SOCIAL Security for the poor, mainly workers of the informal economy, is squarely on the global agenda. The Social Security Campaign is soon to be launched in India by the International Labour Organisation. Meanwhile, the UPA government has developed its Common Minimum Programme (CMP) in which social security for the poor, especially the unorganized or informal sector, has been given priority and finds special mention: ‘...The UPA government is firmly committed to ensure the welfare and wellbeing of all workers, particularly those in the unorganized sector who constitute 93% of our workforce. Social security, health insurance and other schemes for such workers like weavers, handloom workers, fishermen and fisherwomen, toddy tappers, leather workers, plantation labour, beedi workers, etc. will be expanded.’

This recognition of the overwhelming need for social security for informal workers, at both the global and national levels, is a welcome step. The fact is that there are about 400 million citizens who constitute the working poor in our country, most of whom eke out a living in the informal economy. For the most part, and with the notable exception of workers covered by the Workers’ Welfare Fund of the labour department, informal workers remain unprotected.

In fact, there are numerous schemes for social security and social protection in India with rather uneven or limited implementation. Even after all these years of experience, we have not been able to develop appropriate mechanisms to ensure implementation of social security services and proper outreach and coverage for our poorest citizens, especially in the rural areas. There are, of course, numerous reasons for this gap between intent and actual practice on the ground which are by now fairly well-known. It is useful to point out that the need for proper implementation mechanisms and even how these may be achieved were outlined well before independence in several planning-related documents. One such is the Bhore Committee which focused on the need for public health in India and how this might be ensured. This landmark document is still so relevant in our current context.

In sum, we have some idea of what we need to do to ensure that social security reaches the poorest of Indians. What we struggle with is how we can do this in a country as vast, diverse and complex as ours. And, as always, the numbers – the sheer millions we are to reach – are daunting.

 

 

Our experience at SEWA points to the fact that social security can indeed be organized, but this must be done by the poor themselves and led by women. What we have learned over decades of organizing workers in our union, SEWA, is that services – whether health, childcare, housing or insurance – cannot be delivered by one set of people for another set. Rather, the poor, especially women, must organize and demand these services which can be jointly developed by them and the government and other partners.

It is women workers who must use, run and control their own services, and through their own membership-based organizations. These may be unions, cooperatives, self-help groups (SHGs) and their associations, mahila mandals, credit societies, mothers’ groups, youth clubs, community-based organizations and others. NGOs can help initiate, support and train local membership-based organizations for the task of developing and running their own social security organizations. These services should not be of the ‘one size fits all’, standardized model. Rather we should ‘let a hundred flowers bloom’, agreeing on some basic principles and non-negotiables but developing models and mechanisms suited to local conditions and realities.

Perhaps some examples from our own experience will be useful at this stage. Fourteen years back, SEWA-promoted its first health workers’ cooperative, Lok Swasthya Mandli. At the time, the cooperative department scoffed at the idea. How could such a cooperative be sustainable? What would we produce? We will produce services at people’s doorsteps, was the women’s reply. It took two years of convincing before we got our coveted registration certificate. Today Lok Swasthya is growing with 500 dais, health workers and public health professionals as its shareholders. With a turnover of over one crore rupees, it is a small but self-reliant effort, covering all its costs including a team of 50 full-time staff and 200 part-time health workers. It encouraged SEWA sisters in other districts to organize similar cooperatives, resulting in three others – still small but active in their own area.

 

 

Similarly, child care cooperatives, SHG associations, CBOs providing housing and infrastructure services and now an insurance unit attempting to develop itself into a cooperative have been registered. Initially promoted by SEWA, and still very much part of the SEWA family or movement, these are autonomous legal entities with democratically elected boards, each determining its own services, rules, outreach plans and budgets. SEWA, the union, provides support in terms of policy action, capacity-building and the collective strength needed to boost, bolster and protect their grassroots action. It also helps with the initial fund-raising and encourages both financial independence and self-reliance.

The common principles underlying our social security services are:

* These should be membership based, owned by women through shares and controlled by a women workers-led board of directors.

* They should be decentralized in terms of planning and implementation of services – i.e. doorstep approach to providing services.

* Services should be organized for self-reliance and for long-term sustainability – both financial and managerial (thus a lean administration and simple but cost-effective mechanisms are sought).

* Workers’ contributions in cash or kind are essential; we start with our own contributions, no matter how modest and then leverage them for government and other contributions.

* Following from the above, partnerships must be developed to reach much needed services to the poor; they alone cannot and should not bear the burden of providing social security.

* Social security services should be demand driven – i.e. based on workers’ needs and demands, a bottom-up approach.

* Health care, child care, insurance, shelter and infrastructure services, and pension are the core social security needs of informal women workers, and hence should be a starting point for comprehensive and integrated social security coverage.

* Organizing for social security at the grassroots level must be linked to policy action in favour of the poor, especially women and children.

* Organizing for social security must promote organizing of workers for their rights and be empowering.

Based on the above core principles, we have been working towards a comprehensive insurance coverage for informal workers run by themselves. We do not see this as an answer to the many social security needs of the poor, but as an important step forward in this direction.

 

 

Health insurance is the most urgently required of all insurance coverage for the poor. Women workers across the country, time and again, identify it as causing the maximum stress in their lives – i.e. sickness is the number one stressor. It also creates indebtedness and leads to decapitalisation. And among the poor sickness is a common event leading to expenditures ranging from Rs 300 per month in urban slums (Source: Study by SEWA’s Social Security Team) to Rs 800 per episode of illness (Source: SEWA Academy Research Team).

