Income security during periods of ill health: a scoping review of policies, practice and coverage in low-income and middle-income countries

Abstract

The COVID-19 pandemic is a reminder that insufficient income security in periods of ill health leads to economic hardship for individuals and hampers disease control efforts as people struggle to stay home when sick or advised to observe quarantine. Evidence on income security during periods of ill health is growing but has not previously been reviewed as a full body of work concerning low-income and middle-income countries (LMICs). We performed a scoping review to map the range, features, coverage, protective effects and equity of policies that aim to provide income security for adults whose ill health prevents them from participating in gainful work. A total of 134 studies were included, providing data from 95% of LMICs. However, data across the majority of these countries were severely limited. Collectively the included studies demonstrate that coverage of contributory income-security schemes is low, especially for informal and low-income workers. Meanwhile, non-contributory schemes targeting low-income groups are often not explicitly designed to provide income support in periods of ill health, they can be difficult to access and rarely provide sufficient income support to cover the needs of eligible recipients. While identifying an urgent need for more research on illness-related income security in LMICs, this review concludes that scaling up and diversifying the range of income security interventions is crucial for improving coverage and equity. To achieve these outcomes, illness-related income protection must receive greater recognition in health policy and health financing circles, expanding our understanding of financial hardship beyond direct medical costs.

Keywords: health policy; public health.

Figure 1

Diagram to show the direct and indirect costs of ill health which facilitate a spiral of decline in health and income. Adapted from Dahlgren and Whitehead.

Figure 2

Flow diagram to show each stage of the scoping search process, adapted from the PRISMA statement by Liberati et al. CCT, conditional cash transfer; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; LMIC, low-income and middle-income countries

Figure 3

Percentage of countries offering legally mandated sickness, injury and disability payments (stratified by region). Source: ILO. ILO, International Labour Organization.

Figure 4

Maximum amount of disability/sickness benefits available to eligible unconditional cash transfer (UCT) recipients per month, compared with the National average monthly per capita income (GDP per capita PPP) in selected low-income and middle-income countries (presented using a logarithmic scale). Sources: Brazil, India,; Ukraine; West bank & Gaza; Yemen; other: Africa; Asia & Pacific; conversion resources.LICs, low-income countries; MICs, middle-income countries; GDP, gross domestic product; PPP, purchasing power parity