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Mapping Solutions to Universal Health Coverage Inclusive of the Informal Workforce

During the workshop presentations and discussions on how to meet the health and safety needs of informal workers in developing countries, two reoccurring themes arose: the potential of global employers to provide coverage to informal sector workers, and the need to understand and map the size, characteristics, and needs of the informal sector workers. This chapter includes presentations and discussions on these themes.

ROLES OF GLOBAL EMPLOYERS IN UNIVERSAL HEALTH COVERAGE

Lorna Friedman, Mercer

Global corporate employers are answerable to their shareholders, Lorna Friedman from Mercer noted, and thus any role they serve in promoting universal health care (UHC) must have a value component that is recognized by the shareholders. Friedman’s own perspective from working with corporate clients is that employers have multiple potential roles to play in establishing UHC: for instance, extending coverage through existing formal schemes for their own populations for employees; addressing management efficiency issues in the delivery system; developing funding mechanisms with innovative components; and importantly addressing the issues of stigma in health care. She added that global corporations have an opportunity to address UHC by working through

an integrated sustainability model that integrates corporate resources in the areas of occupational health, benefits coverage, and human capital and talent.

Friedman said that a major issue for global corporations is acquisition and retention of human capital and talent. There is often poor alignment between where talent is needed and where it is located geographically. In particular, it is increasingly the case that the employees of U.S.-based corporations are predominantly outside the United States, so these corporations are invested in competing for talent outside the United States and the quality of health available to the labor pool is important.

Concerning why global corporations have an interest in the health and wellness for their workforces, Friedman presented several key factors: employee engagement, consumer engagement, reputation, medical and disability costs, and safety (see Figure 3-1). Furthermore, the health and wellness of populations within countries has been recognized by the World Economic Forum as one of the four pillars that undergird economic prosperity.

The corporate sector is investing in ways to better meet the health needs of its employees globally, Friedman said. She added that offering supplemental health insurance is an increasingly popular response to public systems that are increasingly under duress and to employees who

are looking for options that will meet their needs. However, progressive global employers are realizing that supplemental insurance is not always in sync with either corporate philosophies or employee needs. These progressive employers see a role in mitigating stigma and promoting access within the countries where they operate. Through such actions, they are influencing local market norms in regard to both the expansion and the elements of coverage.

THE ROLE OF EMPLOYERS IN COVERAGE AND OCCUPATIONAL HEALTH: A PERSPECTIVE FROM THE U.S. EXPERIENCE

Marleece Barber, Lockheed Martin

From her perspective as an occupational physician within the corporate sector, Marleece Barber from Lockheed Martin shared her thoughts on the role of the corporate sector in universal health coverage and on where opportunities exist for potential partnerships with public entities. In examining solutions for providing universal health coverage to the global and informal workforce, Barber suggested that there are lessons to be learned from experiences in the United States. There are examples of employer-sponsored health benefits that date back to the colonial era, but it was not until the early 1900s that the concept of a partnership between employers, workers, and government emerged. Employer-sponsored benefits offer citizens a safety net that can protect workers and their families from catastrophic losses due to unforeseen illnesses. Businesses need a healthy, robust, energized, and committed workforce to be able to develop innovative products and deliver services. Providing health coverage is a mechanism that directly addresses productivity: Healthy workers are able to perform meaningful tasks and to perform at their peak, which allows companies to be competitive in the marketplace. Government is also heavily invested in the model of employer-based coverage because a nation needs a workforce that is economically stable and healthy. Thus, governments contribute to this model by offering tax incentives to employers who offer benefits to their employees.

Given escalating health care costs in the United States and the changes that will occur as a result of health care reform, Barber suggested that employers are considering the impact on how they will provide health care coverage to their workers and their families. Employers are also looking to their employees to share more of the costs of coverage and to take a more active role in their health maintenance. Recognizing that productivity is essential in order for businesses to thrive, most employers remain committed to supporting their employees’ health for the good of the employer and employee.

Beyond profitability and workforce productivity, Barber stressed, most corporations want to be good corporate citizens and are interested in developing partnerships with other groups that are in sync with their core values. She suggested that, given this context on the health care climate and the motivations of global corporations, the time has never been better to start advancing smart collaborative approaches to addressing health issues that are affecting workers and communities around the world. Barber offered some examples of areas where she believes there is progress emerging and pointed to some opportunities for advancing these efforts through partnerships.

Within occupational health, Barber said, there is a movement toward a focus on health as an outcome and toward a public health approach focused on determinants of health. From this movement, promising population health strategies are emerging and changing the way that companies think about where they want to make investments in their workforce and their communities. For example, companies are offering free preventive care to their workers, and some are erecting medical clinics and hospitals in their communities to extend the care to family members and beyond.

Employers are developing health behavior change strategies and, by providing education, tools and ongoing support, employees and their families have an opportunity to be more successful in reaching their health goals. Barber suggested that this is an area that is ripe for collaboration among community advocates, businesses, and local public and private entities. For example, such collaborations could sponsor events in which workers and their families come together to participate in health-related activities and to receive information or services related to preventive care. There also are opportunities for corporations to invest in improving the social and environmental conditions of communities in ways that promote health and safety—for example, building safer roads and erecting safe recreational spaces.

