The mapping of the national social protection system in Ethiopia, including social health insurance, is carried out as part of a joint technical study by the International Labor Organization (ILO) and United Nations (UN) partner agencies . Such studies have been carried out in a number of West and Central African countries by the ILO and the Office of the United Nations High Commissioner for Refugees (UNHCR) and are currently being intensified within the framework of the Partnership for improving the prospects of host communities and forcibly displaced people (PROSPECTS). .
The PROSPECTS partnership focuses on improving access to employment, education and social protection for refugees and host communities.
The mapping of the current social protection system in Ethiopia, including social health protection, is carried out with the aim of identifying opportunities and possible activities to be undertaken under the social protection component of ILO PERSPECTIVES, in line with project objectives, products and timeline in the current context. The mapping exercise used qualitative approaches.
The social protection mapping exercise observed that Ethiopia has a strong enough fundamental policy and legislative framework to promote social protection programs effectively. The country has a national social protection policy and strategy as well as different sectoral strategies such as the urban food security and job creation strategy.
Although still in its infancy, the system of contributory and non-contributory social protection programs is institutionalized to some extent in the country. The two main contributory social protection schemes are the social security scheme for civil servants and the social security scheme for employees of private organisations.
The social security for civil servants currently covers 2.5 million public workers, while the scheme for employees of private organizations has 1.67 million members out of a total of 203,458 private companies (3.6 per cent of the population). The expansion of social security from private organizations has the potential to embrace refugees, as their economic integration is ensured under the Comprehensive Refugee Response Framework (CRRF) and additional commitments the country has made during the first Global Refugee Forum in December 2019.
In terms of institutional structure, the Ethiopian Health Insurance Agency (EHIA) promotes social health insurance in the country based on the mandates given to it by Proclamation No. 191/2010. The agency operates two contributory health insurance schemes, which are Social Health Insurance (SHI) for civil servants, public development enterprises, private organizations, non-profit organizations and pensioners, and the Community Health Insurance Scheme (CBHI), primarily designed for small informal sector workers and the general public.
Although the SHI has a fully-fledged legislative framework and its implementation should be simple, it is not operational at present due to the difficulties encountered when it was first put into practice. On the other hand, the CBHI programme, which started as a pilot project in 13 woredas (districts) and four regions in 2010-2014, has grown in scale and has a significant number of members. It currently covers around 70% of all woredas in the country, with over 22 million members in rural and urban areas.
EHIA has developed a second Health Insurance Strategic Plan (HISP) envisioning to provide Universal Health Coverage (UHC) for all by 2030. Over the next five years (2020-2025), the second HISP aims to reaching 80% of the population. in the informal sector and 100 percent of civil servants in the formal sector (via SHI) with health insurance coverage.
The three major social protection programs implemented in rural and urban areas are the Rural Productive Safety Net Project (RPSNP), Humanitarian Food Assistance (HFA) and the Urban Productive Safety Net Project (UPSNP). The RPSNP is implemented in rural areas of eight regional states providing services to over 8 million beneficiaries. The UPSNP is implemented in 11 regional capitals, ensuring a transfer to 604,000 different categories of beneficiaries. The HFA2 is triggered in the country when there is a natural or man-made disaster; the number of beneficiaries is determined on the basis of seasonal evaluations carried out every six months.
Although the RPSNP does not have interventions targeting refugees, the redesign of the Productive Safety Net and Urban Jobs Project (UPSNJP), which is funded by the World Bank with a government contribution, has paradigm shift by incorporating a component for the integration of refugees and host communities in selected localities. The project aims to include refugees and host communities living near selected towns in a joint public works and livelihoods programme. It should foster social cohesion and sustainable integration of host and refugee communities through shared activities and communication.
The Agency for Refugees and Returnees (ARRA) has developed a five-year refugee response plan (2020-2021) which commits to going beyond simple care and maintenance and combines broader support for refugees and host communities.
Three different proclamations are currently in draft form and one is under consideration.
These are: (a) proclamations establishing a national council for social protection; b) a proclamation for the creation of a national fund for social protection; (c) a proclamation for the promotion of community health insurance. In addition, the EHIA has identified key concerns and issues to be considered when amending the SHI for formal sector employees, all of which are currently awaiting approval and further action by the Council of Ministers.
Based on the findings above, some of the opportunities available to strengthen the social protection system, programs in general and social health protection in particular, are indicated below.
► Provide advocacy and advisory support to the Ministry of Labor and Social Affairs (MoLSA) to continue its efforts to establish and institutionalize a National Social Welfare Council, which provides strategic guidance and oversight to all social protection programs and strategies in the country. By strengthening the Social Welfare Council, it is likely that issues related to the inclusion of refugees in the existing system can be better advocated and ensured.
► Support MoLSA and EHIA to develop appropriate guidelines and implementation instruments to translate the legislative framework into inclusive and robust social protection activities and interventions.
By doing so, it is possible to ensure that the law and regulations are better applied and implemented.
► Support the creation of a social protection fund which could have a significant impact on the financing of pro-poor social protection schemes such as the CBHI, which is the cornerstone of the country’s UHC 2030 goal to improve health insurance access outreach services for refugees and host communities.
► Supporting the Urban Jobs and Food Security Agency (JOBFSA) to consider enrolling refugees and host communities in AMC, as a complementary service, along with public works, could also address the integration and inclusion of economic and health services of refugees and host communities .
Agencies implementing this component could receive technical support to consider sensitizing refugees on AMC in the form of a memorandum of understanding.
► Support ARRA to effectively implement Refugee Proclamation No. 1110/2019 and the Five-Year Refugee Response Plan, which provides a range of opportunities for the economic and social integration of refugees into communities reception.