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Accroitre la participation dans les dispositifs effectifs de mutualisation des risques de sante dans les pays en developpement est un element essentiel des ensembles de mesures visant a proteger les menages vulnerables des consequences de l'appauvrissement du aux aleas en matiere de sante. Les personnes pauvres, celles presentant des risques eleves et les travailleurs independants et les employes a titre informel constituent trois categories qui soulevent des questions particulieres dans la formulation d'une politique de mutualisation des risques de sante. Cet article examine les grandes options pour l'extension de la mutualisation des risques dans les pays en developpement. Il met particulierement l'accent sur les avantages et les inconvenients a remedier aux insuffisances d'une assurance financee par l'impot sur la masse salariale a travers un role accru du financement du secteur de la sante par le budget de l'Etat.

Aumentar la afiliacion a programas eficaces de cobertura conjunta de los riesgos en los paises en desarrollo es un elemento fundamental del paquete de politicas disenadas para proteger a las familias vulnerables de las consecuencias empobrecedoras de las crisis de salud. Las personas que son pobres, las que tienen un elevado riesgo y los trabajadores autonomos o del sector informal son los tres grupos que plantean cuestiones particulares en la formulacion de la politica de cobertura conjunta de los riesgos de salud. En este articulo se discuten las opciones politicas para extender la cobertura conjunta de los riesgos en los paises en desarrollo, prestando particular atencion a los meritos y desventajas de superar las carencias del seguro financiado con impuestos sobre la nomina mediante un papel mas importante de los ingresos fiscales generales en el sector de la salud.

“Mit dem Begriff ‘Versicherung’ bezeichnen unterschiedliche Menschen unterschiedliche Dinge: ein Instrument, das Individuen Schutz vor Risiken bietet, oder einen versicherungsmathematischen Mechanismus. Im ersten Fall wird Versicherung in Bezug auf ihre Ziele de finiert, im zweiten mit Blick auf einen Mechanismus, mit d em dieses Ziel erreicht werden konnte. Selbst dort, wo Institutionen keine Versicherung im zweiten Sinne sind, konnen sie insofern immer noch als Versicherung betrachtet werden, als sie Schutz vor Risiken bieten.”

Increasing participation in effective health risk-pooling arrangements in developing countries is an essential component of the package of policies designed to protect vulnerable households from the impoverishing consequences of health shocks. People who are poor, those at high risk and self-employed/informally employed workers are three groups that raise particular issues in the formulation of health risk-pooling policy. In this paper, policy options for extending risk-pooling in developing countries are discussed, with particular attention to the merits and disadvantages of overcoming the shortcomings of payroll-tax-financed insurance through a greater role for general tax financing in the health sector.

In the past decade, many Latin American governments have radically restructured their old age income security systems, following the lead of Chile, which undertook its major pension reform in 1981. The defining characteristic of the reforms has been a shift in the basis of public pensions from social to individual responsibility: instead of the widely used system that “collectivized” or pooled the risk of being without the capacity to earn while aged, numerous countries in the region have adopted a system that relies on individual savings accounts. The reforms have maintained a role for a modified version of public pooling; this combination of individual and social savings to finance pensions is known as the “multipillar” approach. This article is based on a report prepared for the Office of the Chief Economist of the Latin America and Caribbean Region of the World Bank (Gill, Packard and Yermo, 2004).1 The report recognizes that the system of individual accounts, the essential aspect of the reform, has been a necessary and positive development, and one that is consistent with the economics of insurance and social welfare objectives. Beyond this recognition, however, the results of reform are much more complex. Each country has implemented its own version of the multipillar system. The article therefore draws on country evidence in order to determine: How has the new approach to public pensions in Latin America fared? In particular, have the changes left workers and their families in reform countries better off? The first section provides a brief description of the reforms. The second discusses the main macroeconomic concerns and effects. The third describes the impact on coverage levels, and other social welfare implications. The fourth evaluates the stagnation of coverage levels and presents various possible explanations. The fifth makes specific proposals to improve the multipillar pension system in Latin America. The last section concludes.