This article is part of our special report Fighting diseases: The challenges ahead.
SPECIAL REPORT: Billions of people in developing nations lack the health and social protections that most Europeans take for granted, a gap that experts say harms efforts to reduce poverty and prevent crises like the killer Ebola epidemic in West Africa.
Some 73% of the world’s 7 billion people have little or no access to health and disability insurance, jobless benefits, or a pension, according to the International Labour Organization (ILO). In low-income countries, the dearth of health coverage is even higher – up to 90% – while the vast majority of Africa’s poor are unable to access basic medical services.
“The global community agreed in 1948 that social security and health care for children, working age people who face unemployment or injury, and older persons are a universal human right,” Sandra Polaski, ILO Deputy Director-General, said in laying out the case for cradle-to-grave protections after releasing the ILO’s latest World Social Protection Report last June.
The promise of universal social protection, she said, “remains unfilled for the large majority of the world’s population”.
There are signs that things are changing – both at the global and national levels.
“On the whole, the interest in social protection has been growing in the international development context,” said Francesca Bastagli, head of the social protection programme at the Overseas Development Institute (ODI), an independent research group that focuses on ways to reduce poverty.
Increasing numbers of governments – including those in low-income nations – are paying more attention to how to expand and pay for social protection systems, Bastagli told EURACTIV. They recognise that universal health, education and social protection “can have a significant impact on poverty both in the short and long term”.
In a move hailed by proponents of a legal minimum safety net in every country, worldwide negotiators have included health and social protection provisions into the UN’s draft Sustainable Development Goals, the successor to the Millennium Development Goals (MDGs). The post-2015 poverty-fighting agenda is due to be considered at a plenary session of the UN General Assembly in September.
The draft document mentions social protection three times – in goals on eradicating poverty, boosting gender equality, and reducing inequality.
‘Global health worker crisis’
But when it comes to turning goals into realities, the challenges are staggering.
The ILO estimates that nearly three out of four people lack basic social protection schemes. In 44 low-income countries – most of them in sub-Saharan Africa – 90 per cent of the population has no legal guarantee of basic health coverage. Even where there is formal health cover, the poor often can’t afford co-payments to see a doctor.
Those lucky enough to have some insurance may not find the right help. Globally, according to the ILO figures, there is a “deficit” of 10.3 million health workers and this shortage is most acute in densely populated Asian regions and in sub-Saharan Africa, where some 80 percent of the population have no access to basic health care.
The shortage is “so severe that we speak about a global health worker crisis,” Xenia Scheil-Adlung, the health policy coordinator in the ILO’s Social Protection Department, told EURACTIV from Geneva.
“In Sierra Leone, this was very clear with the Ebola – they had just no health workers available even to tell the people what to do, not to mention the care that was needed,” she said.
EU advocates for social protections
Discussions on providing a social safety net is not new to the post-MDG agenda.
The end of the Cold War led to momentum to use the “peace dividend” to help developing and post-colonial countries provide a social helping hand for all ages, a guarantee enshrined in the 1948 Universal Declaration of Human Rights and the 1966 International Covenant on Economic, Social and Cultural Rights.
More recent initiatives to expand protections beyond high-and middle-income countries include:
- The European Union’s key overseas development policies – the Agenda for Change, and Decent Life for All communication – both call for investing in health and social insurance for the world’s poorest nations.
- The 185-member nations of the ILO, including the 28 EU states, in June 2012 adopted a resolution urging all countries to provide minimal social protections in the build-up to the UN Conference on Sustainable Development.
- The International Monetary Fund and World Bank – often the target of criticism for counselling cash-strapped governments to rein in social spending – have begun to encourage the social and health insurance floors as a way to boost worker productivity.
- African Union leaders have backed the expansion of guaranteed health and social insurance through two key agreements – the 2004 Ouagadougou Declaration and the 2008 African Union Social Policy Framework.
“The EU deserves a lot of credit for some of these outcomes, since they were really pushing the idea that health, child and maternal care and other social protections can help reduce the inequality that exists within and among countries, especially the low-income ones,” a former aide to Latvian politician Andris Piebalgs, the previous EU Commissioner for Development, told EURACTIV.
“Of course this is sensitive, even within Europe, because why should we help other countries when we have our own problems at home, and politicians care more about short-term costs and not the long-term gains,” the EU official said, asking not to be identified because of on-going involvement in the post-MDG process at the United Nations.
To address financing challenges, some advocates have called for the creation of a special fund to help low-income countries provide or expand health and social insurance schemes.
In 2012, Belgian law professor Olivier De Schutter, the former UN Special Rapporteur for food rights, and his Chilean colleague Magdalena Sepúlveda, who was the UN’s Special Rapporteur on extreme poverty, called on advanced countries and international lending institutions to create a Global Fund for Social Protection.
