Notes |
Universal basic income
policies and their potential for
addressing health inequities
Transformative approaches to a healthy,
prosperous life for all
Universal basic income policies
and their potential for addressing
health inequities
Transformative approaches to a healthy,
prosperous life for all
Louise Haagh
Barbara Rohregger
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v
Contents
Abbreviations....................................................................................................... vii
Executive summary............................................................................................ viii
Chapter 1. Introduction ......................................................................................... 1
1.1. Approach.......................................................................................................................................... 2
Chapter 2. Context factors shaping the case and conditions for basic
income reform........................................................................................................3
2.1. Explaining UBI ................................................................................................................................. 3
2.2. Shifts in welfare state development ............................................................................................... 4
2.3. Structural context factors in the case for UBI reform..................................................................... 4
2.4. Effects of changing income security transfer systems on poverty, health and social cohesion
in Europe................................................................................................................................................. 8
Chapter 3. Why UBI?............................................................................................. 10
3.1. Rationales for UBI ......................................................................................................................... 10
3.2. Normative and moral challenges ................................................................................................. 11
3.3. Challenge of complementarity within UBI .................................................................................. 12
Chapter 4. UBI: how to make it work for health equity .................................... 15
4.1. Design ............................................................................................................................................ 15
4.2. Administrative, legal and institutional dimensions ..................................................................... 19
4.3. Financing........................................................................................................................................ 20
4.4. The role of local government ....................................................................................................... 21
Chapter 5. Discussion and recommendations ..................................................22
5.1. What role for WHO? ....................................................................................................................... 24
References.............................................................................................................25
Annex 1. The WHO European Health Equity Status Report Initiative
(HESRi)..................................................................................................................36
Annex 2. Structured interview guideline............................................................37
Annex 3. The equality paradox: public finance conditions for human
development and a health-effective basic income reform.............................. 40
Annex 4. UBI initiatives in Europe and Canada ................................................ 44
Annex 5. Case countries...................................................................................... 49
A5.1. Finland ......................................................................................................................................... 49
vi
A5.2. Denmark ...................................................................................................................................... 49
A5.3. Netherlands ................................................................................................................................. 50
A5.4. Canada ........................................................................................................................................ 50
A5.5. Scotland....................................................................................................................................... 50
A5.6. Spain ............................................................................................................................................ 51
Annex 6. Example of the effects of taxes and benefits .....................................52
Annex 7. How to make it work for health equity – success factors ................53
Annex 8. Example of the effect of social transfers on child poverty rates ......55
Annex references................................................................................................. 56
vii
Abbreviations
GDP gross domestic product
HESR Health Equity Status Report
HESRi HESR initiative
HIV human immunodeficiency virus
IMF International Monetary Fund
MIHL minimum income for healthy living
MIS minimum income standards
NIT negative income tax
OECD Organisation for Economic Co-operation and Development
UBI universal basic income
WHO World Health Organization
viii
Executive summary
Over recent years, universal basic income (UBI) has become an important reference point when
discussing innovative basic income policies as promising alternatives to address shortcomings resulting
from the changing nature of traditional employment patterns and work. Related to this is the notion
of new insecurities that have arisen, which existing welfare state arrangements are not in a position to
adequately tackle.
These aspects also resonate with the debate on health and well-being, emphasizing the role of income
security – either through employment or social protection measures – in playing a key role in achieving
more equitable health. More recently, this debate has gained momentum, as global and domestic
factors are forcing a rethink of income security design, to generate conditions in which income support
systems effectively counteract insecurity.
Changing employment and income patterns, the impacts of technological change, austerity, and
structural trends in providing and reforming income security have rendered increasingly insecure the
provision of income security through employment and social protection mechanisms. The rise in nonstandard employment as a consequence of increasing globalization and liberalization of trade makes
it increasingly difficult to obtain income security through work. Automation is compounding these
effects, in particular for low-income population groups and those with lower levels of education. At the
same time, non-standard employment patterns increasingly limit access to welfare state provisions,
which in turn is linked to a large extent to the capacity of workers to contribute.
Austerity measures since 2008 have led to increased use of targeted approaches, which further limit
access to basic social welfare schemes. The economic crisis has reinforced the use of behaviour
conditionalities as a punitive approach aiming to promote labour market participation; it has also
increased the application of sanctions regimes in response to failure to comply with requirements
relating to work searches and employment offers.
Health consequences are substantial. The generally poor job quality – including a range of measures
of “low worker control” – is considered an important dimension of public health risk. In particular, the
adverse mental health impacts of unstable in-work patterns are increasingly recognized. The rise in
inequality and poverty across Europe has also increased the public financial costs of poverty. There is
ample evidence across countries that insecurity surrounding income support status has adverse effects
on people’s physical and mental health. Conditionalities that cast benefit status into doubt tend to
reinforce these effects further.
In this context, UBI policies, that is, the first steps towards a UBI, are increasingly perceived as one set
of measures that may insulate subsistence guarantees from increased economic pressure; increase the
impact of other welfare policies, such as education and health; as well as re-incentivize employment
and savings.
Recently, several countries and cities within Europe and North America have embarked on basic income
experiments in order to test some of these assumptions. The rationales behind the experiments are
fourfold: (1) anti-poverty and health-linked rationales, which are very prominent in countries with
mid-sized welfare states and higher levels of poverty (and their associated health inequalities) (e.g.
Canada and Scotland); (2) a self-motivation and socio-psychological rationale, focusing on positive
motivational impacts of controlling resources in relation to labour market participation, which has
ix
been strong in countries with high income dependency (e.g. Denmark, Finland and the Netherlands);
(3) administrative efficiency, which has played a role in particular within welfare states with strong
income behaviour control systems; and (4) concerns about labour market change (automation and
increasing non-standard employment) and preparing for a new model of social protection to better fit
the modern labour market have also been mentioned among stakeholders.
While these basic income experiments mimic only some features of UBI, in particular un-conditionality,
they mark a significant turning point in moving the emphasis away from disqualifications and sanctionbased regimes to self-motivation. This is particularly significant from a health equity perspective and
the massive negative mental health impacts that have been observed in this regard. At the same time,
the experiments in most countries are taking place in complete isolation from other ongoing debates
on inequality, including those about health.
Local government and municipalities play a key role in initiating and carrying out these experiments. On
the one hand, this is the result of the traditional role of local government in delivering social assistance;
on the other hand, local governments are also usually the first to notice the effects of austerity and
cut-backs in public services, including in terms of the administrative and financial burden of increased
demand and casework.
The UBI experiments have heralded a new way of thinking around the close interconnectivity between
basic social services and basic income security, which have become increasingly disconnected in the
context of austerity and fiscal constraints, being juxtaposed against each other in reference to fiscal
trade-offs and value-for-money alternatives. However, it is only in their complementarity that they may
realize their respective full potential.
The UBI debate covers a range of different design options, in view of the broad variety of existing
welfare state typologies, institutional and legal challenges, as well as fiscal space across countries and
regions. This report focuses on a foundation model put forward by Louise Haagh and by the Council of
Europe, proposing an additional third basic income tier in addition to the traditional two-tier welfare
state model (detailed in Chapter 4). The proposal involves both targeted income support schemes and
contributory schemes, which it argues appears to be the most comprehensive approach, also allowing
for other income security mechanisms to develop or remain in place.
As part of a tiered model, UBI – in close complementarity with universal services – can help support
the building of welfare systems based on the principle of proportionate universalism, providing basic
income stability that is both crises-preventative and health-constitutive. This is in line with WHO’s
proportionate universalism approach, providing universal policies that act across the whole gradient
but are implemented at a level and intensity that is proportionate to need.
Adopting a universal income scheme would imply a profound transition in how social welfare systems
are currently set up. Hence, UBI is best thought about as a long-term goal and as part of a basket of
measures, which gives room for adopting differently staged transitions and models across countries,
in view of differential institutional and fiscal capacity and political contexts. The type and scale of
challenges involved will vary by country and across the WHO European Region.
An understanding of UBI as a long-term objective should not prevent policy-makers from undertaking
first steps towards this goal. UBI experiments have shown that even small changes to the current
known welfare logic can have huge impact, such as lifting conditionalities and sanctioning regimes.
Other potential short-term measures towards UBI as a long-term goal include the universalization of
access to specific benefits, such as child allowance or disability benefits.
x
UBI policies are but one measure in a policy basket to improve systems of economic security and
health. While a UBI can help support work incentives, the overall impact of it on the labour market
and health will depend on a wider range of factors; labour market policies, such as better control
over working life or more stable contracts may be equally important for people to experience better
health. Wider macroeconomic dimensions, such as (among others) disinvestments in the productive
sphere, and innovative solutions for creating fiscal space are key to creating a more stable economic
environment that allows for inclusive growth. This, in turn, may create feedback effects on financing
social protection measures.
In many countries across the WHO European Region, the health sector has only recently started to
respond to these developments. One of the reasons for this seems to be that the health sphere largely
lacks the vision and narrative in order to engage in the institutional and political debate around
economic security and health. Herein, WHO may have an important role to play to support Member
States in doing just that.
In particular, this involves supporting Member States in developing a health (equity) narrative that
moves away from health as a lifestyle issue towards health as a social justice agenda, as well as
emphasizing the key role of implementing income security as part of a set of preventative health
measures. Understanding health as a common good would imply a stronger engagement of the health
sector with other sectors, in particular in the debates around much-needed universal income policies,
in close interconnectivity with universal health care services.
As a regional knowledge broker and facilitator, WHO could play an important role in creating
communities of interest by uniting different stakeholders engaged at various levels in health, social
services and income protection. As such, it could be a centre of excellence that collects and provides
evidence on health inequities across countries, policy sectors and different government tiers, providing
guidance on methodological issues in collecting evidence, as well as identifying priorities for building
datasets on health equity at country level to support such efforts. This would include the promotion
and further development of tools for data collection (e.g. health impact assessment for health equity
purposes, or the recent WHO European Health Sector Social and Economic Footprint Initiative), as well
as supporting countries in feasibility research, modelling and micro-simulation of different UBI models.
