Cash and medical benefits for pregnant and breastfeeding women. Luis Frota Social security specialist ILO DWT Pretoria

Transcription

1 Cash and medical benefits for pregnant and breastfeeding women Luis Frota Social security specialist ILO DWT Pretoria

2 Summary Overview of current problem situation ti Who is concerned and what risks What options for social security coverage Challenges in coverage

3 THE LESOTHO SOCIO ECONOMIC CONTEXT OF MATERNITY PROTECTION

4 Maternal mortality not on track / target Developed Developing Sub Saharan Lesotho Regions Regions Africa Lesotho is not on track for 2015 target of reducing by three quarters the level of maternal mortality. Access to emergency obstetric and neonatal care is a challenge.

5 due insufficient quality ante and postnatal care Over 9 in 10 pregnant women receive antenatal care from skilled health personnel. But42 percent of women who gave birth did not get a postnatal check-up within 6 weeks of delivery 70% of pregnant women have the WHO recommended e four or more antenatal a a visits s (46% in SSA) Yet a quarter of pregnant women are anaemic (defined as haemoglobin < 110g/L) increasing their risk of preterm delivery, low birth weight babies, stillbirth and newborn death

6 Births attended by skilled l 62% women deliver with the assistance of skilled personnel health personnel but; 90 percent of women in the wealthiest quintile 35 percent of women in the poorest quintile obtained 90 such assistance rths attended by skilled health personnel tio highest-lowest wealth quintile Centr Tanzania, Ethiopia 2 Chad 2 Niger 2 Eritrea 2 Nigeria Guinea 2005 Kenya 2003 Guinea-Bissau 2006 Senegal Mauritania 2007 Ghana 2008 Burundi 2005 Mozambique 2003 Liberia ral African Rep Zambia 2 Gambia 2 Sierra Leone Uganda 2006 Cameroon Côte d'ivoire 2006 Madagascar 2004 Togo 2006 Lesotho Burkina Faso 2003 United Rep. of 2005 Rwanda Malawi 2004 Swaziland 2007 Percentage of life bi Mali 2 Zimbabwe 2 Benin Namibia 2007 Congo 2 Gabon Rat Highest w ealth quintile Low est w ealth quintile Ratio highest-lowest wealth quintile 6

7 Reasons for not delivering in a health service Barriers refer to quality of services (such as absence of drugs), but also financial i barriers (money for treatment, t t for transport..) t

8 RISKS AND THEIR COVERAGE

9 High prevalence of women informal employment (in HH and formal sector) Most of the informal employment is in Households and in the formal sector informal employment women; 95116; men, 30% 71732, 23% Formal employment informal women, employment 40448, 13% men; ; 34% Lesotho Integrated Labour Market Survey, 2008

10 Rising Female Labour Force Participation a Risk Factor? In Lesotho, 52,3% percent + (and rising) women participate in the labor force. Many young women are benefiting from arising opportunities in the urban labor market, mostly in the textile til sector Higher levels of women s wages, and labor market participation are associated with improved reproductive health outcomes if modern and effective protection is in place

11 Fertility declining but unequal and high amongst the poorest It has been slowly declining (from 7 6 births in It has been slowly declining (from 7.6 births in 1976 to 3.3 births per woman).

12 Are all the chances on my side during my pregnancy, at the time of delivery and in early life of my Xholani? What are the risks involved in my condition and how best to cope with them?

13 RISKS and links between medical and cash protection in maternity Absence of maternity leave can result in the inability to attend to any necessary medical follow up of the pregnancy, rest and/or treatment resulting in higher risks for mother and child No cash payment in maternity can result in high opportunity cost and financial barriers for women to access medical services and an increased pressure to remain at work longer and return faster this increases health risks for mother and this increases health risks for mother and children especially for higher risk pregnancies and in cases of after birth complications

14 OPTIONS FOR COVERAGE

15 Benefits for whom? ILO C, 183 All employed women including those in atypical forms of dependent work. This means not only women in the formal economy but all women whatever their form of employment Atypical means part time, casual, seasonal, job sharing, home, temporary, disguised, piece work, informal work of all sorts.

