(which is a measure of inequality of income distribution) and the SRA deficits is weaker,
even though there is still an association between greater inequality and national access
deficits. The latter is most likely the result of the confounding effects of the general
association between inequality and income levels. The obvious interpretation is that
countries improve their health infrastructure as they grow economically but it is not
necessarily the case that countries with low overall access deficits are countries with a
fairly equal income distribution.
This latter indicates the limitations of the SRA indictor with respect to redistributive
effects. The SRA index indicates overall national staff shortages but does not indicate that
in case of a staff shortage all people face similar access deficits, it is far more likely that
people in lower income brackets face much graver deficits than people with higher
incomes. The distributional effects of access deficits can only be analysed on the basis of
individual country studies.
Figure 4.6. Regression between access deficit and Human Development Index (HDI)
1.00
Norway
United States of America
Germany
Greece
0.90 Port ugal
Czech Republic
Poland Chile y = -2E-05x2 - 0.0028x + 0.8308
Uruguay
Cost a Rica R2 = 0.7305
Cuba M exico
Panama M alaysia
0.80 Brazil Colombia
Human Development Index
Saudi Arabia
Ecuador China Peru
Paraguay Sri Lanka
Georgia
Turkmenist an Jamaica El Salvador Cape Verde
Kyrgyzst an Viet Nam Indonesia
0.70 Egypt Nicaragua
Honduras
Guat emala
Sout h Af rica
M orocco
Namibia
India
0.60
M yanmar
Bot swana
Pakist an Bangladesh
Congo
0.50 Cameroon Uganda
Kenya Zimbabwe Togo
Gambia Hait i
Senegal
Nigeria Guinea Rwanda
Angola
Benin Unit ed Republic of Tanzania
Côte d'Ivoire
Zambia
0.40 M alawi
Burundi
Et hiopia
Guinea-Bissau
M ali Sierra Leone
Niger
0.30
- 10 20 30 40 50 60 70 80 90 100
Staff-related national access deficit (% of population)
f. Some observations on recent developments

in social health protection
Despite evident gaps in data availability and reliability, as well as the given
methodological limitations, the analysis of formal social protection coverage and
estimating standardised access deficits has produced insights into various interesting and
challenging developments in a number of countries around the globe. These observations
include:

Coverage
1. Pluralistic use of health financing mechanisms
Public health services, although narrowing and deteriorating due to structural

adjustment policies, public expenditure cuts and privatization, continue to play an
important role in providing health services through social protection mechanisms. For
example, formal coverage still amounts to 47.6 per cent in Egypt and 25 per cent in
Kenya.
Alongside public services, the pluralistic use of other health financing mechanisms is
found in almost all countries. For example, in the Syrian Arab Republic, practically
all public companies and most large private enterprises offer relatively
comprehensive health benefit packages free-of-charge to their staff. Dependents are
sometimes covered by the scheme itself, or through contribution-borne schemes
implemented by trade unions (Schwefel, 2006b). In Yemen, a number of public,
private and mixed companies offer various types of health benefit schemes ranging
from relatively low flat-rate reimbursement to comprehensive coverage packages, and
average per capita expenditure varies between €10 and €450 (Schwefel et al., 2005, p.
66 f.).
There is also a growing interest in and introduction of social and national health
insurance to increase coverage and access, as well as an attempt to address issues
related to fiscal space.
2. The effect of legal social health protection coverage on out-of-pocket payments is

heterogeneous
There is only a relatively small difference of the share of OOP expenditure as a

percentage of private expenditure on health between Tunisia (83 per cent), which has
almost universal legal coverage, Nicaragua (95.7 per cent), where almost 70 per cent
of the population has formal health protection, and Niger (89.2 per cent), where less
than 1 per cent of the population is formally covered (Appendix II, table A2.2). At the
same time, OOP as a percentage of total expenditure on health accounts for only
around 10 per cent in Slovenia and South Africa, while it rises to 26.8 per cent in
Ukraine and to 45.1 per cent in Tunisia, although all these countries have achieved
universal legal coverage. And the burden of OOP on practically unprotected
households in Uganda (36.7 per cent) is only slightly higher than in Turkmenistan
(32.6 per cent), where over 80 per cent of the population is covered (Appendix II,
table A2.2). The findings likewise indicate that the scope of benefit packages,
including financial protection and the quality of services provided, have a stronger
effect on private health expenditure than the number of persons or households legally
covered by any kind of prepayment system for health. Social health protection should
provide a reasonable level of financial protection in order to shield the population
from high private expenditures and impoverishment.
3. The role of community-based schemes
A current trend in low-income countries is to increase the role of mutual health

organizations and social health insurance when mainstreaming pro-poor policies in
social health protection and addressing issues of high user fees. Voluntary and
community-based schemes are also gaining support in many of these countries. Their
success and sustainability depend to a great extent on the attractiveness of benefit
packages, related financial protection and the quality of services. The coverage of
workers and their families in the informal economy may also contribute to their
success. Key issues concerning sustainability - e.g. capacity to pay and adverse

selection - are currently addressed by creating financial and administrative linkages
among schemes at various levels based on different ownerships.
Current country examples show that schemes can work successfully, one of them
being the Yeshasvini scheme in India which covers some two million workers and
their families. National data from India indicates that the share of informal economy
workers (unorganized workers) covered by social security arrangements, both in
public and private not-for-profit schemes, is 8 per cent. Out of the total number of 370
million workers in the Indian informal economy, only around 30 million are covered
by social protection including health (Kannan, 2006). In these contexts, community
based schemes can thus play a crucial role in accelerating progress towards coverage
of the informal economy workers.
4. Employer-facilitated insurance systems are not very frequent in most developing

countries although they are common in Arab States
Enterprise-based health plans usually provide care directly through employer-owned

or on-site health facilities, or rely on contracts with outside providers and facilities.
Employer-driven insurance schemes are highly exclusive since only stable workers -
and in some cases their families - are covered. The concept is often closely related to
the existing labour legislation on work accidents and occupation-acquired diseases.
Examples from Africa include employer-provided medical care in Zambia and

Nigeria, as well as in the rubber forests in Liberia and the Democratic Republic of the
Congo (Develtere and Fonteneau, 2001, p. 29). Company health benefit schemes
often reflect a paternalistic relationship between employer and employees, relying
partly on individual, case-to-case decisions rather than on vested rights. Even more
important is the fact that the size of the schemes is, in many cases, too small to
provide an effective coverage of catastrophic diseases. Trade-union-related health
insurance systems may be found in countries like Zimbabwe, South Africa, Mauritius,
Burkina Faso, Guatemala and Argentina. Some foster dual membership and
automatically insure all trade union members through the insurance plan, while others
develop mutual insurance systems that are relatively autonomous of the union and are
open to members and non-members alike (Develtere and Fonteneau, 2002, p.30).
5. Data limitations
Often, information is only available on certain cut-off dates or averages pertaining to

utilization of services and other indicators. In-depth analysis reveals that a large
quantity of data on coverage rates of existing social health protection schemes rely on
surveys that have limited samples for estimating the total number of beneficiaries.
The data gaps show that statistical figures on population coverage of health benefit
schemes should be interpreted carefully, taking into account the methodology used
for obtaining them.
6. Access
It is possible to obtain global and national estimates of access deficits. It can be

estimated that the global (staff related) access deficit is equivalent to about one third
of the population not having any access to health care. As stated earlier, the SRA
deficit indicator on a national and global level is a compounded figure of different
national structural deficits and does not disaggregate by type of care of by recipient
groups. On a global scale, there is very little comparative data on the quality of
access by different population groups notably people with low income. However,
there is evidence from a sufficient number of national studies to assume that access
deficits are concentrated in low income groups.

The above review of existing coverage trends and the dimension of the prevailing health
access deficits set the scene for the formulation of a pragmatic strategy for the extension
of social health protection. Existing approaches are often driven by the need to extend
coverage to workers and families in the formal and informal economy by various means to
increase fiscal space for health care. A strategy would incorporate, to the extent possible,
existing national, regional and community-based approaches, rather than building new
systems or developing a new one building on only one out of different financing options
available.
When accepting the co-existence of different subsystems then these subsystems need to be
coordinated at the national level in order to create synergies and avoid gaps in coverage. It
would help maximising overall national resources and avoid tensions and frictions. The
ILO has developed a strategy on achieving universal access to health care that will be
discussed in the next chapter.

5. Rationalizing the use of pluralistic financing
mechanisms: An ILO strategy for achieving
universal coverage in social health protection
a. Overall concept of the ILO strategy on rationalizing

the use of pluralistic financing mechanisms
Worldwide experience and evidence show that there is no single right model for providing
social health protection or one single pathway towards achieving universal coverage.
Countries use various means of resource generation, risk pooling, health care delivery and
financing. Experience has also revealed that social protection evolves over years or even
decades and is contingent upon historical and economic developments, social and cultural
values, institutional settings, political commitment and leadership within countries. In
addition, most national health financing systems are based on multiple options that cover
disjointed or overlapping subgroups of the population, while others remain uncovered.
Against this background, it is necessary to achieve the following objectives: 1) to

rationalize the use of pluralistic financing mechanisms in order to achieve universal access
to essential and affordable care; and 2) to increase fiscal and financial space to fund
universal coverage. The ILO suggests to coordinate all financing mechanisms within a
country in order increase the volume of resources and risk pools available for universal
health care. However, this increase should not be consumed by an equal increase in
transaction and administrative costs (Cichon, 2007).
A pragmatic strategy to rationalize the use of various health financing mechanisms with a
view to achieving universal coverage and equal access should be developed in three stages:
by first taking stock of all existing financing mechanisms in a given country;
by subsequently assessing the remaining coverage and access deficits; and finally
by developing a coverage plan that fills gaps in an efficient and effective way.
In this context, the government should play a pivotal, active role as facilitator and
promoter and define the operational space for each subsystem. This entails developing an
inclusive legal framework for the country and ensuring adequate funding and
comprehensive benefits for the whole population. The framework should also regulate
voluntary private health insurance, including community-based schemes, and consider
regulations to ascertain good governance and effective protection. This framework
establishes a rights-based approach to social health protection, which takes into account
the needs and capacity to pay, thereby realizing the objective of including the population
not covered by social health protection.
When developing the coverage plan, all options of financing mechanisms – including all
forms of compulsory and voluntary schemes, for-profit and non-profit schemes, public and
private schemes ranging from national health services to community-based schemes –
should be considered if they contribute, in the given national context, towards achieving
universal coverage and equal access to essential services for the population as a whole.
The coverage plan should be accompanied by, or include, an overall national health
budget, making it possible to establish and project - on the basis of a National Health
Account - the total resources such as taxes, contributions and premiums available to
finance health care. It should also estimate the expenditure of the different subsystems in

such a way that the process of achieving affordable universal coverage and access might be
accelerated and built in line with a realistic and sustainable plan.
Appendix I describes the national health-care system in Thailand as an example of the

rational use of pluralistic financing mechanisms. The system consists of social health
insurance, major occupational systems, a tax-based system and private health insurance
schemes, and combines the various mechanisms through legal benefit entitlements.
Apart from developing a legal framework that would usher in a clear coverage plan, other
prerequisites for ensuring the efficient functioning of pluralistic financing include: a
legally defined and affordable benefit package; fair pricing; efficient provider-payment
systems; and risk equalization among subsystems. The ILO promotes a strong role for a
stable government and the social partners, particularly through social dialogue and broad
participation in policy processes and governance of schemes - including other partners
such as civil society, the insured and other stakeholders in social health protection.
The most promising strategy for attaining universal coverage within a realistic time frame
is to coordinate and rationalize the use of pluralistic financing mechanisms with a view to
achieving the step-by-step extension of effective social health protection coverage, through
national health services, social health insurance, community-based insurance and mandated
private health insurance. This is not only an integrated approach but also respects existing
coverage and financing arrangements, and can be adjusted to the specific social and
economic context of each country.
b. Core elements of the ILO strategy on rationalizing

the use of pluralistic financing mechanisms
When applying the suggested ILO strategy on rationalizing the use of pluralistic financing
mechanisms on a national basis, it will be necessary to follow a certain number of steps.
These include:
assessing the coverage gap and the access deficit;
developing a national coverage plan;
strengthening national capacities for implementation.
i. Assessing the coverage gap and the access deficit
The ILO proposes that access deficits be measured by utilizing detailed national health
surveys, as well as regional disaggregated analyses of formal legal coverage by each health
financing subsystem. This involves taking stock of all existing social health protection
mechanisms within the country and analyzing which portion or sector of the population
they cover. This would yield an approximation of the coverage gap and access deficit,
thereby providing guidance to the national coverage plan.
ii. Developing a national coverage plan
The national coverage plan aims to provide a coherent design of pluralistic national health
financing coverage and delivery systems consisting of subsystems, such as national tax-
based services and social health insurance schemes, private insurance schemes etc. Aiming
at universal coverage, these would operate within a clearly defined scope of competence
and cover defined subsections of the population. The objectives of the coverage plan thus
consist of:

determining subsystems covering all population subgroups;
developing adequate benefit packages and related financial protection in each subsystem;
determining the rules governing the financing mechanisms for each subsystem and
the financial linkages between them (also as financial risk equalization between
different subsystems, if any);
maximizing institutional and administrative efficiency in each subsystem and the

system as a whole,
determining the time frame in which universal coverage would be reached.
The development of a national coverage plan involves the following activities, which are
described below:
(a) Development of a coverage map
(b) Development of a national health budget
(c) Improving health financing mechanisms
(d) Building rational linkages between subsystems
(e) Designing adequate benefit packages
(f) Creating institutional and administrative efficiency
a. Development of a coverage map
The coverage plan aims to close the coverage gap and the access deficit by the rational use
of existing health financing mechanisms in a given country. The national coverage plan
should first establish a coverage and access map that could be structured as follows
(table 5.1): Where applicable and feasible, the plan could go into further detail than
outlined below, covering aspects such as gender or ethnic groups, if such data is available.

Table 5.1. Health care coverage and access map specimen
Population Proportion of group that can access Proportion of the group whose services are funded by
Government Private Total General Social Community- Employer- Private Out- of- Subtracting Total
health services sector revenues security based based insurance pocket double
health initiatives initiatives counting
services
Public
employees
Private
employees
Workers
Dependents
Self- employed
Outside
Agriculture
Workers
Dependents
Self -employed
in agriculture
Workers
Dependents
Unemployed
persons of
active age
Children not
covered
Persons of
pensionable
age not covered
elsewhere
Total
This map could be used, on an annual basis and within the framework of a multi-annual
coverage plan, to project intended progress on coverage.
b. Development of a national health budget
Before establishing the coverage plan, the government should document the funds
available for social health protection. This requires developing a national health budget
that assesses the financial status and development of national health-care schemes. A
health budget initially compiles the status quo of all the expenditures and revenues in the
health sector in the form of a national health account. This could be structured in tables
similar to the one outlined in table 5.1 for a given start year and coverage map.
The ILO Tool Box includes a generic health budget model that can be found in Appendix
III of this document. Box 5.1 describes the methodology and results of an abridged health
budgeting exercise that the ILO undertook in collaboration with the Thai International
Health Policy Program in 2004.

Box 5.1
A health budget for Thailand
The basic structure of the model is mapped out in figure B.1 below. The basic modelling philosophy
follows the pragmatic modelling philosophy of ILO’s genuine social budgeting models. Instead of building
a complete national social budget encompassing all social transfer schemes in Thailand, the non-health
parts of a social budget were excluded and the budgetary analysis was limited to the health sector and its
impact on the government budget.
The model provides classical and pragmatic “if–then” projections, i.e. it depends on exogenous demographic
and economic assumptions and then simulates their impact on health expenditure and revenues and the
government budget. Observation years are 2002 and 2003 and projection years are 2004 to 2020.
The model consists of four deterministic sub-models that are driven by a set of exogenous assumptions:
the first sub-model is a demographic model that projects the population and the labour force on the
basis of assumptions on future developments of fertility, mortality and labour force participation rates;
the second sub-model is an economic model that derives employment and wage data from
exogenous assumptions on growth, labour productivity and the wage share at GDP;
the third sub-model is a health budget model which projects health expenditure of the four major
financing schemes (UC, SSO, CSMBS and privately funded health care) and the health resources
(contributions to SSO and WCS, out-of-pocket and other private outlays, and general taxation). The
two central result variables are overall national health expenditure and the resource requirement
from general revenues;
the last sub-model, the government model, links public health expenditure and the general revenue
resource requirement to government budget projections. The central result variable is the
government annual budget deficit.
This (abridged) health budget model therefore makes it possible to trace the effects of changes in the
health delivery and financing system to overall national health expenditure and the government’s
budgetary balance, i.e. to one global health system performance indicator and a public finance
performance indicator. Two model scenarios were developed: the first (status quo scenario or variant)
reflects the legal status quo; the second scenario (reform or UC scenario or variant) uses identical
demographic and economic assumptions and differs only in the health budget sub-model which simulates
the introduction of the UC Fund and the implementation of the two major cost-reducing measures in the
perspective of NHSO (extension of SSO coverage and CSMBS contributions) after 2005.
Figure B.1. Structure of the first version of the National Health Budget Model for Thailand
Demographic and
Economic model
labour force model
Abridged National Health

Budget
Government budget
The key demographic and economic assumptions are provided in figure B2.
Figure B.2. The assumed development of key economic variables for Thailand, 2002-2020
percent
10
Real GDP growth
8
6 Labour productivity
growth
4 Unemployment rate
2
Population growth
0
2001
2003
2005
2007
2009
2011
2013
2015
2017
2019
ye ar