1
Chapter 1. Introduction
Chapter 1. Introduction
The debate on UBI, a “periodic cash payment unconditionally delivered to all on an individual basis,
without means-test or work requirement” (BIEN, 2019) has experienced a remarkable renaissance over
recent years, attracting the attention of policy-makers and decision-makers alike (OECD, 2017a; Council
of Europe, 2013, 2018; ILO, 2018). Most policy options discussed do not resemble a full UBI. However,
in the context of increasingly volatile economic conditions and constrained social spending, UBI has
become an important point of reference to discuss basic income policies that represent promising
alternatives to address shortcomings resulting from the changing nature of traditional employment
patterns and work and, related to this, new insecurities that existing welfare state arrangements are
not in a position to adequately tackle (Handler, 2006; Jordan, 2008; Haagh, 2006, 2017a, 2017b). In
reference to its universal and unconditional character, UBI is perceived as having a positive impact
on what are known as the “underlying drivers of equity”, including empowerment, participation,
democratization and equal opportunities for all through fairer redistribution of resources, and social
justice (Patemann, 2004; Wright, 2006; Haagh, 2011a, 2017b; Goodhart et al., 2012; Sloman, 2017;
Ruckert, Huynh & Labonté, 2018).
These aspects also resonate with the debate on well-being and health equity, emphasizing the role of
income security – either through employment or social protection measures – as playing a key role for
health and well-being (Lundberg et al., 2010; Reeves et al., 2016; Haagh, 2011a, 2011b, 2019b, 2019c;
Forget, 2011; Samuels & Stavropoulos, 2016). The role of wider policies and governance mechanisms
in addressing pathways to better health by taking action on social, economic, environmental and
commercial determinants also lies at the heart of the new WHO European health policy framework
Health 2020, adopted in 2012, emphasizing an integrated and multisectoral approach to achieving
better health and well-being (WHO Regional Office for Europe, 2013b).1
The determinants of health
equity are represented in many – if not all – of the 17 Sustainable Development Goals (SDGs) of the
2030 Agenda for Sustainable Development (United Nations, 2015) and resonate in the European Pillar
of Social Rights (EC, 2017), emphasizing the role of social rights in the creation of efficient employment
and better social outcomes, and an inclusive and fair growth model (WHO Regional Office for Europe,
2017).
The implementation of Health 2020 is progressing significantly in all WHO European Region Member
States. Despite progress being made, the regional situation remains mixed, in particular with regards
to gaps in health between countries; significant gaps persist in mortality and amenable morbidity, wellbeing and self-reported health between countries with similar economies, cultures and health systems.
Within-country inequities in health remain high, and in some cases have increased since the mid-2000s
(WHO Regional Office for Europe, 2012, 2013a, 2013b). Constrained fiscal spending on public policies,
including on health and social protection, along with reinforcement of conditionalities on these
policies, have further increased the risk for many of falling into poor health and have exacerbated the
situation for those already experiencing poor health and well-being. As a consequence, health sector
representatives within countries are increasingly urged to respond to and act upon health challenges
that lie beyond their own sectoral boundaries. For this, they look to WHO for guidance.
1 Health 2020 aims to support action across government and society to “significantly improve the health and well-being
of populations, reduce health inequalities, strengthen public health and ensure people-centred health systems that are
universal, equitable, sustainable and of high quality” (WHO Regional Office for Europe, 2013b:11).
2
Universal basic income policies and their potential for addressing health inequities
Based on a series of requests from Member States, the WHO European Health Equity Status Report
Initiative (HESRi)2
has commissioned this policy paper on UBI policies, which is part of a new series of
discussion papers on innovative approaches to implementing a healthy, prosperous life for all. The aim
is to contribute to a more structured debate on social and economic policies that may in turn contribute
to accelerating progress to reduce inequities in health within the diverse context of the WHO European
Region. This exploratory discussion paper aims to provide a more hands-on debate, contributing to
a formal dialogue informing the WHO European HESRi’s position on policies discussed in the context
of UBI, and their potential role in reducing health inequities. The paper does not seek to promote a
specific type of UBI. Rather, it takes as its starting point a view of UBI as one potential option that,
alongside and as part of a basket of other, complementary proportionate UBI policies and services,
may contribute together, in such a way as has proven effective elsewhere, to reducing health inequities.
1.1. Approach
The discussion paper is based on a broad literature review, including academic literature, policy
documents, impact evaluations from UBI pilot approaches, and other, similar programmes currently
being implemented (with a specific focus on the WHO European Region and North America), along with
media clippings and relevant websites discussing UBI. The conceptual debate on UBI is underpinned by
primary data collected though qualitative interviews3
with public health practitioners, health experts
and policy-makers involved in the implementation of experiments and trials testing one or more
features of UBI; in particular, unconditionality. Several countries, regions and cities across the WHO
European Region and beyond have recently embarked on social welfare experiments testing two or
three features of UBI, in particular applying no or alternative forms of conditionality.4
While in the public
debate they are commonly termed UBI experiments, they can at best be considered partial UBI trials,
partially mimicking some of the features. The aim of the interviews was to get a better understanding
of how people from within and outside the health sector perceive UBI as a potential mechanism for
addressing health inequities and to provide a more structured overview of the major emerging issues
around UBI, in particular in view of the relatively minor role of health in the UBI debate so far.5
2 See Annex 1 for a short description of the HESRi, a forthcoming suite of tools being developed to promote and support
policy action for health equity and well-being in the WHO European Region.
3 In total, six in-depth interviews were carried out, based on a structured interview guideline (see Annex 2). Questions revolved
around income security and pathways to health, resulting health inequities, the potential role of UBI in reducing health equity,
the role of health and well-being in current UBI experiments, the public debate around UBI (in particular with regard to moral
and social justice arguments), as well as related perceived design and implementation challenges. The interviews were either
conducted over the phone or using Skype and were recorded, transcribed and analysed using ATLAS.ti software.
4 These countries and regions include the Canadian region of Ontario, the city of Barcelona in Spain, along with Denmark,
Finland, and five Dutch cities (Groningen, Nijmegen, Tilburg, Utrecht and Wageningen). In several other countries (e.g. Italy,
Scotland, and the United Kingdom), intense debates and planning for trials are ongoing.
5 Morris et al. (2007) and Davis et al. (2012) developed minimum standards for a healthy living in the British context, sparked
by the conspicuous absence of health needs from the minimum income requirements. The minimum income for healthy living
(MIHL) and the minimum income standards (MIS) both define health needs as being more than food, clothes and shelter.
They also consider resources needed for physical activity, as well as for psycho-social integration and participation in society,
including costs for (among other things) telephone and television (Marmot et al., 2010). Historical evidence on the positive role
of UBI policies for health and well-being exists, for example from the 1970s Manitoba negative income tax (NIT) trial (Forget,
2011). However, the more substantial debate around UBI as a potentially powerful mechanism to tackle structural barriers and
inequalities to health and well-being is only just beginning to evolve (see, for example, Ruckert, Huynh & Labonté, 2018; Haagh,
2011b, 2019c; Painter, 2016; Prochazka, 2017; NHS Health Scotland, 2017a, 2017b; Richardson et al., 2018; Forget, 2017).
3
Chapter 2. Context factors shaping the case and conditions for basic income reform
Chapter 2. Context factors shaping the case and
conditions for basic income reform
The debate about UBI relates to major social, economic, institutional and political shifts that have
affected the way welfare schemes are able to provide income security at a broad level. This also has
major impacts on health and well-being, in particular health inequalities. The pathways through which
income security impacts health are complex,6
but a central factor relevant to the discussion about UBI
is the role of certainty around basic income flows and legal rights to protection. This means that the
design of income security systems has both direct and indirect implications for health outcomes and
policies.
This chapter reviews the sources of new challenges to income security systems, in response to
which basic income can be viewed as a central pillar within a basket of measures to strengthen the
effectiveness of health systems and policies. It is important to separate general reasons why UBI is
viewed as an anchor within welfare state development, on the one hand (internal factors), and the
specific problems surrounding development policy, employment, and social contribution systems,
which generate contextual challenges, on the other hand (external factors). More recently, several
contextual factors that compound health risks and health equity concerns have become more central
to the case for UBI, in response to both a challenging external environment, and changes in government
responses to income security risks. While poverty and inequality have increased in the WHO European
Region in response to labour market reforms, economic crises and austerity, public sector cuts to social
provision also have further limited access to social support. This coincidence of global and domestic
factors has forced a rethink of income security design, in order to generate conditions in which income
support systems counteract insecurity effectively.
2.1. Explaining UBI
UBI is generally known to have three basic features: universality, individuality, and unconditionality
(BIEN, 2019). In addition, most UBI experts consider uniformity and regularity (Van Parijs, 1995),
payment in cash (Torry, 2013), and lifelong coverage (permanence) (Haagh, 2019b) to be equally
important features. For example, UBI as a cash payment is viewed as a corollary of unconditionality:
UBI is distinct from payments or subsidies in kind (Torry, 2013). Permanence is regarded as a basis
for the psychological impact of basic income, linked with the anticipation of rights-based and lifelong
status security (Haagh, 2019b).7,8
6 The pathways between health and income security are usually described as being a three-way relationship, including direct
consumption effects leading to material exclusion, psycho-social effects of exclusion, and a mix of both (Lundberg et al., 2010).
Beyond individual-level differences, Wilkinson & Pickett (2008), along with Mackenbach (2006) argue that socioeconomic
differences in health also tend to be influenced by the structural differences in society or overall levels of societal inequality.
7 Non-withdrawability (Torry, 2019), non-mortgageability (Haagh, 2019d), and state-backed legality (De Wispelaere & Morales,
2016; Haagh, 2019c) of UBI payments have also been emphasized as relevant factors when considering basic income as an
effective source of income protection. Legal stability of basic income is viewed by many as central to insulating subsistence
guarantees from the economic cycle, and to the potential for UBI to support and extend the impact of other welfare policies,
such as education and health (Haagh, 2007, 2012; Forget, 2017; Jordan, 2008), as well as incentivizing employment and
savings (Haagh, 2017b). The feasibility and efficacy of UBI is connected with a broader challenge involving consolidating the
fiscal basis for welfare policy and supporting the effectiveness of individual interventions by improving the architecture of
welfare provision as a whole (see Annex 3).