While some coverage for sickness, mainly hospitalization, is the most pressing need of the poor, it is also the most complex risk to cover. There are many reasons for this including their access to health care (i.e. if they have access at all both for geographical and economic reasons), the high cost of private health care which has a bearing on the viability of health insurance, and because the world over, health insurance is prone to fraud.

 

 

Small but significant experiences of health insurance for the poor, both in India and abroad, reveal that coverage is indeed possible if certain critical issues are taken into account. The most important is developing a mechanism of implementation, specially tailored to the reality of the poor and organized according to their convenience.

Another contentious issue is that most people, 80%, seek care with private providers. And the private health sector is unregulated especially in terms of standardizing regimens, fees and diagnostic tests. It is a growing sector and costs are escalating in a manner that is leading to greater indebtedness.

SEWA’s experience of insuring around 106,000 workers and their families over 14 years suggests that for health insurance to be viable, it has to be controlled and run by the users themselves, the very women who are the insured. Their organization negotiates fees, treatment regimens and so on with providers, both public and private. Providers who adopt poor quality of care or fraudulent practices are blacklisted. This has already led to providers improving the quality of their care and revising some of their prices. It has also resulted in the public health system gearing itself up to provide the care required, with the public charitable trust hospitals serving as a backup or alternative to the public and private-for-profit health providers.

Finally, our experience with health insurance has encouraged us to develop ‘cashless’ systems with providers, both public and private, enabling women and their families to seek quality care of their choice without having to immediately pay upfront. This new system will soon be tested out in eight talukas in Gujarat, as well as two working class neighbourhoods of Ahmedabad city.

The above experiences point to the need to develop appropriate mechanisms to reach health insurance to the poorest. But first let us see what package we can suggest, based on affordability for both workers and the government.

We see a need for a comprehensive life and non-life insurance package, advisable to ensure a holistic approach to risks and shocks faced by the poor, and an overall viability of insurance for the poor. Further, maternity benefits of Rs 500 per pregnancy and for all pregnancies must be provided to all poor women. No extra premium is required; it is built into the package outlined below. Finally, the health coverage should include hospitalization for complications during pregnancy. Caesarian section, however, may not be covered at this stage.

 

 

Despite the many insurance schemes developed by both government and private insurers, their out-reach has remained very limited. The most important reason is that appropriate mechanisms for both premium collection and claims servicing have not been developed.

The crucial issue is one of trust – no one will part with their hard-earned money as premium unless they are sure that this amount is in safe hands and will deliver the service that they so desperately need. Even if premium is not collected, as in many government insurance schemes, the poor face difficulty in navigating the various procedures and providing the documents required. Even after all the documents have been carefully collected, the claims payments may or may not be honoured. Often it is difficult for them to spare the time and money to comply with insurers’ requirements. And frequent follow-up visits and leakages remain a problem.

For all these reasons, we suggest partnerships with local organizations: unions, self-help group associations, mahila mandals, cooperatives, farmers’ or youth clubs and NGOs to ensure that the health insurance service actually reaches the poor, and at their doorstep.

 

 

The UPA government should consider pilot-testing this new doorstep approach to health insurance with a few organizations and select districts or states in the country. Criteria will have to be developed to ensure the reliability and accountability of partners. These could be worked out by a small, experienced working group like the one currently set up by the Ministry of Finance (financial sector). This group has already developed some criteria to ensure that ‘fly-by-nighters’ are kept out.

 

 

Health & Other Insurance for Below Poverty Level (BPL) (per insured)
Cover	Worker contribution in Rs towards premium	GOI contribution in Rs towards premium	Total premium	Sum insured(Rs)
Life	–	24	24	5000
Health (hospitalization)	–	130	130	14000
Asset	–	15	15	10000
Personal Accident (PA)	–	6	6	40000
Administration & Marketing	25	25	50	–
Total	25	200	225	–
N.B: * The above is based on discussion and rates offered by some insurers (life and non-life). * In case of BPL families, a worker will contribute only Rs 25 towards administration and marketing.

 

Children’s Health Insurance for Below Poverty Level (BPL) (as an option)
Cover	Worker contribution in Rs towards premium	GOI contribution in Rs towards premium	Total premium	Sum insured(Rs)
Health (hospitalization)	20	80	100	2000
Administration & Marketing	–	–	–	–
N.B: * Children between 3 months-18 years of age only will be covered. * Covers all children in the family with one sum insured limit (i.e. Rs 2000).

 

Health & Other Insurance for Above Poverty Level (APL) (per insured)
Cover	Worker contribution in Rs towards premium	GOI contribution in Rs towards premium	Total premium	Sum insured(Rs)
Life	24	–	24	5000
Health (hospitalization)	30	100	130	14000
Asset	15	–	15	10000
Personal Accident (PA)	6	–	6	40000
Administration & Marketing	25	25	50	–
Total	100	125	225	–
N.B: * The above is based on discussion and rates offered by some insurers (life and non-life)

 

Children’s Health Insurance for Above Poverty Level (APL) (as an option)
Cover	Worker contribution in Rs towards premium	GOI contribution in Rs towards premium	Total premium	Sum insured(Rs)
Health	100	–	100	2000
Administration & Marketing	–	–	–	–
N.B: * Children between 3 months-18years of age only will be covered. * Covers all children in the family with one sum insured limit (i.e. Rs 2000).