The projections for the government budget use the growth rate of nominal GDP as the main driver for all income
and revenue items of the central government accounts that are neither driven by wages (such as income tax) nor
imported from the abridged health budget sub-model. Further assumptions are documented in the model itself.
The central results of the projections are summarized in figures B.3 and B.4. The model estimates show
that the overall health-care expenditure in the country – measured as a percentage of GDP – will rise by
about 0.3 per cent of GDP over the next half-decade, starting from an initial level of around 3.5 per cent of
GDP. This is largely an effect of two factors: the assumed substantial real GDP growth rates over the next
decade; and the fact that the cost development of the major share of public health expenditure is
contained through the use of the capitation mechanism which is exercising an overall cost-containment
effect on the health financing system as a whole. Total national expenditure is expected to slowly increase
back to the original level until 2020 as the GDP growth rates decline.
For the status quo, the general revenue share at financing total health expenditure stagnates throughout
the period at a level of 1.98 to 2.17 per cent of GDP. This would not pose a major problem if the overall
budgetary balance were projected to remain positive throughout the projection period. However, the
model (prudently) suggests that the government budget remains negative throughout the projection
period, with a minimum level of deficit of 1.19 per cent of GDP in 2020. The Ministry of Finance assumes
– more optimistically – that the budget will turn positive over the years, but in this model it will reach the
minimum deficit at the end of considering period. It could well be that this health budget model is too
pessimistic. In any case, it can safely be assumed that the trend towards tighter budgetary situations will
recommence at the end of the decade if all our assumptions – cum granu salis – hold true.
The first scenario simulates the effects of the suggested revenue increases and cost reductions for the
government and the introduction of a special UC fund that would generate earmarked income for the UC
scheme from taxes on alcohol and cigarettes. In this scenario, the general revenue share at overall health-care
financing would decline over the next two decades to a level of 1.5 per cent of GDP in 2020 and the overall
government deficit would shift up by about 1.5 per cent of GDP and remain at a slightly negative level until the
end of the projection period at 0.55 per cent of GDP. The second scenario was produced on the basis of
assumptions that SSO would expand coverage to non-working spouses and dependants (estimate of 6 million
beneficiaries) in 2005. IF SSO expanded their coverage without increasing any contributions and the
government did not introduce any additional taxes, the government would reduce the health-care budget
subsidy from 2.17 to 1.99 per cent of GDP by the end of the projection. The first and second scenarios were
combined together into the third scenario. The government would decrease the budget for health-care financing
from 2.17 per cent to 1.35 per cent of GDP by the end of the projection if SSO expanded their coverage to
spouses and dependants and introduced additional taxes.
Figure B.3
Tot al Healt h Expendit ure and Government Cont ribut ion
4.50% THE as % GDP

3.88%
4.00% 3.53%
3.50% Govt subsidy as %GDP
3.00% (STATUS QUO)
2.17%
% GDP
2.50% 1.98% Govt subsidy as %GDP

2.00% 1.99% (SCENARIO I)
1.50% 1.53% Govt subsidy as %GDP
1.00% 1.35% (SCENARIO II)
0.50% Govt subsidy as %GDP
0.00% (SCENARIO III)
2001
2003
2005
2007
2009
2011
2013
2015
2017
2019
year
Figure B.4
Estimated Government Deficit
0.50%
Total Govt deficit
0.00% (STATUS QUO)
-0.55%
-0.50% -0.55% Total Govt deficit
in % of GDP
-1.00% -0.92% (SCENARIO I)

-1.19%
-1.50% Total Govt deficit
-1.53% (SCENARIO II)
-2.00%
-2.50% Total Govt deficit
-3.00% (SCENARIO III)
2001
2003
2005
2007
2009
2011
2013
2015
2017
2019
year

c. Improving health financing mechanisms
Based on the results of the national health budget, issues related to improving health
financing mechanisms and conceiving linkages need to be addressed. There are essentially
five ways to improve health financing mechanisms with a view to extending social security
coverage, namely:
implementing and expanding existing social insurance schemes;
introducing universal benefits or services financed from general state revenues;
establishing or extending means-tested benefits or services (social assistance)

financed from general state revenues;
encouraging micro-insurance schemes, and
mandating private health insurance.
Table 5.2 highlights the scope of each of the health financing mechanisms. It is vital for
countries to take account of this aspect when developing policies to improve health-
financing mechanisms, design adequate benefit packages, include financial protection and
create institutional and administrative efficiency.
Government revenues usually obtain sizable coverage and outreach which might imply
good performance regarding equity. They also have the potential to achieve efficiency and
sustainability. The scope of payroll taxes can bring about increased fiscal space, financial
soundness compared to tax funding and public support – as well as create the possibility of
having public funds to target the poor. Regarding the premiums for community-based
schemes, the scope may increase fiscal space and reach the poor, those who are unable to
contribute - e.g. the non-salaried - and those who are subsidized. Premiums for commercial
health insurance demonstrate the capacity for financial soundness (table 5.2).
Table 5.2. Scope of health financing mechanisms
Criteria for choosing the mechanisms for particular sub-groups of the population should
include: the number, structure and performance of existing schemes; political and cultural

context; size of the tax base; size of the informal economy; disease burden; availability of
infrastructure; capacity to collect taxes / contributions / premiums, managerial capacity;
possibilities to enforce legislation; and regulation and related impacts on equity.
At the country level, both the pros and cons of each of these options need to be carefully
discussed. The applicability and performance of the different mechanisms need to be
judged on the basis of the countries’:
capacity to mobilize funds;
efficiency in targeting public funds to the poor;
ability to shift funds and power from the supply to the demand side in order to
improve efficiency and quality; and
level of accountability and quality of budgeting.
A summary of the pros and cons of various financing mechanisms is presented in the
overview in table 5.3.
Table 5.3. Overview: Pros and cons of key financing mechanisms for social health protection
Mechanisms Pros Cons

Tax-based health protection • Pools risks for whole population • Risk of unstable funding and often
• Potential for administrative efficiency underfunding due to competing public
and cost control expenditure
• Redistributes between high and low risk • Inefficient due to lack of incentives and
and high- and low- income groups in effective public supervision
the covered population
Social health insurance • Generates stable revenues • Poor are excluded unless subsidized
• Often strong support from population • Payroll contributions can reduce
• Provides access to a broad package of competitiveness and lead to higher
services unemployment
• Involvement of social partners • Complex to manage governance and
• Redistributes between high and low risk accountability can be problematic
and high- and low- income groups in • Can lead to cost escalation unless
the covered population effective contracting mechanisms are in
place
Micro-insurance and community- • Can reach out to workers in the informal • Poor may be excluded unless
based schemes economy subsidized
• Can reach the close-to-poor segments • Maybe financially vulnerable if not
of the population supported by national subsidies
• Strong social control limits abuse and • Coverage usually only extended to a
fraud and contributes to confidence in small percentage of the population
the scheme • Strong incentive to adverse selection
• Maybe associated with lack of
professionalism in governance and
administration
Private health insurance • Preferable to out-of-pocket expenditure • High administrative costs
• Increases financial protection and • Ineffective in reducing cost pressures on
access to health services for those able public health financing systems
to pay • Inequitable without subsidized
• Encourages better quality and cost- premiums or regulated insurance
efficiency of health care content and price
• Requires administrative and financial
infrastructure and capacity

Generally, taxes are considered an efficient and equitable source of revenue for the health
sector. They may lead to national risk pooling for the whole population and redistribute
between high and low risks, and high- and low- income groups. The civil service has the
potential to be administratively efficient and control costs.
However, the contribution that taxes make to health-care financing is largely contingent
upon national macroeconomic performance and competing demands from other sectors;
the quality of governance; the size of the tax base; and the government's human and
institutional capacity to collect taxes and supervise the system. In practice, government
schemes often tend to be under-funded due to competing public expenditures, which might
lead to a shortage of goods and services and to under-the-table payments and lack of
efficient governance.
The success of social health insurance schemes depends on the generation of stable
resources as revenues, strong support of the population, provision of a broad package of
services, involvement of the social partners and redistribution between risk and income
groups. However, schemes are administratively complex and governance and
accountability can be problematic. Also, from a macroeconomic point of view, payroll
contributions can reduce competitiveness and lead to higher unemployment.
Furthermore, in countries with sizeable informal economies, social health insurance might
have an impact on equity if coverage is not universal. It should be emphasized that health
care for the workforce is not free and that enterprises and the economy have to bear a
respective share of the financial burden. In the case of social health insurance schemes,
funding should consist of shared financial resources from both employers and employees.
For specific benefits such as maternity benefits, specific rules might apply; for instance,
full coverage might be provided through public funds to avoid disadvantages for particular
groups.
Specific schemes such as private or community health insurance schemes can be an

efficient mechanism to collect non-salary-related contributions and reduce costs for the
poorest at the point of delivery. But they often experience problems of coverage and
therefore fail to achieve sufficient pooling; they also frequently find it difficult to organize
membership across different ethnic groups and struggle with management capacity and
inadequacy of resources.
Private for-profit health insurance schemes are also found in many countries, ranging from
OECD countries to developing countries such as Peru and the Philippines (Appendix II,
table A2.2). If they are not subsidized, they cover the wealthier part of the population and
are based on risk-related premiums. Although they provide a better quality of service, their
exclusive character and high administrative costs are often criticized.
Improving and linking these different approaches might overcome the pros and cons of the
individual financing mechanisms. In the context of coverage plan development, an
evaluation should be undertaken to identify the mechanisms best suited to raise sufficient
and sustainable revenues in an equitable manner, thereby providing for adequate benefit
packages and financial protection for the population as a whole. Given the country-specific
nature of the evaluation, there is no general rule as to the way a country should develop its
portfolio of national health financing subsystems in an optimal manner. However, it is
suggested that a set of guiding principles be applied during the system building, including:
solidarity in financing, according to capacity to pay, and equity in access to all health
services. This includes risk pooling and sharing contributions payments in social
health insurance between employees and employers; and
inclusion of all citizens without discrimination on the basis of gender, ethnicity,

religion, etc.

A health financing policy checklist is provided in box 2.
Box 5. 2
Checklist for key policies on health care financing
Mobilizing and collecting sufficient resources to achieve policy objectives.
Ensuring strong political commitment based on social and national dialogue.
Improving equity and solidarity in financing through burden sharing by income level.
Setting up risk equalization and solidarity funds where appropriate.
Maximizing risk pooling and reducing fragmentation.
Introducing, in insurance schemes, government subsidies for the poor and for informal economy
workers and their families (either direct or for contributions/premiums).
Minimizing out-of-pocket payments.
Setting user charges according to capacity to pay.
Increasing financial sustainability.
Ensuring efficient and effective use of resources.
Using a mix of health financing mechanisms to accelerate achievement of universal coverage and to
balance equity, efficiency and quality of care.
Improving health financing mechanisms and extending health protection require increasing
funds, particularly in public spending on health. However, in many middle- and high-
income countries, revenue collection based on public funds and payroll taxes often
encounters obstacles because spending on health is perceived as an unproductive cost that
hampers economic development. In many low-income countries, fiscal space and domestic
revenues are considered too limited to ensure access to health services for the majority of
the population. Ensuring financial sustainability involves addressing the issue of
identifying other sources of funds and their collection. Some countries have employed the
use of consumption taxes such as “sin taxes” as additional sources of funding.
Governments should nevertheless ensure that the proceeds of these earmarked taxes are
used for their intended purpose and not incorporated into general revenue.
Furthermore, mobilizing additional government resources usually requires a functioning

formal economy, whereas many low-income countries have large informal economies.
Over the past few years, the share of total labour supply in the informal economy has been
constantly growing, particularly in Asia (ADB, 2006). This applies even in countries with
high rates of economic growth in the formal sector.
Increasing fiscal space is essential for the improved sustainability of social health
protection. It often presupposes changes in government policies - and, for countries relying
on international aid - more sustainable support from donors. The most successful methods
for increasing fiscal space through government policies include:
more efficient use of public resources;
strengthened efficiency in public institutions and service delivery;
budgetary reallocations;
greater efforts to collect taxes and contributions;
effective governance of funds; and
introduction of new sources of funding for the national health budget.

These approaches require strong political commitment; priority setting with a view to
extending social health protection; and determination to address issues of transparency and
accountability. In this context, it is crucial that a democratic management be established
and based on tripartite governance. It is also vital that there should be a participatory
approach in scheme management, as well as governance based on social and national
dialogue among policy makers, social partners, civil society groups, public and private
insurers, health-care providers and others.
d. Building rational linkages between subsystems
Another approach to improve health financing mechanisms consists of creating financial

linkages between various schemes. Linkages can achieve redistributive effects, e.g. by
means of subsidies and financial consolidation (through reinsurance and guarantee funds,
for example).
Further administrative and governance linkages include: sharing management functions;

mutual support regarding registration and collection of contributions/premiums; mutual
audits and control; co-contracting of providers; and pooling of information.
In order to achieve sustainable solutions when conceiving new linkages between different
health financing mechanisms, it is vital to test, evaluate and monitor integrated approaches
linking the schemes.
Box 5.3
Checklist for policies on building rational linkages between
different health financing mechanisms
Introducing subsidies.
Developing efficient fee schedules.
Setting up risk equalization and solidarity funds where appropriate.
Maximizing risk pooling through increasing membership.
Introducing, in insurance schemes, government subsidies for the poor and informal sector workers
and their families (either direct or for contributions/premiums).
Mandating private insurances, hospitals and facilities to cover (for example in part) the health care
services for the poor.
Facilitating reinsurance and guarantee funds.
Establishing joint management functions.
Introducing mutual support in registration and collection of contributions/premiums.
Co-contracting health service delivery networks.
Establishing mutual audit and control.
e. Designing adequate benefit packages
In addition to improving health financing mechanisms, the coverage plan should develop
policies on adequate benefit packages, including protection against catastrophic spending.
Generally, the health challenges to be addressed in benefit packages of social health

protection vary in low-, middle- and high-income countries:
Low-income countries are primarily confronted with health challenges relating to

primary health care, maternal and child care and infectious diseases such as
HIV/AIDS, TB and malaria.

Middle-income countries are saddled by the double burden of infectious diseases
found in low-income countries and non-communicable diseases such as cardio-
vascular diseases, drug abuse and tobacco use found in high-income countries.
High-income countries are faced with the long-term care of the elderly, the treatment
of non-communicable diseases mentioned above and stress-related syndromes.
Services covered in the benefit package and financial protection should be based on a
consensus derived from broad consultations with all stakeholders involved in social health
protection, taking into account the diverging views of the medical profession, various
groups in the population – e.g. the poor, the old, the minorities – and others. Therefore, the
policy mechanism to define health care needs should include national and social dialogue
on health care priorities.
Box 5.4
Checklist for key policies on adequate benefit packages
and protection from catastrophic spending
Introducing comprehensive and complementary benefit packages of various schemes providing for
an adequate level of services and income protection.
Ensuring acceptability of the protected, professionals and politicians.
Balancing the trade-off between equity and quality in broad consultations with all actors.
Addressing health-related poverty by covering catastrophic health expenditure (> 40 per cent of a
households' income net of subsistence).
Covering out-of-pocket payments / user fees etc. in order to ensure equal access.
Ensuring adequacy through focus on patients needs regarding quantity, adequacy and quality of
services.
Minimizing out-of-pocket payments.
Providing access to primary, secondary and tertiary care (through referral systems), including
maternity care, preventive care and care in relation to HIV/AIDS.
Providing for transportation costs, e.g. for groups living in remote areas.
Addressing loss of income through adequate cash benefit.
While the size of the benefit package involves a balance between cost and risk protection,
it is recommended that benefit packages be defined, including financial protection, with a
view to providing equitable access to a comprehensive range of services as outlined in ILO
Conventions and Recommendations. This may consist of defining primary health care, in-
patient care, prevention and maternity care rather than a "minimum benefit package".
The design and scope of the benefit package coincides with the general policy of the ILO
to ensure universal access at all times and in all facilities. The cost of the benefit package
or the individual’s place of residence should not deny anyone of health care. Health care
services should therefore be provided with dignity and without discrimination, taking into
consideration traditions and preferences of individuals within the locality.
Under the ILO Social Security (Minimum Standards) Convention, 1952 (No. 102), the
following benefits in case of sickness are foreseen: general practitioner care, including
domiciliary visits; specialist care; pharmaceutical supplies; and where necessary,
hospitalization.