8 In the literature that is concerned with using basic income to improve the welfare state, basic income is thought to extend
the well-known social, health and political benefits of institutions such as the basic citizen pension and universal child grants
(Haagh, 2007, 2011a, 2012, 2017b; Jordan, 2008; Downes & Lansley, 2018).
4
Universal basic income policies and their potential for addressing health inequities
For most UBI experts the key aim is to ensure a lifelong structure of security that cannot be withdrawn,
in the assumption that support in this form of individuals’ basic sense of security also positively impacts
other government functions and society at large (Haagh, 2017a, 2019b). These assumed features of UBI
play a salient role in present-day debates about how to improve income security and welfare systems
in European countries in response to changing conditions.
2.2. Shifts in welfare state development
During the 2010s in Europe a pattern of long-term problems in income security design emerged,
intensified by increasing tensions in the context of what are known as workfare policies, existing since
the 1990s and sandwiched between rising insecurity and income benefit reform (Bambra, 2011). This
involved states having reduced capacity to adapt proactively within the constraints of the European
budgetary framework (Radice, 2014). Before examining how conditions generated by structural change
have pushed the case for UBI to the forefront, it is apt to examine flaws in the design of post-war
income security systems, which lay the groundwork for the policy menus through which countries have
responded to global trends.
2.3. Structural context factors in the case for UBI reform
Four long-term structural shifts have accentuated failings in modern income security provision systems,
based on means testing as the lowest tier of income security. The same trends also generate new
challenges for countries seeking to build formal income security systems for the first time.
2.3.1 Employment and income trends
Global marketization of development, comprising trade and finance liberalization, privatization
and labour market deregulation, along with fiscal pressures on countries, have all contributed to
changes in production structures, wage compression, income insecurity, and poverty. Since the 1990s,
Organisation for Economic Co-operation and Development (OECD) guidelines have promoted financial
and labour market deregulation as an instrument to achieve growth (OECD, 2012). A number of studies
find that deregulatory reform contributed to financial imbalances and reduced welfare, in particular
but not only for lower-income households (Bertola & Lo Prete, 2015; IMF, 2015; OECD, 2018).9
For example, looking at England, interregional health inequalities relating to unemployment fell
approaching the 2008 crisis (Buck & Maguire, 2015). However, between 2006 and 2016 in the United
Kingdom, the number of employees on precarious contracts – defined as being in jobs linked with status
insecurity – rose from 5.3 to 7.1 million, to around 20% of the labour force, leading to both new levels
of health equity and general public health risks (Booth, 2016). Part-time, temporary work, and selfemployment have also substantially increased disproportionately during the crisis at European level,
affecting workers with fixed-term contracts. On average 14% of dependent employment is temporary,
9 A 2015 International Monetary Fund (IMF) World Economic Output report found no evidence of a positive link between
deregulation and countries’ potential for economic growth (IMF, 2015). The OECD Employment Outlook edition for 2018
recognizes that rising employment was overshadowed by unprecedented wage stagnation. In addition, while low inflation
and productivity growth have a part to play, the dynamics of low-paying jobs and the wages associated to them also play a
significant, but understudied, role (OECD, 2018).
5
Chapter 2. Context factors shaping the case and conditions for basic income reform
with high variations across countries.10 Similarly, there was rapid growth in part-time employment
during the crisis, increasing from 14.6% in 2007 to 16.5% in 2015 across the EU (COPE, 2017). The crisis
has also accelerated informal employment. Whereas comparable data over time do not allow clear
regional trends to be identified, country-level data indicate either a reverse trend towards increased
informalization in some countries, including Serbia and the Russian Federation (ILO, 2017), or a high
level of informal employment in a number of eastern European countries and the Russian Federation
(ILO, 2018). In particular, the share of informally employed people among women who are employees
is greater in high-income countries, which highlights the particular threat of informalization of formal
work for women in Europe (ILO, 2018), along with the associated vulnerability in benefit systems that
follows. This means that the negative health impacts associated with contemporary punitive benefit
systems – affecting those in precarious employment – are likely to be most acute in the gendered
dimensions of health inequality (Etherington & Daguerre, 2015; Haagh, 2019b).
According to European data on working conditions, the period 2010–2015 saw no improvement
in subjective impacts of precariousness, albeit with fixed-term contract work, marginal part-time
employees, and agency workers most at risk (Eichhorst & Tobsch, 2017). Consequently, while the negative
health impacts of unemployment (Voss et al., 2004) and in particular involuntary unemployment
(Gallo et al., 2004) are well-known (BMA Board of Science, 2016; Bramley et al., 2016), today generalized
poor job quality – including a range of “low worker control” measures – is considered an important
dimension of public health risk (Eurofound, 2014). In particular, the adverse mental health impacts of
unstable in-work patterns of working are increasingly recognized (BMA Board of Science, 2016; Marmot
et al., 2010).
Such development not only leads to a widening of the inequality gap to the detriment of those who are at
the lower end; while the link between labour deregulation, employment growth, reduced work quality,
and rising inequality is well-established (Bertola, 2008; European Comission, 2010), in a deregulatory
context a fall in the quality of employment at the lower end contributes over time to a corroding of
standards across the board.11 This explains how a “levelling down” effect can highlight an equalization
of outcomes along some dimensions of disadvantage, followed over time by a generalization of poor
outcomes for all (Rubery & Piasna, 2016).
A consequence is to make economic stability a general health equity and social justice concern. A call
for re-regulation – to achieve a more inclusive labour market – is emerging within the European agenda
(EC, 2017), which entails levelling up instead of the aforementioned levelling down, as was seen at the
core of the deregulation agenda of the 2000s.
2.3.2 Impacts of technological change
Rapid changes in the structure of work and impacts of new technologies in work organization have led
to new forms of displacement that are beyond individuals’ control. While a lot has been written about
prospective job losses caused by automation (e.g. Acemoglu & Restrepo, 2017),12 also significant in
10 In 2015, over 20% of the jobs in Poland, Portugal and Spain were temporary; in the United Kingdom the figure was 6%, and
around 35% in Estonia (COPE, 2017).
11 Hence, the general state of social opportunity (conveyed by general employment and welfare standards) ultimately affects
the standards enjoyed by those with the least opportunities. Conversely, where the standards for those with least opportunity
are lowered, as typically occurs at the beginning of a trajectory of deregulatory reform, over time the effect of low-wage, lowskill competition degenerates the average social standard for all (Pagano, 1991; Haagh, 1999, 2002, 2012).
12 The speed and level of displacement are hard to predict, with certain job markets (such as in the United States) that rely
more heavily on services and global outsourcing facing greater disruption.
6
Universal basic income policies and their potential for addressing health inequities
the case of basic income are the effects of technology on work processes and lifestyle patterns, which
generate a need to support in new ways economic autonomy and systems of access to lifelong learning,
respectively.
The impact of changes in work organization is complex and unpredictable in ways that contribute to
different forms of psychological stress. For example, according to a study commissioned by the United
Kingdom’s Advisory, Conciliation and Arbitration Service (Briône & IPA, 2017) the nature and pace
of technological change carries significant mental health risk, linked with disruptive effects of rapid
change, a loss of boundary between work and private life, and reduced worker autonomy. Key factors
in the negative mental health impacts of technology are loss of control and lack of voice. The United
Kingdom Workplace Employment Relations Survey (2011) showed that about half of workplaces
consulted with staff about technological change, and a much smaller number engaged in formal
negotiation (cited in Briône & IPA, 2017: 39). “While workers are in principle welcoming of technology,
their concerns about management intentions and potential control over it might be the bigger source
of concern.” (Ibid.: 36)
An independently guaranteed income in this context would also have a positive impact on improving
people’s voice in the labour market and within employment, while simultaneously facilitating other
public policies targeted towards developing systems of lifelong learning. The effect of technological
change is one of the key factors in the promotion of lifelong learning systems within the education
segment of the United Nations 2030 SDG framework (Education 2030) (UNESCO, 2016). In this context,
the existing income security division around unemployment in countries is increasingly out of date.
Systems of individual responsibility for unemployment and employment failure – built into current
income security systems, including active labour market policies – are no longer realistic.
There also is growing evidence that economic security structures need to be rebuilt to support
individuals in work and equity in care roles (Lawrence, Roberts & King, 2017), partly because women
are more likely to adjust time schedules to fit work around family roles (Parker, 2015).
2.3.3 Austerity
Given the rise in inequality that typically follows a financial crisis and ensuing recession, combined
with the poorer segments of society’s greater reliance on services, it can be predicted that austerity in
response to economic crises will exacerbate inequality across a number of different dimensions. Within
European countries, negative health impacts of sanction-based policies in income security provision
are widely documented (Quaglio et al., 2013; Karanikolos et al., 2013; van Gool & Pearson, 2014).13
Three factors are important in shaping the impact of austerity programmes: the overall scale of cutbacks against the existing level of public provision; the distribution of cuts; and these factors set against
the structure of provision already in place. The scale of the social embedding of public finance within
societal institutions, along with public laws put in place to protect (which distinguish different varieties
of capitalist economy (Haagh, 2012, 2015)), served to cushion the impacts of austerity on vulnerable
groups, which are recognized as presenting health risks (Haagh, 2019b, 2019c ). Faced with a more direct
financial shock, Iceland chose to insulate the effects on welfare spending and the structure of social
provision. Research by Stuckler and Basu (2013) also found that governments that have responded to
financial crises by increasing public sector spending have seen faster economic recoveries and better
health outcomes.
13 There is evidence that austerity contributes to homelessness, and that homelessness is a serious health risk (Burki, 2010).
