Xenia Scheil-Adlung

Health financing reform in Kenya- assessing the social health insurance proposal

Kenya has had a history of health financing policy changes since its independence in 1963. Recently, significant preparatory work was done on a new Social Health Insurance Law that, if accepted, would lead to universal health coverage in Kenya after a transition period. Questions of economic feasibility and political acceptability continue to be discussed, with stakeholders voicing concerns on design features of the new proposal submitted to the Kenyan parliament in 2004. For economic, social, political and organisational reasons a transition period will be necessary, which is likely to last more than a decade. However, important objectives such as access to health care and avoiding impoverishment due to direct health care payments should be recognised from the start so that steady progress towards effective universal coverage can be planned and achieved.

Beyond legal coverage: Assessing the performance of social health protection

A frequently used indicator to measure social health protection performance is the extent of population coverage as stipulated in national legislation. However, this indicator does not provide meaningful information on performance in terms of effective access to benefits that are available, affordable and of acceptable quality, not least for the poor and workers in informal economies. This article proposes a new approach to measuring performance by applying a set of relevant indicators in an analytical framework for assessing the performance of social health protection. The approach allows policy-makers to conclude from comparisons among groups of countries facing similar challenges. Preliminary results include comprehensive information on deficits that need to be addressed when striving for effective universal coverage. With further refinement, the suggested approach could become a standard assessment tool for measuring performance. issr_1400 21..38

Health workforce benchmarks for universal health coverage and sustainable development

Universal health coverage (UHC) includes the guarantee that everyone will be protected over the entire life-cycle by a defined set of essential health services fulfilling four interrelated criteria, as set out in Social Protection Floors Recommendation, 2012 (202) of the International Labour Organization (ILO): availability, accessibility, acceptability and quality. 1 Insofar as it furthers health, which is essential to human productivity and economic progress, UHC – and the health workforce needed to attain it – serves as a foundation to sustainable development. Gaps in the health workforce – in number, distribution and skills – undermine service availability, acceptability, accessibility and quality. Such gaps can also create financial barriers and impoverish people when they have to seek care without being covered by a social health protection system or scheme. Access to quality services is vitally dependent on the existence of a health workforce that is able to meet needs and enjoys decent working conditions, characterized by training opportunities, attractive employment, good career prospects, fair remuneration, adequate social protection, a safe work environment and access to dispute settlement mechanisms, as described in the ILO Nursing Personnel Convention No. 149. 2 Service accessibility is further compromised by factors external to the health sector that influence the financing of health and of the health workforce. Of particular relevance are the socioeconomic contexts in which people live and work. Poverty, unemployment and low wages affect a household’s ability to pay for needed health care, be it through taxes, employee contributions, premiums or out-of-pocket expenditure. At the national level, high poverty rates and the existence of large informal economies often result in tax revenues that are insufficient for adequate funding of health care and that challenge governments’ technical capacity to supply services in areas where unregistered workers and their families live. In highly vulnerable countries, defined by the ILO 3 as those where most people work in the informal economy and most of the population is poor, health care is accessible to much fewer people than in countries with low poverty rates and small informal economies. 4 Furthermore, in such countries most health care is financed by out-of-pocket payments that can reach catastrophic levels and plunge families into dire poverty or bar their access to needed care. According to the ILO, over 1.5 billion people in the world are living and working in socioeconomic contexts that challenge adequate financing of UHC and the attainment of sustainable development, so critically dependent on the presence of a healthy population. Any health workforce benchmark for measuring sustainable progress towards UHC must reflect the above-mentioned aspects, including the basic socioeconomic causes of UHC gaps beyond the health sector. 5 One such benchmark is the

Gaps in social protection for health care and long‐term care in Europe: Are the elderly faced with financial ruin?