Box 5.5
ILO Convention No. 102 / Article 10
The benefit shall include at least:
a. In case of a morbid condition:
(i) general practitioner care, including domiciliary visiting;
(ii) specialist care at hospitals for in-patients and out-patients, and such specialist care as may be
available outside hospitals;
(iii) the essential pharmaceutical supplies as prescribed by medical or other qualified practitioners;
and
(iv) hospitalization where necessary; and
b. In case of pregnancy and confinement and their consequences:
(i) pre-natal, confinement and post-natal care either by medical practitioners or by qualified
midwives; and
(ii) hospitalization where necessary.
Applying ILO Conventions and Recommendations avoids inequities in access to health

services between formal and informal economy workers, and between the rich and the
poor. However, when implementing and extending social health protection systems,
deficiencies in infrastructure or the non-availability of certain services, in some cases, must
be taken into account. Against this background, it is possible to limit access at an initial
stage - for example to services available - and to include full access at a later stage.
Given the fact that private health expenditures are among the primary causes of
impoverishment, benefit packages should be designed with a view to minimizing out-of-
pocket payments. This also applies to high-income countries where long-term care
expenditure accounts for a significant proportion of out-of-pocket payments. In this
context, ILO policies aimed at achieving equity in access to health services refer to the
adequacy and comprehensiveness of health services covered under the benefit package and
include financial protection against impoverishment, particularly due to catastrophic health
expenditure. 10
When choosing appropriate mechanisms to promote equity and access to health services,
alleviate poverty and improve health, countries should take the following into account:
the actual level of spending on benefits matters more than the choice of funds (e.g.
taxes, contributions or premiums) for achieving equity, poverty reduction and a
positive impact on health;
universal benefits and targeted benefits have a different impact on equity: whereas
universal benefits contribute more to achieving equity than to reducing poverty,
targeted benefits impact more significantly on poverty reduction than on equity.
f. Creating institutional and administrative efficiency
The coverage plan for the extension of social health protection also requires creating
institutional and administrative efficiency.
The ILO aims to achieve institutional and administrative efficiency through leadership,
transparency and economic responsibility. These elements point to good governance and
10
Defined as health care costs exceeding a household's capacity to pay.

form an integral part of the overall strategy design and implementation. It defines good
governance in social health protection as referring to decision-making based on:
existing legal frameworks;
accountability;
transparency;
effectiveness and efficiency;
equity and inclusiveness;
participation and consensus.
Tools for participatory and inclusive decision-making include ILO Conventions, as well as
national and social dialogue. In this context, ILO particularly stresses the importance of
tripartite governance and the participation of stakeholders such as the insured and civil
society. The ILO also highlights the need for government supervision of related
administrations, funds and private insurances, and government responsibility for covering
deficits in social health protection schemes.
ILO quantitative tools for financial governance (ILO Tool Box, Appendix III) aim at
achieving quality assurance and monitoring progress and outcome: They include:
social budgeting;
Social Protection Expenditure and Performance Reviews (SPERs);
Social Security Inquiry;
STEP tools on community-based insurances.
In order to fulfil the criteria of good governance, the financial and administrative
separation of health insurance funds from Ministries of Health and Labour is essential.
Generally, revenues earmarked for social health protection should be separated from
government budgets. Contributions should only be used for health-care benefits and
administration of the scheme, and not in support of Ministry of Health functions; it is
particularly important to ensure that health-care contributions are not used for other
contingencies.
A recent trend in organizing social health protection with a view to efficiency includes
various forms of decentralization of responsibilities from the national to local governments
or other sub-national institutions. However, the related shift of financial burden to the local
level is often problematic, since fund transfers from the national level may be insufficient
and result in increasing inequities in access, for example, of the poor (OECD, 2006a).
Another form of decentralization of social health protection concerns community-based
schemes. They mobilize additional funds at local levels and provide financial protection of
out-of-pocket payments, particularly for informal sector workers and their families (ILO,
2006d).
Creating efficiency also relates to purchasing services. Generally, the provision of services
can be organized through public or private providers. The most efficient mechanisms to
purchase services are:

budgeting, such as setting caps on annual expenditure;
contracting and accreditation of providers based on performance; and
provider payment methods such as salary, capitation, case-based payments and fee-
for-service.
Further, funds – e.g. social health insurance – may act as purchasers. By so doing,
insurance funds shift (financial) power from the supply to the demand side. This might
result in important changes in the availability and affordability of services, particularly for
poor segments of the population.
Box 5.6
Checklist for key policies on creating institutional
and organizational efficiency
Ensuring good governance based on efficient management, transparency and accountability.
Designing insurance schemes based on tripartite governance of independent, quasi-autonomous
health insurance funds ruled by public law, governments, social partners, and others.
Minimizing administrative costs.
Introducing participatory decision-making regarding policy formulation and implementation of social
health protection, involving key actors in social health protection, such as government, social
partners, representatives of the insured and civil society at national, district and/or local levels.
Decentralizing organizational structures with a view to reducing the burden of governments and
improving responsiveness.
Introducing referral systems acting as gatekeepers.
Developing adequate purchaser methods using incentives to improve quality and reduce oversupply.
Using public and private purchasing.
Introducing regulations for private insurers including voluntary health insurance.
Enforcing regulations.
iii. Strengthening national capacities for implementation
Capacity building in this context consists primarily of training; upgrading capacities in

designing, implementing and monitoring; and knowledge development - e.g. through
research and exchange of experiences.
Building administrative capabilities through training and the establishment of efficient

structures and procedures is one of the key preparatory activities for a sustainable social
health protection. The successful implementation of a reform, along with effective
monitoring, good governance and reliable delivery of service, are dependent on well-
trained, effective and committed staff.
Moreover, strengthening institutional technical and administrative capacity is essential for

ensuring that the necessary conditions are in place to guarantee the viability of national
security schemes and their responsiveness to their members' needs. The capacities gained
will further contribute to the design, implementation and testing of national health
protection to ensure its viability.
Currently, however, many developing countries lack sufficiently trained staff to ensure
successful extension in social health protection. It is particularly important to train
administrators who are expected to implement related reforms.

In addition, enhancing technical capacities of public authorities, social partners and other
stakeholders is crucial for overall governance and supervision. Evidence from many
countries proves that successfully extending social health protection to the poor requires
the consensus of various levels and entities of government, social partners, civil society
and others. Given the diverse interests of stakeholders, obtaining the necessary support is a
highly complex and difficult task. Problems often arise when stakeholders and social
partners feel that they have been ignored in the process involved in the design and
provision of social health protection; that concerns have been misunderstood; or that the
quality and depth of participatory decision-making was limited. 11 This might result in a
lack of support in implementation, enforcement, funding, and compliance to new laws and
regulations, leading to a complete failure of important reform activities - even when
parliamentarian hurdles have been cleared.
Against this background, it is important to enhance technical capacities of public

authorities, social partners and other stakeholders and improve their participation in social
and national dialogue. This can be achieved through appropriate training at a tripartite or
even broader level.
11
An example might be seen in the recent experience with social health insurance in Kenya:
"Ngilu's fit of fury", in: The Standard (Kenya), 16 November 2004.

6. Conclusion
Both developed and developing countries are faced by challenges that have direct
implications to the provision of social health protection. High-income countries are
confronted by coverage problems related to ageing populations, a shortage of health
workers, and an increasing prevalence of lifestyle-related diseases. On the other hand, low-
and middle-income countries suffer from low public expenditure, poor population
coverage and access to health services, as well as from high out-of-pocket expenditures
and the effects of the vicious ill health and poverty cycles.
Access to health services is an impact indicator related to social health protection.

Globally, data limitations exist to successfully determine gaps in access. Measuring the
global access deficit is the ILO’s initial attempt to quantify the discrepancies in access to
health services with the use of proxy indicators: density of health professionals and the
births attended by skilled health personnel. Statistical analysis was done using these proxy
indicators and the Human Poverty and Human Development Indices. According to the
analysis made on the Human Development Index and health professional deficit, and with
Thailand as the benchmark, one-third of the global population does not have access to
health care.
Overall, data showed that there is no single approach to providing protection against
financial and health risks. Both developed and developing countries are simultaneously
employing various health financing mechanisms to work towards providing universal
coverage to the whole population based on adequate benefit packages.
The ILO strategy on rationalizing the use of pluralistic financing mechanisms for
achieving universal coverage in social health protection is aimed at accelerating the
achievement of universal coverage, promoting equity and supporting global international
efforts to alleviate poverty and improve health. The strategy is built on the central credo of
incorporating all existing coverage and financing subsystems in a country into one
pragmatic pluralistic national system, as long as the existing subsystems and the system as
a whole meet a number of outcome and process criteria.
The system should provide for the:
achievement of universal coverage of the population within a realistic time frame;
effective and efficient provision of adequate benefit packages, including financial

protection for all, but not necessarily uniform benefit packages;
existence of a governance system that confirms the overall responsibility of the

government for the functioning of the system as a whole, but also involves covered
persons, financiers (contributors and taxpayers, including employers and workers in
the formal and informal economy) and providers of care; and
fiscal and economic affordability.
A framework was provided to design the ILO strategy, involving the assessment of the
coverage gap and access deficit; development of a national coverage plan; and the
strengthening of national capacities for implementation. These are the core elements that
underpin the approach to social health protection.
The approach is part of the ILO decent work strategy and the Global Campaign on Social
Security and Coverage for All. It builds on in-depth analyses of the extent of social health
protection coverage and the gaps in access to health services. The ILO, in cooperation with
other agencies (notably within the ILO-WHO-GTZ Consortium on social health

protection), recommends a comprehensive social protection tool box and information base
to governments and other actors in the field of social health protection; it also offers
support in closing gaps and addressing limitations. ILO believes that the suggested strategy
has the potential to achieve universal coverage in health.

Appendix I
Country experiences: A brief overview
This part of the report provides a selection of recent national experiences in extending
social health protection in countries in Africa, Asia, Europe and Latin America.
a. Africa
This section provides an overview of the health systems of selected countries in the
African region, focusing on trends in social health protection. The case studies included are
Benin, Burkina Faso, Egypt, Ghana, Kenya, Senegal and Tunisia. The experience in some
African countries with community-based health insurance schemes is particularly
noteworthy.
Figure A.1 illustrates the differences and similarities among selected African countries in
coverage, access deficit and out-of-pocket spending. Out-of-pocket expenses are generally
very high in the region, accounting for over 45 per cent of total health expenditures in all
countries selected - and even for more than 68 per cent in Ghana. Similarly, staff-related
access deficit at 60 per cent and above is high for the countries selected; only Egypt
achieves a comparatively low percentage at 19 per cent. Total formal coverage varies
between 0.2 per cent in Burkina Faso and almost universal coverage in Tunisia, with Egypt
lying in the middle at 47 per cent.
Figure A.1. Comparison of selected countries in Africa
100
90
80 Total Formal Coverage %
70
Percentage
60 Staff related national access

50 deficit %
40
Out of pocket payments as %
30 of total health expenditure
20
10
0
na
l
n
so
a
t
a
ga
yp
ny
ni
si
Fa
ha
ni
Be
Eg
ne
Ke
Tu
G
Se
a
in
rk
Bu
Source: Appendix II, table A2.2
Benin
According to an ILO study on Social Protection Expenditure and Performance Reviews

(SPER) in Benin (ILO/STEP, 2006e; see also, Affo-Massim Ouali et al., 2004), 6.21 per
cent of the country's active population benefits from an old-age pension and 0.5 per cent of
the country’s population has health-care coverage (table 1). Social security for salaried
workers in the semi-public and private sectors is managed by the National Social Security
Fund (CNSS). It covers old-age and invalidity pensions, family benefits, occupational
accidents and illness, maternity, and survivors’ benefits.

Benin has a multiplicity of insurance mechanisms for health protection, broadly falling into
three categories. First, there is a public, non-contributory scheme covering about 33,000
state employees and their families, amounting to almost 200,000 people - or 2.95 per cent -
of the population. State employees are covered for 80 per cent of their health-care costs
(except for pharmaceutical costs), old-age pensions from the National Retirement Fund of
Benin (FNRB) and family benefits.
Second, private sector schemes for workers in the formal labour market cover about 45,000
workers, adding up to about 270,000 beneficiaries, or 3,98 per cent of the population.
Social security for salaried workers in the semi-public and private sectors is managed by
the CNSS. It is obligatory and covers old-age and invalidity pensions, family benefits,
occupational accidents and illness, maternity, and survivors’ benefits.
Third, a number of workers in the informal economy are covered by the mutuelles de santé
– mutual health organizations - that have been developing rapidly in Benin since 1994
when they were first established. These are generally small in size (covering 200-100
beneficiaries, or about 10 per cent of the people in communities where mutuelles exist) and
offer membership at a low cost (between 100 and 500 FCFA). Cost recovery in these
schemes is estimated at 45-55 per cent. Over 100 health micro-insurance schemes have
been set up, covering an estimated 100,000 people. These schemes are administered by
their members and are run on the basis of solidarity. Moreover, there is an umbrella
organization - the Réseau Alliance Santé - that provides technical assistance and financial
support to the mutuelles (technical and financial management, claims processing,
organization of their General Assembly); it also owns a guarantee fund and a reinsurance
fund. The mutuelles pay 10 per cent of the contributions raised for the services of the
Réseau Alliance Santé (Churchill, 2006).
Table 1. Selected indicators of social health protection in Benin
Selected social health protection indicators Percentage

Total formal coverage as % of population 0.5
(State, social, private and mutual health insurance schemes)
Staff-related national access deficit as % of population 72
Total health expenditure as % of GDP 4.4
Out-of-pocket payments as % of total health expenditure 51.4
Out-of -pocket Payments as % of private health expenditure 79.3
Burkina Faso
Formal social security schemes in Burkina Faso (ILO/STEP, 2006e) cover less than 10 per
cent of the total population and are limited to old-age pensions, work accidents and
maternity. Total formal coverage in health is estimated at 0.2 per cent; the staff-related
access deficit is very high, at 85 per cent, as is the percentage of OOP of total health
expenditure at 52.2 per cent (table 2).
Since the 1990s, new initiatives have emerged to provide social protection. These include:
mutuelles de santé, caisses de solidarité, systèmes de pré-paiement, assurance santé-
crédit. By 2003, over a hundred mutual health organizations, micro-insurance and other
schemes were operating in the country. These initiatives are closely supervised and
supported by the State through the Direction for the Mutual Benefit Associations within
the Ministry of Employment, Labour and Social Security.

In 2006, the Government launched a national campaign on social protection and risk
management that confirmed the role of micro-insurance and its approach to extend services
to the informal economy within the national strategy. This strategy aimed to reform
existing mechanisms of formal social security to improve their management. In addition,
strong support was provided to the micro-insurance schemes in order to increase coverage
rates through the implementation of pilot projects in rural and urban areas for farmers and
informal economy workers.
Table 2. Selected indicators of social health protection in Burkina Faso

Out-of-pocket payments as % of private health expenditure 98.1
Egypt
The health-care system in Egypt (Normand and Weber, 2007) is mainly tax-funded and
publicly provided, with a small but long-established social insurance sector and some
private funding and provision.
Some health protection coverage is available to the whole population through the public
system; however, total effective coverage is at 47.6 per cent of the population (table 3).
Social insurance provides for 8.4 per cent of the population (ranging from only 3.4 per cent
in the area with the lowest coverage to 12.7 percent in the area with the highest coverage).
The benefit package covers primary care, outpatient hospital services, dental care,
pharmaceuticals, medical appliances, hospital care and even evacuation for specialized
surgery. It does not generally cover dependents.
A mixture of public and private practitioners provides the health services. Most outpatient
care services are dispensed by private practitioners, working in their own clinics in public
or private health facilities contracted by the social insurance. Private providers are paid on
a fee-for-service basis - and this may partly account for the high OOP payments of 53.5 per
cent of total health expenditure (table 3). Inpatient care is mainly provided in hospitals
funded and owned by the Health Insurance Organization (HIO).
Social health insurance is funded by contributions of 4 per cent of earnings, of which the
employers pay 75 per cent and the employees 25 per cent. Pensioners pay 1 per cent and
widows 2 per cent of their income. For government employee contributions, the
government contributes 1.5 per cent and the employee 0.5 per cent. A ceiling on the level
of income used to calculate contributions and small co-payments are employed for the use
of services. The Employment Injury Scheme, on the other hand, subsidizes the HIO.
Benefits under social insurance are six to seven times greater than those offered by the
state health services. Half of HIO spending is on medicines, and around one third is on its
own facilities.

There are plans to extend the scheme to cover more occupations, dependents and some
self-employed people, bringing coverage to around 35 per cent. The main constraint is the
lack of administrative capacity to develop the scheme in these more difficult areas.
Table 3. Selected indicators of social health protection in Egypt

Ghana
Ghana's economy is predominantly agrarian, with agriculture dominating in terms of

employment, revenue and export earnings (ILO, 2005a). In 2005 Ghana’s real GDP growth
was both broad-based and robust, at 5.9 per cent. The 2005 budget deficit has been
estimated at 2 per cent of GDP. Total health expenditure as a percentage of GDP in 2003
was 4.5 per cent, and private out-of-pocket payments accounted for about 68 per cent of
this expenditure (table 4). Total health expenditure per capita amounted to US$98. Ghana
is divided into ten regions with 110 decentralized districts that constitute the lowest level
of political administration.
The National Health Service in Ghana was introduced in 1957, a model that was based on
the British system. Entitlement to free health care and services from publicly owned
facilities were afforded to everyone; however, this entitlement proved to be unsustainable
as the country’s economic performance declined. In 1985, co-payments were introduced to
prevent the disintegration of the publicly funded services, followed by the “cash-and-carry
system” in 1992. The employment of user fees generally limited access to health care,
served as a disincentive to the utilization of health care facilities and excluded the poorest.
In the early 1990s, voluntary mutual health organizations (MHO) / community based
health insurance schemes (CBHI) were established with the help of international donors
and agencies to provide access and financial protection to those not covered by formal
schemes and those affected by the implementation of user charges. After almost a decade,
these schemes had proliferated and covered the larger sections of the population.
Since the out-of-pocket health financing system (“cash and carry”) excluded many of the
poor from accessing health care, the Government of Ghana decided to abolish and replace
it with a national health insurance scheme. The National Health Insurance System (NHIS)
was passed by the Ghanaian Parliament in 2003 and came into effect in November 2004.
Its aim is to pool risks, reduce individual burden and achieve better utilization rates, as
patients do not have to pay cash at the point of delivery. The NHIS’s declared objective is
to ensure that at least 50-60 per cent of Ghana's residents belong to the new health
insurance system within the next five to ten years.
The system is coordinated and supervised by the National Health Insurance Council that
manages, inter alia, the National Health Insurance Fund. The Fund receives the proceeds of
contributions from the Social Security and National Insurance Trust (2.5 per cent); the
health insurance levy (2.5 per cent); grants, donations and other sources; and voluntary
contributions from the informal economy workers (figure A.2). The contribution amounts
to 72,000 cedis per adult family member and 144,000 cedis per family of five.

About 77 per cent of the funds are mobilized by the National Health Insurance levy and 23
per cent by the Social Security and National Insurance Trust. The funds are subsequently
allocated to the district mutual health insurance schemes that offer minimum health care
benefits as stipulated by the Act; reinsure district funds against fluctuations in the cost of
care; subsidize costs of health care for the indigent; and support programmes to improve
access to health services.
Despite its commitment and the measures it has initiated, Ghana faces tremendous
challenges in extending social health protection to the informal economy and those in the
rural areas. Not only must it increase its coverage (at present only 18.7 percent) but it also
has to cope with a staff deficit of 66 per cent; and its out-of–pocket expenditure accounts
for 68 per cent of total health expenditure (table 4). Aside from financial constraints, there
are insufficient linkages between national and community-based health-care schemes.
Figure A.2. Ghana National Health Insurance sources of funds
2.5 % Health insurance levy (VAT on • District mutual health

goods and services) insurance schemes that
offer minimum health care
benefits stipulated by the
2.5 % Payroll NHI Act
tax from formal
NHI economy
employees Provides • Reinsure district funds
Fund against fluctuations in the
(Social Security subsidy cost of care
National
Insurance
Trust- SSNIT) • Subsidize costs of
health care for the indigent
Voluntary • Support programmes to

contributions of improve access health
informal services
economy Grants,
workers donations other
sources
Ghana is progressively implementing specific measures to respond to these challenges

based on different strategies, reflecting and building on distinct experiences to extend
social security. The establishment of the NHIS was key in launching the strategy for
extension and interventions at provincial and district levels. The creation of fiscal space
through the approval of the National Health Insurance Fund in 2005 will ensure the
scheme’s sustainability.
Furthermore, the Ghana Poverty Reduction Strategy (GPRS) highlights the Government's
commitment to provide access to health care through the improvement of basic health care
for the poor. It sets out to bridge gaps in access to health, nutrition, and family planning
services; ensure sustainable financing arrangements that protect the poor; and enhance
efficiency in service delivery (Ghana, 2003).

