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 Labour Organization (ILO) and partner United Nations (UN) agencies. Such studies have been carried out in a number of West and Central African countries by the ILO and United Nations High Commissioner for Refugees (UNHCR) and are now being scaled up under the Partnership for improving prospects for host communities and forcibly displaced persons (PROSPECTS).
The PROSPECTS partnership focuses on improving access to jobs, education and social protection for refugees and host communities alike.
The mapping of the current social protection system in Ethiopia, including social health protection, is conducted with the objective of identifying opportunities and possible activities to be undertaken as part of the ILO PROSPECTS social protection component, in line with the objectives of the project, output and timeline within the current context. The mapping exercise employed qualitative approaches.
The social protection mapping exercise has observed that Ethiopia has a fundamental policy and legislative framework strong enough to promote social protection programmes effectively. The country has a national social protection policy and strategy as well as different sector-specific strategies such as the Urban Food Security and Job Creation strategy.
Although it is at an early stage, the system for contributory and non-contributory social protection programmes is institutionalized to some degree in the country. The two main contributory social protection schemes are the public servants’ social security and the private organization employees’ social security schemes.
The public servants’ social security currently covers 2.5 million public workers, while the private organizations employees’ scheme has enrolled 1.67 million members out of a total of 203,458 private enterprises (3.6 per cent of the population). The expansion of private organization social security has a potential to embrace refugees, as their economic integration is ensured as part of the Comprehensive Refugee Response Framework (CRRF) and the additional pledges the country 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 mandates provided to it by Proclamation No. 191/2010. The agency administers two contributory health insurance schemes, which are the Social Health Insurance (SHI) for public service employees, government development enterprises, private organizations, non-profitmaking organizations and pensioners, and the Community-based Health Insurance (CBHI) scheme, mainly designed for small-scale, informal sector workers and the general public at large.
Although the SHI has a fully-fledged legislative framework and its implementation should be straightforward, it is not operational at present because of the challenges it encountered when first being put into practice. On the other hand, the CBHI scheme, which started as pilot in 13 woredas (districts) and four regions back in 2010–2014, has gathered strength and has a significant number of members. It currently covers about 70 per cent of all the woredas in the country, with more than 22 million members in both rural and urban areas.
The EHIA has developed a second Health Insurance Strategic Plan (HISP) envisioning to provide Universal Health Coverage (UHC) for all by 2030. Over the coming five years (2020–2025), the second HISP aims to reach 80 per cent of the population in the informal sector and 100 per cent of public servants in the formal sector (through SHI) with health insurance coverage.
The three large social protection programmes 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 for more than 8 million beneficiaries. The UPSNP is implemented in 11 regional capital cities, providing transfer to 604,000 different categories of beneficiaries. HFA2 is triggered in the country when natural and man-made disaster occurs; the number of beneficiaries is determined based on seasonal assessments conducted every six months.
While the RPSNP has no interventions that target refugees, the new design of the Urban Productive Safety Net and Job Project (UPSNJP), which is financed by the World Bank with a contribution from the government, has made a paradigm shift in incorporating a component for the integration of refugees and host communities in selected localities. The project aims at including refugees and host communities living in the proximity of selected cities in a joint public works and livelihoods programme. It is expected to foster social cohesion and sustainable integration of host and refugee communities through shared activities and communication.
The Agency for Refugee and Returnee Affairs (ARRA) has developed a five-year Country Refugee Response Plan (2020–2021) which vows to go beyond mere care and maintenance and combines wider support to refugees and host communities.
Three different proclamations are currently in draft stages, and another proclamation is under review.
These are: a) proclamations to establish a national social protection council; b) a proclamation for the establishment of a national social protection fund; c) a proclamation for the promotion of communitybased health insurance. Additionally, the EHIA has identified key concerns and issues to be considered in amending the SHI for formal sector employees, all of which are currently awaiting approval and subsequent actions from the Council of Ministers.
Based on the above findings, some of the opportunities that are available to strengthen the social protection system, the programmes in general and the social health protection in particular, are indicated below.
► Provide advocacy and advisory support for the Ministry of Labour and Social Affairs (MoLSA) to pursue its ongoing effort to establish and institutionalize a national social protection council, which provides strategic guidance and oversight to all social protection programmes and strategies in the country. By strengthening the social protection council, it is likely to ensure that issues related to the inclusion of refugees in the existing system can be better advocated and ensured.
► Support the MoLSA and EHIA to develop appropriate implementation guidelines and instruments to translate the legislative framework into all-inclusive, robust social protection activities and interventions.
By doing so, it is possible to ensure that law and regulations are better enforced and implemented.
► Support the establishment of a social protection fund which could have a far-reaching impact on paving a way to financing pro-poor social protection schemes such as the CBHI, which is the cornerstone of the 2030 UHC goal of the country to enhance health insurance access outreach for refugees and host communities.
► Support the Urban Job Creation and Food Security Agency (JOBFSA) to consider enrolling refugees and host communities in CBHI, as a complementary service, along with the public works, could also address the economic and health service integration and inclusion of refugees and host communities.
The agencies implementing this component could be given technical support to consider outreach of refugees to CBHI in a form of Memorandum of Understanding.
► Support the ARRA to effectively implement Refugee Proclamation No. 1110/2019 and the five-year Country Refugee Response Plan, which provides an array of opportunities for the economic and social integration of refugees with host communities.