20 Universal Health Protection
the temptation to switch to a different, better-paid job or to emigrate to another country where health workers’ wages and working conditions are more favorable
McCoy et al., 2008.
Health workers’ wages are very modest, especially in developing countries ILO, LABORSTA, 2013; National Institute of Statistics, Rwanda, 2008. They are relatively
low in comparison to the wages of other professions and in some cases not even sufficient to meet their basic needs. The quality of services delivered may consequently be
suboptimal. In addition, low wages hinder the process of attracting and keeping sufficient staff of adequate quality.
3.2. Socio-economic impacts of gaps in health protection
3.2.1. Impacts at national level: Effects on health, poverty and employment resulting in economic
costs for the society as a whole
Health protection consists of an economic sector with its own health industry and workforce, as well as unique financing mechanisms that have consequences at the national
level. Thus, the population concerned by ill health and their employers are not the only beneficiaries of investments in health protection; the employment sector can also be
considered as a stakeholder given the high shares of employment of the health workforce in total employment in many countries. On the other hand, gaps and deficits in health
coverage may lead to significant costs for the society as a whole, because of:
avoidable expenditure within health-care systems due to costs related to treatments for more severe health conditions and essential public health measures;
increasing poverty rates due to high private health expenditure that is not shared in risk pools;
productivity losses due to working while sick and to absenteeism; rising costs of social protection schemes such as disability, long-term care and social
assistanceincome support, due to increased risk of work accidents and development of chronic diseases, resulting in incapacity to work and impoverishment; and
lower employment rates in the health and public sector. The close relationship between poverty and high OOP can be observed in figure 3.12. In
countries where more than 50 per cent of the population are living in poverty on less than US2 a day, OOP reached levels of more than 50 per cent of total national health
expenditure in 2010.
Universal Health Protection 21
Figure 3.12. Out-of-pocket payments OOP by country level of poverty, 2011 percentages
Source: ILO, 2013a.
These developments most likely derive from gaps in legal health coverage, as we can see in figure 3.13. In countries where the majority of the population is living in poverty on less
than US2 a day, only about 10 per cent of the population have legal health coverage.
Figure 3.13. Legal health coverage to a health system or scheme, population living on less than US2 PPP a day percentages
Source : ILO, 2013a
Limited levels of formal employment are also closely related to coverage and thus access to essential care. Figure 3.14 demonstrates the association between the share of workers in
19.6 37.4
40.1 57.1
46.7 40.5
10 20
30 40
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2 2.1–25
25.1–50 50.1–75
75 Total
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Groups of countries defined by the percentage of the population living with less than 2 PPP a day
Out-of-pocket expenditure as a percentage of total health expenditure by the proportion of the population living with less than 2 PPP a day
2011 weighted by total population
Total 75
50.1 - 75 25.1 - 50
2.1 - 25 2
Percentage of total population covered P
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