Table 4. Selected indicators of social health protection in Ghana

Out-of-pocket payments as % of private health expenditure 100
Kenya
Historically, government revenues have financed Kenya’s health system

(WHO/GTZ/ILO/KfW/DFID, 2004). In 1966, Kenya was the first country in Africa to
introduce compulsory health insurance. Initially, only salaried workers were enrolled on a
mandatory basis, but the programme was expanded to include the self-employed in 1972.
More recently, organized groups and pensioners have been allowed to enrol on a voluntary
basis. Despite this progressive expansion, the scheme has only 1.5 million members, and 8
million dependents, i.e. covering about 25 per cent of the population as of February 2007
(table 15). Premiums are income-based and set per family, ranging from KSh30 to 320 per
month for formal sector workers and KSh160 for informal economy workers and
pensioners. The scheme covers in-patient medical needs and most admissions for a fixed
number of days. However, OOP are also very common, amounting to 50.6 per cent of total
health expenditure (table 5).
In 2004, legislation for the national social health insurance fund (NSHIF) was submitted to
Parliament. It was conceived as a compulsory insurance scheme with solidarity-based,
income-related contributions, and aims to cover the entire population. The new scheme
will take over the infrastructure of the existing insurance. The underlying aim of the
proposed reform is to achieve universal coverage and thus appropriate health care at an
affordable cost for all. By accrediting and remunerating private service providers, it should
also bring the public and private sectors under one financing umbrella. However, the social
health insurance law has not yet been approved, and it is still an open question as to how
soon this might be achieved.
The existing National Hospital Insurance Fund (NHIF), as the future carrier of the NSHIF,
has already made far-reaching improvements to the current system. These include the
accreditation of private and public providers and the introduction of financial incentives to
promote quality improvements.
Table 5. Selected indicators of social health protection in Kenya

Total formal coverage as % of population
25

Senegal
In Senegal (Asfaw, 2004; Wade, 2007), only some 12-17 per cent of the population is
covered by statutory social security schemes, namely salaried staff from the private sector
as well as civil servants and their dependants. Rural and informal economy workers
(70-80 per cent of the population) do not enjoy any kind of organized social protection,
except for those who are members of mutual benefit associations (health coverage). The
indigent population (representing 10-20 per cent of the total population) is also excluded
since social assistance programmes provide only scarce and erratic benefits. Moreover,
OOP as percentage of total health expenditure are at a high level of 55.5 per cent, and the
staff-related access deficit amounts to 88 per cent of the population (table 6).
Extending social protection to the uncovered population is a high priority for the
Senegalese Government and various initiatives have been taken at political level to this
end:
In 2003, the National Commission on Social Dialogue (Comité national du dialogue

social) was set up to develop a strategy to specifically address issues on extending
social security.
In April 2004, Senegal launched the Global Campaign on Social Security and
Coverage for All.
In December 2004, the transport operators’ trade union (Syndicat National des
Travailleurs des Transports Routiers du Sénégal (SNTTRS)) included in its demands
the question of social protection.
Senegal also hosted the ILO Conference on “Organizing for Decent Work in the
Informal Economy: The Way out of Poverty” in Dakar (25-27 October 2005) that
brought together representatives from African trade unions to discuss the extension of
social security to the informal economy.
This priority has also been translated into the new Agricultural Law adopted in June
2004 (Loi d’Orientation Agro-Sylvo Pastorale), which specifies that the Government
should design and implement a social security scheme for the rural population which
represents more than 50 per cent of the country's population (5 million people).
As part of its Poverty Reduction Strategy Paper (PRSP) process, Senegal has revised
its social protection strategy and policy to address coverage for the formal and
informal economy, notably the extension of social security to those currently
excluded. The new National Social Protection Strategy is the third pillar of the PRSP,
which was presented and adopted at the World Bank/African Development Bank
regional meeting on PRSP (Tunis, July 2005). The objective is to increase the health
insurance coverage rate from 20 per cent of the total population to 50 per cent by
2015.
In line with these initiatives, various projects aimed at extending social security to rural
and informal economy workers are being conducted, based on a new type of scheme
including a centralized structure at the national level and relying on community-based
sections (either area- or occupation-based) at the local level. However, extending coverage
to the population in the informal economy remains a significant challenge.

Table 6. Selected indicators of social health protection in Senegal

Tunisia
Tunisia pursues an integrated health policy, focusing on both demand-side and supply-side
policies as well as creating links between the health sector and national economic
development plans. Overall, the state plays a major role in the provision of health
infrastructure, specialized equipment, drugs, preventive measures, training, research and
the provision of social health insurance. The health infrastructure in Tunisia is well
developed. 90% of Tunisians live within less than 5 km of a basic health facility. The
number of doctors has increased steadily arriving at a ratio of 968 inhabitants per doctor in
2007. Tunisia has also invested in pharmaceutical industries, producing 46% of its drugs.
The social health protection system in Tunisia is ranked amongst the best of all developing
countries and Tunisia has achieved remarkable progress on several health indicators,
especially relating to communicable diseases and maternal and child mortality. Child
mortality dropped from 51.2 per thousand in 1984 to 18.4 per thousand in 2007. Life
expectancy at birth has increased from 68 to 74.2 over the past two decades and
vaccination rates for children are at 100%. Overall, social expenditures have risen from
44% to 56.2% of total government budget with health expenditures growing sevenfold
over the same period. According to UN estimates, Tunisia is well on track to meet all
MDGs before 2015.
Since the end of the 1950s, two out of three Tunisians (Achouri, 2007; Asfaw, 2004) have
been insured under either public or private schemes that offer social security to civil
servants and workers in the public sector (National Pension and Social Provision Fund or
CNRPS), as well as to those in private enterprises (Social Security Fund or CNSS). In
total, there are 12 different schemes in place, based on different professional categories. In
addition, the Government provides free health-care services for the poor and low-income
population as well as for disabled persons in public facilities run by the Ministry of Health,
so that Tunisia achieves a close-to-universal coverage rate (table 7). In addition, a
supportive regulatory framework has been created for private societies or public bodies
offering complementary private health insurance to their employees, covering the same
package as the public insurance.
In the 1990s, the Tunisian health insurance system faced a series of problems and
difficulties regarding efficiency, quality, equity, and satisfaction of stakeholders and users.
The burden of contribution payments of employers and employees was unequally
distributed - and OOP remains relatively high at 45.1 per cent of total health expenditure
(table 7).
The current health insurance reform (1994) pursues two major goals: to harmonize the
benefits of the different health insurance regimes and introduce a sole mandatory health
insurance body, the Caisse Nationale d’Assurance Maladie (CNAM); and to create
optional complementary regimes to cover OOP that currently remain uncovered. Reforms

undertaken are placing the citizen at the center and emphasize the importance of national
and social dialogue and participatory processes.
At present the national debate is focusing on issues such as the coverage of the benefit
package, cost containment (including provider payment methods), quality assurance,
management procedures, regulation and guidelines.
Table 7. Selected indicators of social health protection in Tunisia

Total formal coverage as % of population 99
Staff-related national access deficit as % of population -
b. Asia
This section presents brief summaries of social health protection systems in China, the
Republic of Korea, India, Indonesia, the Philippines and Thailand. As can be seen in the
overview in figure A.3, the countries selected are very different, as are their situations
concerning health protection. The Republic of Korea and Thailand mark examples of
countries that have achieved very good outcomes with comparatively few resources;
indeed, both countries have achieved almost universal coverage. However, OOP are - at
41.9 per cent of total health expenditure - rather high in the Republic of Korea, as
compared to 28.7 per cent in Thailand. In contrast, China and India have low levels of
coverage - 23.9 per cent and 5.7 per cent, respectively; and they have high levels of OOP -
55.9 per cent and 72.9 per cent, respectively. The figures for the staff-related access deficit
show a rather diverse picture, ranging from 29 per cent in the Philippines to 76 per cent in
Indonesia.
Figure A.3. Comparison of selected countries in Asia
100 Total Formal

90 Coverage %
80
Percentage
70
60 Staff related access
50
40 deficit
30
20
10 Out of pocket
0 payment as % of total
health expenditure
s
a
ia
na
nd
ne
di
re
es
hi
la
In
Ko
pi
n
C
ai
ilip
do
Th
of
In
Ph
lic
ub
ep
R

China
China is enjoying impressive and sustained economic growth (Tang et al., 2007; Hu, 2007;
Drouin and Thompson, 2006), and since the early 1980s the living conditions of the vast
majority of its population have improved significantly. The world’s most populated
country is currently experiencing major social and economic changes, but the social
agenda is still incomplete since inequity in health remains a major concern. Until the
1970s, China enjoyed a relatively well functioning health system, with about 90 per cent of
the population covered by health insurance. However, since the 1980s both the quality of
health services and the proportion of the population insured have declined dramatically,
and health indicators have deteriorated accordingly. The collapse of cooperative medical
schemes in rural areas and the crippling of the public insurance schemes have produced
serious problems in health financing and access. Out-of-pocket payments increased from
20 per cent in 1978 to 60 per cent in the early 2000s. At the same time, public funding for
the health sector had been reduced while health expenditure has continued to rise.
In response to these developments, China has set up “Basic health care services for all” as
one of the principle requirements for attaining the goal of building a moderately
prosperous society in all respects. Health insurance and social assistance are therefore
expected to play an important role. This is one of the underlying reasons for their
remarkable expansion over the last decade: the number of persons having health insurance
cover rose from less than 150 million (about 12% of the population) in 1997 to an
estimated 900 million (above 70% of the population) in 2007. 12 The established national
objective is to achieve universal coverage for health insurance by 2010. 13
The Chinese public health insurance system consists of four principle schemes, namely HI
for civil servants and those with similar status, HI for urban working population, HI for
urban economically inactive residents (HIUR) and the New Rural Cooperative Medical
Care (NRCM) for the rural population. The first two can be traced back to the 1950s
despite a series of restructuring they have experienced over the time, whilst the last two are
more recent initiatives, being only launched in 2003 and 2007 respectively. Both have a
heavily charged task to accomplish: To cover 780-910 million and 220-300 million under
NRCM and HIUR respectively by 2010. 14 As far as the 2003-launched NRCM is
concerned, it operated in 2448 counties or 85.53% of the total with 726 million people
insured at the end of September 2007. 15 Among other factors, this extension can be
attributed to the firm determination and commitment of the Government with a high share
of direct. This is expected to apply to the HIUR too.
12
Estimates made by A.Hu based on China Statistical Yearbooks from 1998 to 2006, China Labour
Statistical Yearbook 2001, various Government’s periodical bulletins and media information.
13
Decision on further improving the rural health jointly made by the Central Committee of the
Party and the State Council, (Circular No. 13 (2002); Notice of the Cabinet of the State Council on
the Guidelines for setting up the New Rural Cooperative Medical Care formulated by the MOH and
other responsible ministries, Circular No. 3 (2003); Chen, Zhu (Minister of MOH). Speech at a
Press Conference on the latest development of the New Rural Cooperative Medical Care, held on 5
September 2007 in Beijing; Guidelines on piloting the a health insurance scheme for urban
economically inactive residents issued by the State Council (Circular No. 20 (2007); Hu, X (Vice
Minister of MOLSS), speech at the Press Conference with regard to the new health insurance
scheme for urban economically inactive residents, held on 15 August 2007 in Beijing.
14
These are estimates made by various government’s departments and academic people, as no
accurate statistics are available due to many causes, such as rural-to-city migration and Huko
registration systems.
15
See http://news.xinhuanet.com/politics/2007-12/17content_7264119.htm

In parallel with health insurance mechanisms, social assistance is also assuming a more
active role for achieving the goal of basic health care services for all: not only providing
basic income, housing, education, etc., to low-income families, but also health care
assistance. In contrast with that, private health insurance and other types of health
protection are still under-developed in the country, assuming rather a marginal and
complementary role. However, a multi-pillar health protection system including a more
enhanced component of private insurance has been envisioned for the future.
Table 8. Selected indicators of social health protection in China

Republic of Korea
The Republic of Korea (Kwon, 2002; Yang and Holst, 2007; and comments from the
Ministry of Labour of the Republic of Korea) is an outstanding example of the successful
introduction of a universal health insurance system (reaching coverage rates of 100 per
cent, see table 19). This system was started with the passing of the Health Insurance Act in
December 1963. It took just 26 years from that date for the Republic of Korea to achieve
universal insurance coverage. It is important to note that the country’s GDP per capita in
real terms in 1963 was still under US $ 1,600 - only two-thirds that of the Philippines and
around the same level as Mozambique, Niger, Sri Lanka, and Cameroon.
For the first 14 years after the Health Insurance Act had been introduced, there was more
emphasis on building functional structures than providing coverage for a significant
proportion of the population. Under the strong stewardship of President Park Jung-Hee, the
introduction of a compulsory health insurance began in 1977. The Employee Scheme was
the first social insurance programme, which was initially compulsory for companies with
more than 500 staff. This later expanded to smaller firms of 300, 100 and finally 16
employees. Social health insurance (SHI) schemes for civil servants and educational staff
started in 1981 and became important promoters of extending social protection. When the
uncovered population became aware of the substantial financial protection benefits
provided by the existing schemes, the motivation to join SHI increased significantly.
The Korean Government introduced and expanded the National Health Insurance system to
address social disparities arising from government-and-large companies-driven rapid
industrial development and to fulfil the growing health care needs of the public due to
increased level of income. This system ranked very high on the political agenda for many
years. Enrolment in social welfare programmes was a central issue in the 1988 presidential
election campaign. Mr. Noh Tae-woo, the then candidate of the ruling party, promised to
cover the self-employed by the SHI scheme by 1991 – but contribution collection from
informal sector beneficiaries with irregular incomes remained a major hurdle to overcome.
However, this goal was reached a full two years before the actual target date and, since
1989, health insurance has been compulsory for all groups within the population.
Certainly, the burgeoning economic development in the late 1980s played a substantial part
in the rapid expansion of the country's social security systems.

The SHI health system was encumbered with many problems, mainly regarding fairness
and efficiency of financing. For many years, beneficiaries had to assume high co-payments
and co-insurance rates, and a series of benefits were expressly excluded from SHI
coverage. The share of out-of-pocket payments (reaching levels of above 40 per cent of
total health expenditure, see table 9) was an important cause of the low level of equity in
insurance financing and proved to be highly regressive. A lack of horizontal equity and
chronic shortages of funding finally led recently to the standardization of health insurance
and the implementation of a single-payer system.
Table 9. Selected indicators of social health protection in the Republic of Korea

India
The Indian health-care sector is growing rapidly, following on the country’s general
economic and social development (Gupta, 2007; ILO, 2003b; van Ginneken, 2000).
However, at just one per cent, the share of GNP spent on health care remains very low.
All health financing mechanisms coexist in India: OOP constitutes the main form of
financing (above 72 per cent of total health expenditure, see table 10). Social health
protection is available through social health insurance, such as the Employees’ State
Insurance Scheme (ESIS), which was promulgated in 1948 and provides for compulsory
coverage of government employees and staff in larger companies. The Central
Government Health Scheme (CGHS), started in 1945, provides comprehensive medical
care facilities to the central government employees, including pensioners and their
families. There are also employer-based schemes, voluntary (commercial) health insurance
and community health insurance.
Despite the Government’s initiatives to support health insurance schemes, only some 5 per
cent of the population is enrolled for health insurance (table 10). Indeed, the majority of
the population cannot afford premium and contribution payments.
Shortfalls in provision, high contributions, drastic co-payments and poor quality of

providers have led to the emergence of micro-insurance schemes in rural areas, as well as
in major cities. Micro-insurers often purchase products from state insurance companies.
For the population in the informal economy, coverage of outpatient services, medicines
and the indirect costs of illness (e.g. transport costs and loss of earnings) are crucial.
Against this background, some community-based and commercial health insurance
schemes offer related benefits.