7
Chapter 2. Context factors shaping the case and conditions for basic income reform
In contrast, cuts to health care spending in Greece following the start of the recession led to a decline in
public health standards (including malaria outbreaks and rising HIV rates). Other countries, such as the
United Kingdom, pursued an overall programme of deep cuts to public provision. In England, a health
inequalities strategy (in effect between 1997 and 2010) – aiming to decrease the disparity between
those living in the bottom fifth of the most deprived local authorities and the rest of the population –
succeeded in decreasing the health gap between these groups; however, after 2010, during the period
of austerity, this trend was reversed (Forster, 2017; cited in BMA Board of Science, 2016: 6). Data from
the United Kingdom show geographical health inequalities rose in England in particular, in response
to austerity measures implemented under an already decentralized approach to budget responsibility
(Barr, Higgerson & Whitehead, 2017). In Scotland, mental health inequalities between regions widened
in the period between 2008–2009 and 2012–2013 (Kellock, 2015). In OECD countries, where austerity
was a more marked response to the 2007–2008 crisis and consequently public finances were hit
particularly hard, adverse mental health trends were more pronounced, whereas other countries that
were also subject to severe budgetary constraints saw rising mortality among the elderly, and rising
food poverty (Stuckler et al., 2017).
In this context, moving the welfare and income security systems as a whole towards greater targeting
of services risks reducing capacity for comprehensive coverage, inducing a negative downward spiral in
funding and capacity for social provision. Comparative studies suggest that the propensity to cut public
services is greater where provision is targeted (Rothstein, 1998; Haagh, 2012; Hills, 2015). According to the
British Medical Association (BMA), spending cuts have more severe impacts in welfare states in which social
spending predominantly targets the poorest households (BMA Board of Science, 2016). An important case
for UBI in this context is a wider need to rebuild comprehensive income security and services systems,
defined as covering the whole population, while also servicing particular areas of need.
2.3.4 Structural trends in income security provision and reform: reinforcing
sanctions and increasing targeted approaches
In OECD countries the response to austerity has entailed a narrowing, rather than a broadening of social
provision. Across these countries, austerity in response to the 2007–2008 crisis reinforced the use of
behaviour conditionalities, connected with income benefit reforms (which had been under way since
the 1990s), with differential health impacts, filtered by variation in the institutional form of the public
administration of benefits (see Haag, 2019a: Annex A).14 Pressures on countries, combined with new
ideological approaches to welfare state provision linked with neoclassical models of work behaviour
introduced in the 1990s, meant that the range of solutions to the poverty traps of the 1970s and 1980s
that emerged focused on punitive approaches to promote labour market participation.
Across mature European welfare states, public sector reforms and the intention to cut benefit
dependence formed the background for a policy of increased sanctions on benefit claimants in
response to failure to comply with requirements surrounding work searches and employment offers
(Adler, 2016; Haagh, 2019c, 2019e). Sanctions systems in many European countries have become more
indiscriminate as a result of being more simply applied in relation to labour market objectives, despite
the rise in precarious employment. Sanctions are increasingly applied on single parents, as well as longterm sick and disabled people, exacerbating the adverse social effects of economic transformations,
particularly in relation to poverty, health inequalities, and patterns of social exclusion.
14 The design of the initiatives taken in many cases exacerbated existing labour market insecurities, while generating new
insecurities surrounding income support status, with different effects in different European states.
8
Universal basic income policies and their potential for addressing health inequities
2.4. Effects of changing income security transfer systems on
poverty, health and social cohesion in Europe
A rise in inequality and poverty across Europe has placed families at risk, while increasing the public
financial cost of poverty. In the case of the United Kingdom, a Joseph Rowntree Foundation study
found that 25% of health care costs could be attributed directly to poverty (Bramley et al., 2016).15 The
adverse impacts on mental health resulting from instability of and uncertainty about employment and
benefit status have already been mentioned (Watts et al., 2014). These are compounded by increasing
uncertainties regarding entitlement to benefits and legal redress. Over 40% of appealed cases have
been found to be faulty in both the United Kingdom and Denmark (Adler, 2016; Haagh, 2019c), showing
a high degree of error and uncertainty surrounding the sanctions regime. A common theme that
emerges across different jurisdictions in terms of sanctions administration involves the adverse health
effects of anticipating status assessment. This has been reported in Norway (Barr et al., 2016), Denmark
(Haagh, 2019d), and the United Kingdom (Johnson, 2018), despite different systems of application. The
application of benefit design policies which generate uncertainty about subsistence status was cited as
the key factor in the rise of cases of children underperforming at school, in a recent survey of teachers in
England (Adams, 2018). Many studies have found the employment effects of sanctions are short term,
and sanctions sustain higher rates of crime (Griggs & Evans, 2010; Watts et al., 2014; Loopstra et al.,
2015a). Other studies have found that sanctions have the effect of pushing disabled groups away from
the labour market (Reeves, 2017). Predictably, a rise in unemployment has been linked with a rise in the
use of food banks (Loopstra et al., 2015a). In the United Kingdom a growing number of clinicians act as
referral points for food banks (27 000 front-line care professionals in 2013–2014), and a link has been
found between higher rates of benefit sanctions and use of food banks, in a comparison of different
areas (Loopstra et al., 2015b). Adverse effects of benefit reforms have been recognized in a number of
public enquiries (APPG, 2016) and cross-country studies into the physical and mental health impacts
of insecurity surrounding income support status in European countries (Karanikolos et al., 2016).
Insecurities about the terms of employment along with conditionalities that cast doubt over benefit
status have been found to contribute to income poverty, stress, ill health, and social exclusion (Reeves
et al., 2016; Griggs & Evans, 2010).
Other studies show a strong association across local authorities between the implementation of work
capability assessment and adverse mental health problems (suicide, reported mental health problems,
and antidepressant prescribing) (Barr, et al., 2012; Reeves, 2017). Welfare reforms linked with caseload
reduction targets have exacerbated the impact of structural trends that drive social determinants
of ill health. Intensification of sanctions facing carers of young children has deepened child poverty
(BMA Board of Science, 2016). In a letter to The Guardian in 2015 (also cited by the BMA (2016: 12)), 442
psychotherapists, counsellors and academics highlighted the adverse psychological effects of austerity,
and emphasized the role of a lack of control over housing and benefit status (The Guardian, 2015).
While a number of studies exist on the positive long-term employment impacts of more sustained
income security (Tatsiramos, 2006), sanctions have been linked with a lower probability of long-term
employment integration (Arni, Lalive & van Ours, 2009). In addition, there is strong evidence that
sanctions lead to social exclusion, meaning people become disassociated from formal benefit systems
(Haagh, 2019c; Loopstra et al., 2015a). Such effects are kerbed in welfare states in which cuts to benefits
15 The Joseph Rowntree Foundation assessed the financial side of the public health costs of poverty, counting, for example,
additional hospital beds and primary care costs (Bramley et al., 2016). The methodology is based on studies from the United
States (Holzer et al., 2007), which found that the health, crime and output/productivity costs of poverty each accounted for
1.3% of lost gross domestic product (GDP) (overall therefore nearly 4% of GDP).
9
Chapter 2. Context factors shaping the case and conditions for basic income reform
have been more limited and in which public administrators avoid sanctioning the most vulnerable
groups from a health perspective (Haagh, 2019b, 2019c, 2019d).
In all, owing to new economic pressures, basic income is viewed by many as being key to insulating
subsistence guarantees from the economic cycle, and as an important instrument to expand the impact
of other welfare policies, such as those involving education and health (Haagh, 2007, 2012, 2019b;
Forget, 2017; Jordan, 2008), as well as to re-incentivize employment and savings (Haagh, 2017b). The
feasibility and efficacy of UBI policies is closely connected with the broader challenge of consolidating
the fiscal basis for welfare policy and supporting the effectiveness of individual interventions by
improving the architecture of welfare provision as a whole (see Annex 3).
10
Universal basic income policies and their potential for addressing health inequities
Chapter 3. Why UBI?
3.1. Rationales for UBI
Support for UBI within European populations is growing. According to the European Social Survey,
support for UBI averaged around 50% across the European countries surveyed. More in-depth analysis
of trends in support across several countries is still pending; however, looking at the United Kingdom,
which has an average level of support for UBI, it is very clear that dissatisfaction among the electorate
with existing benefit systems is a key driver. A recent Populus poll showed that only 19% of respondents
felt the existing system of income security functioned well and no changes were needed (Populus, 2018).
Although the poll shows that support for UBI is paradoxically lower in relatively wealthy states and/or
countries with more comprehensive welfare systems (e.g. Switzerland and Sweden), in countries with
high levels of equality, in which partial basic income trials have been taking place, support is higher.
In all, there are four main identifiable forms of rationale for UBI, which are to varying degrees present
in the case for UBI made by stakeholders involved in various experiments.
1. An anti-poverty and health-linked rationale has been very prominent in experiments in countries
with mid-sized welfare states, higher levels of poverty and associated health inequalities, for
example Canada and Scotland.
2. A self-motivation and socio-psychological rationale – focused on positive motivational impacts
of controlling resources in relation to labour market participation – has been more dominant
in experiments in countries with more established welfare states, less poverty and associated
health inequities, but high rates of income dependence, for example Denmark, Finland, and the
Netherlands.
3. Administrative efficiency within income security behaviour control systems has been an associated
rationale, particularly in more established welfare states that spend more on administration, for
example Denmark, Finland and the Netherlands.
4. Concerns about labour market change (e.g. automation, increases in non-standard employment)
and preparing for a new model of social protection to better fit the modern labour market have
also been mentioned among stakeholders. However, this tends to be somewhat of a secondary
concern.
Some country experiments represent hybrids in terms of their motivational rationale; for example, the
Spanish experiment is heavily dominated by an anti-poverty and economic inequality focus, but at the
same time also includes strong motivational factors.
The political debate around UBI policies in the experimenting countries reflects this field of unresolved
tensions between fiscal constraints, rising poverty rates and the pressure involved in delivering more costeffective and responsive income security. While they are closely connected and difficult to disentangle,
countries vary as to which aspect they emphasize or prioritize. In more mature and comprehensive
welfare states, such as Finland and the Netherlands, the efficiency aspect appears to play an important
role. The over-bureaucratization of welfare, the high opportunity costs of conditionalities, and active
labour market policies all have a part to play. They are also the key objectives of these interventions,
and form the basis of the hypotheses to be tested in the impact evaluations. This search for efficiency
is also captured to a certain extent in the nature of the interventions being considered for experiments
11
Chapter 3. Why UBI?
or trials (as opposed to pilots), with a strong emphasis on testing and evidence-based policy. In some
countries they are just one of a bundle of experiments, or simulations running in parallel, in order to
look for the most efficient new welfare model.