While public expenditure on health care and long-term care (LTC) has been monitored for many years in European countries, far less attention has been paid to the financial consequences for older people of private out-of-pocket (OOP) expenditure necessary to access such care. Employing representative cross-sectional data on the elderly populations of 11 European countries in 2004 from the Survey of Health, Ageing and Retirement in Europe (SHARE), we find that OOP payments for health care and LTC are very common among the elderly across European countries and such expenditures impact significantly on disposable income: up to 95 per cent of the elderly make OOP payments for health care and 5 per cent for LTC, resulting in income reductions of between 5 and 10 per cent, respectively. Failure to prevent financial ruin, as a consequence of excessive OOP payments, is evident in 0.7 per cent of elderly households utilizing health care and 0.5 per cent of elderly households utilizing LTC. Those particularly concerned are the poor, women and the very old.

Revisiting policies to achieve progress towards universal health coverage in low-income countries: Realizing the pay-offs of national social protection floors

Despite progress on extending social health protection coverage, most low�?income countries are still far from achieving universal health coverage and thus key objectives related to improvements in health, such as those aimed at by the Millennium Development Goals (MDGs), will almost certainly not be realized by 2015. Principally affected are the most vulnerable populations: the rural and urban poor and workers in the informal economy and their families. It is of particular concern that progress might not only remain limited but even be reversed if policies continue to fail to address the root causes of gaps and deficits in health coverage. This article provides evidence that these causes lie both within and beyond the health sector and are strongly related to poverty and other forms of vulnerability. It argues that sustainable progress towards universal health coverage can only be achieved in an adequate time frame when focusing simultaneously on i) extending health coverage and improving access to needed health care; ii) providing income security through income support to those in need; iii) addressing limitations, or the inability to participate, in income generation from work; and iv) implementing coherent policies within and across the social, economic and health sectors that set priorities on poverty alleviation. Such policies can best be implemented in the context of national social protection floors (SPF) that focus on access to at least essential health care and on providing at least basic income security over the life cycle to all in need. Implementing SPFs may result in breaking the mutual linkages between ill health, poverty and other vulnerabilities and achieving sustainable progress towards universal health coverage and other social protection objectives.

Health sector employment: a tracer indicator for universal health coverage in national Social Protection Floors

BackgroundHealth sector employment is a prerequisite for availability, accessibility, acceptability and quality (AAAQ) of health services. Thus, in this article health worker shortages are used as a tracer indicator estimating the proportion of the population lacking access to such services: The SAD (ILO Staff Access Deficit Indicator) estimates gaps towards UHC in the context of Social Protection Floors (SPFs). Further, it highlights the impact of investments in health sector employment equity and sustainable development.MethodsThe SAD is used to estimate the share of the population lacking access to health services due to gaps in the number of skilled health workers. It is based on the difference of the density of the skilled health workforce per population in a given country and a threshold indicating UHC staffing requirements. It identifies deficits, differences and developments in access at global, regional and national levels and between rural and urban areas.ResultsIn 2014, the global UHC deficit in numbers of health workers is estimated at 10.3 million, with most important gaps in Asia (7.1 million) and Africa (2.8 million). Globally, 97 countries are understaffed with significantly higher gaps in rural than in urban areas. Most affected are low-income countries, where 84 per cent of the population remains excluded from access due to the lack of skilled health workers. A positive correlation of health worker employment and population health outcomes could be identified. Legislation is found to be a prerequisite for closing access as gaps.ConclusionsHealth worker shortages hamper the achievement of UHC and aggravate weaknesses of health systems. They have major impacts on socio-economic development, particularly in the world’s poorest countries where they act as drivers of health inequities. Closing the gaps by establishing inclusive multi-sectoral policy approaches based on the right to health would significantly increase equity, reduce poverty due to ill health and ultimately contribute to sustainable development and social justice.

Response to health inequity: the role of social protection in reducing poverty and achieving equity

Health inequities are determined by multiple factors within the health sector and beyond. While gaps in social health protection coverage and effective access to health care are among the most prominent causes of health inequities, social and economic inequalities existing beyond the health sector contribute greatly to barriers to access affordable and acceptable health care.

Paid Sick Leave: Incidence, Patterns and Expenditure in Times of Crises

The paper focuses on the national and international evidence on paid sick leave and provides insights into the concepts, patterns and expenditure on paid sick leave in countries throughout the world. Further, it is argued that providing for sick leave and related income replacement is of key importance in times of financial and economic crises and beyond.