Demande directe (CEACR) - adoptée 2008, publiée 98ème session CIT (2009)

With reference to its previous comments, the Committee notes that Act No. 1122 of 2007 has been adopted in order to reform the General Social Security Health System (SGSSS), provide the resources needed ultimately to cover the whole population and improve the quality and efficiency of the health services. The Committee wishes to draw the Government’s attention to the following points.

Article 2 of the Convention. Persons covered by sickness insurance. The statistical information sent by the Government shows an increase in the number of persons affiliated to the SGSSS contributory scheme, from 5.3 million in 2000 to nearly 8 million in 2008. The Committee notes this development with interest and requests the Government to continue to keep it informed on the process for expanding health coverage, indicating whether, in practice, there are still persons protected by the Convention who do not as yet have sickness insurance coverage.

Article 3, paragraph 2. Waiting period. The Committee requests the Government to state whether, as the Committee understands it, payment of sickness benefit is subject to completion of a waiting period of four days, and reminds the Government that according to the Convention, a waiting period must be no longer than three days at most.

Article, 4, paragraph 1. Minimum periods of contribution required for entitlement to medical care. In its previous comments, the Committee draws the Government’s attention to the fact that this provision of the Convention does not allow for the possibility of making entitlement to medical care subject to the completion of a qualifying period. The Government indicates that Act No. 1122 mentioned above has had the effect of capping at 26 weeks the minimum periods of contribution required for entitlement to the benefits. It further indicates, in respect of medical benefits, that SGSSS coverage is effective from the date of affiliation to the social security system as a whole; only emergency services are provided during the first month of affiliation. The Committee takes note of this information and requests the Government to indicate whether Act No. 1122 has in effect rendered inoperative section 61 of Decree No. 806 of 1998 on the social security health scheme which provides for very long minimum periods of contribution for entitlement to the care needed for the treatment of high-cost diseases: 100 weeks of contribution for diseases classified as disastrous or ruinous under level IV of the compulsory health plan (POS), and 52 weeks for illnesses requiring selective surgery, as set out in group 8 of the manual of activities, medical acts and procedures (insured persons wishing to receive treatment before completing this period of contributions have to pay a percentage of the total value of the treatment corresponding to the percentage of the missing weeks of contribution required to complete the minimum period of contribution). The Committee also invites the Government to consider the possibility of eliminating in future all qualifying periods for medical care so as to bring the national legislation fully into line with Article 4, paragraph 1, of the Convention. Please indicate whether there are any mechanisms whereby it can be ensured that workers who lack the financial means to cover their medical costs are nonetheless able to receive the necessary medical services.

The Committee notes from the information sent by the Government that the qualifying period of four weeks required for entitlement to the medical benefits covered by the compulsory health plan (POS) does not have to be completed when a worker changes health-care provider (EPS).

Article 6, paragraph 1. Non-profit-making and profit-making sickness insurance institutions. The Government indicates in its report that the SGSSS is a public service but is so designed that it can be administered and operated both by private interests and by the State. The State is responsible for organization and oversight and for ensuring that it runs efficiently so that the entire population has access to health services. In its report, the Government refers in this context to an Order of 2001 issued by the Constitutional Court allowing Parliament the freedom to choose among various social security organization systems; the Constitution opts neither for a strictly private system nor for a purely public one. The Government adds that the SGSSS may, therefore, be organized and run for profit. The Committee takes note of this information and recalls that, according to the Convention, sickness insurance must be administered by self-governing institutions under the administrative and financial supervision of the public authorities and must not be carried out with a view to profit. Institutions founded by private initiative must be specially approved by the public authorities. The Government is asked to indicate the proportion of workers covered by public EPSs as compared to those affiliated to private ones, and to specify the procedures set up to oversee the proper running of private EPSs by the public authorities and to protect workers from risks related to sickness insurance carried out for profit (overcharging, negative selection, etc.). Please provide information on any difficulties encountered in practice by the SGSSS contributory scheme (coverage of all workers, guaranteeing the benefits provided by the POS to all insured persons, financial problems, etc.).

Article 6, paragraph 2. Participation of insured persons in management. In its previous comments, the Committee noted that Decree No. 1757 of 1994 determines procedures for social participation in the public health service, of which there are three: civic participation, community participation and participation in the institutions of the SGSSS. Furthermore, pursuant to sections 9 to 16 of the Decree, health-care institutions (public, private or mixed) are required to call on their members to establish users’ alliances or associations and appoint their representatives. These associations participate in the steering committees of public and mixed EPSs in order to propose and agree on measures to maintain and improve service quality. As for private EPSs, participation is possible, in accordance with the relevant legal provisions. The Committee notes that the Government’s report does not provide the information requested previously on the participation of insured persons in the management of private EPSs, including their steering committees, and trusts that the Government will not fail to provide this information in its next report.

The Committee further notes that Act No. 1122, adopted in 2007, established the Health Regulation Committee (CRES), which is now the main regulatory body for health, replacing the National Social Security Council (CNSSS), which nonetheless has consultative status with the CRES. Unlike the CNSSS, which is composed, inter alia, of employers’ and workers’ representatives, the new regulatory body consists mainly of experts appointed by the President of the Republic from a shortlist proposed, inter alia, by properly organized users’ associations. The Committee invites the Government to keep it informed of the implementation of the new system and to indicate in particular the users’ associations that were called on to nominate the experts appointed to the CRES. Furthermore, the Committee observes that the social partners have a lesser role in the new regulatory body, being replaced by independent experts. It asks the Government to specify the reach of CNSSS consultation in decision-making by the CRES.

Article 9. Appeal. The Government indicated previously that, in the event of a dispute, appeal lies to the civil courts, the labour courts or, through administrative channels, to the local health directorates or the National Health Supervisory Authority. The Committee, in response, asked the Government to provide additional information on the administrative channels of appeal (procedures, relevant provisions of laws or regulations and their implementation, etc.). In its latest report, the Government merely refers the Committee to Decree No. 1018 of 30 March 2007 to restructure the abovementioned Supervisory Authority, which contains no provisions on the organization of the administrative means of redress open to insured persons wishing to file claims concerning their entitlements. The Committee hopes that the Government will ensure that all relevant information is sent in its next report.

Lastly, with reference to its observation, the Committee notes from the information sent by the Government that the matter of the non-payment of social security contributions by Intercontinental de Aviación between 1998 and 2004 is still under examination by the labour inspection services responsible for implementing the decision ordering payment of the sums due in respect of the social security contributions. The representatives of the parties are shortly to be called to another hearing by the inspection services since the workers’ representatives did not respond to the summonses to proceedings addressed to them in July and August 2008. The Committee hopes that the Government will be in a position to inform it in its next report that the workers of the abovementioned enterprise have been reinstated in their rights pertaining to sickness insurance.