Social protection in health: the need for a transformative dimension.

Today, Social Protection in Health (SPH) is commonly understood as an arrangement safeguarding income and financial support in case of sickness and ensuring that all people in need have effective access to adequate care of sound quality (ILO 2008). Yet, for many people worldwide, affordable health care of good quality remains elusive. Especially in developing countries, large groups of citizens remain uncovered by adequate mechanisms for SPH of any kind. For the excluded, illness jeopardises more than just their health. Their predicament often boils down to the uneasy choice between forgoing treatment and getting trapped in a downward spiral of impoverishment because of high health care expenses (Whitehead et al. 2001). According to the International Labour Organization (ILO), 80% of the world population remains excluded from adequate social protection (Pal et al. 2005). The World Health Organization (WHO) (2004) estimates that each year 178 million people suffer financial catastrophe as a result of out-of-pocket health payments while 104 million are forced into poverty simply because of health payments. These deficits in social protection were well documented before the current financial crisis and are likely to become worse if no appropriate action is undertaken (ILO/WHO 2009). Today, ILO estimates that 30–36% of the world population (and more than 74% of the population in developing countries) has no effective access to basic medical services (ILO 2010). In most developing countries, formal SPH is of recent origin. In the early independence years, Social Health Insurance (SHI) – a European public construct geared to a model of industrial labour – was the norm. While, in principle, SHI aims at universal entitlement based on citizenship, in most developing countries, it typically did not cover more than a few fortunate groups because of financial and labour market-related constraints (DESA 2007). Similarly, tax-funded public provision of health care services also turned out to be problematic in the developing world and was rarely achieved in terms of coverage and quality. Financial constraints and liberalisation led to a steady rollback in public provision of health care and social protection. The introduction of user fees for health care in the 1980s prompted the initiation of private non-profit Community Health Insurance (CHI) by non-government organisations (Criel et al. 2008). Alongside CHI and other private savings-account schemes, there has also been a shift to means-tested safety nets, implying targeting (DESA 2007, 2009). In most developing countries, the picture today is one of a rich variety of organisational arrangements of SPH [SHI, private-for-profit health insurance, CHI, maternity benefit schemes, Health Equity Funds (HEF), conditional cash transfers and health vouchers amongst others], but with, unfortunately, poor results. Still, there is room for hope. At least in the international policy sphere, the strong relationship between health and poverty was recognised by the inclusion of three specific health objectives amongst the eight Millennium Development Goals. From 2004 on, a consortium led by the German Gesellschaft für Technische Zusammenarbeit (GTZ), ILO and WHO has made a plea for the extension of SPH in developing countries (ILO/GTZ/WHO 2007). In 2005, ILO experts calculated that basic social protection – including health – would be affordable in poor countries, within a reasonable timeframe (Pal et al. 2005). In 2008, the WHO Commission on Social Determinants of Health Tropical Medicine and International Health doi:10.1111/j.1365-3156.2010.02529.x