In other countries, the administrative dimension is related to a notion of effectiveness. This is especially
so where welfare state administrations are highly centralized, as is the case, for example, in Scotland
and Spain. While it renders access to services challenging, in particular for people with low incomes
– who tend to have more difficulties than others in navigating these welfare complexities – it also
creates gaps in the welfare systems, especially where central and local services overlap and weak legal
regulations lead to exclusionary mechanisms. In most countries, fiscal constraints are a major driver
to engage in innovative ways that will allow a response to rising needs but with unchanging resources.
In the context of fiscal decentralization, these structures tend to result in conflict between central and
local government levels, especially where welfare states are highly decentralized, and where rising
demand is not matched with additional resources (e.g. in the Netherlands). In such situations, the local
level has a strong interest in testing innovative solutions to deal with the rising demand or caseload,
but this is also at the cost of going against centralized labour market policies.
Economic inequality is rising in all the case countries and represents a constant undercurrent in the
debate around innovative welfare solutions, coupled with automation and changes in the employment
and economic sphere of the post-industrial era. Where the degree of economic inequality is high and
effective welfare state structures are not in place that may (even inadequately) respond to it, open
political pressure to react is created; this is the case in Barcelona, where the sharp increase in poverty
and economic inequality after the crisis built up significant public and political pressure to act.16
3.2. Normative and moral challenges
Public norms have led to conditioning, historically, to regard social contribution as directly linked with
employment, or much specified status exceptions. This is one of the principal motives for basic income
experiments which have tended to focus strongly on identifying impacts on the work ethic. However,
four other factors also contribute to explaining the concern with disproving negative effects of income
guarantees on the work ethic. (1) First, a key factor that has contributed to UBI experiments focusing on
testing work behaviour is the long-standing influence of neoclassical economics on public policy; that
is, the so-called leisure–work trade-off assumption. (2) Second, the notion that has been put forward
in some libertarian arguments for basic income – that social democracy is coercive and paternalistic
because it emphasizes social transformative goals – has caused concern about basic income among the
social democratic-leaning public and trade unions. This has also contributed to the need to prove the link
between income security and work behaviour through UBI experiments, even though there is already
good evidence of this link from existing studies. (3) Third, public concerns about reciprocity emanate
from the tendency to associate income with market contributions, and services with rights. (4) A fourth
factor in experimentation can be considered inertial and is linked with public administration itself.
Public managers of local income security administration, who have experimented with giving income
grants without conditions, are concerned about social integration and the willingness of different
populations to contribute to society. In welfare states that provide more generous social protection,
such as some Nordic countries, the expectation of contributory obligations, as administered through
public benefit offices and social work, is very strong. A challenge in this context is to emphasize the role
of basic income security in enabling not only a range of non-market social contributions, such as social
16 Qualitative data gathered from a selection of interviews carried out by the author team.
12
Universal basic income policies and their potential for addressing health inequities
and charitable activities, staying longer in education or care, but also social insurance and other failing
shared insurance systems. In countries with stronger contributory institutions, new mechanisms are
needed to reverse the effects of slow decline.
3.3. Challenge of complementarity within UBI
Despite the many influences that shape the discussion and varying designs of UBI experiments in
European government and municipal-led trials, the strongest impetus to undertake the experiments is
practical. The main concern for policy-makers in all cases has been to improve the effectiveness of the
public administration of income security in general, and in relation to the labour market in particular.
The circumstances are slightly different depending on the case (see Annex 4 and Annex 5 for more
details).
Current UBI experiments in Europe are characterized by adopting primarily one feature of UBI:
unconditionality.17 Notwithstanding, there are good reasons why these experiments should be
considered related to UBI, despite mimicking only some features and doing so partially (for example,
in the case of low-value grants in Finland). First, given the current context, which is one of intensified
use of conditionalities, disqualifications and sanctions regimes (which threaten to exclude groups
from access to social assistance), the experiments mark a significant turning point in emphasis. From
a health equity perspective, the switch from emphasizing sanctions to focusing on self-motivation is
significant, given the evidence cited concerning the negative mental health impacts of sanctions.
So far the evidence from the Danish experiments is mainly qualitative, concerning the experience
of social workers, select beneficiaries, and sets of beneficiaries in terms of the areas of spending
prioritized in self-budgeting plans (Haagh, 2019c). The most outstanding finding, according to both
the director of the programme in Aarhus, and social workers involved in the experiment in Kalundborg,
related to the sense of reported self-control. Beneficiaries’ attitude to their own condition and to
social workers changed in a positive direction. The phrase “can we decide, ourselves?” was reportedly
common, according to Vibeke Jensen of the Aarhus council (Thougård Pedersen, 2016). Beneficiaries
were so used to being told what they should and could do that they were shocked to find that some
independent decision-making was possible in finding their way into the labour market. Other senior
social workers interviewed (Haagh, 2019b, 2019c) noted that some social workers had resisted the
experiment at first, but came to value the changed relationship with citizens. In the case of Kalundborg,
social workers running coffee mornings with unemployed people who were given the option to lead
their own integration plans said the relationship with citizens changed, stating “we got teased a lot –
that was new.” Citizens in these experiments reported a feeling of freedom in being able to “say no” to
employment offers they did not think suited them (Haagh, 2019b, 2019c).
Anecdotal evidence from qualitative interviews carried out in Spain shows that, despite health not
being mentioned in the interview questions, it features strongly as a core area in which beneficiaries
have seen positive programme impacts on health and well-being. This is also the main finding of the
experiment on the effects of lifting conditionalities on the receipt of the major share of income benefits
17 Some also adopt individuality. In some experiments the payment is uniform (e.g. in Denmark and Finland – although
in Denmark some municipalities also give development grants). In the Netherlands, different amounts are experimented
with, and – apart from grants given without any conditons – different types of conditionalities (see Annex 4 and Annex 5 for
descriptions of the experiments). Different types of conditions, inlcuding unconditionality, are also part of the Barcelona trial.
In Denmark, the amounts are related to assistance benefit levels, plus in one municipality there are added benefits. In Finland,
the amounts are below the subsistence level. However, all experiments retain means tests, and they are of limited duration.
13
Chapter 3. Why UBI?
among 2000 unemployed recipients of income security in Finland (Kangas et al., 2019). The fact that
the main employment-related effects of the experiment were motivational rather than behavioural
substantiates the well-being effects of economic security found in other economic security surveys,
with the implication emerging that motivational effects are greater in the context of stable employment
opportunities (Haagh, 2011b).
A second reason for considering these experiments to be linked to UBI is that they tend to emphasize
individuality of status and personhood. Although this is not the same as a guarantee of status
independence, as basic income supporters highlight, the emphasis on the right to self-control of basic
resources is a step in that direction. Third, the UBI experiments herald a new way of thinking about social
assistance bureaucracy, delivery mechanisms and positively connecting income security regimes with
wider social goals. In Europe, the connection between basic services – such as health and education,
and income security systems – has been taken for granted, and the growing disconnect between health
and education services and income security has been allowed to deepen without acknowledgment.
Bringing into view the close interconnection and positive mutual impact of basic income security
and services can be considered an important challenge. Debates which have been more prominent
in the United Kingdom concerning the choice or trade-off between universal basic services and
UBI (Social Prosperity Network, 2017) can be considered as prematurely discounting the important
complementarities between the two approaches. The debate about the two approaches has been
presented in terms of fiscal trade-offs and value-for-money alternatives. This, however, overlooks how
positive complementarities between social services and basic income security for human development
outcomes are stronger in systems in which different social groups benefit from a range of income
transfers and shared services (Haagh, 2012, 2019b). This is also acknowledged by the BMA (BMA Board
of Science, 2016): where a high level of social spending enables provision of shared services, along
with additional support for specific risks and vulnerabilities, a form of proportionate universalism is
possible that protects vulnerable groups without sacrificing universalism.18 Austerity and the processes
of narrowing, targeting and undercutting shared provision involved undermining this logic, juxtaposing
basic services against basic income.
As with partial services, the partial form of so-called UBI trials raises a concern in this context. One
risk of partial UBI in countries that are experiencing high or/and rising inequality is that UBI becomes
an anchor in the development of a reduced-value welfare state, or gets “stuck” in a partial form,
which weakens its impact and stability. While UBI is tested in partial ways, it is only in its entirety of
individuality, universality, unconditionality, permanency and constancy that it is able to deliver on
all the problems listed.19
However, UBI is not a silver bullet. It is therefore important to distinguish between short-term observable
impacts of experiments and the longer-term changes that can be foreseen from the provision of a
stable basis of basic income security. An important indicative finding from the Aarhus experiments in
Denmark is the extent of exclusion and deprivation affecting claimants, and the likely slow progress
of impacts from income security regimes that undergo changes. A particular concern is having too18 An analysis of the effects of taxes and benefits on United Kingdom household income for the finanical year 2017 shows that
the poorest quintile of households received relatively larger amounts of both cash benefits and benefits in kind, while richer
households, on the other hand, paid higher amounts in taxes. Benefits in kind and in cash had the largest impact on reducing
inequalities, while the role of tax benefits was negligible: the ratio of disposable income of the richest quintile to the poorest
quintile in the financial year 2017 was 5:1. The ratio increased to 6:1 on a post-tax income basis (disposable income minus
indirect taxes), but fell to less than 4:1 on a final income basis (post-tax income plus benefits in kind) (ONS, 2018). For details,
see Fig. A6.1 in Annex 6.
19 For why all five elements are considered important, see Haagh (2019b).
14
Universal basic income policies and their potential for addressing health inequities
high expectations linked with labour market integration of beneficiaries, given their vulnerability, low
capabilities, and the depressed nature of labour markets.20 This suggests the sustained integration
of beneficiaries would also depend on other measures, including education, health or housing and
broader economic and labour market policies that transcend national boundaries.
20 The spending plans of the Aarhus experiment beneficiaries revealed a preference for self-development or capability spend,
glasses, a driving licence, a bicycle, a computer, a sewing machine, a delivery van, and so on (Haagh, 2019b, 2019c, 2019e).