16 Financing mechanisms Social insurance covers formal the economy, provides medical care and income replacement. Typically financed by worker and employer contributions, sometimes with a government subsidy Individual employer liability schemes place liability for providing cash maternity benefits on individual employers Social assistance schemes base benefit eligibility on some level of financial need on the part of the woman or household. No previous contributions are required. Typically y financed by state revenues and administered by governments Universal benefits,, available to all women who are residents of a country and meet certain eligibility criteria, no requirement of prior 9 contributions

17 Categories of Social Security Schemes Social Security System Contributory Non-contributory Private Public Cash benefits In-kind Pensions Incapacity Loss of support Health Pensions Health Illness Unemployment Occupational injuries and diseases Incapacity Loss of support Means tested Income Tested Universal Social worker support to households Health Service

18 BENEFITS: When no insurance is available, social assistance must be available (Art. 6, C 183) Vertical dimension: progressively ensuring higher levels of protection, guided by Convention No.102 and more advanced standards high level of protection floor level low extension strategy Voluntary insurance under government regulation Social security benefits of guaranteed levels Social Protection Floor: Access to essential health care and basic income security for all Outcomes can be guaranteed through different means p there is no one-size-fits-all Social Protection Floor Recommendation, adopted at ILC 2012 low individual/household income high Horizontal dimension: Guaranteeing access to essential health care and minimum income security for all, guided by Recommendation No

19 The Social Protection Floor: a basic set of social security guarantees comprised of essential health care and income security for unprotected people Universal access to essential health care for all in need, including pre, post maternal care and hospitalization i if necessary Family/ child benefits, to provide access to nutrition, education, and care Also help pay early early Income child care support in for the working- community age poor underemployed, and unemployed, to be provided as cash benefits or through public works programs Income transfers for women A universal during basic last weeks pension of pregnancy for all persons and after in childbirth old age or with disabilities.

20 Unlocking untapped LM/Productive capacity with Linked Social Protection Employment creation for elderly Employment creation for women Employment creation for youth New markets in private sector Jobs in Social and Health services Child care policies, ECD Work/Family Balance Time Policies Social insurance based maternity leave Fees Further vocational training Guidance / Orientation School to Work transition First Job Experience through Wage Subsidies

21 Public financing in social assistance case 1: Ethiopia - Maternity, Sickness and Temporary Disability Benefits Ethiopia Productive Safety Net Programme + Cash Transfer scheme for Temporary Labour Constrained groups = maternity leave benefit or sickness for target HH. - women working in PSNP become pregnant can be transferred to direct support if no other adult household members are available to undertake the work. - from 4th month of pregnancy to 10 months after the birth. - if men or women are temporarily unable to work because of sickness or some other transitory disability, they should also continue to receive their income.

22 What are key distinct features? most public works do not have a defined entitlement for each beneficiary if no work is done, there is no entitlement to a transfer most public works programmes do not operate in parallel with a transfer programme the level of the benefit does changes when people move from public works to direct support Lack of common registries No possibility to transfer recipients as a basis of entitlement Recipients may not necessarily want to be moved implementation difficulties because of the operational difficulties of transferring households and beneficiaries

23 Social assistance case 2: Mozambique Cash Transfers Programme Target Basic Social Benefit Program (PSSB) Permanently Labour Constrained Households Social Direct Suport Program (PASD) Temp. Labour Constrained Households Productive Social Action National Program (PNASP) Non-labour constrained HHs Benefit Monthly cash transfers at 1/3 of the Poverty Line for the main beneficiary... Households with Elderly Eligibility (+55 for females and +6- for males) and/or disabled and/or chronically ill... Value of a basic food basket (fixed per Household) Child Headed HHs; Poor HH with members on TARV ; Poor HHs with adults being temporarily unavailable to work (ex. Pregnant women head of HHs) Value of the Povery Line fixed by Household Poor HHs with at least one adult able body... 23

24 Social insurance financing Convention o No. 183: Financing by soca social insurance or public funds or in a manner determined by national law and practice Employer liability is only permissible, if Employer agrees, or In force nationally before 15 June 2000, or There is a tripartite agreement there after 8

25 compliance with individual employer liability schemes is often problematic: in developing countries, employers may not pay the wage replacement the legislation may not be fully enforced. Individual id employers liability can impose an excessive cost on small enterprises struggling for survival and on businesses operating in female-dominated industries. i

26 In social security financing countries, employers and workers contribute to social security, Government usually as an employer In mixed systems, employers may pay the difference between the social security benefit and a woman s previous earnings.

