Solicitud directa (CEACR) - Adopción: 1998, Publicación: 87ª reunión CIT (1999)

With reference to its observation concerning the adoption of the new general social security system for health care, established by Act No. 100 of 1993, as amended by Decree No. 1298 of 22 June 1994, and the regulations issued thereunder (Decrees Nos. 1919 and 1938 of 1994), the Committee requests the Government to provide detailed information on the following points.

Article 3, paragraph 1, of the Convention. The Committee notes that under section 11 of Decree No. 1938 of 5 August 1994 and section 8(b) of Decree No. 1919 of 5 August 1994, the Compulsory Health Plan (POS) provides for the award of cash benefits to persons insured under the contributory scheme in the event of temporary incapacity resulting from a general disease. In this respect, the Committee would be grateful if the Government would specify the amount of these benefits and the period during which they can be provided, with an indication of the legal provisions that are applicable.

Article 3, paragraph 2. The Committee requests the Government to indicate whether and, if so, under which provisions, the payment of a cash benefit in the event of temporary incapacity for work as a result of sickness is subject to the completion of a qualifying period.

See also under Article 4, paragraph 1, point 2(b) below.

Article 4, paragraph 1. (1) The Committee notes that, in accordance with section 2(f) of Decree No. 1919 of 1994, the Compulsory Health Plan guaranteed by the health care providers (EPS) to their insured persons includes preventive, medical and surgical care, rehabilitation and the provision of essential medicines. Section 3(b) of Decree No. 1938 of 1994 specifies that the procedures for the provision of these health benefits are governed by manuals of procedure and guidelines for integral assistance established by the Ministry of Health. The Committee would be grateful if the Government would supply detailed information in its next report on the nature of the care guaranteed by the POS and copies of the above manuals and guidelines adopted by the Ministry of Health. The Committee also requests the Government to indicate the period of which the medical care supplied in the context of the POS is provided to workers.

(2) The Committee recalls that Article 4, paragraph 1, does not provide for the possibility of submitting entitlement to medical care to the completion of a waiting period. In this respect, it wishes to draw the Government's attention to the following points.

(a) The Committee notes that section 26 of Decree No. 1938 establishes minimum periods of contribution for entitlement to care required for the treatment of high-cost diseases: 100 weeks of contribution for diseases classified as catastrophic or ruinous under level IV of the POS and 52 weeks for diseases needing surgery of an "optional nature", as from group 8 of the manual of activities, medical acts and procedures. Insured persons who wish to receive treatment before having completed this period of contribution 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. In these conditions, the Committee hopes that the Government will be able to re-examine the matter in the light of Article 4, paragraph 1, of the Convention and will indicate the measures which have been taken or are envisaged to abolish, or at least in the first stage to reduce these waiting periods, which are particularly long. Please also indicate whether the completion of these waiting periods is required each time that a worker changes EPS. The Committee also requests the Government to provide the list of diseases for which the treatment is subject to the completion of one of the above waiting periods and the medical acts concerned. Finally, it would be grateful if the Government would provide information on the effect given in practice to the above provisions and on the measures which have been taken or are envisaged to give effect to Article 4, paragraph 1, in the case of workers who do not have sufficient financial means to pay the proportion of the medical expenses which corresponds to the remaining weeks of contribution.

(b) Furthermore, the Committee notes that, in accordance with section 24 of Decree No. 1938 of 1994, workers are entitled to the benefits guaranteed by the POS four weeks after their registration with an EPS, except for emergency care, which is provided immediately. Furthermore, in cases where workers have been insured under the same EPS for six months, they benefit from a supplementary four-week period of protection after the date on which their contract with the EPS comes to an end. However, during this period of protection, care is only provided for diseases which are currently being treated or which are of an urgent nature (section 25 of the Decree). In these conditions, the Committee requests the Government to indicate whether workers who decide to leave the Social Security Institute to become insured under an EPS or to change EPS must once again wait four weeks to be entitled to the medical and cash benefits guaranteed by the POS in the case of new diseases or accidents which occurred after changing the insurance scheme.

Article 4, paragraph 2. The Committee notes that, in accordance with section 63 of Decree No. 1298 of 1984, persons who are insured under the general social security system for health care are required to share in the cost of health care in order to rationalize the use of the services provided by the system, although this cost-sharing must not in any event constitute a barrier to access to care for the most impoverished. The Committee would be grateful if the Government would supply additional information in its next report on the mechanisms of this cost-sharing.

Article 6, paragraph 1. (a) The Committee would be grateful if the Government would indicate the manner in which effect is given to this provision of the Convention, in accordance with which sickness insurance shall be administered by self-governing institutions, which shall be under the administrative and financial supervision of the competent public authority and shall not be carried on with a view of profit.

(b) The Committee notes the provisions of Book V of Decree No. 1298 of 1994 respecting the inspection, control and supervision of the general social security scheme for health care, and particularly respecting the National Health Authority. In this respect, it requests the Government to provide detailed information on the manner in which the system, and particularly EPS, are supervised in practice.

Article 6, paragraph 2. Under the terms of section 3(10) of Decree No. 1298, the participation of representatives of the organizations of the persons protected is compulsory in the administrative bodies of public entities. Furthermore, the Committee notes that section 8(5) of the above Decree guarantees the participation of insured persons, either individually or through their organizations, in all the assemblies and representative and inspection mechanisms of entities which manage, promote and provide health services under the general social security scheme (see also sections 5(h) and 42 of the Decree). It would be grateful if the Government would indicate how the participation of insured persons is guaranteed in practice in the management of the system, and particularly EPS.

Article 9. The Committee requests the Government to indicate whether and under which provisions, the legislation recognizes a right of appeal to insured persons in the event of disputes concerning their entitlement to health care benefits, in accordance with this provision of the Convention.