Social Protection in Health: Conceptual Framework Honduras, November 2006

1. Social Protection in Health: Conceptual Framework Honduras, November 2006 Cecilia Acuña Program Manager Social Protection in Health PAHO/WHO

2. Social Protection in Health for maternal, neonatal and child populations:Background • Social Protection in Health (SPH) for the Maternal, Neonatal and Child (MNC) populations is not a new issue in the public policy sphere, but it has recently experienced new momentum (MDG, PRSP) • Certain countries have developed targeted maternal-child SP schemes, as is the case with Bolivia, Ecuador, Peru and Argentina • Others, like Brazil and Chile, have strengthened their maternal-child social protection strategies within the broader context of universal social protection in health schemes • Many countries in the region have implemented a mix of interventions aimed at protecting the health of mothers, newborns and children • What currently characterizes Latin America in terms of its schemes aimed at protecting the health of mothers, newborns and children is the great heterogeneity in the strategies that are being implemented or developed

3. Social Protection:An evolving concept Safety nets • This concept appeared for the first time in the British Poor Law, which was in effect from 1598 to 1948 • Its goal was to keep people out of poverty, guaranteeing a minimum income in order to satisfy their basic needs (Bonilla and Gruat, 2003; IDB, 2001) • A new definition views safety nets as mechanisms for social assistance in countries where, due to poverty or institutional weakness, it is not possible to introduce integrated social welfare programs (World Bank, 1993) • Safety nets function as a temporary cushion against specific shocks, through the use of income transfers (residual welfare)

4. Social Protection:An evolving concept Social management of risk • Its objective is to support individuals, households and communities when they confront risk, mainly the risk of falling into poverty or not being able to get out of it, therefore, passing it on to future generations • In the health arena, it includes both reducing the exposure to risks through targeted interventions and mitigating the consequences of this exposure through the distribution of risks in private or informal insurance schemes • The focus is based on the individual’s capacity to manage risks and its goal is individual well-being • It does not consider inter-personal redistribution of income or resources as necessary to achieve improved distribution of well-being (Doryan et al, 2001, p.11)

5. An evolving concept Common central elements • Vulnerability • Risk • Financial insecurity • Economic protection COMMON IDEA Transfers of goods/services or money to replace/compensate for the loss of income to specific population groups determined according to certain attributes

6. An evolving concept: Need to incorporate other elements • Citizenship • Democracy building • Equity • Social inclusion • Focus on social justice: redistribution of resources, goods and opportunities

7. Social Protection under changing conditions • The growth of informal labor, demographic changes associated with an increase in life expectancy at birth and increased mobility linked to broader migratory movements have forced many countries – both industrialized and developing – to re-examine their social protection systems • A number of working groups have initiated the process of reviewing and expanding the concept of social protection, recognizing that the traditional notion of social protection focused on economic, not social, protection (Important documents: “Transformative social protection,” S. Devereux, R. Sabates-Wheeler IDS working paper 232, Sussex 2004 “Enhancing Social Protection and Reducing Vulnerability in a Globalizing World,” UN, 2001 Report of the Secretary-General “Sustainable Social Development in a Period of Rapid Globalization: Challenges, Opportunities and Policy Options,” Capítulo V – United Nations Economic and Social Commission for Asia and the Pacific, UNESCAP 2005 )

8. The debate about social protection doesn’t take place only in developing countries • Current discussion about social policies in the EU Social Protection Social support networks? (Assistance for poor and marginalized immigrant groups) Universal protection? Expression of the solidarity of society as a whole (Finland, Sweden, Norway) Social Security? Formalize the benefits for informal workers, new labor pact • Current discussion about Social Security in the USA: • Shared fund or individual capitalization funds (pensions)? • Benefits Package that should be included in Medicare • Extension of protection to illegal immigrants?

9. Need to incorporate other concepts Social protection in the framework of social rights • Social protection is economically possible even in the poorest countries (Sen, 1999) • It should not be understood as residual or basic assistance programs for the poor or for poor countries; it should be universal (NU 2001, OIT 2003) • It should allow for people to actively integrate themselves into society and not just confront a temporary or structural risk situation • It should be a central part of countries’ economic development agendas • It should be understood as a tool for social transformation within a framework of human rights, equity and human development • It should integrate traditional and innovative public, private and community-based strategies

