Social Insurance Schemes Research Articles

How resilient is health financing policy in Europe to economic shocks? Evidence from the first year of the COVID-19 pandemic and the 2008 global financial crisis

The COVID-19 pandemic triggered an economic shock just ten years after the shock of the 2008 global financial crisis. Economic shocks are a challenge for health systems because they reduce government revenue at the same time as they increase the need for publicly financed health care. This article explores the resilience of health financing policy to economic shocks by reviewing policy responses to the financial crisis and COVID-19 in Europe. It finds that some health systems were weakened by responses to the 2008 crisis. Responses to the pandemic show evidence of lessons learnt from the earlier crisis but also reveal weaknesses in health financing policy that limit national preparedness to face economic shocks, particularly in countries with social health insurance schemes. These weaknesses highlight where permanent changes are needed to strengthen resilience in future: countries will have to find ways to reduce cyclicality in coverage policy and revenue-raising; increase the priority given to health in allocating public spending; and ensure that resources are used to meet equity and efficiency goals. Although many health systems are likely to face budgetary pressure in the years ahead, the experience of the 2008 crisis shows that austerity is not an option because it undermines resilience and progress towards universal health coverage.

Urban-rural health insurance integration in china: impact on health care utilization, financial risk protection, and health status

ABSTRACT China has been making efforts to establish a universal health care coverage system through multiple social health insurance schemes. As these insurance schemes cover different populations with different financing and reimbursement levels, large disparities remain in health care access and health outcomes among people covered. The government has launched an urban-rural integration policy for social health insurance to reduce disparities in access and health outcomes. We adopt a difference-in-differences propensity score matching approach to estimate the effects of this integration policy on health care utilization, financial risk protection, and health status, using nationally representative Chinese household survey data. The results show that the integration policy has significantly improved financial risk protection and self-assessed health of rural residents in China, which could be attributed to a decline in out-of-pocket payment. The low-income rural residents benefit most from this policy. There is no evidence that it has pronounced effects among urban residents. Greater efforts to increase reimbursement rates and to expand beneficiary populations could help to mitigate remaining urban-rural disparities. The findings in this study would contribute to a better understanding of the impacts of health insurance expansion in low- and middle-income countries. JEL code: I18, I10

ПРАВОВЕ РЕГУЛЮВАННЯ ОПОДАТКУВАННЯ СІЛЬСЬКОГОСПОДАРСЬКОЇ ДІЯЛЬНОСТІ В КРАЇНАХ ЄС

An analysis of the legal regulation of agricultural taxation in the EU member sates on the example of Poland, Czech Republic and Austria was made. A number of tax benefits for agricultural producers, which are contained in the legislation of the above countries, have been identified: reduction of income tax on farms; real estate tax benefits; discounts on tax on fuel; absence of taxes on property inherited or agricultural land and buildings, the ownership of which is acquired on the basis of a gift agreement; reduction of contributions under a special social insurance scheme. The urgency of the issue of providing tax benefits for agricultural producers in Ukraine, introduction of a special tax regime, which would contribute to the formation of a balanced structure of agro-industrial production was highlighted. It was noted that implementation of the experience of EU member states in the field of taxation of agricultural activities in domestic agricultural sector of the economy is extremely important and requires changes to legislation. Tax burden affects the profits of agricultural producers and is one of the key factors influencing the development of the agricultural sector in the country, the competitiveness of small and medium-sized socially oriented agricultural businesses, and reflects the priorities of agricultural activities. Therefore, the legal regulation of agricultural production is one of the key issues on the agenda. Ukraine needs to reform the system of taxation of agricultural production in order to form a balanced structure of agro-industrial production on the model of European countries.

