6 Universal Health Protection
To be meaningful, legal health coverage needs to result in effective access for all residents of a country, regardless of the financing subsystem to which they belong. However, this
does not preclude national health policies from focusing temporarily on priority groups such as the most vulnerable when extending social protection in health. Frequently,
vulnerable population groups do not have equal access to necessary health care. This is often due to gaps in legislation, and particularly concerns the following categories:
the poor; workers in the informal economy and their families;
women; persons with special needs, such as persons living with HIVAIDS PLHIV; and
ethnic minorities and migrants.
2.1.2. Effective access to health care
Despite legal coverage, the sick are often not in a position to access necessary quality health care without risk of poverty and financial hardship. This is not solely dependent on
the existence of legislation or affiliation to a scheme or system; it depends also on a range of issues such as gaps in the implementation of legislation as well as social, economic and
other factors.
In order to ensure adequate protection in terms of effective and equitable access to health care, affordability and financial protection in addition to availability of quality services
must be guaranteed by the removal of financial barriers such as out-of-pocket payments OOP. Furthermore, there must be sufficient funding for quality service delivery, and
excellence in governance and management of health systems and schemes. An overview of key aspects to be assessed is provided in figure 2.3.
Figure 2.3. Dimensions of effective access to health care
Source: ILO, 2013a.
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Non-existence of financial barriers to access services
Financial contribution in relation to ability to pay
Absence of catastrophic health- care costs
Absence of impoverishment due to health-care costs and inability
to generate income
A v
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Excellence of social health protection at the systemic,
organizational and managerial level e.g. use of funds,
efficiency, management capacity, legislation and enforcement,
decision-making process Excellence of the service delivery
system e.g. responsiveness, provider behaviour, medical
interventions, infrastructure, staff, equipment
Availability of a set of essential services
Universal Health Protection 7
Affordability and financial protection of health care Access to health care frequently involves costs such as co-payments, other direct payments
for health services and goods, and indirect costs such as transport, resulting in out-of- pocket payments OOP. The criteria of affordability of health care relates to the non-
existence of such financial barriers to access for individuals, population groups and societies as a whole.
ILO Recommendation No. 202 stresses the importance of affordable health care by emphasizing the principle of solidarity in financing para. I. 3h. This includes
minimizing OOP by increasing fairness in financing through pre-payments and risk pooling, while ensuring that taxes, contributions and premiums are charged according to
capacity to pay.
The Recommendation also states that “persons in need of health care should not face hardship and an increased risk of poverty due to the financial consequences of accessing
essential health care” para. II. 8a. High OOP on top of decreased productivity and earnings may cause such hardship and impoverish individuals and their families. Financial
protection has the potential to protect against various types of expenditures incurred when accessing health care, including transport costs to reach health-care facilities and
compensation for the economic loss caused by reductions in productivity and earnings due to ill health.
In order to provide protection against OOP as well as loss of earnings, social protection systems should be in place for all in need, including vulnerable groups. Particularly in
times of crisis, when workers may be forced to choose between risking their health or losing income when reporting sickness, paid sick leave is an important tool of financial
protection. In this context it is interesting to note that the economic costs of working while sick exceed the costs of paid sick leave, because of an increased number of persons to be
treated with more severe signs of ill health. Additionally, the lower productivity of sick workers has been found to slow down growth and development Scheil-Adlung and
Sandner, 2010. Figure 2.4 illustrates the number of days of paid sick leave as a share of annual working days in selected European countries, ranging from between three and ten
days per year.
Figure 2.4. Paid sick leave days as a percentage of annual working days, selected European countries, 2006
Source: Scheil-Adlung and Sandner, 2010.
5 9.4
3.8 5
5.5 5.5
4.8 8.8
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