Social Protection in Africa
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The design and implementation of social protection systems requires a coherent policy framework which includes long-term strategies and planning. However, research shows that, when taken as part of a package of measures supported by international community, government-led social protection programmes are both affordable and necessary for sustained economic growth in low income countries. Also extremely important is the development of administrative and management capacity, in order to ensure simple, well-operating and effective schemes.1
In light of resource constraints, the provision of social protection in Africa is often targeted rather than universal. Experiences to date show that targeted benefits have often resulted in low coverage of people in greatest need and that the testing and categorical targeting mechanism (e.g. for the elderly and disabled) in fact created a barrier to social protection.2
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Social health protection
In general, Africa has low levels of social security expenditures on health and proportionately very high private/out-of-pocket health expenditures – which account for roughly 60% of total health expenditures in 2005.3 As a result, many people defer or do not seek care because they cannot afford treatment, with the main consequences being impaired access to health care services and worsened health status and poverty levels. Within African countries, inequities at the regional and national levels result in significant geographical differences in health status, access to health services and financial protection.
In addition to insufficient financial protection, the lack of infrastructure, facilities and trained personnel necessary to provide and deliver basic health care services –particularly in rural areas – affects the lives of millions of poor people, especially children, women, elderly and people living with disabilities. Generally, access to maternal health services, to pre- and post-natal care and to primary health care is very limited in most African countries. 4 Moreover, the situation is often aggravated by further barriers to accessing care, including: gender inequities, reflecting a variety of cultural and social factors; uneven urban and rural distribution of health care facilities; and the financial impact of the HIV/AIDS pandemic.
The key question therefore is how to improve the extension of social health protection, with the ultimate aim of achieving universal coverage. One approach is to use different funding mechanisms, in order to maximize the affordability of social health protection at the national and household level. The cases of Ghana or Burkina Faso, for example, clearly show how mixed financing arrangements can significantly widen access to health care. Coherent legislation and institutional responses are also important in this process. Sierra Leone and Uganda, two of poorest countries in the continent, recently committed to designing social health insurance schemes which explore the concepts of universal coverage and social health protection.5 These cases show that political commitment and willingness to reform the systems are thus key in order to start the process.
Countries such as Tunisia, Rwanda and Senegal are further examples of integrated approaches to health protection. Tunisia has a health-care system dominated by the public sector, with a growing private sector presence.6 Rwanda has some of the highest health care coverage in the developing world, with all formal sector workers covered through either public or private schemes and the rest of the population covered by community-based health mutual insurance. Rwanda’s health mutuals are said to play an especially significant role in eradicating malaria.7 Finally, in Senegal, a two-dimensional strategy of building and improving the health-care system and hospitals has also been marked by a favourable outcome, largely due to international development assistance well-coordinated with national reform strategies.
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Income security schemes
When analyzing income security schemes in Africa, a distinction must be made between the situation in the formal sector and in the informal one. Many countries have established contributory social insurance schemes for the formal sector that provide benefits based on statutory entitlements that are usually available only to workers in full-time, paid employment who have contributed for a certain period of time. In Africa, these schemes are often government schemes for public servants. The contingencies covered typically include old age (pension benefits which sometime also provide benefits in case of disability or death of the main bread winner) and employment injury. The least covered contingency is unemployment, followed by family, sickness and maternity benefits, which are usually directly provided by employers and not by social insurance schemes. Many countries in Africa are in the process of debating reforms aimed at increasing scheme efficiency and addressing problems such as employer non-compliance, inappropriate statutory retirement age, early withdrawal of funds, the situation of migrant workers, inadequate benefit levels and discrimination against women.
However, the most serious challenge for countries in Africa remains the extension of social protection to a larger share of the population. Coverage rates in North Africa and countries such as South Africa and Mauritius are higher than the continental average but, in most countries, effective coverage rates of contributory schemes fall well below 10 per cent.8 For this reason, governments are seeking to establish more comprehensive strategies.
The South African government, for example, approaches health care, education, work-related benefits and social assistance through cash grants and programmes, as part of a comprehensive response to address poverty. Contributory schemes and non-contributory social assistance programmes in the form of cash transfers are meant to support the whole population – without these, over 50 per cent of households in South Africa would fall below the minimum subsistence level.9
However, contributory schemes in Africa are characterized by problems such as employer non-compliance, inappropriate statutory retirement age, early withdrawal of funds, the situation of migrant workers, inadequate benefit levels and discrimination against women, issues which make the schemes not always effective in protecting the rights of the workers.10
On the informal side, apart from very few social assistance programmes, there has been hardly any provision of income security or income support programmes reaching a significant portion of the population in need. Those countries which did introduce social assistance programmes for the informal sector have often faced great obstacles in ensuring their smooth implementation and sustainable financing. In addition, contributory schemes provide little or no coverage for those employed in agriculture or for domestic workers, despite the fact that agricultural workers represent the majority of those employed in most countries of the region. As a result, 80 per cent of older women and men work until they are incapacitated.11
In recent years, experts have suggested that transfers in cash or in kind are the most efficient way of reaching the poorest and most vulnerable, especially if transfers are provided on a universal basis. There is now an ongoing debate everywhere in Africa on scaling up government financed non-contributory programs. In addition, a range of new policies are being implemented or piloted in order to improve the situation on a two-dimensional basis, in terms of both horizontal (universal coverage) and vertical (improvements of the services already existing) coverage extension.12
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