SOCIAL PROTECTION FOR WORKERS POSTED TO AND FROM SOUTH AFRICA: A CRITICAL ASSESSMENT

Given the globalised nature of work in the twenty-first century, labour and social security law issues relating to worker-posting are sure to increase in the years to come. The purpose of this note is to assess critically the social protection of workers posted abroad from a South African perspective. The contribution addresses this topic by discussing various questions. It concludes by stressing the need for the adoption of a coherent approach as far as social protection for posted workers is concerned by, inter alia, promulgating an act of parliament to regulate the social security and labour law entitlements and obligations of these workers as well as their employers.In addition, it emphasises the need for and the importance of bilateral and multilateral social security and labour agreements between South Africa and other countries, particularly those where South African companies have established themselves. A sizeable number of South African companies (such as MTN, Vodacom, SABMiller, Sasol, Woolworths and Debonairs) have established, or are successfully establishing themselves, in African countries and beyond. At the same time, foreign companies (such as BMW, Levi Strauss, Barclays Bank and Vodafone) have registered, or are in the process of registering, in South Africa at an unprecedented rate. It is true that these companies do employ locals. However, situations do arise requiring a global company to send a worker for a limited period (usually not exceeding twelve months) to carry out work in the territory of a State other than the State in which he or she normally works. This scenario is commonly known as worker-posting and does yield some benefits (including international exposure) to the (posted) workers, their employers and the economy in general. Nevertheless, if not properly regulated, worker-posting may have an undesirable effect, particularly on workers. For example, posted workers may find themselves concurrently covered (ie, at home and abroad) by social insurance schemes or not covered at all. As will be explained later, this can yield undesirable results. For example, it unnecessarily raises the costs of doing business for transnational employers. Furthermore, the period of stay for posted workers is limited and, as a result often does not lead to any entitlement to benefits. In addition, in the labour law sphere, posted workers may fall victim to abuse as regards the basic conditions of employment (eg, relating to pay and working time). The purpose of this paper is to assess critically the social protection of workers posted abroad from a South African perspective. According to the Asian Development Bank (ADB), “social protection” consists of policies and programmes designed to reduce poverty and vulnerability by promoting efficient labour markets, diminishing people’s exposure to risks, enhancing their capacity to protect themselves against hazards and interruption/loss of income”. The aim of social protection for that reason, is to avert or minimise social risks – in that way preventing or minimising human damage – by increasing capabilities and opportunities. As noted by the UN Commission: “The ultimate purpose of social protection is to increase capabilities and opportunities and, thereby, human development. While by its very nature social protection aims at providing at least minimum standards of well-being to people in dire circumstances enabling them to live with dignity, one should not overlook that social protection should not simply be seen as a residual policy function of assuring the welfare of the poorest – but as a foundation at a societal level for promoting social justice and social cohesion, developing human capabilities and promoting economic dynamism and creativity”. This contribution addresses this topic by discussing the following questions: What is the social protection status, with reference to social security and labour law, of workers posted to and from South Africa? Is the present social security and labour law protection framework ideal for extending social security and labour law protection to posted workers? To the extent that it is not, where and what are the gaps and challenges that are likely to hinder efforts to extend or strengthen social security and labour law coverage to this category of workers? Finally, what are the alternatives for improving, in a worker-posting context, the current social protection framework?

Catastrophic Healthcare Expenditures and Household Poverty in Kenya: The Case of Cancer, Hypertension, and Diabetes

It is estimated that non-communicable diseases account for 27% of all deaths suffered by Kenyans, equivalent to almost 100,000 people per year. Kenya is experiencing an upsurge in the prevalence of non-communicable diseases (NCDs), with current estimates showing that NCDs account for a third of the disease burden. This promoted the basis of the study to examine the effects of catastrophic healthcare expenditures due to cancer, hypertension, and diabetes on household poverty in Kenya. The study used the latest Kenya Household Health Expenditure and Utilization Survey (KHHEUS) 2018 dataset. Data analysis was undertaken by employing STATA Software. A significance level of p of <0.05 was used. The results indicated catastrophic health expenditure, education level, working status, household size, and locality are significant determinants of household poverty. The presence of chronic illnesses such as hypertension, cancer, and diabetes increases the probability of being poor as a result of high out-of-pocket expenditures. It was noted that the households with catastrophic health expenditure of 40 percent and above are classified to be poor. The study recommended that the reliance on out-of-pocket expenses to finance medical services needs to be reduced because it leads to catastrophic health expenditures even as the country gears towards universal healthcare coverage. County governments are encouraged to be innovative in trying to come up with social health insurance schemes to lessen the burden of financing NCDs. Keywords: Catastrophic healthcare expenditures, out of pocket expenditures, cancer, hypertension, diabetes, household poverty, Kenya DOI: 10.7176/JESD/12-16-09 Publication date: August 31 st 2021

Negative Incentives for Noninstitutional Births Are Associated With a Higher Rate of Facility-Based Births in the Eastern Visaya Region, Philippines.