EFFORTS TO MAP THE INFORMAL WORKFORCE AND HEALTH COVERAGE IN LATIN AMERICA

Orielle Solar, Latin American Social Sciences Institute, FLACSO Chile¹

Understanding the size and characteristics of populations of informal workers as well as their current access to services can help stakeholders target the workers’ health and safety needs. Orielle Solar from the

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¹ The speaker acknowledges the contributions of the additional members of the research team: Pamela Bernales, Amalia Valdes, Andrew Cardenas, Simon Ramirez, Maria Jose Gonzales, Alejandra Vives, Denise Lama, Rodolfo Tagle, and Vicente Alamos.

FLACSO Chile presented preliminary findings from the Project for Health Inequalities and Access to Social Security of Informal Workers in Latin America, Asia, and Africa. Supported by The Rockefeller Foundation, this ongoing research program is mapping the size of and trends concerning informal workers in Latin America; the heterogeneity of informal workers; their working conditions, access to health service, and barriers they encounter; and existing interventions to address their needs.

To provide context for analyzing and comparing interventions and results across countries, Solar’s research group developed a taxonomy based on a set of indicators that divides countries into four groups (see Figure 3-2). Group 1 is characterized by low informal sector size and high health system coverage. Group 2 has medium-low informal sector size and medium-high health system coverage. Group 3 has a medium-high informal sector and medium-low health system coverage. Group 4 has a high informal sector and low health system coverage.

Using the taxonomy, Solar’s research group has mapped trends of informal employment over time across the Latin American countries included in their study (see Figure 3-3). Solar also commented on the

heterogeneity of the informal workforce within and across countries and how this affects the types of interventions that are needed. Income levels, age, employment status, and gender are all variables that affect the needs and types of interventions for the target population groups in the informal workforce.

Solar’s research group has developed a model to understand the barriers to access that are associated with employment conditions and as well as those associated with the organization of the health system (see Figure 3-4).

The next step of their research program included collecting primary information through qualitative studies on the informal workers’ perceptions of access and barriers to access to health care, employment conditions, and working conditions and health status; and building indicators of informal work and health that are relevant, robust, and comparable between countries. The indicators were developed through a secondary data analysis of each survey, recognized key survey questions, potential indicators, and proxies; and per country information on the magnitude of informal work, the health of informal workers, and their access to social protection and health care. The final product was a minimum set of core indicators and questions for surveillance and monitoring. Solar’s team is in the process of mapping interventions that are available to informal workers. Through a preliminary review of the gray literature, key informants, and a review of case studies, the research team has iden-

tified 361 interventions, 54 percent of which are focused specifically on informal workers. Most of them focus on expanding social protection (23.7 percent), followed by formalizing informal jobs (20.1 percent), and expanding health care coverage (17.1 percent). The majority of the interventions are programs and projects; very few are legislative interventions. Most interventions were initiated by the central and local government (60 percent) with workers’ organizations accounting for the second-highest number (10 percent). Solar said that the majority are not implemented with a specific focus on informal workers and they approach informality from a general and generic perspective. In the case of interventions that are directed specifically to informal workers, 21 percent of them were focused on own account workers and 17 percent on depend informal workers.

Solar said that the challenge for UHC for informal workers is that on one side there are barriers associated with employment conditions, while on the other side there are barriers associated with the organization of the health system. To address the barriers on both the demand and supply sides, Solar suggested it may be necessary to extend the labor rights of informal workers and to provide health care options that are not conditional on employment status and recognized the heterogeneity of informal workers.

DISCUSSION

During the discussion, several workshop participants offered comments on the role of employers in developing solutions for UHC for informal sector workers. Derek Yach from The Vitality Institute suggested five reasons why global employers should be investing in the health and well-being of informal sectors workers:

• Investments in the corporate supply chain: The health and well-being of informal workers in the supply chain affects productivity just as the health and well-being of formal employees does. Additionally, corporations are beginning to be evaluated based on the treatment of workers in their supply chains.
• Investments in future employees: Informal workers may be future employees of global corporations, and investments in their health are investments in the future workforce productivity.
• Investments in the consumer base: For many corporations, informal workers are the consumer base. Investing in their health can improve their stability and purchasing power.
• Investments in reverse innovation: The best opportunities for reverse innovation occur where the price point is extremely low and where developing new products and services can be done in the most cost efficient way. Many of these reverse innovations are springing up from the informal sector.
• Investment in corporate reputation: Many companies can be persuaded to invest in the health of their local communities if doing so will have positive impacts on their reputation or if inaction or harm to the health of the community will negatively affect the corporate reputation.

Marty Chen from Harvard University and Women in Informal Employment: Globalizing and Organizing added to Yach’s list the observation that informal workers are also part of the distribution chain, whether they are selling newspapers, soft drinks, or other products. Thus, corporations should be investing not only in informal workers who are part of the production chain and consumer base but also in informal workers who are part of the distribution chain.

Victor Dzau of the National Academy of Medicine said that employers’ increasing engagement in health is encouraging, but developing the right tools and being able to measure outcomes will also be important. Barber said that occupational health professionals and corporations have long admired the success of their safety peers. Often occupational health has struggled to have the same level of support that the safety community

has had. She suggested that perhaps what is lacking is transparency and the sharing of information on the health status of the workforce. Yach added that there is currently an initiative under way to develop corporate health metrics as part of integrated financial and environmental reports and to build that into the reporting structures of the sustainability index, the global reporting initiative.

In elaborating on the opportunities for employers to engage in UHC, Paurvi Bhatt suggested that one area ripe for partnership is providing technical assistance to UHC efforts through the application of various tools that corporations have developed, such as insurance models and wellness packages.

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