15
Chapter 4. UBI: how to make it work for health equity
Chapter 4. UBI: how to make it work for health
equity
In response to global transformations, there is growing recognition of economic stability as a matter of
social justice, well-being and policy efficacy (Haagh, 2012; Goodhart et al., 2012), and as a preventative
health intervention (Reeves et al., 2016). Economic stability is distinct from economic security as a policy
concept. The former comprises the state(s) of enjoying permanent security. This chapter aims to link
the debate on UBI back to health equity by discussing some of the major controversies and challenges
around UBI as concrete policy measures, discussing different models and design options, legal and
institutional challenges and fiscal space, in the light of competing policies between income support
and services. Against this background, an argument exists for an embedded three-tier UBI model,
which may also best respond to health inequities issues (Haagh, 2012, 2019b). Annex 7 summarizes the
debate, distilling the success factors required.
4.1. Design
In the debate around UBI, various models are distinguished: (1) a full basic income model (full UBI),
whereby everybody in society receives the same amount, irrespective of income and situation, replacing
means-tested benefits; (2) NIT; (3) other models of income support, testing different conditionalities
and forms of delivery, which are sometimes also subsumed under basic income policies; and (4) a basic
income model as one tier and in addition to certain social security and social insurance or earningsrelated benefits (Kela FPA, 2016; Forget, 2017).
4.1.1. Full UBI
A full UBI model is usually understood as an approach that would replace a large part of social security
benefits (both contributory and non-contributory). In financial terms, this would mean that the UBI
would certainly need to be higher than current social assistance benefits (Kela FPA, 2016). More
importantly, the model could imply a more complete break between the notion of work and that of
income, implying a radical transformation of welfare, but also of societal thinking as a whole (van der
Veen & Van Parijs, 2006). From the literature reviewed and the interviews with policy-makers involved
in current experiments, it appears that the debate about this model is largely settled. While attracting
a lot of attention as an idea, it is considered largely unfeasible and even undesirable. However, new
normative perspectives are emerging, which conceptualize basic income in terms of the values of
welfare universalism, endorsing a low basic income as a baseline onto which other non-contributory
and contributory transfers and services can build (Haagh, 2013, 2019b).
4.1.2. NIT
NIT, sometimes also termed a partial basic income model, is a tax-based classical social security measure
based on means-tested income compensation by means of taxation once an individual’s income falls
below an agreed threshold. NIT differs substantially from the UBI model in terms of its underpinning
philosophy, which aims to reduce the depth and breadth of poverty by targeting the (working) poor,
with benefit levels varying according to income. Payment modes also differ. The models have similar
end results, aiming to guarantee minimum income and increase incentives for work. A major difference
16
Universal basic income policies and their potential for addressing health inequities
to the basic income models is that it is means-tested.21 In the literature, NIT is discussed as one steppingstone in a broader-based welfare context, where social assistance for specific social and economic risks
– such as motherhood, illness, old age, studying, disability or unemployment – would continue to exist
(often as a combined payment; see, for example, Forget (2017)). In some countries, the proposed NIT
models are combined with active labour market policies in order to reduce disincentives to work.
One of the criticisms of NIT relates to its ex-post character. In order to provide real-time security, real-time
periodic updates of income and salaries across society are needed. Without such updates, the NIT would
become outdated, arbitrary and prone to mistakes (Kela FPA, 2016). Another critical aspect is to create
the NIT in such a way as not to be regressive; that is, to avoid placing the burden on low-income groups.
However, adopting a long-term, welfare system perspective, it is not clear that means testing even
the basic layer of income security is optimal in relation to poverty and health equity goals.22 The
expectation that income security will be clawed back when earnings increase does not fully resolve
the status uncertainties linked with current systems, or the poverty trap and disincentives linked with
reducing benefits; nor does it enable the transformative potential associated with giving individuals
more control over their employment relationship and time for a range of productive activities (including
care). Maintaining dependence on the labour market can have the effect of sustaining the underbelly of
an informal, low-skilled, low-wage economy, which reinforces poverty and sustains the preference for
targeted income security. 23
4.1.3. Other models
Various other models exist that are being discussed or implemented in various countries across the
WHO European Region, testing alternative forms of conditionalities that are discussed in the context
of UBI because they suggest a type of contribution to society other than labour (see Atkinson (1996)).
Participation income, or participatory social security links benefits with communal work, such as care
work or work for nongovernmental organizations, with the aim of strengthening social cohesion and
inclusion. The Dutch and the Spanish trials are currently testing these options: an additional participation
income may be obtained as a top-up to the basic benefits, if beneficiaries participate in voluntary work. In
other countries (such as Germany), this option is being discussed as a potential conditionality.
Critics state that while the content of the conditions would change, participation income would not
change the basic problems and caveats of conditionality and access to basic income in general.24
Contrary to common cost-saving arguments, the creation of participatory work that makes sense to
21 Historically, several NIT-trials have been carried out in the United States and Canada in the 1960s and 1970s. In particular
the B-Mincome Manitoba trial gained a lot of attention (Forget, 2011). The trial in Ontario is assessing a classical NIT model,
which aims to provide income security for the working poor population, while at the same time incentivizing working through
a stepwise threshold model; that is, the compensation is not withdrawn immediately, but progressively, as employment
continues (for an overview, see Annex 4).
22 Moreover, while immediate benefits from a very low baseline can be found, alternative designs might result in improved
heath equity goals.
23 Targeting is more likely to emerge, be sustained or reinforced in conditions of rising inequality or/and poverty. Low real
wages, and unstable income from employment are likely causes of rising inequality and poverty, which tends to entail targeted
grants that are set at a low level to retain incentives to work.
24 This includes questions regarding what is considered participatory work, and how much of it would be necessary, in
order to be eligible. Moreover, who should define such participatory work, or should individuals be allowed to choose their
participatory contribution themselves, including raising children, taking care of elderly or undertaking further education (Kela
FPA, 2016; De Wispelaere & Stirton, 2018)?
17
Chapter 4. UBI: how to make it work for health equity
society may actually be quite costly, often including high administration and management costs.25
Overall, critics also see the risk that participation income could replace paid work and eliminate the
incentives to move into the open labour market (Kela FPA, 2016; De Wispelaere & Stirton, 2018).
Another alternative approach to addressing current welfare challenges is rolling a range of benefits into
one to simplify and flatten income security whilst retaining conditionalities and targeting. Although
only superficially connected to UBI, policy-makers and practitioners sometimes consider universal
credit as a second-best alternative to UBI policies.26 However, the only commonality between universal
credit and universal income policies is semantic. The model currently being implemented in the United
Kingdom combines elements of basic social assistance in one “universal” credit, which decreases as
income increases. It is thus strongly means-tested and involves sanctions in case of non-compliance.
The basic aim of this so-called active welfare model is to reduce poverty by eliminating disincentives to
work and integrate as much people as possible in the labour market. The workfare focus, as opposed to
a needs-based approach, can also be seen in the basic means-testing model, based on household rather
than individual income. Simplifying the scheme through a unification of benefits for different social
risks is also thought to render welfare more efficient and effective, both for providers and beneficiaries.
However, evidence so far is mixed. While participation in the labour market has increased, this often
concerns non-standardized, highly insecure jobs. Contrary to expectations, the change has increased
the complexity of application and delivery processes, increasing exclusionary mechanisms and leading
to major delays in the delivery of benefits. Sanctions create a lot of mental stress, while the householdbased calculation model is considered a major intrusion in peoples’ lives, as it would substantially
influence the way people live, which goes beyond welfare ethics. Universal credit has also engendered
a change in payment modalities, which causes a lot of distress, especially among people with low
incomes who have difficult expenditure decisions to make. While, previously, housing allowance was
paid directly to housing associations, the merging of the housing allowance into universal credit has
put many people at the risk of eviction, as they can no longer manage to pay their rent (NAO, 2018).27
4.1.4. Putting UBI into a broader welfare context: a three-tier model as a longterm goal
Looking at UBI policies through a health equity lens, two aspects deserve specific attention: first, the
relationship between health and income security. While pathways between the two are complex and
context specific, more income does not necessarily translate into more health for all, but needs to be
looked at against the social gradient and the extent of poverty, emphasizing the need to address health
equity simultaneously across the gradient and at its lower, poorest end (Lundberg et al., 2010, 2014;
Marmot et al., 2010). Second, considering the institutional aspect is just as important; namely, how
social policies to address health equity would need to be designed in order to provide incentives and
address (health) needs, including generosity, coverage, and the way they are linked and complement
other policies. Focusing on the poorest in society, the NIT might be perceived as the best approach,
having a strong impact on the lower end of the gradient, but it would probably have limited impact
across the gradient, and the other models seem to be rather unspecific in terms of their impact on health
25 In this context it is worthwhile looking at the controversial debates around public works and guaranteed employment
programmes (McCord, 2010). One reason for the Dutch partial income trial was that the creation of communal works
as prescribed in the active labour market guidelines was so costly for communities that they decided to experiment with
unconditional programme designs and invest the money in more “useful” projects, such as building a communal library
(according to qualitative data from an interview carried out by the author team).
26 Qualitative data gathered from interviews with health practitioners and social policy experts involved in the trials.
27 Qualitative data gathered from an interview carried out by the author team.
18
Universal basic income policies and their potential for addressing health inequities
or, in the case of universal credit, actually work against it; that is, increasing poverty and exclusionary
practices, with considerable negative health impacts.
Adopting a three-tier model of income security with basic income as a foundation (Haagh, 2013, 2019b)
provides a supportive structure within which other needs-based policies and contributory, savingsbased schemes can be built and sustained.28 This foundation model of UBI sits within a broader
income security structure. The three-tier model separates UBI from needs-tested schemes (second
tier) and contributory schemes and occupational incentives (third tier). This system retains the central
features of UBI, which contribute to generating basic income stability for individuals; universality,
unconditionality, individuality, as well as permanence. At the same time, it allows flexibility in terms
of how UBI is combined with other needs-based and contributory systems. Basic income therefore
acts as a structure that supports other systems, and avoids over-simplification of welfare policies by
rolling too many policy functions into a single transfer. The level of UBI can vary with the fiscal capacity
of individual countries, and with the existence of other contributory and needs-based institutions,
depending on political preferences. Within this system, UBI acts as an independent basic foundation
for other needs-based and contributory systems, but entitlement is guaranteed and separated from
entitlements under the other systems. In this sense it has the advantages of two-tier models that
already exist in Scandinavian countries (Haagh, 2007), including the ability of wage earners to retain a
higher level of cover for a period of time, before turning to basic income assistance, thereby generating
a deeper sense of security. The two-tier system also generates social contributions, thus alleviating
fiscal pressures and enabling a broader sense of having a shared stake in mutual insurance across
societal classes, as state subsidy allows lower earners to benefit from this system as well. In the case of
Denmark, studies have shown how tax subsidy avoids an outcome whereby otherwise premiums would
have the effect of excluding people with lower incomes (Bjørn & Høj, 2014; Haagh, 2013).29 Overall,
this makes it possible to provide the sense of basic stability in subsistence entitlement that has been
lacking in Europe, with the health benefits that have been documented, while preserving needs-based
systems (around maternity, and disability, among others), as well as contributory and occupational
affiliations systems and policies.
