ILO concepts and definitions

The ILO’s ultimate objective in the field of social health protection is to achieve universal access to affordable health care of adequate quality and financial protection in case of sickness.

The concepts and definitions of terminologies related to social health protection advocated by the ILO are introduced here and will be used in describing the ILO approach.



Coverage

This definition of coverage encompasses relevant dimensions of effective access to health care. These include besides population coverage by legislation, the availability of services, affordability, financial protection and quality. The availability (see under 'Access indicators') of services relates among others to the density of health professionals. Affordability and financial protection are defined by the absence of financial barriers to access services, such that, out of pocket does not pose a threat to livelihood or result in diminished quality of care.

To be effective, universal coverage needs to ensure access to care for all residents of a country, regardless of the financing subsystem to which they belong. This does not preclude national health policies from focusing at least temporarily on priority groups such as women or the poor when setting up or extending social health protection.

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Effective access

Compared to legal coverage that describes rights and formal entitlements, effective access refers to the physical, financial and geographical availability of services.

The ILO advocates that benefit packages (i.e. packages of health services that are made available to the covered population) should be defined with a view to maintaining, restoring or improving health, guaranteeing the ability to work and meeting personal health-care needs. Key criteria for establishing benefit packages include the structure and volume of the burden of disease, the effectiveness of interventions, the demand and capacity to pay.

Effective access includes both access to health services and financial protection. Financial protection is crucial to avoid health-related impoverishment. Financial protection includes the avoidance of out-of-pocket payments that reduce the affordability of services and – ideally – some compensation for productivity loss due to illness.
 


Affordability

Affordability of services refers to the non-existence of financial barriers of access to health services for individuals, groups of individuals and societies as a whole.


Affordability for particular groups concerns first of all the poor and aims at avoiding health-related poverty. This concept should be defined in relation to the maximum share of cost for necessary health care at total household income net of the cost of subsistence; for example, health-care costs could be considered affordable if they amount to less than 40 per cent of the household income remaining after subsistence needs (i.e. food and basic housing) have been met. In line with the WHO, the ILO considers health-care costs below that share to be non-catastrophic for households. Universal coverage is thus associated with equity in financing, implying that households should only be asked to contribute in relation to their ability to pay (Evans, 2007, p.9).

Macroeconomic affordability relates particularly to the fiscal space that can be made available to finance a level of expenditure that ensures universal access to services of adequate quality without jeopardizing economic performance or crowding out other essential national services (such as social cash transfers or education, internal security, etc.). Necessary expenditure levels depend on a population’s health status, the availability of infrastructure, the price level of services and the efficiency of service delivery. While the ILO does not advocate specific benchmarks on public spending on health, it advises the population access to medical services in countries with low vulnerability at in terms of poverty and extent of informal economies be used as a benchmark for other countries. Further, it recognizes that several benchmarks for spending on health have been set by other international organizations and commissions, such as the World Bank and the Commission on Macroeconomics and Health (CMH) established by the WHO.
 


Quality

The notion of quality refers to various dimensions. These include quality of:

  • medical interventions, e.g. compliance with medical guidelines or protocols as developed by WHO or other institutions,
  • health-related services, e.g. ethical dimensions such as dignity, confidentiality, respect of gender and culture, and issues such as choice of provider and waiting times,
  • administration and management of social health protection systems and schemes, e.g. with accountability, transparency and participation.

In all cases, quality is strongly linked to the availability of sufficient financial and human resources.
 


Financial protection

Financial protection includes minimizing out-of-pocket payments and compensation for productivity loss due to illness. Financial protection addresses the risk of impoverishment due to catastrophic health events, out-of-pocket payments, transport costs to reach health care facilities particularly in rural areas.

The utilization and therefore access are influenced by the quality of services provided which is strongly correlated to the availability of sufficient resources.

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