Preventing Ebola and other scourges
Meanwhile, there were other priorities, including a devastating drought and hunger crisis in Africa’s Sahel region that affected millions of people, a massive exodus of refugees from Syria, and the outbreak of the Ebola virus in West Africa last year that sent shockwaves around the world.
The World Health Organization (WHO) estimates that the Ebola epidemic has killed more than 9,500 people and affected at least 23,000 others in Guinea, Liberia and Sierra Leone. The WHO is asking for more than $370 million (€327 million) for its Ebola response in the first six months of 2015 alone, and so far is nearly $270 million (€238 million) short of that goal.
The ILO’s Scheil-Adlung says the Ebola outbreak has had a “severe economic impact” on the affected countries.
“This could have been avoided if there had been had a functioning health system,” she said. “It is not very sufficiently taken into account that there is a close relationship between development and health protection.”
“There is a clear return of investment in the health system that can be seen in economic terms and of course in other aspects of social cohesion, fairness and social peace,” Scheil-Adlung added.
Even as new Ebola cases were reported in West Africa, last week, the WHO appealed to donors not to overlook “17 neglected tropical disease”, calling for spending $2.9 billion a year for the immediately future to combat afflictions that can cause blindness, disfigurement, disability and death and often hit marginalised people the hardest.
Laudable but affordable?
For all the attention given to social and health protections for countries in need, there are concerns about their effectiveness.
A report by the Copenhagen Consensus Center, an American think tank that analyses the costs and benefits of development programmes, commends global measures to reduce malnutrition, tropical diseases and tuberculosis, and efforts to guarantee universal health care. But the group questions the inclusion of broader social protection goals in the post-MDG document that will emerge later this year.
“The introduction of a social protection floor, while laudable, is difficult to achieve well (properly targeted at low cost.) Additionally, the resources required to implement full social protection are large and it risks creating very large (even 100%) effective marginal tax rates for the poor with disincentives to increase income,” the group’s assessment says.
In addition, the centre’s analysts say there is growing evidence to suggest that safety nets and cash transfer programmes – which are designed to provided immediate aid to marginalised communities – can hurt non-target groups “either because local prices are raised or because of the distortion in employment choices with expanded social protection leading to more informal employment”.
The authors of the ILO’s World Social Protection Report 2014/2015 see it differently.
“Social protection powerfully contributes to reducing poverty, exclusion and inequality – while enhancing political stability and social cohesion. It also contributes to economic growth by supporting household income and thus domestic consumption,” the study recommends.
“Social protection, specifically social protection floors, are essential for recovery, inclusive development and social justice, and must be part of the post-2015 development agenda.”
Dr. Dirk Engels, in charge of the World Health Organization’s neglected tropical diseases department, said in a statement on 19 February that some of these diseases “are no longer strictly tropical. The potential for spread provides yet another strong argument for making the needed investments – while ramping up research and development efforts – to bring all these diseases under control and eliminate as many of them as rapidly as possible.”
The Overseas Development Institute’s Francesca Bastagli was the author a study commissioned by the European Parliament that urged the EU to encourage the growth of social schemes for low-income nations through aid as well as offering expertise drawing on Europe’s own experience in providing universal health and pension systems.
The study - Feasibility of Social Protection Schemes in Developing Countries – was released two years ago as European leaders were preparing recommendations for the post-MDG negotiations.
In testimony before the Parliament’s overseas development committee on 18 March 2013, she said that the EU and other donors could help governments in developing nations close the gap in social protection coverage.
“There is a very clear case for the role of government to provide coverage for the poorest of the poor and to ensure that the services are of decent quality,” Bastagli said in testimony before the Parliament’s Committee on Development.
“This reflects broad support, in light of the crisis, for investment in social protection schemes that can ensure social protection in future crises,” she said.
According to the UN Food and Agriculture Organization’s statement on social protections:
“Social protection has proven to be effective in reducing poverty and hunger, building resilience while promoting more inclusive and sustainable growth. Universal access to health care, education and income supplements for the needy fosters healthier, more productive and more equitable societies.
“With the necessary political will, social protection is financially affordable for all countries – high, middle and low-income – albeit with different levels of provisioning. Social transfer programmes that combine income support with better access to social services, particularly health and education, have greatly reduced malnutrition and enhanced income-generating capabilities. Last, but not least, social protection can transform societies by helping to empower previously marginalized groups.”
- 2015: European Year for Development
- 25-27 Sept. 2015: United Nations Summit on the Post-2015 Development Agenda.
- 29 Sept. 2015: 70th U.N. General Assembly general debate