In the Philippines, the "no home-birthing policy" implemented in 2008 has encouraged local governments to endorse ordinances that prohibit noninstitutional deliveries (NIDs). The Philippines' social insurance scheme has also enabled them to provide incentive payments to women who deliver at birthing facilities (BFs). This study evaluated whether these positive and/or negative incentives were associated with an increased facility-based delivery (FBD) rate and examined challenges in implementing those incentive measures in the Eastern Visaya Region of the Philippines. Cross-sectional data were collected regarding delivery locations during 2017, and barangay-level data were collected regarding positive and negative incentives and the characteristics of 4,371 barangays in the region. Multivariate logistic regression analysis, using "ordinance with nonmonetary sanction" as the reference category, indicated that no ordinance to prohibit NIDs was significantly associated with a lower FBD rate (odds ratio [OR]: 0.90, P=.013), and ordinance with low cash penalty (OR: 1.37, P<.001) and high cash penalty (OR: 2.52, P<.001) had higher FBD rates. Positive incentives were not associated with FBD rates (OR: 1.02, P=.563). The FBD rate was also significantly associated with urban barangay status (OR: 1.45, P<.001), availability of a vehicle (OR: 3.19, P<.001), availability of public transportation to a government BF (OR: 1.25, P<.001), and distance to the most accessible government BF (OR: 0.89, P<.001). Substantial proportions of barangays had no vehicles available for transportation (34.1%) or no available vehicles and no public transportation to a government BF (5.5%). Although negative incentives for NIDs could motivate pregnant women to seek FBD, local governments in the Philippines should be aware of barriers that limit access to government BFs in underserved barangays before introducing those negative incentives. Above all, barangay-level investments in making a vehicle for transporting pregnant women might help address these barriers and increase the FBD rate.

The Introduction of Bismarck's Social Security System and its Effects on Marriage and Fertility in Prussia

AbstractEconomists have long argued that introducing social insurance will reduce fertility. The hypothesis relies on standard models: if children are desirable in part because they provide security in case of disability or old age, then State programs that provide insurance against these events should induce couples to substitute away from children in the allocation of wealth. We test this claim using the introduction of social insurance in Germany in the period 1881–1910. Bismarck's social insurance scheme had three pillars: health insurance, workplace accident insurance, and an old‐age pension. Earlier studies typically focus on the pension alone; we consider all three pillars. We find that Bismarck's social insurance system affected fertility overall only via its effects on the incentive to marry. The old‐age insurance by itself tended to reduce marriages, but the health and accident insurance components had the opposite effect. For people exposed to all three pillars of social insurance, the two effects cancelled each other and the aggregate effect on fertility was muted.fertility transition; economics; social insurance

Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data

BackgroundLittle is known about hip fracture inpatient care in East Asia. This study examined the characteristics of patients, hospitals, and regions associated with delivery of hip fracture surgeries across Japan, Korea, and Taiwan. We also analyzed and compared how the resource use and a short-term outcome of the care in index hospitals varied according to factors in the respective health systems.MethodsWe developed comparable, nationwide, individual-level health insurance claims datasets linked with hospital- and regional-level statistics across the health systems using common protocols. Generalized linear multi-level analyses were conducted on length of stay (LOS) and total cost of index hospitalization as well as inpatient death.ResultsThe majority of patients were female and aged 75 or older. The standardized LOS of the hospitalization for hip fracture surgery was 32.5 (S.D. = 18.7) days in Japan, 24.7 (S.D. = 12.4) days in Korea, and 7.1 (S.D. = 2.9) days in Taiwan. The total cost per admission also widely varied across the systems. Hospitals with a high volume of hip fracture surgeries had a lower LOS across all three systems, while other factors associated with LOS and total cost varied across countries.ConclusionThere were wide variations in resource use for hip fracture surgery in the index hospital within and across the three health systems with similar social health insurance schemes in East Asia. Further investigations into the large variations are necessary, along with efforts to overcome the methodological challenges of international comparisons of health system performance.

A Study on the Awareness and Effective Utilization of Employees State Insurance Benefits

The paper explores the level of awareness and satisfaction along with the efficient utilization of the ESI policy. The study attempts to view the benefits pertaining to the working employees. The study is to analyse the effects of utilizing the Employee State Insurance (ESI) policy by using SPSS software tools. The study has been done by using a structured questionnaire. ESI is a self financing social security scheme and health insurance scheme for the workers in India. It is an essential to give social security to the employees via Employee State Insurance Act ,1948 against the employee sickness, women employee maternity, Total disablement, Partial disablement and employee death in the during employment and to provide benefits to the effected employees and their dependents. ESI is certainly various from other insurance scheme like Health Insurance i.e. It actually provides the full coverage of the hospital expenses. The employers and employees contribution were made in ESI. The study was conducted with the objective of understanding the ESI frameworks with its benefits, schemes and allowances.