The thinking behind the three-tier system is that basic income as a foundation will strengthen capabilities
and incentives to contribute and save, which therefore replaces the need for compulsion mechanisms
linked with subsistence support. As such, it also avoids the poverty traps associated with means-tested
basic assistance. This can help address the documented negative health impacts of conditional and
benefits sanctions approaches. Sanctions and conditions can be relevant in contributory systems with
defined access rules, but in this case without putting claimants’ basic security status at risk.
Such an approach may also be useful in dealing with poverty in older individuals, the necessity of which
is expected to increase further as a result of precarious employment trajectories. A basic income grant
understood as being a baseline, in addition to existing ones, would provide important basic security for
this group, as well as for people who – for one reason or another – are not able to find employment. A
three-tier model could also help to close the gaps in existing social protection mechanisms (which lose
their protective capacity as a result of changing labour market and employment conditions), such as
access to unemployment insurance for young people who (depending on temporary jobs) may not be
able to contribute sufficiently (Eurofound, 2017; COPE, 2017). It would also fit well with overall health
equity concerns and the identified pathways in tackling them, in particular proportionate universalism
28 This concerns in particular people with special needs, such as (among others) people with disabilities and social or health
care services involvement, drugs prescription, or child care services (Zon, 2016, 2017; Forget, 2017).
29 For a single person aged over 25 years, coverage was about DKK 7800 per month (after tax) in 2013, compared with the
equivalent of about DKK 2756 in the United Kingdom (not counting housing support in either case) (Haagh, 2019b).
19
Chapter 4. UBI: how to make it work for health equity
(Marmot et al., 2010; Pillas et al., 2014). At the same time as providing a basic income security for all, the
model would encompass targeted policies in order to strengthen health and well-being of specifically
vulnerable groups across the gradient, but in particular at the lower end.
This presupposes that well-being and health equity are considered key concerns and objectives in this
process. Where this is not the case, UBI policy reforms may miss the opportunity to impact on health
equity dimensions in a more purposeful way. In ongoing trials, health equity concerns play no or only
a marginal role (with the notable exceptions of Canada and Scotland). This is not to say that health
equity concerns are not a public concern. On the contrary, the debate around unequal health outcomes
for specifically vulnerable population groups linked to unequal access to public services and related
reforms is quite high on the political agenda.30 However, both debates are taking place in complete
isolation. While evaluation and monitoring frameworks of all trials include a series of health indicators,
the number and quality vary widely and tend to be rather unspecific. Generally, health is considered
a secondary outcome,31 with the main interest focusing on testing impacts on work/workfare/
employability in the context of changing labour markets and bureaucratic welfare state arrangements.
Poverty and income inequality play a role, but they are not central to the debate.
4.2. Administrative, legal and institutional dimensions
Ongoing trials faced considerable legal, administrative and institutional challenges during
implementation; notably, the need for a separate legal framework to enable a temporary exemption of
participants from active labour market policies, taxation and social insurance contributions. This was
compounded by fiscal concerns in some countries, leading to intense conflicts between the central and
local levels, with the latter fearing substantial curtailments to their local tax basis.32
These experiences would clearly speak to a transition to full coverage, rather than proceeding through
isolated experiments creating major legal and moral problems. This is not to deny that implementing
UBI effectively is a long-term challenge and would imply profound administrative, legal and institutional
changes to the current system, notably a reorganization and redefinition of the links between the
various tiers, in particular with regards to insurance mechanisms. Furthermore, the question of the
central State and its responsibility in adequately financing social policies would also need re-opening.33
However, what is evident from all the experiments is that a UBI cannot be implemented in isolation,
30 In Finland, the debate on health inequities is centred on unequal access to health care services that is strongly related
to socioeconomic differences, including employment, education and gender, resulting in large differences in mortality rates
(Kangas & Blomgren, 2014; and qualitative data gathered from an interview carried out by the author team). A broad-based
primary health care reform is currently being discussed, in particular linked to health insurance schemes. In Barcelona there
is great concern about the large gaps in life expectancy between the richest and the poorest areas; these have substantially
increased since the onset of the financial crisis. At the same time, Barcelona is facing huge demographic changes, with an
increasingly old population, which increases the pressure on public services in terms of care services and social integration. In
the Netherlands a major political concern in terms of health inequalities centres on the differences in life expectancy between
so-called blue-collar workers with low education levels, and those with higher educational backgrounds. Currently, a change
in the pension system is envisaged, allowing workers with a long career in blue-collar jobs to retire earlier, so as to regain a
few years in life expectancy.
31 In some countries the inclusion of basic health indicators in the evaluation frameworks is the result of the professional
interest of researchers involved, rather than the ministries, municipal departments or insurance institutions commissioning
the experiments.
32 Qualitative data gathered from an interview carried out by the author team.
33 In a number of trial countries, design and implementation of the experiments led to intense conflicts between central and
local government levels in terms of financial responsibilities, with the latter fearing potential cuts in their tax base, as well as
in terms of legal issues related to the exemption from centralized conditional labour market policies.
20
Universal basic income policies and their potential for addressing health inequities
but would need to be implemented on an incremental basis and simultaneously to complementary
adjustments and modifications of existing welfare arrangements.
4.3. Financing
An important dimension of the UBI debate is how to finance it. Various models exist dealing with how
to calculate the costs of UBI.34 Here, some general points should be raised. First, a major criticism of
UBI is that financing aspects are not critically discussed and advocates tend to turn a blind eye to the
economic realities, in particular the deregulatory tendencies in global economic development. The
divestment of finance institutions from the productive sector, by concentrating its investments on
the speculative sphere, some authors argue will have an enormous impact on the real economy, as
interest on loans may increase substantially over the following years and lead to a major increase in
debt problems (Lavinas, 2018; Haagh, 2019c). In a recent paper, Flassbeck (2016) critically questions
the fact that calculations on costs for a UBI systematically tend to exclude the political dimension that
is invariably linked to such proposals, such as an increase in VAT or taxing financial transactions – often
against the interests of entrepreneurs, big companies and rich people. At the same time it is worth
noting that global financial institutions (IMF, 2017) are advocating the need to rebuild fiscal capacity,
especially in relation to progressive taxation, and have considered UBI as being relevant in some
country scenarios.
In the case countries, broader financial implications have not been discussed, as most trials are clearly
limited in time and are termed “experiments” and not “pilots”, which would suggest an expansion into
the future. However, one important aspect that transpires from all the interviews is to consider the
costs of not implementing any intervention at all; that is, the financial, economic and social costs of
neglecting rising economic inequalities and, for that matter, health inequities too: “while UBI inspired
reform policies may mean an increase in costs, so will costs increase if we stick to the current system”35
(see Cecchini & Martínez, 2012; Bonilla Garcia & Gruat, 2003).36
Since countries also face pressures to increase spending on services, the likelihood is that public policy
debate will become politicized and focus on the choice between income and services as means of
human development. It is difficult to avoid this trap in the short term and it is therefore important to
create awareness of its conditions and impacts, and in particular of the necessity to strengthen both
basic services and income security in order to achieve intended outcomes (see Section 3.3 on the
challenge of complementarity within UBI). Engaging this challenge productively requires political will,
long-term planning, effective political communication, and making human development an overall
goal and a public priority guiding fiscal reforms. See Annex 7 for a more detailed insight.
34 Estimates vary widely, clearly also depending on the design and proposed benefit level. Various financing models and
calculations have been carried out by various institutions and researchers (Kela FPA, 2016; Arcarons, Raventos & Torrens,
2014; OECD, 2017b; Widerquist & Lewis, 2005; Richardson et al., 2018; Citizen’s Basic Income Trust, 2018). Different financing
modalities are being discussed, ranging from traditional means of increasing income, property tax or VAT to more innovative
solutions of additional taxes on natural resources, or on air pollution (Goldhill, 2016). An aspect which dominates the financing
debate is whether UBI would actually cost more than existing schemes, or whether UBI could be largely financed by merging
existing schemes, in addition to proposed efficiency gains through leaner administration and bureaucratization.
35 Qualitative data gathered from an interview carried out by the author team.
36 Evidence from Latin America suggests that the most important drivers for narrow targeting as the model of choice in income
security were flawed, represented by the theory that poverty is temporary and represents an individual responsibility, and the
theory that insecurity of income or status is conducive to motivation and effort. This has important implications for countries
in Europe with less-developed income security systems, highlighting the importance of adopting a road map for income
security coverage that is motivated by long-term social development goals, rather than short-term costs or political trade-offs.
21
Chapter 4. UBI: how to make it work for health equity
4.4. The role of local government
Local government plays a key role in the reform context of social protection and UBI policies in
particular, being one of the main drivers behind UBI experiments and wider social policies in many
countries. This is on the one hand related to the traditional role of local government in delivering social
assistance, which in many countries is also linked to a certain degree of autonomy in setting transfer
levels or deciding conditionalities – often in addition to national programmes; on the other hand, the
local level is the most decentralized government level, whereby effects of austerity and cut-backs in
public services have more immediate impacts (also in terms of administrative and financial burden),
through increased demand and casework.37 It is thus not surprising that local government has a strong
interest in basic income policies, as any shift in changing living conditions and/or demand in services
are registered more directly and sooner than at other government levels. A basic income policy funded
and extended at national level could give a much-needed boost to local government services, by
making policies that target needs and employment policies at this level more effective.
