Dear Isabel, dear all
I follow this discussion with great interest, and wish to express my total agreement with Isabel Ortiz, while adding a note of concern on the World Bank from my field of work- health.
She is absolutely right to demand that we look at the global picture.
In the debate between universalism versus targeting, we should remember that the European models of social protection were 'universal' not in the banal sens that it included 'all persons' (the sense that the Bank tends to give to the word 'universal'), but in the sens that each contributes according to his means and receives according to his needs - and therefore even the well to do have an interest in the system. It is a system of solidarity between employed and unemployed, the young and the old, the rich and the poor. Interestingly, the country with the highest rate of economic growth in 2011, China, adopted the French tripartite system. That is the reason the large textile multinationals are moving out of China towards Bangladesh and other countries with least labor regulations they - the companies- don't have to pay into a system of social protection for their employees but they do in China today.
Unfortunately, in France, our successive governments have been constantly decreasing corporate contributions into the system over the years, which is a disguised way to decrease real wages and a dangerous slope towards the dismantling of the national system of social protection.
As members of civil society, some of us have participated in several WHO-World Bank-Governments meetings in which UHC (Universal Health Coverage) was the topic in 2012-13. We heard and saw a majority of governments speak against 'targeting', several rich, poor and emerging country governments did so, only to hear the Bank representative give a summary of the discussion saying that 'targeting' was a good option!! Similarly, Sri Lanka, or Thailand and others offer to help desiring governments set up national universal systems of social protection as well as functioning primary, secondary and tertiary systems of health delivery, (all part of UHC) yet the World Bank representative and meeting chair sums up the discussion saying that providing vouchers for the poor to 'buy in' health services (ie from either public or private suppliers) is a good option!
Today the Bank appears split on the issue, and true, there are some progressive elements new in health who, at least, are open minded, when it comes to UHC. But the world wide trends are more in the direction of systems of financial insurance on the private model. And, as is the case according to my Indian friends (PHM India), it can mean public State money to finance vouchers for the poor to buy from private providers!.
Then, many contributors speak of 'costs' and it is important to bear in mind that the costs to one stakeholder may be the benefits to another!
Reducing the 'costs' to the national government may not be a rational objective if it means that government will have more 'money' to repay its foreign debt (the IMF policy of SAP for years, no?). If a government is sovereign in terms of its currency, then spending on social security is the best investment possible with very high returns.
The terrible Greek experiment shows that reducing State expenditures into social security type of expenses to, allegedly, attain a certain debt to GDP ratio, not only does not achieve that ratio, (no change in 5 years) but drives a large size of the population into absolute poverty!
Tomorrow, Aid agencies / Bank could propose to the very poor Greek populations, targeted safety net programs.
Today 'health' is attractive field of development studies because it is also seen by the private sector as the most profit making industry (right after armaments). If we have public financing of comprehensive social protection system with a concomitant development of public services (as was the case in the UK, France after the war- I only speak of what I know), the money is profitably invested into a system whose outcome is a stronger workforce, a society tending towards increasing solidarity and decreasing inequality - I'm not saying it was perfect, but it tended in the right direction.
For an excellent overview of health economics I recommend the book of Julian Tudor Hart, The Political Economy of Health Care: a clinical perspective. 2006. (Bristol Policy Press)
So, with Thandika Mkandawire, we should be very weary of targeting, and the fact that some programs are better in 'means testing' than others, does not make the system any good.
The Bank also use "equity" as an argument against the limited coverage of small social protection systems in Sub Saharan Africa (which I know well) - They argue that limited social protection for public employees, for example, are 'inequitable' because they don't cover the informal or very poor sectors. So the Bank argues for the dismantling of these limited schemes in favor of targeting. In fact, scientifically, the argument is absolute nonsense, like saying that proper water for some part of the population is not 'equitable' because it is not feasible to have clean water for everyone overnight!
Some countries are able to resist and try instead to provide for an extension over time of these limited social protection schemes to larger and larger segments of society.
Concerned parties are organizing a world conference in Quito later this year, if all goes well (it would be a follow up to the Brazilia inter-ministerial conference of December 2010, a conference entitled: "Towards universal systems of social security" a great initiative bringing together Ministers of health, trade unions, NGOs and 'experts' (such as UNRISD's) wishing to develop these type of systems.
By dividing the poor or very poor from the rest of society, the targeting programs generally supported and promoted by the World Bank, the regional development banks and a large array of think tanks and development agencies, further contribute to the terrible drive of economic liberalism - financial power globally- and in the name of 'development aid', these programs effectively prevent national development and further contribute to shrink the State and its national attributes. In fact, targeting can, in its worse form, be seen as a tool to undermine democracy!
If there is no real economic development in LMIC, then the support for 'the very poor' is dependent on foreign aid, and contributes towards what Erik Reinert called "Welfare colonialism", (his assessment of the MDG, and Reinert is certainly not a fringe radical) and if we take an average country among the poor, for example, Senegal, 80% of the population is poor, so what does it mean to engage in research to identify 'The Poor'?