Table 10. Selected indicators of social health protection in India

Out-of pocket payments as % of total health expenditure 72.9
Indonesia
In 1992, Indonesia reformed its compulsory social health insurance scheme for civil
servants to include their dependants (spouses and up to two children under 21 years of age)
and introduced a social health insurance scheme for private sector employees (WHO,
2005, pp. 17-19). The contribution of the public scheme (PT Askes) was set at 2 per cent
and was solely shouldered by civil servants until 2003, when a government contribution of
0.5 per cent of basic salary was introduced. The contribution of the private sector scheme
(PT Jamsostek) is set at 3 per cent of the salaries for single and 6 per cent for married
employees, to be paid by the employers without employee contribution. The private sector
scheme is compulsory for employers with 10 or more employees. However, it is estimated
that only 10 per cent of these enterprises are covered by the scheme since employers can
be exempted if they provide better health benefits than those offered by the scheme.
In the 1970s, the Dana Sehat programme encouraged the building up of community-based
risk-sharing schemes. In 1992, the Ministry of Health introduced a nation-wide ‘Managed
Health Care Scheme’ called Jaminan Pemeliharam Kesehatan Masyuarakat (JPKM) to
provide health benefits in the form of payments to health care providers on a capitation
basis. By 2002, the scheme had licensed 24 health insurance carriers and covered around
one million people. After the economic crisis in the late 1990s, a nation-wide Social Safety
Net Programme was set up to reduce the financial burden of the poor by subsidizing health
care, reaching an estimated 12 million people. All schemes combined, the coverage rate of
Indonesia is 54.6 per cent (table 11).
Recent developments include the President’s initiative in 2002 to restructure existing social
health insurance schemes to create a system of uniform benefits for all under a National
Social Security System. The National Social Security Bill, endorsed in September 2004,
covers social health insurance as part of social security measures and is expected to lay the
foundation for universal coverage in Indonesia.
Table 11. Selected indicators of social health protection in Indonesia


Philippines
The original Medicare Programme launched in 1969 in the Philippines (WHO, 2005, pp.
26-28) made health insurance mandatory for salaried workers under the separate social
security systems for the public and for the private sector. Dependents were covered,
entitlement was continued on to retirement, and workers in the informal economy and the
self-employed could join the scheme voluntarily. Contribution rates were set at 2.5 per cent
of salary, shared equally between the employer and employee with low ceilings. However,
benefits were limited to inpatient hospital treatment and the total amount of reimbursement
was less then 50 per cent of the hospital charges. Moreover, the system was plagued by
fraud and non-compliance, with OOP reaching levels of 44 per cent of total health
expenditure (table 12). Private investors set up health maintenance organizations, which
offered pre-payment plans linked to the use of specific providers. Despite the substantially
higher premiums, these plans became an attractive alternative for those who could afford
it. Alongside, NGOs began to organize community-based health insurance schemes on a
non-profit basis.
In 1995, the Government passed the National Health Insurance Act that replaced the
previous scheme with the National Health Insurance Programme, administered by
PhilHealth. The Act set the target of achieving universal coverage within 15 years and
recognized the role of the community-based schemes in reaching this goal. The programme
also established user fees and provided for subsidies for the indigent and poorest families.
The scheme included ambulatory care benefits and introduced standards and regulations
for the accreditation of health facilities. Implementation of the programme has come up
against the challenges of non-compliance, under-funding and high administrative costs as a
consequence of the search for appropriate targeting mechanisms.
Since its implementation, PhilHealth has introduced five programmes: the individually
paying program; the employed sector program; the sponsored program; the non-paying
program; and the overseas workers’ program. The individually paying program is
PhilHealth’s approach towards extending health service coverage to the informal
economy. It is a voluntary program that covers the freelance professionals and those not
eligible for the employed or indigent program. The annual contribution of every member is
US$ 24. The adoption of the organized group enrolment (KaSAPI) is a recent intervention
employed by PhilHealth to increase membership in this programme.
Another programme designed to reach the vulnerable subgroups of the population is the
“indigent program”, initiated by local government units. These units participate in the
programme’s implementation by identifying the indigents among their constituents in the
locality. The central and specific local governments sponsor the indigents’ premium. To
ensure stability from political issues, legislative developments are underway for more
sustainable funding - among which is the earmarking of a portion of additional revenues
(2.5 per cent) resulting from an increase in “sin taxes”.
Table 12. Selected indicators of social health protection in the Philippines

Staff-related national access deficit as % of population
Total health expenditure as % of GDP 29

Thailand 16
The Thai health care coverage consists mainly of three schemes: fringe benefit schemes;
health insurance under the social security schemes; and the universal health care scheme
(WHO, 2005; ILO, 2004c).
The fringe benefit schemes consist of the Civil Servant Medical Benefit Scheme (CSMBS)
and the State Enterprises Medical Benefit scheme. CSMBS covers government employees,
pensioners, and dependents (spouse, parents, not more than 3 children under 20 years of
age). The State Enterprise Medical Benefit Scheme, on the other hand, covers state
enterprise employees and their dependents. To provide extension of coverage to private
formal economy workers, the Social Security Act was implemented in 1991, thereby
creating the Social Security Health Insurance (SSO). It initially provided health protection
for establishments with 20 or more workers. In 2002 this coverage was enlarged to include
enterprises with at least one employee.
Further, in 2001, Thailand took a historical step towards achieving full population
coverage in health care by introducing a universal health-care scheme called "UC scheme"
(also commonly known as the "30 Baht" scheme). The scheme offers any Thai citizen, who
is not affiliated either to the SSO scheme or the CSMBS, full access to health services
provided by designated district-based networks of providers (consisting of health centres,
district hospitals and cooperating provincial hospitals).
Thailand's national health-care financing system has the following coverage:
the SSO scheme covering at present about 7.4 million card holders who are eligible
for health-care benefits;
the non-contributory civil servants’ medical benefit scheme (CSMBS) covering

roughly 7 million eligible people (some 3 million civil servants, as well as about 4
million eligible dependants, i.e. children, spouses and parents);
the UC scheme with a registered total membership of 46.5 million; UC beneficiaries

fall into two groups: 24.3 million beneficiaries who are exempted from a co-payment
of 30 Baht (US$0.75) per episode (or UCE), and 22.2 million beneficiaries who must
contribute a co-payment of 30 Baht at point of service (or UCP);
a self-payer/non-covered group (i.e. people in remote areas) of about 3 million

people,
voluntary private health insurance covering about 5 million people (Surasinangsang,

2004).
As of 2006, the overall health insurance coverage in Thailand accounted for 97.8 per cent
of the population. Of this figure, 75.3 per cent consisted of UC coverage and 22.5 per cent
of SSO and CSMBS coverage (Jongudosmsuk, 2006). Thailand’s pluralistic approach has
therefore succeeded in achieving near-universal coverage. Table 13 summarizes the scope
of the major schemes:
16
Comments of the Ministry of Labour of Thailand on the ILO strategy paper, based on the report:
Sustainability and effectiveness of health care delivery: National experiences of Thailand
(New Delhi, ISSA, 2003).

Table 13. Thailand’s social health protection mechanisms
Characteristics Social security scheme CSMBS UC/ 30- Baht scheme
Membership Private employees Government employees, Self employed and those

public sector workers and not covered by CSMBS and
their dependents SSS
Type Compulsory and Contributory Fringe benefit Compulsory
Financing source Contribution for sickness, General taxes General taxes except for the
maternity, invalidity and death patients’ co-payment of 30
is 1.5% from employers, Baht
employees and the government.
Total contribution is 4.5% of
employee’s wages
For sickness benefits (in kind and

in cash) the insured pays
3 months contribution within
the last 15 months.
Authority Social Security Office Ministry of Finance National Health Security

Office (NHSO)
Provider payment Capitation Fee-for-service Global budget and

mechanism capitation
Benefits Includes: medical benefits Includes ambulatory and Comprehensive package

for non-work related illness inpatient care at public includes
or injuries, maternity benefits, hospitals with minimum Curative and rehabilitative
invalidity and death benefits co-payments, inpatient care and health promotion
care at private hospitals and disease prevention
with more than 50% benefits
For sickness benefits, after
co-payments, and
paying the contribution, then
reimbursement for
will receive medical care free
medicine prescription in
of charge at a registered
case of outpatient care.
hospital and cash benefit
(50% of wages) for a maximum
of 90 days each time and not
more than 180 days each year.
Access to a provider Through a contracted hospital Member is free to choose Through contracted units
(public, university, military and a provider (primary care (CUP),
private hospitals) or its network; subcontractors of CUP,
with registration requirement; secondary care (CUS) or
Member is free to choose a tertiary care (CUT) and
provider super tertiary care); with
registration requirement
Focusing on the most recent scheme established, the UC/ 30 Baht scheme sets a specific
legal entitlement for all people to access health services. This scheme virtually abolishes
all financial barriers to access as co-payments are small and the needy are even exempted
from them. That entitlement is backed up by a new allocation mechanism for public sector
health-care resources, i.e. the capitation payment, which should ensure that all provider
networks receive a fixed budget for each person to whom they provide care. In its present
state the UC scheme is a variant of a national health service type of health-care financing

system that combines insurance elements (through legal benefit entitlements) and public
service elements (through general revenue financing).
In theory, the UC scheme at present enables more than 70 per cent of the population to
have access to health care. The proportion of the population it caters to is likely to be
smaller, as not all people eligible and/or holding UC cards actually take up the service. The
2003 Health and Welfare Survey conducted by the Thai National Statistical Office (NSO)
showed that only about 57 per cent of registered members used the outpatient care services
in public health centres and hospitals, and 81 per cent used the inpatient care services. Both
services are offered by the scheme. The up-take rate varies greatly according to income
groups and is significantly higher in the lower-income groups. It appears that about one-
third of the population in higher-income groups tend to use the UC scheme as a fallback
solution.
In terms of government spending on health care, it is obvious that the change to the UC
system in 2001 has increased investment in health care. The actual amount is difficult to
determine, as the counterfactual (i.e. government spending on health in the absence of the
new UC scheme) is obviously unknown. But from the increase in the spending level
between 2000 and 2003, it may be concluded that the additional cost of the scheme is in
the order of 25 billion Baht per annum. That order of magnitude is confirmed by the
International Health Policy Program (IHPP) estimates of the extent of household savings
of out-of-pocket health expenditure. The amount was estimated at around 10-13 billion
Baht for all households that were newly covered by the UC third-party arrangement. Due
to the differential take-up rates by income strata, this is a substantial income transfer to the
lower-income households and confirms the Ministry of Health’s assessment that the reform
has had significant pro-poor effects.
The scheme did not have the earmarked resources upon which it could rely during the first
years of existence and its resource base had to be renegotiated in an annual government
budgeting process. From the point of view of long-term scheme sustainability, it was in the
interest of the UC scheme to shrink as much as possible by conceding “market share” to
the other two or three schemes. At the same time, it seemed logical to try and establish
earmarked income sources that would be protected against annual budgetary competition.
This was done in 2005, when a certain proportion of the taxes on tobacco and alcohol were
earmarked for the financing of the UC scheme - thus helping to safeguard the resources for
health care of the economically weakest sections of the population in times of fiscal
difficulties. However, the financial situation of the UC schemes can only be stabilized in
the long run if it constantly shrinks at the expense of other players. The most effective way
to reduce government expenditure is through the extension of social security (SSO)
coverage.
Table 14. Selected indicators of social health protection in Thailand


c. Europe
Country experiences covered in this region (Gamkrelidze, et.al., 2002; Nuri, 2002; Holley
et al., 2004; Meimanaliev et al., 2005; Ahmedov et al., 2007) include Albania, Belarus and
Georgia. Generally, countries that were under the influence of the Soviet Union at some
point in their history inherited a highly centralized system on the lines of the Semashko
model - characterized by government revenue financing mechanisms and almost complete
public ownership. Planning, organization, control and resource allocation were undertaken
in Moscow, leaving local authorities with administrative tasks according to pre-determined
plans. In theory, health care was free but under-the-table-payments were very common.
Hospitals dominated the delivery system with parallel systems under various ministries.
After the collapse of the Soviet Union, countries in the region embarked upon designing
new health strategies and health system reforms. They differed in the extent to which they
managed to contain costs and the degree to which they decentralized their health systems,
with Georgia having decentralized the most and Belarus the least.
Out-of-pocket payments are widespread in the lower-income countries of the region and
constitute a serious barrier to access health services. OOP as percentage of total health
expenditure is as high as 74.4 per cent in Georgia and 58.2 per cent in Albania. Although
many countries achieve legally universal coverage, e.g. through mandatory state medical
insurance or tax-financed national health systems, effective access to health services
remains a major challenge for many countries in the region.
Albania
Albania (Nuri, 2002) was also part of the Semashko system during its brief period under
Soviet influence. It’s very centralized health system was continued even after its break
with the Soviet Union. The Ministry of Health regulated, managed and organized the
health sector, and provided all health services in every district until the early 1990s. Staff
at the local level had no discretion to improve services - for instance by reallocating staff.
Administrative reforms in 1993 introduced decentralization measures, shifting some
authority to the 12 newly created prefectures, each of which comprised on average three
districts. Responsibility for running and maintaining rural primary health care facilities has
now largely devolved to the local governments.
A comprehensive health sector strategy has still to be implemented - but proposals for the
strategy envisage a further restructuring of the central institutions. However, for the time
being, the Ministry of Health remains the major funder and provider of health services in
Albania, owning most health services and devoting most of its time to their administration
rather than policy and planning.
Social health insurance, organized by the Health Insurance Institute (HII), was introduced
in Albania in 1995 as a national statutory fund. Most of the unwaged (children, women
who work at home and the elderly) were automatically covered by the state budget. By
1999, about 40 per cent of the active workforce were covered. Coverage remains low,
especially in rural areas, because people are poorly informed about the scheme, are unable
to pay the contribution and enrolment does not seem to confer any advantage; the scheme
covers limited services and doctors treat all patients without discrimination, although
benefits are legally limited to members of the scheme.
Contribution rates are set at 3.5 per cent of wages, split equally between employers and
employees. The self-employed contribute between 3 per cent and 7 per cent of their
incomes, depending on whether they live in rural or urban areas. Lower rates have been set
for private farmers, amongst whom the coverage rate remains particularly low (4 per cent).

Initially, the HII was responsible for financing only the salaries of primary health care
doctors and essential pharmaceuticals. However, pilots are being undertaken to extend this
financing to all primary health care expenditures in the Tirana Prefecture, including
salaries of nurses and other personnel, as well as the recurrent costs for these services.
Despite some resistance, the HII is expected to become the primary funder of health
services in Albania.
In addition to health insurance contributions and legal co-payments set at a low level,
under the-table-payments are widespread in Albania - although it is difficult to estimate
their magnitude. OOP represent 58.2 percent of total health expenditure (table 15). A
survey conducted in 2000 reported that 87 per cent of respondents admitted to having
tipped a doctor or a nurse. It is generally perceived that such payment is necessary to get
proper treatment, or any treatment at all.
Table 15. Selected indicators of social health protection in Albania

Total formal coverage as % of population -
Belarus
The whole population of Belarus (Arnaudova, 2006) is entitled to free health services
financed through general taxation. After 1989, priority was set on the continuation of the
inherited Soviet system and the health system thus remained highly centralized. Primary
care is widely available through a network of health posts and health stations in rural areas
and through polyclinics in urban settings. Excess capacity for secondary and tertiary care is
common and facilities are publicly owned.
Legislation to introduce insurance schemes with a view to generating additional resources

failed to get parliamentary support in 1992 and 1996/97. Taxation is therefore expected to
constitute the major source of financing for the foreseeable future. Resources are difficult
to estimate since nine ministries and many enterprises run parallel health services and no
formal arrangements for hospital charges or cost-sharing exist. Overall, the system is
challenged by inefficiencies and ineffectiveness. It has been very difficult to contain costs
and ensure quality of services in the health system, especially due to the excessive number
of health personnel, the heavy emphasis on hospitals and the absence of a defined benefit
package. The number of physicians and nurses is 456 and 1,166 per 100,000 inhabitants,
respectively, compared to a regional average of 343 physicians and 779 nurses in the
EU 25; the number of hospitals and hospital beds is roughly twice the EU 25 average. This
excess capacity is also reflected in the staff-related national access deficit data listed as 0 in
table 16.
Despite these figures, indicators of people’s health status have been declining over the past
decade and the healthy life expectancy for males ranks amongst the lowest in the region.
The most urgent need for reform in Belarus consists of ensuring that more rational use is
made of its resources, e.g. by restructuring inpatient care so that medical care is delivered

at the appropriate level and by better coordinating the different government bodies and
institutions active in the health sector.
Table 16. Selected indicators of social health protection in Belarus

Georgia
In 1995, the Government of Georgia initiated a health policy reform plan and established
the State Committee for Regulating Social Policy for its implementation (Gamkrelidze,
2002). The Committee made up of representatives from different sectors of government
and business, reports to the President and guides the Ministry of Labour, Health and Social
Affairs (MoLHSA). The Government also decided to hand much of its decision-making
power, as well as responsibility for funding, over to 12 Regional Health Departments
(RHDs). The RHDs report to the MoLHSA and monitor local activities. The
decentralization process also made most health care providers financially and managerially
autonomous from MoLHSA control. In addition, a large number of polyclinics, hospitals,
dental clinics and pharmacies have been privatized. In 2000, MoLHSA developed a long-
term strategic plan (2000-09), which reiterated decentralization as a key element of the
reform process to improve responsiveness and efficiency.
The 1997 Law on Medical Insurance introduced a state compulsory medical insurance
programme and set up the State Medical Insurance Company (SMIC) to run it. Private
health insurance companies (seven companies existed in 2001) offer insurance that is
supplementary to the compulsory state insurance to cover extra costs. The SMIC has 12
regional branches in addition to its headquarters in the capital. It is publicly owned and
collects mandatory premiums from the population (1 per cent of salary) and employers (3
per cent of salary) to finance the Basic Benefit Package (BBP) through contracts with
health care providers. By 1999, nearly 700 health care providers were carrying out work on
1,300 contracts.
The BBP initially consisted of nine federal (state) and five compulsory municipal health
programmes but has gradually expanded to 28 federal and 8 municipal programmes. This
expansion has not, however, been accompanied by a corresponding increase in funding; in
fact government expenditure on health as a percentage of GDP declined dramatically
throughout the 1990s. While the programmes outlined under the BBP appear to be wide-
ranging, their content is fairly limited. Services included under the state BBP are free-of-
charge. Co-payments have been formalized for the municipal programmes provided under
the BBP. Direct fees-for-service must be paid for all other health services at set rates. OOP
amounts to 74.7 per cent of total health expenditure (table 17). A large number of people
(estimated at up to 30 per cent of the population) are deterred from seeking medical
services due to the high level of out-of-pocket payments charged. Others delay their visits
to health care providers. Nearly 22 per cent of individuals with health problems do not see
a health provider because of their inability to pay.

