Pan American Health Organization

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 individuals 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

• 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

Common central elements
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 doesnt 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

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Analytical framework
Social protection in health scheme Financing/expe
nditure Organization of the supply Stewardship/reg
ulation 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
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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