Willingness to Pay for a Contributory Social Health Insurance Scheme: A Survey of Rural Residents in Akwa Ibom State, Nigeria.

Background: Health insurance is seen as a pathway to achieving Universal health coverage in low- and middle-income countries. The Nigeria Government has mandated states to set up social health insurance as a mechanism to offer financial protection to her citizens. However, the design of these schemes has been left to individual states. In preparation for the set-up of a contributory social health insurance scheme in Akwa Ibom State, Nigeria. This study assesses the willingness-to-pay for a social health insurance among rural residents in the state.Methods: The study was conducted in three local government areas in Akwa Ibom State, South south Nigeria. It was a cross-sectional study with multi-stage data collection using a demand questionnaire. Interviews were conducted with 286 household heads who were bread winners. Contingent valuation using iterative bidding with double bounded dichotomous technique was used to elicit the WTP for health insurance. Multiple regression using least square method was used to create a model for predicting WTP.Findings: About 82% of the household heads were willing to pay insurance premiums for their households. The median WTP for insurance premium was 11,142 Naira ($29), 95% CI: 9,599–12,684 Naira ($25–$33) per annum. The respondents were predominantly middle-aged (46.8%), Ibibio men (71.7%) with an average household size of five persons and bread winners who had secondary education (43.0%) and were mainly pentecostals (51.5%). The mean age of respondents was 46.4 ± 14.5 yrs. The two significant predictors of WTP for insurance premium amongst these rural residents were income of breadwinner (accounts for 79%) and size of household (2%). The regression coefficients for predicting WTP for insurance premium are intercept of 2,419, a slope of 0.1763 for Bread winner income and a slope of 741.5 household size, all values in Naira and kobo.Conclusion: Majority of rural residents in Akwa Ibom State were willing to pay for social health insurance. The amount they were willing to pay was significantly determined by the income of the breadwinner of the household and the size of the family. These findings are relevant to designing a contributory social health insurance scheme that is affordable and sustainable in order to ensure universal health coverage for the citizens.

Cost, uncertainties and profit in commercial and social insurances

Here, we argue that the commercial for-profit insurance companies act more like a memory-less system in a way that the premiums paid by the policy holders during one accounting period will be of no avail to them during subsequent periods, although the excess premiums earned in the previous periods may rest in the companies’ retained earnings. Moreover, commercial insurances are subject to many over-head costs, taxations and uncertainties which are not present in the realm of social insurances. As the costs and uncertainties are greatly reduced and the profits earned in the previous periods are available to meet present and future expenditures, social insurances entail a lower amount of premium for the policy holders than its conventional commercial counterpart. The objective of this study is to quantify the extent of profit made by the commercial insurance companies born out of the premium after meeting up operating expenditures and claim settlements and how this profit evolves over time after being invested at the risk-free rate. To us, this is the amount of money that would otherwise rest in a trust fund available for future claim settlement if there were equivalent social insurance schemes in place. To do so, we collect annual country-level data of premium collection, claim settlement and operating expenditure incurred for 04 (four) OECD countries from OECD insurance database (OECD in, OECD Insurance Database. https://stats.oecd.org/Index.aspx?DatasetCode=INSIND. Accessed 27 Apr 2020, 2020a) and extrapolate the profit trends into the future using appropriate ARIMA/ARIMA–GARCH framework. As anticipated, the profit shows an explicit upward trend after making a V-shaped recovery right after the global financial crisis of 2008.

Urban-Sensitive Social Protection: How Universalized Social Protection Can Reduce Urban Vulnerabilities Post COVID-19

Experience with urban social protection programmes is relatively limited in the Global South. Extensions or duplicates of rural social assistance programmes do not reflect the distinct vulnerabilities of the urban poor, who face higher living costs and more precarious employment, and are not reached by social insurance schemes that are designed for formally employed workers. Neither the Sustainable Development Goals nor the New Urban Agenda reflect a specific focus on urban social protection. COVID-19 has exposed this major gap in coverage, given the disproportionate impact of lockdowns on the livelihoods of the urban poor. To ‘build back better’ post COVID-19, we propose rights-based national social protection systems with two components: categorical social assistance for non-working vulnerable groups (children, older persons, persons with disability) and universal social insurance for all working adults (formal, informal or self-employed), financed out of general revenues rather than mandatory contributions by employees and employers. These ideas are explored in the case of South Africa, which has comprehensive social assistance but inadequate social insurance for urban informal workers.