Table 17. Selected indicators of social health protection in Georgia

d. Latin America
From the late 1990s to the early 2000s, many countries in the Latin American region
embarked upon major reforms in their public sector, particularly, in the health sector.
Some of these reforms were motivated by achieving the MDGs, and some were inspired by
the Chilean experimentation with privatizing public services - especially with respect to
old-age security and health. The case studies presented here describe the situation of a
number of countries that are comparatively well off in the region, like Chile and Costa
Rica, and poorer countries such as Ecuador and Colombia. The comparison shows that
Chile and Costa Rica are achieving better outcomes, reaching almost universal coverage
and keeping OOP relatively low at around 20 per cent. Ecuador and Peru are in the process
of extending coverage, scoring above 70 per cent; but in Colombia, coverage at 31.1 per
cent is quite low for the region. However, high OOP, especially in the case of Ecuador
(54.1 per cent), indicate that barriers to access remain high, especially for the poor. Given
Chile’s overall economic performance, its staff-related access deficit of 46 per cent is
rather high compared to the other countries in the region (figure A.4).
Figure A.4. Comparison of selected countries in Latin America
Total Formal Coverage

100 %
90
80
Percentage
70 Staff related national

60 access deficit %
50
40
30 Out of pocket payment
20 as % of total health
10 expenditure
0
a
ru
r
le
do
bi
ic
hi
Pe
R
om
ua
C
ta
Ec
ol
os
C
Chile
In 1981, Chile's health-care system (Holst et al, 2004) drew widespread attention because it
became one of the first market-oriented models to introduce private health insurance funds
aimed at achieving efficiency gains and overcoming bottlenecks in provision and funding.
Twenty-five years later, the coexistence of public social health insurance and several for-

profit private health insurance companies assures universal coverage (96 per cent, see table
18). However, the Chilean health system still faces shortcomings in terms of equity and
fair financing and is challenged by risk selection. The staff-related access deficit of 46 per
cent is comparatively high.
The National Health Fund (FONASA) currently covers two out of three Chileans,
including 3 million people considered to be very poor.
Chile has achieved universal health protection coverage by combining, in a single-payer

system, a Bismarck-type contribution system with a tax-financed health system covering
the poor.
Employees in the formal sector and some of the self-employed pay income-related
contributions to gain access to a comprehensive benefit package. Indigents are
covered by the public health insurance fund, FONSAS, which receives substantial
subsidies for this purpose from general taxation.
Exempted enrolees are not entitled to claim for private health services as other
beneficiaries may do for paying high co-payments. However, as affiliation to
FONASA is free-of-charge, they are protected from discrimination and stigmatization
when receiving health care at public providers.
Table 18. Selected indicators of social health protection in Chile

Colombia
Before the Colombian health sector reform of 1993 (Castano and Zambrano, 2005),
employment-based social health insurance schemes covered about one-third of the
population. Formal sector workers were compulsorily enrolled in closed pools and paid
mandatory contributions. While the largest fund, the Instituto de Seguridad Social (ISS),
covered private sector workers, public sector workers were enrolled in funds restricted to
state-owned enterprises, public universities or government units. Besides two large public
sector funds (Cajanal, for central government employees, and Caprecom, for workers in
the state-owned telecommunications, television and postal enterprises), the overall risk
pool was divided into more than a thousand small-scale insurance schemes.
The 1993 reform was inspired by the fundamental changes that Chile had applied to its
health system 12 years earlier. However, Colombians tried to avoid the obvious undesired
effects that were becoming more and more evident in Chile. By creating a contributory
system for all formal sector workers and employees, the previously existing monopolistic
funds were exposed to a sort of managed competition, since new insurance companies
were allowed to enter the market and citizens had the right to choose their insurer
according to their own preference. Financing was based on mandatory payroll
contributions of 12 per cent of the salary (employer 8 per cent, employee 4 per cent).

In order to avoid market failure and inefficient competitive behaviour by health insurers
(most of them were private, and some for-profit), Colombians tried to implement effective
regulation. In order to prevent competition on prices, contributions within the contributory
scheme were pooled in a single equalization fund, which then allocated insurers a risk-
adjusted community-rated premium for each enrolee defined by age, gender and
geographic location (urban/rural). Thus, enrolees paid according to their ability to pay, but
insurers receive contributions according to the individual risk of the insured persons.
Furthermore, a standardized benefit package defining covered/excluded services and
qualifying periods for full coverage and co-payment rates was established; insurers are
now mandated to contract all applicants; enrolment is compulsory for all registered
workers; and full portability of benefits is guaranteed.
With regard to the challenge of extending social health protection beyond formal sector
employees and workers, the creation of a subsidized system alongside the contributory
scheme is especially worth mentioning. Citizens lacking financial means to pay
contributions are required to register with the Administrator of the Subsidized System
(ARS). However, the number of poor and indigent people affiliated to the subsidized
scheme still remains below expectations, as does the overall coverage rate of 31.3 per cent
(table 19).
To improve the targeting of the needy and the poor, Colombia has developed a Beneficiary
Identification System (SISBEN) based on comprehensive questionnaires and individual
contacts by social workers. Entitlement to the subsidized system is conditioned on an
adequate SISBEN qualification. Financing of the subsidized scheme relies on tax revenue
and on the solidarity contribution of the better off who pay 13 per cent instead of 12 per
cent for health insurance - the additional 1 per cent contribution being designated to
subsidize the poor. The benefit package covered by the solidarity scheme is more limited
than the comprehensive one of the contributory system; the main advantage for its
beneficiaries lies in co-payment exemptions at public health-care providers.
Table 19. Selected indicators of social health protection in Colombia

Costa Rica
The health sector in Costa Rica (Weber and Normand, 2007) is mainly funded by social
insurance, with preventive services provided by the Ministry of Health. The Costa Rican
Social Security Fund (CCSS) was created in the early 1940s to administer the social
security insurance system. The system has been very successful in improving the health
status of the population. Costa Rica's health indicators resemble those of Europe, the
United States and Canada, rather than those generally exhibited by countries with similar
per capita incomes (US$1,750). Population coverage has expanded and access to CCSS
health services is now more or less universal, while out-of-pocket payments are at a
relatively low level of 18.8 per cent of total health expenditure (table 20).

The Ministry of Health (17 per cent of total expenditure in 1990) oversees health
promotion, disease prevention and environmental health. The CCSS (80 per cent of total
expenditure) provides curative and rehabilitative care, individual preventive services (e.g.
immunization) and some educational services. The National Insurance Institute (INS)
covers the treatment, rehabilitation and compensation of policyholders for occupational
illnesses and injuries, as well as automobile-related injuries.
The CCSS owns and operates all of the country's 29 hospitals, providing 95 per cent of
hospital services and around 70 per cent of all consultations. Except for three private
clinics, virtually all health facilities are operated by the CCSS, the Ministry of Health or
the INS, and belong to the national health system. While the quality of care for inpatient
services is considered to be quite high, dissatisfaction with the quality of care provided in
ambulatory settings is increasing.
Health-care providers in the Ministry of Health and CCSS mainly receive a salary,
although the CCSS has been experimenting with other options, including the Company
Medicine Scheme (where a company pays the physician's salary and provides a clinic for
employees) and capitation payments to physicians or cooperative clinics.
Table 20. Selected indicators of social health protection in Costa Rica

Ecuador
The constitution of Ecuador recognizes health as a right that must be guaranteed, promoted
and protected through permanent access to health services by people in need (Panamerican
Health Organization, 2007, pp. 304-321). Moreover, the national health policy is based on
the principles of equity, universality, solidarity, quality, plurality, efficiency, ethics and
comprehensiveness. The National Health System Law of 2002 aspires to put these
principles into practice through specific laws such as: the Free Maternity and Health Care
Act (in force since 1994); the Law on Patient Rights and Protection; the Law on HIV/Aids
Prevention and Comprehensive Care; and the Law on Food and Nutritional Safety.
In line with the country’s decentralization process, the health service is divided up into
national, provincial and cantonal levels with corresponding councils at all levels. The
National Health System Law expressly mentions social and community participation for
the implementation and development of the councils, and recognizes all existing
neighbourhood and community organizations.
A variety of health protection programmes cater to different sectors and societal groups,
resulting in an overall coverage of 73 per cent of the population (table 21):
— The Ecuadorian Social Security Institute is geared towards providing coverage to

workers in the public and private sector, which account for about 10 per cent of the
population.

— The Farmers Social Security system covers primary medical care for workers and
their families in rural areas – reaching an estimated 9.2 per cent of the rural
population.
— The Armed Forces and Police Health Services offer ambulatory care and
hospitalization.
In 2004, 50.4 per cent of total health spending came from the public sector (Ministry of
Public Health, IESS, Armed Forces and Police Health Services, and sectional
governments) and 49.2 per cent from the private sector. Public social spending in health as
a percentage of GDP increased from 0.6 per cent in 2000 to 0.8 percent in 2001, 1.2 per
cent in 2002, and 1.5 per cent in 2004. Only 31.8 per cent of public expenditure was geared
toward the poor. Ninety per cent of the total private health spending corresponded to direct
household spending (61 per cent for the purchase of medications and inputs; 24.3 per cent
for medical care; and 4.7 per cent for laboratory examinations, dental materials, and
orthopaedic devices); the remaining 10 per cent accounted for official direct payment to
medical providers. However, out-of-pocket spending remains high at 54.1 per cent of total
expenditure of health (table 31).
Table 21. Selected indicators of social health protection in Ecuador

Peru
In July 2001, the Peruvian Government policies on universal access to health services and
social security (Panamerican Health Organization, 2007, pp. 576-595) were approved,
alongside the Sectoral Policy Guidelines for 2002-2012. The nine defined guidelines
emphasized health promotion, comprehensive health care, universal insurance, financing
for the poorest, and modernization of the Ministry of Health. The trend is to continue
progressively toward universal insurance. Comprehensive Health Insurance is the public
insurer for the poor and extremely poor, as well as for the population working in the
informal sector (covering about 20-30 per cent of the population in 2004). The social
security system (ESSALUD) aims to insure the salaried population (covering about 17.6
per cent of the population in 2004), leaving complementary plans and insurance open to
the private sector for those who prefer them (about 10 per cent in 2004).
The 2002 Basic Decentralization Law defined the responsibilities for the three levels of
government (national, regional and local). In 2005, the Ministry of Health began the
transfer process from health offices to regional governments, by means of an accreditation
process carried out by the National Decentralization Council. This process involved the
development of capacities in the regions to lead, direct, and manage health services,
following the transfer of certain responsibilities agreed upon with the Council. The first
evaluation of the Coordinated and Decentralized National Health System was carried out
in 2005 and showed that several adjustments were needed to harmonize the rules
governing the agencies making up the System. The impact of decentralization on the
public health sector is still in its initial phases, because the process of transferring

functions, competencies, responsibilities, and resources is gradual and taking place by
stages, depending also upon the areas involved. Overall, Peru’s health system is segmented
and has various actors in both services provision and public insurance, which carry out
different but not necessarily complementary functions and with high degrees of overlap.
This situation could become more marked with the decentralization of the Peruvian
Government.
The Peruvian health system suffers severe access deficits, especially due to lack of
payment capacities. 32.1 per cent of the poor with symptoms of disease or who have been
involved in accidents do not seek medical treatment for economic reasons. As a strategy to
improve access for the poor, the above-mentioned comprehensive health insurance, created
in 2001, covers those less than 18 years of age, pregnant women, and certain groups of
adults living in poverty. According to different estimates, the programme reaches between
20-30 per cent of the population and has thus improved the population’s access to health
services - even though 40 per cent of the population is still excluded from health services
in some way. This is mainly due to poverty, living in a rural area, and social and ethnic
discrimination; problems intrinsic to the health system are also important factors, including
the inadequate provision of essential services in the poorest areas. To address some of
these problems and provide care to the poor and dispersed populations living in the most
distant rural areas of the mountains and Amazonia, the regional governments and the
Ministry of Health have organized mobile care units, supported by the comprehensive
health insurance; these units provide care at regular intervals to this population and offer a
package of basic or essential services They also organize promotional and community
organization actions. This service covers approximately 200,000 people.
Based on the data, Peru allocates 4.4 per cent of its GDP to health, with almost 41 per cent
of this value attributed to out-of-pocket expenditures. Seventy-one per cent of its
population is covered by social health protection. As for the staff-related deficit, this
amounts to 42 per cent (table 22).
Table 22. Selected indicators of social health protection in Peru


ILO Strategy Social Health Protection.Sept
Appendix II
Estimated access deficit and formal coverage in social health protection
Table A2.1. Estimated access deficit in social health protection
Population GDP 1 Human Human poverty Gini-Index Estimated access deficit

Development Index 3
Country Total Urban Total Per capita Staff-related national Estimate of access
Index 2
(2003) 4 population (in billion access deficit deficit (skilled
(%) (2004) 5 US$) (% of population) attended births)
Albania 3 45 6 1 740 0.78 28 - 6
Algeria 32 63 60 1 890 0.73 22 35 - 8
Angola 14 53 10 740 0.44 41 62 53
Argentina 38 90 140 3 650 0.86 4 52 - 1
Armenia 3 64 3 950 0.77 38 - 3
Australia 20 88 0 431 21 650 0.96 13 35 - 1
Austria 8 66 215 26 720 0.94 30 - -
Azerbaijan 8 52 7 810 0.74 37 - 16
Bangladesh 141 25 55 400 0.53 44 32 88 87
Belarus 10 72 16 1 590 0.79 30 - -
Belgium 10 97 267 25 820 0.95 12 25 - -
Benin 7 40 3 440 0.43 48 72 34
Bolivia 9 64 8 890 0.69 14 45 - 39
Bosnia and Herzegovina 4 45 6 1 540 0.80 26 - -
Botswana 2 57 6 3 430 0.57 48 63 4 6
Brazil 179 84 479 2 710 0.79 10 59 - 50
Bulgaria 8 70 17 2 130 0.82 32 - 1
Burkina Faso 12 18 4 300 0.34 58 48 85 43
Burundi 7 10 1 100 0.38 41 33 93 75
77
78
Development Index 3
Country Total Urban Total Per capita Index 2 Staff-related national Estimate of access
Cambodia 14 19 4 310 0.58 39 40 76 68
Cameroon 16 54 10 640 0.51 36 45 44 38
Canada 32 80 757 23 930 0.95 11 33 - 2
Cape Verde 57 0.72 19 57 11
Central African Republic 4 38 1 260 0.35 48 61 88 56
Chad 9 25 2 250 0.37 58 90 86
Chile 16 87 69 4 390 0.86 4 57 46 -
China 1 297 40 1 417 1 100 0.77 12 45 34 17
Colombia 45 72 80 1 810 0.79 8 58 40 9
Congo 4 60 2 640 0.52 28 64 64
Costa Rica 4 61 17 4 280 0.84 4 47 29 2
Côte d’lvoire 17 45 11 660 0.42 42 45 77 37
Croatia 5 56 2 5 350 0.85 29 - -
Cuba 10 76 0.83 5 - -
Czech Republic 10 74 69 6 740 0.89 25 - -
Dem. Rep. of the Congo 55 32 5 100 0.39 41 80 39
Denmark 5 86 182 33 750 0.94 8 25 - -
Dominican Republic 9 66 18 2 070 0.75 12 47 - 1
Ecuador 13 62 23 1 790 0.77 9 44 4 31

Egypt 69 43 94 1 390 0.70 20 34 19 31
El Salvador 7 60 14 2 200 0.73 16 53 36 31
Eritrea 5 1 190 0.45 38 80 72
Estonia 1 69 7 4 960 0.86 37 - -
Ethiopia 70 16 6 90 0.37 55 30 93 94
Finland 5 61 141 27 020 0.95 8 27 - -
Development Index 3
France 60 77 1 523 24 770 0.94 11 33 - -
Gabon 1 83 4 2 739 0.63 27 - 14
Gambia 1.5 53 12 8 0.48 45 59 45
Georgia 5 53 4 830 0.74 37 - 4
Germany 83 75 2 085 25 250 0.93 10 28 - -
Ghana 21 47 7 320 0.53 33 30 66 53
Greece 11 59 147 13 720 0.92 35 - -
Guatemala 13 47 23 1 910 0.67 23 48 - 59
Guinea 8 33 3 430 0.45 52 40 79 65
Guinea-Bissau 1.5 30 12 960 0.35 48 75 65
Haiti 9 38 3 380 0.48 39 89 76
Honduras 7 46 7 970 0.68 17 55 42 44
Hungary 10 66 64 6 330 0.87 24 - -
Iceland 0.3 93 858 2 932 0.96 - -
India 1 080 29 568 530 0.61 31 33 56 57
Indonesia 218 47 173 810 0.71 19 34 76 34
Iran, Islamic Republic 67 66 133 2 000 0.75 16 43 45 10
Ireland 4 60 106 26 960 0.96 16 36 - -
Israel 7 92 105 16 020 0.93 36 - -
Italy 58 68 1 243 21 560 0.94 36 - -
Jamaica 3 53 7 2 760 0.72 15 38 22 5
Japan 128 66 4 390 34 510 0.95 12 25 - -
Jordan 5 82 10 1 850 0.76 36 - -
Kazakhstan 15 57 27 1 780 0.77 31 - 1
79
Kenya 32 21 13 390 0.49 36 45 60 58

80
Development Index 3
Korea, Republic of 48 81 576 12 020 0.91 32 - -
Kuwait 3 98 38 16 340 0.87 - -
Kyrgyzstan 5 36 2 330 0.71 29 - 2
Lao People’s Dem. Rep. 6 20 2 320 0.55 36 37 49 81
Latvia 2 68 9 4 070 0.85 32 - -
Lebanon 5 87 18 4 040 0.77 10 - 7
Lesotho 2 19 1 590 0.49 48 63 79 45
Lithuania 3 67 16 4 490 0.86 32 - -
Luxembourg 1 83 25 664 56 780 0.95 11 - -
Madagascar 17 27 5 290 0.51 36 48 81 49
Malawi 11 17 2 170 0.40 43 50 81 39
Malaysia 25 66 94 3 780 0.81 8 49 35 3
Mali 12 30 3 290 0.34 60 51 82 59
Mauritania 3 40 1 430 0.49 41 39 77 43
Mexico 104 76 637 6 230 0.82 7 55 10 14
Moldova, Republic of 4 47 2 590 0.69 36 - 1
Mongolia 3 57 1 480 0.69 19 44 - 1
Morocco 31 58 40 1 320 0.64 33 40 59 37
Mozambique 19 34 4 210 0.39 49 40 93 52