27 Percentage of countrie s with statutory provision by branch Beforee Pos t 2005 Old age Disability Survivors Employment injury Sickness and health Maternity Family and children Unemployment 27

28 SADC Country Length of leave % of wages Source of funding Botswana 12 weeks 50% of basic pay Employer liability Lesotho 12 weeks 100% Employer liability Malawi 8 weeks (every 3 100% Employer liability years) Mauritius 12 weeks 100% Employer liability Namibia 12 weeks 100% Social security South Africa 17 weeks (4 Up to 60% Social security months) depending on the level of income Tanzania 12 weeks (84 100% Social security days) Zambia 12 weeks 100% Employer liability Zimbabwe 14 weeks (98 days) 100% Employer liability

29 it is possible to finance a social insurance scheme providing cash maternity benefits for less than 0.7 percent of covered wages. In Namibia, the Social Security Administration s s Maternity, Sickness, and Death (MSD) cash benefit programme is financed by a 1.8 per cent contribution rate, of which 0.35 per cent is allocated to maternity. In South Africa, the total cost for maternity, illness, unemployment and death costs 2% shared between employers and employees. The UIF had a surplus, as of March 2011 of ZAR 9,481 million. In the United Republic of Tanzania, the National Social Security Fund plans to earmark just 0.5 per cent of its contribution rate for maternity (today it pays out maternity benefits of far less than this).

30 Interesting features of SA UIF Increase in the category (taxi drivers, domestic workers and seasonal workers) Increase in number of contributors Remittance of domestic workers contributions by employer Payment on line, possible to be done annually

31 Medical benefits Needs to provide for effective coverage combining: Financial protection to address risks of impoverishment due to catastrophic health events and the capacity to finance any kind of out-of-pocket payment, including indirect costs Effective access to health services, medicines and healthcare commodities. Requires the physical availability of health- care infrastructure, workforce, medical goods and products, and the provision of affordable and adequate services 11

32 Medical benefits ILO Conventions call for a maternity package to include prenatal, delivery, and postnatal care, and hospitalization where necessary Convention No. 102 prohibits the charging of co-payments for these services ILO Conventions call for medical benefits to be provided through insurance or the general health services, depending on the health system in the country 12

33 CASE KENYA - BIMA YA JAMI Health Insurance for the family The composite product is designed to provide more complete coverage at a more affordable price for low-income people. The linkage with the National Hospital Insurance Fund provides an interesting ti case for using market-based mechanisms (i.e. public- private partnership) to enable workers in the informal economy to access to health services.

34 Interesting features of some schemes In 2009, Comprehensive Community Based Rehabilitation in Tanzania started using Vodaphone s mobile banking system, M-PESA to help maternal care patients pay for transportation to hospitals/ buy bus fares. The Ministry of Health in Zambia wants to implement an integrated programme on SAFE MOTHERHOOD at the occasion of the introduction of SHI in the country.

35 Health and/or cash benefits? Three patterns tend to predominate for providing benefits collectively: - both maternity health care and paid maternity leave are part of a wider social insurance scheme which also characteristically covers retirement pensions, sickness and invalidity benefits, and health care costs. - both maternity medical costs and paid maternity leave are part of the health insurance system. paid maternit lea e is administered in conj nction ith cash - paid maternity leave is administered in conjunction with cash sickness benefits or cash social insurance, while maternity medical costs are covered by the separate public or national health system.

36 Nevertheless, there are also a few countries with somewhat different patterns. in New Zealand paid maternity leave is funded from general taxation, and the scheme is administered by the Inland Revenue Department. In Canada, there is a linkage to unemployment insurance. A common pattern is for one organization/body, such as a social insurance or health insurance fund, to be the delivery agent for assistance, and another arm of government such as a Ministry of and another arm of government, such as a Ministry of Social Affairs, Labour, or Finance, being responsible for the oversight of the organization.

37 Key points Maternity-related economic and health risks can be mitigated by social security measures that extend social protection to women and their children during maternity. ILO standards offer guidance for developing and implementing social security measures and maternity cash and medical benefits. Cash benefits can be financed through different ways Cash benefits can be financed through different ways. Employer liability schemes raise particular concerns regarding unfair distribution of responsibilities for the costs and potential discrimination against women. 21

38 Extending maternity cash and medical benefits to vulnerable and unprotected women remains challenging, g especially in low-income countries. Cash transfer schemes and tax funded essential health benefits packages represent promising approaches when integrated in broader national social protection systems. Therefore Key strategies: Implement p Maternity Social insurance benefits and Social Health Insurance Include as part of Cash Transfers or Programs for Vulnerable.

39 Thank you!

40 Topics for discussion How can you cover the formal and informal sectors? Is income maternity protection affordable in Lesotho? Calculate for set of typical workers? How can you implement a credible and reliable social insurance system? 40

41 Stakeholder analysis Smith John 41

42 Write a 10 point resolution for roadmap What? who? 5 conclusions 5 recommendations 42

43 Group 1 Sensitisation of the general public by social partners Legal process for establishing SSO G2 It is important to have inclusive maternity protection as it contribute to poverty alleviation job creation and reduces child mortality and improves maternal health Intensive public 43