Garance Upham
NGO Forum for Health, Geneva
I follow this discussion with great interest, and wish to express my total agreement with Isabel Ortiz, while adding a note of concern on the World Bank from my field of work- health.
She is absolutely right to demand that we look at the global picture.
In the debate between universalism versus targeting, we should remember that the European models of social protection were 'universal' not in the banal sens that it included 'all persons' (the sense that the Bank tends to give to the word 'universal'), but in the sens that each contributes according to his means and receives according to his needs - and therefore even the well to do have an interest in the system. It is a system of solidarity between employed and unemployed, the young and the old, the rich and the poor. Interestingly, the country with the highest rate of economic growth in 2011, China, adopted the French tripartite system. That is the reason the large textile multinationals are moving out of China towards Bangladesh and other countries with least labor regulations they - the companies- don't have to pay into a system of social protection for their employees but they do in China today.
Unfortunately, in France, our successive governments have been constantly decreasing corporate contributions into the system over the years, which is a disguised way to decrease real wages and a dangerous slope towards the dismantling of the national system of social protection.
As members of civil society, some of us have participated in several WHO-World Bank-Governments meetings in which UHC (Universal Health Coverage) was the topic in 2012-13. We heard and saw a majority of governments speak against 'targeting', several rich, poor and emerging country governments did so, only to hear the Bank representative give a summary of the discussion saying that 'targeting' was a good option!! Similarly, Sri Lanka, or Thailand and others offer to help desiring governments set up national universal systems of social protection as well as functioning primary, secondary and tertiary systems of health delivery, (all part of UHC) yet the World Bank representative and meeting chair sums up the discussion saying that providing vouchers for the poor to 'buy in' health services (ie from either public or private suppliers) is a good option!
Today the Bank appears split on the issue, and true, there are some progressive elements new in health who, at least, are open minded, when it comes to UHC. But the world wide trends are more in the direction of systems of financial insurance on the private model. And, as is the case according to my Indian friends (PHM India), it can mean public State money to finance vouchers for the poor to buy from private providers!.
Then, many contributors speak of 'costs' and it is important to bear in mind that the costs to one stakeholder may be the benefits to another!
Reducing the 'costs' to the national government may not be a rational objective if it means that government will have more 'money' to repay its foreign debt (the IMF policy of SAP for years, no?). If a government is sovereign in terms of its currency, then spending on social security is the best investment possible with very high returns.
The terrible Greek experiment shows that reducing State expenditures into social security type of expenses to, allegedly, attain a certain debt to GDP ratio, not only does not achieve that ratio, (no change in 5 years) but drives a large size of the population into absolute poverty!
Tomorrow, Aid agencies / Bank could propose to the very poor Greek populations, targeted safety net programs.
Today 'health' is attractive field of development studies because it is also seen by the private sector as the most profit making industry (right after armaments). If we have public financing of comprehensive social protection system with a concomitant development of public services (as was the case in the UK, France after the war- I only speak of what I know), the money is profitably invested into a system whose outcome is a stronger workforce, a society tending towards increasing solidarity and decreasing inequality - I'm not saying it was perfect, but it tended in the right direction.
For an excellent overview of health economics I recommend the book of Julian Tudor Hart, The Political Economy of Health Care: a clinical perspective. 2006. (Bristol Policy Press)
So, with Thandika Mkandawire, we should be very weary of targeting, and the fact that some programs are better in 'means testing' than others, does not make the system any good.
The Bank also use "equity" as an argument against the limited coverage of small social protection systems in Sub Saharan Africa (which I know well) - They argue that limited social protection for public employees, for example, are 'inequitable' because they don't cover the informal or very poor sectors. So the Bank argues for the dismantling of these limited schemes in favor of targeting. In fact, scientifically, the argument is absolute nonsense, like saying that proper water for some part of the population is not 'equitable' because it is not feasible to have clean water for everyone overnight!
Some countries are able to resist and try instead to provide for an extension over time of these limited social protection schemes to larger and larger segments of society.
Concerned parties are organizing a world conference in Quito later this year, if all goes well (it would be a follow up to the Brazilia inter-ministerial conference of December 2010, a conference entitled: "Towards universal systems of social security" a great initiative bringing together Ministers of health, trade unions, NGOs and 'experts' (such as UNRISD's) wishing to develop these type of systems.
By dividing the poor or very poor from the rest of society, the targeting programs generally supported and promoted by the World Bank, the regional development banks and a large array of think tanks and development agencies, further contribute to the terrible drive of economic liberalism - financial power globally- and in the name of 'development aid', these programs effectively prevent national development and further contribute to shrink the State and its national attributes. In fact, targeting can, in its worse form, be seen as a tool to undermine democracy!
If there is no real economic development in LMIC, then the support for 'the very poor' is dependent on foreign aid, and contributes towards what Erik Reinert called "Welfare colonialism", (his assessment of the MDG, and Reinert is certainly not a fringe radical) and if we take an average country among the poor, for example, Senegal, 80% of the population is poor, so what does it mean to engage in research to identify 'The Poor'?
Garance Upham
NGO Forum for Health, Geneva