Myanmar 54.3 6 30 13.8 7 270 0.58 22 77 44
Namibia 2 35 4 1 870 0.63 33 71 - 24
Nepal 25 15 6 240 0.53 38 37 87 89
Netherlands 16 80 427 26 310 0.95 8 33 - -
New Zealand 4 86 64 15 870 0.94 36 - -
Nicaragua 6 59 4 730 0.70 18 55 55 33
Development Index 3
Niger 12 17 2 200 0.31 56 51 92 84
Nigeria 140 47 43 320 0.45 41 51 38 65
Norway 5 77 198 43 350 0.97 7 26 - -
Oman 3 72 0.81 - 5
Pakistan 152 35 69 470 0.54 36 33 62 77
Panama 3 70 13 4 250 0.81 8 56 4 7
Papua New Guinea 6 13 3 510 0.52 41 51 82 82
Paraguay 6 58 6 1 100 0.76 8 57 12 23
Peru 28 72 58 2 150 0.77 12 50 42 29
Philippines 83 62 88 1 080 0.76 15 46 29 40
Poland 38 62 201 5 270 0.86 32 - -
Portugal 10 57 124 12 130 0.90 39 - -
Romania 22 54 51 2 310 0.81 30 - 2
Russian Federation 143 73 375 2 610 0.80 46 - 1
Rwanda 8 19 2 220 0.45 37 29 85 69
Saudi Arabia 23 81 187 8 530 0.78 - 7
Senegal 11 41 6 550 0.46 44 41 88 42
Serbia and Montenegro 8 16 1 910 - 7
Sierra Leone 5 40 1 150 0 52 63 88 58
Singapore 4 100 90 21 230 1 43 - -
Slovakia 5 56 26 4 920 1 26 - 1
Slovenia 2 51 23 11 830 1 28 - -
South Africa 46 59 126 2 780 1 31 59 - 16
Spain 41 77 698 16 990 1 13 33 - -
81
Sri Lanka 19 15 18 930 1 18 34 33 3

82
Development Index 3
Sweden 9 84 258 28 840 1 7 25 - -
Switzerland 7 75 293 39 880 1 11 33 - -
Syrian Arab Republic 18 51 20 1 160 1 14 - 30
Tajikistan 6 25 1 190 1 35 - 29
Tanzania, United Rep. of 37 24 10 290 0 36 38 88 54
Thailand 64 32 136 2 190 1 9 43 - 1
The FYR of Macedonia 2 68 4 1 980 0.80 28 - 2
Togo 5 39 1 310 0 39 85 51
Tunisia 10 65 22 2 240 1 18 40 - 10
Turkey 72 67 197 2 790 1 10 40 4 17
Turkmenistan 5 46 5 1 120 1 41 - 3
Uganda 26 13 6 240 1 36 43 78 61
Ukraine 48 77 47 970 1 29 - 1
United Kingdom 59 90 1 680 28 350 1 15 36 - 1
United States 294 81 10 946 37 610 1 15 41 - 1
Uruguay 3 92 13 3 790 1 3 45 - 1
Uzbekistan 26 37 11 420 1 27 - 4
Venezuela, Boliv. Rep. of 26 93 89 3 490 1 9 49 39 6
Viet Nam 82 26 39 480 1 16 36 66 15

Yemen 20 27 10 520 0 41 33 69 78
Zambia 11 35 4 380 0 46 53 42 57
Zimbabwe 13 35 6 480 0 46 57 72 27
World Bank data sources were used to obtain references of country figures: 1 World Bank (2006b) pp. 292-295. 2 Human Development Report 2006 (2006), pp. 283-286. 3 Idem, pp. 292-295. 4 All data from World Bank (2005),
pp. 256ff. except for Cuba. 5 Human Development Report 2006 (2006), pp, 297-299. 6 Myanmar National Health Accounts, 2004-2005. 7 Health in Myanmar.
Table A2.2. Formal coverage in social health protection
Social security
Formal coverage Out-of-pocket
Total expenditure expenditure on
OOP as % of health as % of expenditure
on health as %
Country Company total exp. on general as % of private
of gross domestic
Total State SHI PHI Other health government expenditure
based/ trade MHI Total product1
(%) (%)2 (%) (%) (%) expenditure on on health1
union
health1
Albania … 58.2 6.5 25.1 99.8
Algeria 85.0 173 684 0 18.3 4.1 28.4 95.3
Angola … 15.8 7.1 89.2 71.1
Argentina 99.9 37.35 13.66 0.27 48.88 28.6 2.8 0.0 100
Armenia 100.0 100 64.3 4.5 0.0 100
Australia 100.0 59.7 40.39 22 8.9 56.8 55.6
Austria 98.1 3.810 94.2 0.19 19.2 6.0 0.0 80.6
Azerbaijan ... 73.8 9.5 0.0 67.8
Bangladesh 0.4 0.41 58.9 7.5 65.8 59.2
Belarus 100.0 10011 23.2 3.6 0.0 96.8
Belgium 100.0 99 57.59 21.8 9.4 88.4 66.6
Benin 0.5 0.44 51.4 4.4 ... 90.3
Bolivia 66.9 30 25.8 10.5 0.6 28.5 6.7 65.0 79.3
Bosnia and Herzegovina 100.0 100 49.3 9.5 77.5 100
Botswana … 12 5.6 ... 28.8
Brazil 85.0 10012 24.5 35.1 7.6 0.0 64.2
Bulgaria 100 10013 44.8 7.5 51.6 98.4
Burkina Faso 0.2 014 0.2 52.2 5.6 1.0 98.1
Burundi 13 1315 0 76.7 3.1 ... 100
Cambodia 0.66 69.6 10.9 0.0 86.2
Cameroon 0.1 0.05 69.9 4.2 0.1 98.3
83
Social security
84

on health as %
Country total exp. on general as % of private
Company of gross domestic
union
health1
Canada 100.0 35 659 0 14.9 9.9 2.1 49.6
Cape Verde 65.0 26.716 0 26.7 4.6 35.5 99.7
Central African Republic 6.0 6.03 58.5 4.0 ... 95.3
Chad … 0.01 57.9 6.5 ... 96.3
Chile 96.0 2517 43.8 17.6 9.6 0 23.7 6.1 32.1 46.2
China 23.9 10.018 13.9 55.9 5.6 53.4 87.6
Colombia 31.3 30.519 0.720 0.13 7.5 4.0 ... 95.3
Congo ... 0 35.8 2.0 0.0 100
Costa Rica 100.0 87.821 12.2 0 18.8 7.3 88.6 88.7
Côte d’lvoire 5.0 5.02 65.5 3.6 ... 90.5
Croatia 100.0 10022 0 16.4 7.8 96.1 100
Cuba 100.0 100 0 9.9 7.3 0.0 75.2
Czech Republic 100.0 100 09 0 8.4 7.5 85.4 83.9
Dem. Rep. of the Congo 0.2 0.17 81.7 4.0 0.0 100
Denmark 100.0 100 0 15.7 9.0 0.0 92.5
Dominican Republic 84 60 7.0 12.0 0 47.3 7.0 17.4 70.8
Ecuador 73.0 28 18 20 7 0 54.1 5.1 31.9 88.1
17.423
Egypt 47.6 34.324 12.925 0.44 0 53.5 5.8 27.1 93.2
El Salvador 59.6 40 18.126 1.5 0 50.4 8.1 44.1 93.5
Eritrea … 0 54.5 4.4 0.0 100
Estonia 94.0 94 0 20.2 5.3 84.9 88.3
Ethiopia … 0 32.7 5.9 0.4 78.7
Finland 100.0 100 0 19.1 1.5 0.0 80.5
Social security

on health as %
union
health1
France 100.0 99.9 9227 0 10 1.5 0.0 80.5
Gabon 55.0 14.428 2329 4.730 12.931 0 33.4 4.4 1.7 100
Gambia 99.9 0 40.2 8.1 0.0 67.0
Georgia 55.0 1432 0 74.7 4.0 59.2 98.2
Germany 101.6 3.933 85.734 1035 236 0 10.4 11.1 87.4 47.9
Ghana 18.7 18.7 68.2 4.5 ... 100
Greece 99.5 109 0 46.5 9.9 32.0 95.4
Guatemala 72.6 26 16.6 30 > 0.00838 55.4 5.4 50.5 91.9
18.237
Guinea 1.1 1.09 82.9 5.4 1.5 99.4
Guinea-Bissau 1.6 1.6 43.5 5.6 2.2 80.2
Haiti 60.0 21 38 1 43 7.5 0.0 69.5
Honduras 65.2 52 11.7 1.5 37.3 7.1 11.6 85.8
Hungary 100.0 100 0 24.5 8.4 83.4 88.9
Iceland 100.0 100 09 16.5 10.5 36.5 100
India 5.7 5.239 0.0440 0.48 72.9 4.8 4.2 97.0
Indonesia 54.6 16.641 36.142 1.943 47.6 3.1 9.9 74.3
Iran Islamic Republic of … 50 6.5 30.9 94.8
Ireland 100.0 100 43.89 13.1 7.3 0.8 61.9
Israel 9.0 28.3 8.9 61.9 89.1
Italy 100.0 100 15.69 20.7 8.4 0.2 83.3
Jamaica … 32 5.3 0.0 64.7
Japan 100.0 100 17.1 7.9 80.5 90.1
85
Jordan ≈80.0 70 5 37 40.6 9.4 0.7 74.0

Social security
86

on health as %
union
health1
Kazakhstan 70-80 70-80 42.7 3.5 0.0 100
Kenya 25.0 2544 0.015 50.6 4.3 10.0 82.6
Korea, Republic of 10095 3.695 96.495 n.a. 41.9 5.6 81.7 82.8
Kuwait 0.0 20.5 3.5 0.0 91.2
Kyrgyzstan ... 0 59.2 5.3 15.2 100
Lao People’s Dem. Rep. 16.1 15.945 0.15 46.4 3.2 1.0 75.5
Latvia 87.0 87 0 46.9 6.4 82.7 94.3
Lebanon 95.1 45.346 26.147 12.648 11.149 0 56.1 10.2 46.0 79.4
Lesotho ... 0 3.7 5.2 0.0 18.2
Lithuania ... 0 23.2 6.6 74.6 96.6
Luxembourg 99.7 1.4450 98.3 2.4 0 7.1 6.8 88.1 77.3
Madagascar ... 0 33.6 2.7 ... 91.7
Malawi ... 0 27.7 9.3 0.0 42.7
Malaysia … 30.8 3.8 0.8 73.8
Mali 2.0 2.0 38 4.8 26.0 89.3
Mauritania 0.3 0.26 23.2 3.7 8.7 100
Mexico 78.6 28.651 4752 353 50.5 6.2 66.9 94.2
Moldova, Republic of 78.6 10054 43.7 7.2 1.1 96.1

Mongolia 100 57.655 78.556 33 6.7 37.8 91.1
Morocco 41.2 3557 0.4 0.558 5.358 50.9 5.1 0.0 76.1
Mozambique … 14.9 4.7 0.0 38.8
Myanmar … 80.4 2.8 0.694 99.7
Namibia 22.5 1059 12.560 5.8 6.4 1.9 19.2
Social security

on health as %
union
health1
Nepal 0.1 0.00861 0.13 66.6 5.3 0.0 92.2
Netherlands 100 76.3 289 7.8 9.8 93.0 20.8
New Zealand 100.0 100 359 15.6 8.1 0.0 72.1
Nicaragua 68.5 60 7.9 0.5 0.13 49.4 7.7 26.6 95.7
Niger 0.7 0.7 41.9 4.7 2.2 89.2
Nigeria … 67.9 5.0 0.0 91.2
Norway 100.0 09 15.6 10.3 17.9 95.4
Oman 100.0 9.5 3.2 0.0 56.1
Pakistan ... 70.9 2.4 53.3 98.0
Panama 100.0 35.4 64.6 27.6 7.6 55.5 82.2
Papua New Guinea ... 9.7 3.4 0.0 87.2
Paraguay 63.7 33.3 14.262 12.4 0.1863 3.59 51.1 7.3 39.8 74.6
Peru 71.0 11.764 27.265 0.34 40.8 4.4 42.4 79.0
Philippines 37.766 21.167 44 3.2 21.8 78.2
Poland … 09 0 26.4 6.5 86.0 87.8
Portugal 100.0 100.0 14.89 0 29 9.6 6.5 95.7
Romania 100.0 10068 0 33.5 6.1 85.8 90.4
Russian Federation 88 8869 0 29.2 5.6 43.7 71.1
Rwanda 36.6 2.670 8.971 25.172 23.6 3.7 9.8 41.7
Saudi Arabia … 0 6.9 4.0 ... 28.6
Senegal 11.7 773 4.72 55.5 5.1 15.8 95.3
Serbia and Montenegro 96.2 96.274 0 20.9 9.6 89.8 85.3
Sierra Leone … 0 41.7 3.5 0.0 100
87
Social security
88

on health as %
union
health1
Singapore … 0 62 4.5 21.5 97.1
Slovakia 96.2 09 0 11.7 5.9 93.5 100
Slovenia 100.0 0 9.7 8.8 82.6 41.1
South Africa 100.0 83.775 1776 0 10.5 8.4 4.6 17.1
15.177
Spain 98.9 2.79 0 23.5 7.7 7.0 82.0
Sri Lanka 0.1 0.12 48.9 3.5 0.3 88.9
Sweden 100.0 100 0 0 13.6 9.4 0.0 92.1
Switzerland 100.0 20 809 0 31.5 11.5 69.3 76.0
Syrian Arab Republic 29.2 10078 0 0.00579 1880 11.2 51.8 5.1 0.0 100
Tajikistan … 0 79.2 4.4 0.0 100
Tanzania, United Rep. of 14.5 14.581 0.005 36.2 4.3 2.6 81.1
Thailand 97.7 75.382 22.483 0 28.7 3.3 32.0 74.8
The FYR of Macedonia 100.0 10084 0 15.5 7.1 97.8 100
Togo 0.4 0.4485 66.2 5.6 14.6 88.0
Tunisia 99.0 3386 65 1 0 45.1 5.4 23.5 83.0
Turkey 69.2 67.2 <2 0 19.9 7.6 54.6 69.9
Turkmenistan 82.3 82.3 0 32.6 3.9 6.1 100

Uganda 0.1 0.098 36.7 7.3 0.0 52.8
Ukraine 100.0 10087 0 26.8 5.7 0.0 78.6
United Kingdom 100.0 100 109 0 11 8.0 0.0 76.7
United States 100 32.488 71.99 0 13.5 15.2 28.4 24.3
66.489
Uruguay 87.8 27.2 15.8 30.8 13.9 0.13 18.2 9.8 48.5 25.0
Social security