10. Social protection in health (SPH) • “The guarantee, granted by society through government, that an individual or group of individuals can meet its health needs and demands through access to services under adequate conditions of quality, timeliness and dignity, without ability to pay serving as a restrictive factor” (PAHO/WHO, Resolution CSP26/12 “Extension of Social Protection in Health: Joint Initiative of the Pan American Health Organization and the International Labour Organization.” Washington DC, September 2002)

11. Goals of Social Protection in Health • Achieve Equity • Guarantee access for everyone under equal conditions (combat exclusion) • Protect the dignity of people • Improve Health Outcomes • Prevent health hazards • Restore health • Return the worker to the labor market • Provide Financial Protection • Avoid the costs associated with illnesses or health hazards that push families or people into poverty • Protect the standard of living of people and/or families against losses in income due to illness or poor health

12. Central dimensions of the concept of Social Protection in Health • Health service coverage: dignity and quality of care • Population coverage: access to health goods, services and opportunities for everyone • Financial protection: solidarity in financing

13. There are three strategies for operationalizing social protection in health • Universal protection (for all citizens or residents) • Protection for low-income people or groups in specific situations • Protection for people that contribute or have contributed to a scheme (fund) or insurance (health, unemployment, pension, other) ALL OF THESE PRESENT BOTH ADVANTAGES AND CHALLENGES THEY ARE NOT MUTUALLY EXCLUSIVE: THERE ARE POSSIBLE SYNERGIES

14. What is a social protection in health scheme? • Organized set of public interventions aimed at guaranteeing that groups and individuals are able to meet their health needs and demands through access to health care services in adequate conditions of quality, dignity and opportunity, regardless of their ability to pay

15. Limitations of the traditional analyses of health protection schemes • Generally one-dimensional and focused on financial analyses • Do not incorporate macro social determinants • Do not explore the role that intervention plays in the institutional and organizational sphere of the health system • Do not consider the impact of the intervention on beneficiaries’ behavior patterns • Do not consider the impact of the intervention on those who are not beneficiaries

16. What other elements should an analysis incorporate? • Equity, since it is a central issue for the health of mothers, newborns, boys and girls • The macro social determinants of health, since it has a powerful influence on maternal and child health • Access to health goods and the coverage and quality of the services provided, because they are key factors in maternal, neonatal and child health outcomes • The context, since the SPH scheme operates within a historical, political, cultural and social framework that determines its performance and the way in which it is evaluated

17. Does the maternal and child health situation improve when a health protection scheme exists? • Social protection in health schemes are neither necessary nor sufficient for improving health outcomes, but are an important determinant of access to and satisfaction of the demand for health goods and services • Promote adequate demand • Allow access • Protect the financial risks associated with illness • GUARANTEE THE RIGHT TO HEALTH

18. Analytical framework Social protection in health scheme: Financing/expenditure Organization of the supply Stewardship/regulation Resource allocation: human, physical, technological Territorial distribution of resources Changing patterns of demand Elimination of barriers (economic, geographic, cultural) Counteract the social determinants that affect the demand for services and the health situation Increase equity in access and/or use Objective Increase access, improve coverage, offset exclusion Improve health outcomes

19. How do these factors interact Social determinants of health Social protection in health scheme Perceived Need for health Equitable Unperceived Health outcomes Access Repressed Demand for health Expressed Inequitable Unmet Met

20. WHY ARE SPH SCHEMES CURRENTLY INDISPENSABLE IN THE REGION OF THE AMERICAS? • Persistence of economic, social, ethnic and cultural exclusion • Existing social protection mechanisms are insufficient for responding to new problems • To what degree are sectoral reforms meeting the needs of the most vulnerable groups?

21. Variables to consider in the design of SPH schemes • Migratory movements • Growing informality-work-related mobility: portability of the guarantee • Changes in the demographic structure: aging • Changes in the family structures: increasing numbers of one-parent families where the household head is female • Changes in the epidemiological profile: increase in costs • National structures: federal, centralized, local: • Integration of sub-national/national programs • Position of the country in the international context/commitments • Size and characteristics of the pool • Make explicit that the set of guarantees brings with it important investments, changes in the systems’ structures, and a political and social negotiation process

22. POLITICAL ECONOMY OF SPH The promotion of SPH strategies requires actors to: • Recognize the legitimate interests of the diverse actors and interest groups involved in the process • Create the conditions and dynamics for a broad social dialogue that allows the democratic participation of the diverse actors and the appropriation of the proposal by all interested parties, ensuring its implementation over time • Conceive the SPH scheme as a sustained, long-term effort and one of the most relevant State policies • Periodically review the policy and generate successive plans of action with defined goals and accountability at the highest political level in the countries