On Sustainable Aged Care Financing in Australia

AbstractThe Final Report of the Royal Commission into Aged Care Quality and Safety (Commonwealth of Australia 2021) highlighted the challenges in developing a sustainable financing system for aged care in Australia. The report recommended additional funding both in the short term and longer term so as to provide an adequate level of aged care quality for older Australians, including exploring an actuarially based contributory social insurance scheme for aged care. Sustainable financing of aged care requires a balance between government tax‐based financing, individual contributions during working life through an aged care levy, copayments for aged care costs for those receiving aged care and means testing for these copayments. There should be a role for private market insurance and financing to supplement government financed aged care support.

Benefit of China's Social Health Insurance Schemes: Trend Analysis and Associated Factors Since Health Reform.

With the deepening of health insurance reform in China, the integration of social health insurance schemes was put on the agenda. This paper aims to illustrate the achievements and the gaps in integration by demonstrating the trends in benefits available from the three social health insurance schemes, as well as the influencing factors. Data were drawn from the three waves of the China Health and Nutrition Survey (2009, 2011, 2015) undertaken since health reforms commenced. χ2, Kruskal–Wallis test, and the Two-Part model were employed in the analysis. The overall reimbursement rate of the Urban Employee Basic Medical Insurance (UEBMI) is higher than that of Urban Resident Basic Medical Insurance (URBMI) or the New Rural Cooperative Medical Scheme (NRCMS) (p < 0.001), but the gap has narrowed since health reform began in 2009. Both the outpatient and inpatient reimbursement amounts have increased through the URBMI and NRCMS. Illness severity, higher institutional level, and inpatient service were associated with significant increases in the amount of reimbursement received across the three survey waves. The health reform improved benefits covered by the URBMI and NRCMS, but gaps with the UEBMI still exist. The government should consider more the release of health benefits and how to lead toward healthcare equity.

In Search of the “Authentic” Universalism in Latin American Healthcare: A Comparison of Policy Architectures and Outputs in Chile and Mexico

The article analyses progress towards universal healthcare in Latin America by comparing the cases of Chile, where coverage was expanded and new benefits were added under a dual public-private model, and Mexico, where a voluntary public insurance programme was layered along existing social insurance schemes. The analysis adopts the framework of policy architectures. Both cases register significant equity gaps and segmentation of the population. Still, the Chilean system achieves higher coverage and generosity due to the unification of the public sector. In Mexico, the low quality of public schemes pushes families into unregulated private providers, triggering a process of implicit commodification.

Changing the healthcare financing paradigm: Domestic actors and international organizations in the agenda setting for diffusion of social health insurance in post‐communist Central and Eastern Europe

AbstractThis study elucidates the role of international organizations and domestic actors in post‐communist healthcare reforms aiming at a paradigmatic shift in healthcare financing and the introduction of social health insurance in Albania, Latvia and Poland. It inductively derives a causal mechanism behind the reform processes from these case studies. We demonstrate that the agenda setting for changing the healthcare financing paradigm was domestically driven and underpinned by the “nothing like the old regime” causal mechanism. In the context of post‐communist transition in Central and Eastern Europe this mechanism translated into an “anti‐communist backlash”. The backlash defined the domestic actors' perception of social health insurance as the only acceptable policy option because of its dissimilarity to the previous healthcare financing paradigm, and led to the rejection of World Bank suggestions to retain tax‐based healthcare financing in Poland and Albania. Doctors as policy entrepreneurs played the key role in agenda setting. Pre‐communist experience with social health insurance schemes and transnational cooperation with German and French experts and doctors served as sources of internal and external validation for the new paradigm.

Government Employees of Bangladesh and their Willingness to Pay for Social Health Insurance

Determining the health insurance premium is the most important aspect in providing social health insurance. In measuring the rate, it is needed to calculate the cost of providing the service. One possible methodological tool of calculating the cost is the contingent valuation method for the evaluation of the consumers’ capacity and their willingness to pay for the services. This study applied a Logit model, having binary depended variable with follow up dichotomous choice at different premium levels, to estimate the factors associated to joining the social health insurance scheme. The study found that 80.1 percent of the government employees of Bangladesh wants to pay on average 6.69 percent of their basic salary as social health insurance premium. The result shows that younger peoples are less willing to pay while older people are more willing to pay for social health insurance. The study also revealed that the area of residence and no of visit to doctor play a key role in determining the willingness to pay. This study should help the policymakers to formulate and implement the social health insurance scheme in Bangladesh.