on health as %
union
health1
Uzbekistan ... 0 54.4 5.5 0.0 95.5
Venezuela, Boliv. Rep. of 100.0 65.6 34.4 0 53.2 4.5 25.2 95.5
Viet Nam 23.4 22.290 1.17 53.6 5.4 16.6 74.2
Yemen 6.3 0 0.0391 4.6592 1.593 0.1 56.4 5.5 ... 95.5
Zambia … 0 33.1 5.4 0.0 68.2
Zimbabwe … 0 36.3 7.9 0.0 56.7
1 World Health Organization (2006), Statistical annex (http://www who int/whr/2006/annex/en). 2 All data regarding OECD countries from OECD Health Data (2006) and for Latin America from Mesa-Lago (2005/2007), except other sources are
indicated. 3 The State is paying contributions on behalf of about 8 million handicapped persons and half a million unemployed; calculating an average number of 3 dependants, this ensures access to health care for about 17% of the total
population. 4 In 2004, the Caisse Nationale de la Sécurité Sociale des Travailleurs Salariés (CNAS) had 7 750 045 beneficiaries. By Oct.. 2006 the number had increased to 9 331 767 beneficiaries (CNAS 2006). For the private sector social
insurance scheme Caisse Nationale de Sécurité Sociale des non-salariés (CASNOS) only dated information on beneficiaries was available: in 2000, the CASNOS had 330,863 contributing members; calculating an average of four dependants that
would correspond to a total number of 1,654,315 beneficiaries (CASNOS 2001). Furthermore, students, war pensioners, unemployed covered through the unemployment program, and some other groups are covered by the CNAS and thus pay
lower contribution rates. 5 Maceira 2005, p.7. 6 9.8% private health insurance only; 3.8% complementary PHI in addition to employee health plan (Maceira 2005 p.7). 7 Maceira 2005 p.7. 8 Employees health care plans (Maceira 2005, p.7). 9 OECD
(2006), except for Germany and the Netherlands. PHI is supplementary (1st number) or complementary (2nd number) to either tax-financed or SHI-borne social protection in health. 10 In 2004, Austria had 170,449 welfare recipients whose SHI
contributions are paid by the municipalities from tax money (Statistik Austria 2006); the treasury also finances practically all contributions for the 138,539 retired farmers (Mehl 2005. p.15). 11 Arnaudova (2006), p.33. 12 All citizens are entitled to
receive benefits covered by the Unified Health System SUS, but availability varies according to regional and geographic conditions. 13 Arnaudova (2006), p.78. 14 The Caisse Nationale de Sécurité Sociale does not cover health benefits other than
some preventive maternal and child health services associated to family allowances and other main benefits and is not considered “health insurance” (CNSS 2007). 15 Direct information from the Département Technique de la Mutuelle de la
Fonction Publique, Bujumbura Jan. 2007 Witter (2002, p.21) had mentioned a coverage rate of 10-15%. 16 In 2000, the total number of beneficiaries of the Instituto Nacional de Previdência Social (INPS) was 115,378 out of a total population of
431,989 (Ferreira 2003, p.8). 17 Since FONASA beneficiaries group A (indigents) are exempted from contributions, this group’s health care is considered to be financed by the State; all other FONASA affiliates pay contributions and are thus
covered by a SHI scheme (FONASA 2006). 18 In 2005, more than 130 million beneficiaries were covered by the Basic Medical Insurance scheme (BMI) (MOLSS, 2005, as cited in Tang et al., 2007, p.32); it should be noted that the BMI is called
Basic Health Insurance System (BHIS) (Drouin and Thompson, 2006). 19 According to Castaño and Zambrano (2005), about 13,800,000 Colombians are currently covered by the contributory or the subsidized system. 20 Equidad insurance for
work-related accidents and diseases covered 309,790 beneficiaries in 2004 (Almeyda and Jaramillo 2005, p.39). 21 Sáenz/Holst 2007. 22 Arnaudova (2006), p.96f. 23 Statistical data from IESS indicate 1,184,484 contributing affiliates in 2003,
261,715 pensioners, 819,405 (= 31.8 per cent of target group) in the Seguro Social Campesino Ecuatoriano (IESS, 2006; González, 2006). 24 16,470,022 pupils covered according to Act 99/1992 and 5,525,125 infants and children (Decree
380/1997). 25 3,629,996 public sector employees covered according to Law 32/1975; 3,121,529 beneficiaries of the government worker programme according to Law 79/1975, plus 1,617,923 pensioners and widows (contributing 1% of their
pensions). 26 Including all beneficiaries of the Salvadoran Social Security Institute (ISSS, 2006) and of Teachers Welfare (Bienestar Magisterial) (Holst, 2003c, p.25). 27 OECD (2006); note that PHI in France complements universal statutory SHI
providing reimbursement for relevant co-payments: some 60% are Mutuelles and the remaining 40% non-for-profit and for-profit PHI. 28 40,000 public employees plus 160,000 dependants covered through the Ministry of Finance; 300,047 indigents
and unstable workers, covered in theory by the Caisse Nationale de Garantie Sociale lack any kind of service (Biyogo Bi-ndong et al., 2005 p.9). 29 92,739 insured private sector employees and 226,515 dependants (Biyogo Bi-ndong et al., 2004,
p.9). 30 22,000 contributing affiliates and the total number of 65,000 beneficiaries were covered through private health insurance (Biyogo Bi-ndong et al., 2004, p.11). 31 Remaining percentage according to the total number of people covered (52%)
minus those covered by any of the schemes mentioned (Biyogo Bi-ndong et al., 2004, p.3f., 9). 32 Until 2002 the State United Social Insurance Fund (SUSIF) had not enrolled more than 14% of the Georgian population (Witter, 2002 p.22) although
the country’s employment structure accounts for 35.4% wage employees (besides 35% self-employed and 37.8% unsalaried employed) (Collins, 2006, p.302f). 33 Municipalities pay for health insurance contributions of welfare benefit recipients who
numbered 2,910,226 in 2004; Furthermore, the central government finances social insurance contributions for 351,409 retired farmers (Krieger, 2006, p.4; LSV, 2005, p.96). 34 Total SHI coverage comprised 74,051,000 people out of the total
population of 82,600,000 citizens which corresponds to 89.65% of the population in Germany. However, SHI beneficiaries for whom central or local governments pay contributions are counted as users of State-borne health care access (OECD,
2006). 35 Substitute for mandatory statutory health insurance for the better off. 36 Busse and Riesberg (2004), p.57. 37 Herrera (2006), p.4. 38 More than 1,000 affiliates of the Servicio Solidario de Salud organized by the mutual of the Central General
de Trabajadores (Develtere and Fonteneau, 2001, p.30f). 39 The Employees State Insurance Scheme (ESIS) covers about 7.9 million insured persons and about 30.7 million beneficiaries; the number of cardholders of the Central Government
Health Scheme (CGHS) is currently about 1 million with the total number of beneficiaries around 4.3 million; Railways Health Scheme 8; defence employees 6.6; ex-servicemen 7.5; mining and plantations (public sector) 4 million beneficiaries
(Gupta, 2007, p.113, 118). 40 Universal Health Insurance Scheme (shared contribution: 416,936 beneficiaries (National Insurance Company). 41 36,146,700 beneficiaries were expected to enter the extended Askesin system for low income people
in Indonesia subsidized by central and local governments (Adang, 2007, p.149f). 42 Since 2005, the new initiative (Askesin) has extended health insurance coverage to an additional 60 million people or 27.6% of the population, including the civil-
89
servant social health insurance scheme Askeswith with about 4.5 million affiliated employees and 9.3 million dependants summing up 13.8 million beneficiaries, or 6.3% of the population. Social health insurance for private employees (Jamsostek)
90
was covering 1.26 million employees and 2.74 million beneficiaries in 2005. About 2 million people were insured by the military health services system covering all armed forces. 43 In 1999 (!), 4 million people were covered by private commercial
health insurance. (Adang 2007, p.148). 44 Witter (2002), p.21; National Health Insurance Fund (NHIF) covers 7% of the Kenyan population (Scheil-Adlung et al. 2007, p.133). 45 875,000 beneficiaries covered by the Public Sector Social Security
Scheme, including ≈91,000 civil servants and ≈100,000 members of armed forces and 48,096 beneficiaries of the private sector Social Security Organisation (SSO) (Hohmann et al., 2005). 46 2,083,662 Lebanese – 1,047,338 male and 1,036,324
female - are eligible for MoPH coverage (MoPH, 2006). 47 Self-reported coverage of the National Social Security Fund was 26.1% in 2001, although household surveys showed a lower rate of 17.8% (Ammar et al., 2000) since in 2003 the NSSF had
386,000 affiliates: 253,000 males (65.54%) and 133,000 females (34.45%) (Papadopoulos 2006, p.4). The average number of dependants would be close to two persons, which appears relatively low for an Arab country. 48 8% of the population has
complete coverage through private insurance, and 4.6% of the population has contracted PHI to complement coverage of other insurance schemes (Ammar et al. 2000, p.24). 49 Beneficiaries covered by any scheme in place for members of the four
arms of the security apparatus (Ammar et al. 2000, p.24). 50 Ministère de la Sécurité Sociale (2005). 51 Frenk et al. (2007), p.24; for tax financing please note the yearly expected inclusion of 14.3% of the target group consisting of 11 million families,
or 50 million beneficiaries representing 49% of the total population. Estimations for the second year after the implementation of the System for Social Protection in Health (SSPH) in 2004. 52 Ibid. 53 Ibid. 54 Arnaudova (2006), p.114f. 55 1,439,544
people were covered by the State in 2002 (Khorolsuren and Tseden, 2005, p.3f). 56 In 2002, the total number of health insurance affiliates was 523,617 corresponding to 1,963,161 beneficiaries (Khorolsuren and Tseden 2005, p.3f). 57 In 2005, the
private sector social insurance scheme Caisse Nationale de Sécurité Sociale (CNSS) covered about 6 million beneficiaries, and the public sector employees’ health insurance scheme Caisse Nationale des Organismes de Prévoyance Sociale
(CNOPS) about 3.2 million beneficiaries. About 4% were covered by employer-based health insurance (Caisse Mutualiste Interprofessionnelle Marocaine) (L’Observatoire de Tanger 2007; Kaddar et al., 1999, p.4f). 58 Direction de la Statistique 2005,
p.485. 59 Witter (2002), p.21. 60 Feeley et al.(2006), p.6. 61 The General Federation of Nepalese Trade Unions was covering about 2,000 beneficiaries (ILO, 2003a, pp.8,10). 62 Instituto de Prevision Social (2003); Holst (2003b). 63 Employees of
Binational Itaipú Company covered through the Seguro Itaipú (Holst 2003b). 64 Also, the publicly run insurance scheme Seguro Integral de Salud (SIS) counted 11,044,140 affiliated beneficiaries (MINSA, 2006, p.IR-1). Only 3,221,090 beneficiaries
enjoyed effective coverage (personal communication by SIS-staff). 65 The total number of formal sector employees and their dependants who are covered by the SHI-scheme EsSalud is 7,500,000 (http://www essalud gob pe). 66 As at 31 Dec.,
2004, PhilHealth covered a total number of 31,290,750 beneficiaries through the sponsored (indigent) programme which provides subsidized premiums to indigents (PhilHealth, 2006). 67 The total number of 17,520,000 beneficiaries comprises
Government employees (compulsory insurance), private sector employees and workers affiliated so far, plus enrolees of the Individual Paying Program offered to informal sector workers (Basa, 2007). 68 Arnaudova (2006), p.132. 69 Balabanova et al.
(2003), p.2126. 70 Beneficiaries of Gacaca (113,770) and prisoners (107,000) are entitled to public sector health benefits free of charge (Musango et al., 2006, p.126). 71 The Rwandaise d’Assurance Maladie (RAMA): 155,394; Fonds d’appui aux
rescapés du génocide (FARG): 283,000; Army: 100,000; and private sector health insurance: 213,512 (Musango et al., 2006, p.126). 72 Musango et al. (2006), p.126. 73 Total number of beneficiaries covered by company and inter-company health
insurance institutions (IPMs) running the statutory formal sector social health protection scheme (Scheil-Adlung et al., 2007, p.133). 74 Information provided by Prof. Laaser Belgrade. 75 Basic health care offered to the large majority in South Africa
through public facilities charging user fees according to region and service (Scheil-Adlung et al., 2007, p.133). 76 Covered through employment-based private health insurance plans (Scheil-Adlung et al., 2007, p.134). 77 Council for Medical Schemes
(2006), p.47. 78 In principle, Syrians are entitled to preventive and primary care at public providers. Furthermore, patients with chronic conditions also receive health care free of charge or for reduced tariffs at public health facilities. 79 PHI is emerging
in Syria since the first companies got licensed in July 2006 (Holst, 2006). 80 Half of the 3 million public sector employees are estimated to be covered by some kind of insurance scheme, according to the first assessment of company-based health
benefit schemes in Syria. About 12-14% of the population is entitled to company-based health benefits. However, corresponding studies did not take into account the fact that trade unions are running additional schemes for their dependants in a
number of public companies, resulting in a higher number of people protected by company-based health insurance (Schwefel 2006a, 2006b; Holst, 2006). 81 The total number of social security beneficiaries in the United Republic of Tanzania is
5,319,378: NSSF 400,000 members, 2,360,000 beneficiaries; PPF 60,000 members, 354,000 beneficiaries; PSPF 193,000 members, 1,138,700 beneficiaries; LAPF 40,000 members, 236,000 beneficiaries; NHIF 248,343 members, 1,142,178
beneficiaries; GEPF 15,000 members, 88,500 beneficiaries (Dau, 2005, p.2; Humba, 2005 p.7). 82 In 2002 the UC scheme covered 47 million people in Thailand (Tangcharoensathien et al., 2007, p.127). 83 Civil Servant Medical Benefit Scheme for
public sector (6 million or 10% of the population) and the Social Health Insurance for private sector employees (8 million or 13%) are both considered SHI systems (Tangcharoensathien et al., 2007, p.127). 84 Arnaudova (2006), p.197f. 85 Concertation
(2004), p.14. 86 Achouri (2007), p.52; it should be noted that the CNSS covers about four out of every five social security beneficiaries. The percentage of people covered through tax-based services includes those entitled to health services free of
charge (8%) and to reduced tariffs in public facilities (25% of the population). 87 Arnaudova (2006), p.233f. 88 In 2003, 41.2 million US citizens were enrolled in Medicare and 54 million in Medicaid (US Census Bureau, 2007). 89 Hoffman et al. (2005),
p.10. 90 At the end of 2005, the compulsory scheme had affiliated 8,142,000 and the voluntary schemes 6,245,000 Vietnamese citizens, while 3,889,000 poor people were enrolled through subsidies from the Heath Care Fund for the Poor (Tien, 2007,
p.64). 91 Estimated number of Yemeni citizens covered through PHI is about 6,000 (Schwefel et al., 2005, p.108ff). 92 Armed forces and police are estimated to have 920,000 personnel who are covered through the military health benefit scheme or
the scheme of the Ministry of Interior (Schwefel et al., 2005, p.105). 93 According to estimations, about half of all formal sector workers and employees are entitled to some kind of health benefit scheme (Schwefel et al., 2005, p.105). 941997 fig.
,Myanmar Statistical Yearbook 2004.95 2005 Report on Health Insurance Statistics (National Health Insurance Corporation).
Appendix III
ILO Tool Box
NATLEX
NATLEX is a database of national labour, social security and related human rights
legislation maintained by the International Labour Standards Department. Database
records provide abstracts of legislation and relevant citation information indexed by
keywords and subjects. NATLEX contains more than 55,000 records covering over 170
countries and territories. Each record in NATLEX appears in only one of the three ILO
official languages (either in English, French or Spanish). As far as possible, the full text of
the law or a relevant electronic source is linked to the record. The database is usually kept
up to date, although some delay between receiving information and updating the records
might occur.
Actuarial and financial advisory services
Many countries require neutral, objective advice on strategic or managerial financial and
fiscal questions or support in building up national capacities for sound financial design and
management of social protection programmes. The ILO's International Financial and
Actuarial Service (ILO FACTS) assists government agencies and autonomous social
protection organisms in developing their own capacity for quantitative planning and
improving the management and governance of their social protection schemes. ILO
FACTS is a public sector advisory group for the exclusive use of national social protection
agencies or social security schemes. It is a service that the ILO provides to its constituents.
It is highly specialized in the actuarial, financial and fiscal questions of social protection.
ILO FACTS is the consulting group with the longest and most extensive international
experience in quantitative aspects of social security in the world.
The ILO model family
Population projections. ILO-POP produces population forecasts that match the standard
UN methodology for demographic projections on the basis of an initial population
structure combined with mortality, fertility and migration assumptions. This model is also
used as a standard input producer for the ILO actuarial pension and social budget models
that require long-term population forecasts. Population forecasting models have recently
been elaborated to take into account the effects of the HIV/AIDS epidemic on mortality.
Social budgeting. ILO-SOCBUD consists of four sub-models: the labour force sub-model
(ILO-LAB) and the economic sub-model (ILO-ECO) together provide data on
employment and earnings to the social expenditure sub-model (ILO-SOC), which provides
information on functional expenditures (expenditure by function of social protection) for
main social security subsystems and schemes, e.g. social health protection and old-age
protection; the fourth sub-model, ILO-GOV, aggregates data for use in government and
institutional accounts of the social security system.
Pension model. ILO-PENS is an actuarial pension model that is traditionally used to

undertake stand-alone long-term financial and actuarial projections for national pension
schemes. It can also be used as an input to ILO-SOCBUD.
Wage distribution. ILO-DIST is developed to generate data on salary distribution. It is

used primarily for pension projections but, as social protection systems are redistributive, it

is also necessary to take income distribution into account when providing policy advice on
the design and financing of such systems.
Health model. ILO-HEALTH is the latest arrival in the ILO social protection modelling
family and is still in the testing process. It is designed as a tool to undertake stand-alone
assessments of the financial status and development of national health-care systems and is
also applicable for generating inputs for the health part of ILO-SOCBUD.
Performance indicators
The Social Security Department has developed a preliminary set of quantitative

performance indicators that can be used by managers and supervisory bodies to assess the
performance of social security schemes.
STEP
In order to address low rates in social protection coverage in developing countries, STEP
develops innovative strategies and mechanisms specifically aimed at providing coverage to
those who are currently excluded from existing schemes. STEP works on community-
based social benefit schemes and in particular on mutual health organizations. STEP works
also on the linkages between the various schemes designed and implemented for protecting
excluded people.
CIARIS
The Learning and Resources Centre on Social Inclusion (CIARIS) is an Internet platform.
It supports organizations and individuals in the conception, planning, implementation,
monitoring and evaluation of projects aimed at combating social exclusion at the local
level. CIARIS contains a wide range of information and resources available in four
languages. It allows users to interact and facilitates mutual assistance through three
services:
CIARISAssist connects people with specialized experts;
CIARISLearning offers a wide range of distance-learning sessions,
CIARISFora provides online discussion forums.
GIMI
The Global Information on Micro-insurance (GIMI) platform is aimed at improving the

knowledge base on social health protection and fostering interaction between actors
through modern information and communication technologies. It provides resources and
services to support users in the design, implementation and management of social
protection schemes, through:
online library including guides, case studies, articles and presentations;
bilingual French-English glossary;
database on microinsurance schemes around the world;
free management and monitoring software;
training packages to be used in online or face-to-face sessions; as well as self-learning

kits;

online assistance from experts in the field;
the e-Gimi discussion forum;
collaborative websites called “wikis” to explore technical issues or conduct joint

projects,
a collaborative newsletter based on contributions from users.

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Social Health Protection: An ILO Strategy Towards Universal Access To Health Care

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Social Health Protection

An ILO strategy towards universal

International Labour Office

Tel.: (+ 41 22) 799 75 65

Social Health Protection

An ILO strategy towards universal

Global Campaign on Social Security and Coverage for All

Social Security Department

ISBN 978-92-2-121161-7 (print) & 978-92-2-121162-4 (web pdf)

International Labour Office; Social Security Dept

ILO Cataloguing in Publication Data

2. What is social health protection? ............................................................................................ 3

3. Financing social health protection: The current situation ....................................................... 7

4. Coverage of social health protection and access to health services ........................................ 16

ILO Strategy Social Health Protection.Sept v

vi ILO Strategy Social Health Protection.Sept

List of Appendix Tables

ILO Strategy Social Health Protection.Sept vii

ADB Asian Development Bank

GDP Gross Domestic Product

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit/

HDI Human Development Index

HPI Human Poverty Index

IHPP International Health Policy Programme

NHA National Health Accounts

MDG(s) Millennium Development Goal(s)

MOH Ministry of Health

OECD Organization for Economic Co-operation and Development

OOP Out-of-Pocket Payments

PRSP Poverty Reduction Strategy Papers

SHI Social Health Insurance

STEP Strategies and Tools Against Exclusion and Poverty

THE Total Health Expenditure

WHO World Health Organization

ILO Strategy Social Health Protection.Sept ix

ILO Strategy Social Health Protection.Sept xi

Michael Cichon, Xenia Scheil-Adlung,

xii ILO Strategy Social Health Protection.Sept

At present, social health protection is increasingly seen as contributing to building human

Everyone, as a member of society, has the right to

ILO Strategy Social Health Protection.Sept 1

2. Rights – as a condition for the empowerment of people to escape from poverty.

3. Social protection - a safeguard of income and financial support in case of sickness.

4. Dialogue - the participation of employers’ and workers’ organizations in shaping and

The importance of strengthening linkages between rights, employment and development

2 ILO Strategy Social Health Protection.Sept

Achieving universal social health protection coverage - defined as effective access to

size of the population covered;

financial and geographical accessibility of covered services;

extent to which costs of a benefit package are covered; and

quality and adequacy of services covered.

Social health protection is a series of public or Social health protection consists of

Generally, the following main resources may be used for funding:

ILO Strategy Social Health Protection.Sept 3

Figure 2.1. Flow of funds

Social health insurance Providers

Contributions or payroll taxes: Contributions are collected to fund social health

Premiums: Premiums are collected by private insurance schemes, including

4 ILO Strategy Social Health Protection.Sept