Health care utilization for patients with stroke: a 3-year cross-sectional study of China\u2019s two urban health insurance schemes across four cities

BackgroundStroke is a devastating disease and a major cause of death and disability in China. While existing studies focused mainly on differences in stroke patients’ health care utilization by insurance type, this study assesses whether health utilization and medical costs differed by insurance type across four cities in China.MethodsA 5% random sample from the 2014–2016 China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) claims data were collected across four cities, Beijing, Shanghai, Tianjin, and Chongqing. Descriptive statistics and ordinary least squares regression were employed to analyze the data.ResultsWe found that differences in healthcare utilization and inpatient and outpatient medical expenses varied more by city-specific insurance type than they did between the UEBMI and URBMI schemes. For example, the median UEBMI medical outpatient costs in Beijing (RMB500.2) were significantly higher than UEBMI patients in Shanghai (RMB260.8), Tianjin (RMB240.8), and Chongqing (RMB293.0), and Beijing URBMI patients had significantly higher outpatient medical costs (RMB356.9) than URBMI patients in Shanghai (RMB233.4) and Chongqing (RMB211.0), which were significantly higher than Tianjin (RMB156.2). Patients in Chongqing had 66.4% (95% CI: − 0.672, − 0.649) fewer outpatient visits, 13.0% (95% CI: − 0.144, − 0.115) fewer inpatient visits, and 34.2% (95% CI: − 0.366, − 0.318) shorter length of stay than patients in Beijing. The divergence of average length of stay and out-of-pocket (OOP) expenses by insurance type was also greater between cities than the UEMBI-URBMI mean difference.ConclusionsSignificant city-specific differences in stroke patients’ healthcare utilization and medical costs reflected inequalities in health care access. The fragmented social health insurance schemes in China should be consolidated to provide patients in different cities equal financial protection and benefit packages and to improve the equity of stroke patient access to health care.

Population Characteristics and Their Implications on the Benefit Basket of National Social Health Insurance Scheme in Sierra Leone: A Prospective View

Background. The government of Sierra Leone introduced social health insurance (SHI) scheme to provide universal health coverage to people. This study was carried out to assess the population characteristics and their implications on the benefit basket of the proposed national health insurance scheme. Methods. A cross-sectional study design was employed in six selected districts in Sierra Leone. Quantitative data were collected for this study through the use of semistructured questionnaires with a sample of 1,185 respondents. Data were analysed using descriptive and inferential statistics. Statistical analysis was run at 5% significant level using Stata 14.0 software. Results. The study found that most (83.54%) of the respondents affirmed that children below 18 years should be excluded from premium payments and as high as 71.65% also stated that pregnant women should be excluded as well. The majority, 63.69%, of the respondents want lactating mothers to be excluded from premium payments. Also, 79.87% of respondents wanted mentally challenged persons not to pay premium, while a significant proportion (84.26%) of respondents further affirmed that the aged (above 70 yrs) should also be excluded from premium payment. Most household heads (89.71%) preferred the accreditation of public health facilities. Regarding the level at which healthcare services should be covered by the scheme, 61.45% preferred the primary care services, 89% mentioned secondary care services, and 98.93% affirmed the provision of tertiary care under the scheme. As for the type of care that should be covered by the scheme, 98.66% and 99.73% affirmed outpatient and inpatient care, respectively. Conclusion. From the findings on population characteristics and their implications on the benefit basket for the proposed nation social health in Sierra Leone, most of the household heads want exemptions from paying premium for a section of the population. This provides a clear insight for policy makers into the formulation of the benefit basket.

Employers’ Mutuals and Accident Insurance Scheme in Spain: From Rejection to Control and Collaboration (1966–1990)

This article discusses the role of employers and their organizations in promoting or hindering social insurance schemes and, ultimately, the welfare state. Unlike most studies that center on countries in periods of democracy, this research focuses on the role of employers, and specifically employers’ mutuals, in the development of the industrial accident scheme during the Franco dictatorship in Spain. The institutional elimination of the class struggle, by repressing the working class and prohibiting class-based unions, led to an evolution of the industrial accident scheme and employers’ liabilities that revolved around the interrelationship between employers and the state. While employers tried to keep control of the management and low cost of the insurance, the state maintained significant bureaucratic intervention and increased auditing and control. The democratic period that began in 1977 prolonged the structure fostered during the Franco regime and enhanced the power of the mutuals in managing this insurance.