UBI design is not only about creating the most technically sound and most efficient and effective
model, but also a politically palpable one. This may imply some trade-offs in the short and medium
term, within an overall long-term perspective. In this respect, the debate on UBI also needs to be
understood as an important platform and catalyst to discuss and propose a broad range of ideas and
policy alternatives, including with regards to wider economic and public policies; for example, in the
debate around tax justice for social justice, which in the long run may lead to the implementation of UBI
policies (Richardson et al., 2018).
37 The Netherlands, which has a highly decentralized social protection system (including in terms of financing), or the
municipality of Barcelona, which suffers from a total mismatch and parallelism between national and local-level social
assistance schemes, are two such examples.
22
Universal basic income policies and their potential for addressing health inequities
Chapter 5. Discussion and recommendations
An unconditional UBI involves building a universal tier of income security that is unconditional and not
means-tested. The presence of such a system allows other supplementary income transfers to be built
in a way that can minimize the problems of stigma, the poverty trap and work disincentives associated
with post-war means-tested systems. A UBI system can support economic adjustments and work
incentives by allowing individuals to take greater control over their lives when affected by changes
in the economy. In doing so, it also addresses health inequalities and well-being. This concerns in
particular the documented negative health impacts of contemporary income security systems, which
involve uncertainties about subsistence status. As part of a tiered model, UBI – in close complementarity
with universal services – can help support the building of welfare systems based on the principle of
proportionate universalism, providing basic income stability that is both crises preventative and health
constitutive. Being based on a basic income fall-back net for the whole population, linked into targeted
policies aimed at specifically vulnerable groups, specific needs and demands can be addressed. This
is in line with WHO’s approach and the concept of proportionate universalism – providing universal
policies that act across the whole gradient but are implemented at a level and with intensity that is
proportionate to need; that is, addressing specifically the needs of people at the bottom of the social
gradient and the people who are most vulnerable (WHO Regional Office for Europe, 2014; Marmot et al.,
2010), without sacrificing universal inclusion.
Adopting a universal income scheme would imply a profound transition in terms of how social welfare
systems are currently set up, which – contrary to the profound transitions taking place in economics
and employment – appear to face much stronger resistance in terms of acceptance. This is the case
politically, financially and socially. This paper’s proposal is therefore to view UBI as a long-term goal
and as part of a basket of measures, which gives room for adopting differently staged transitions and
models across countries in view of differential institutional and fiscal capacity and political contexts.
The type and scale of challenges involved will vary by country and across the WHO European Region.
Some countries with strong fiscal systems can envisage a relatively short transition to UBI.38 In such
cases, reform may involve converting tax-free allowances and the lower tier of comprehensive income
security systems that are already in place. Other countries with less comprehensive minimum income
security systems and fiscal provision may consider a transition via an NIT model, which involves means
testing but in a form that is not directly connected with labour market conditionalities, and thus avoids
some of the key features of current sanctions-based systems, which lead to non-uptake and social
exclusions (see Richardson et al., 2018). In countries with weak income security systems in place and
middle-income countries, the long-term goal of UBI can help avoid some of the problems of conditional
cash transfer schemes, including time delimitation and other access barriers affecting the poor. In
those countries, the basic income tier may actually provide the foundation and primary intervention
on which to build and expand the higher-level tiers.
Building a system of universal support steadily, by first ensuring effective coverage of the lowest-income
quintiles and gradually implementing a comprehensive basic income system can also be used as a way
to support formalization and transparency in tax-benefit systems, and to build or rebuild contributory
systems. The foundation or three-tier model of UBI discussed in Chapter 4 is an adaptable structure
that can be built on over time and in accordance with differing existing levels of fiscal and institutional
38 It can be noted that in countries deemed able to fund a UBI, combined with existing universal services and other contributory
systems the share of tax in GDP is about 50% (Colombino et al., 2010).
23
Chapter 5. Discussion and recommendations
capability across countries. Recommendations concerning basic income as a foundation for other
contributory systems (Haagh, 2019b) are very similar to those made by global organizations concerning
three-tier pensions. In this case, UBI guarantees security – with the health benefits that security is
known to have – but does not exhaust possibilities for added income security protection. Focusing
on the lowest income quintile first would also strengthen the effectiveness of health interventions to
address health inequalities, in particular for those at the lower end of the gradient.
The perspective on UBI policies as a long-term goal should not prevent policy-makers from undertaking
first steps towards this goal. The UBI experiments reviewed in this paper have shown that – despite
mimicking only limited features of UBI – even small changes to the commonly known welfare–workfare
logic have a huge impact, such as lifting conditionalities and sanctioning regimes. Other potential shortterm measures towards implementing UBI as a long-term goal include the universalization of access to
specific benefits, such as child allowance or disability benefits (see, for example, Matkovic, 2017; WHO
Regional Office for Europe, 2014; Marmot et al., 2010).39 Implementing such shifts on a large-scale basis
would allow important pilot experiences to be generated, which may have a much stronger weight in
future policy discussions than small, complex, short-term experiments.
At the same time, it is evident that the scope and legitimacy of three-tier systems (involving lifelong
basic security, means-tested top-ups, and voluntary or compulsory contributions and voluntary savings
elements) depend on the future of work and employment. UBI policies are only one measure in a policy
basket to ensure sustainable and inclusive growth and development. Countries with more stable and
better distributed employment opportunities will be better able to sustain three-tier systems. The
more deregulated the labour market, the greater the pressures will be to raise the level of UBI and/
or means-tested transfers, because contributory systems will be less realistic. Reforms to the current
labour market, wide-ranging fiscal reforms as well as appropriate economic and trade policies are
equally important in order to sustainably reduce inequities and prevent gaps from widening.
This is also in line with the 2030 Agenda, with its focus on health and well-being for all and at all ages,
as a key condition for economic development to which WHO has committed. Equally, it aligns with the
European Pillar of Social Rights, in particular with regards to the creation of efficient employment and
better social outcomes.
Further investigation of the potential for UBI to improve systems of income security and health should
take account of broader factors in the economic and regulatory environment. Insecurities within the
labour market are not directly resolved by a UBI; while a UBI can help support work incentives, the
overall impact of UBI on the labour market and health will depend on a wider range of factors (Haagh,
2019b). Labour market policies, such as better control over working life or more stable contracts may
be equally important for people to experience better health (Haagh, 2011b). Wider macroeconomic
dimensions, such as (among others) disinvestments in the productive sphere, and innovative solutions
for creating fiscal space are key for creating a more stable economic environment that allows for
inclusive growth. This, in turn, may create feedback effects on financing social protection measures.
39 For an example of the effects of child allowances in reducing child poverty, see Fig. A8.1 in Annex 8.
24
Universal basic income policies and their potential for addressing health inequities
5.1. What role for WHO?
The debate around UBI has a clear link to Health in All Policies (HiAP) as a policy approach and an
understanding of health as being influenced by factors other than health policies and conditions, which
are both firmly anchored in Health 2020. Notwithstanding, the health sectors at country level appear
largely to lack vision and a narrative linking to the debate around basic income policies and their role
for health inequalities, creating a political and institutional stake. This appears to be worse in countries
where (health) inequalities are only beginning to widen and debates around universal policies are
largely taking place without the involvement of the health sector.
WHO thus has an important task to perform in supporting countries to explore further the health
implications of universal and stable income security, considering impacts on individuals, society, and
health delivery institutions in particular.
• Health should be promoted as a common good. Supporting Member States in developing a health
(equity) narrative that moves away from health as a lifestyle issue towards health as a social justice
agenda is essential, emphasizing the key role of income security as a preventative health measure
(Reeves & Loopstra, 2017) and the need for the health sector to engage with other sectors (in
particular in the debate around much-needed universal income policies, in close interconnectivity
with universal health care services) (Haagh, 2019b). A range of important policy frameworks exist
on which to build, including Health in All Policies, wide-ranging work on the social determinants
of health, the European Pillar of Social Rights and the SDGs. Herein, WHO could play a key role
in facilitating the exchange of experiences across countries on how to create and influence policy
processes in this direction, including the development of advocacy and communication tools that
support partner countries to better communicate across government, enabling them to create
consensus and “win-win” situations for health.
• WHO has a role as a regional knowledge broker and facilitator. It is important to create
communities of interest by uniting different stakeholders engaged in health, social services and
income protection, as well as across different government tiers.
• WHO should provide guidance and evidence. Evidence on health inequities across policy sectors
and across different tiers of government should be collected and provided. As a regional body,
WHO would be in an ideal position to host such evidence, providing guidance on methodological
issues involved in collecting evidence, as well as identifying priorities for building datasets on
health equity at country level; this also includes the promotion and further development of health
impact assessment as a tool to be systematically applied by governments and health actors to
assess the impact of wider economic and social policies, in order to elevate health considerations
to the same plane as other outcomes of concern (APHA, 2012; Wismar et al., 2007). WHO Regional
Office for Europe’s Footprint Initiative, aiming to measure economic and social impacts of health
systems at local, regional and national levels, may provide an additional tool in this regard (Boyce
& Brown, 2019). Such a role for WHO would also include supporting countries in feasibility research,
modelling and micro-simulation of different UBI models, and promoting and developing further
tools to be provided to Member States in cooperation with countries and regions that have already
moved ahead in this field (e.g. Scotland’s Triple I; see Annex 4).
25
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36
Universal basic income policies and their potential for addressing health inequities
Annex 1. The WHO European Health Equity Status
Report Initiative (HESRi)
The WHO HESRi has three core objectives. It intends to:
1. set a baseline for monitoring health equity status and health equity policy progress within countries
of the WHO European Region (Accountability, and Priority for Health Equity);
2. set an agenda for scaling up action to increase equity in health within countries and across
communities of practice in the Region (Action for Health Equity);
3. create a strong voice for political advocacy for health equity in the Region (Advocacy, Dialogue
and Constituency-building for Health Equity).
A key purpose of the HESRi is to capture what is already working to reduce health inequities and to
bring forward for discussion promising approaches, with the potential to: (a) create the conditions for
all people to prosper and flourish, in health and in life; and (b) remove barriers that are holding people
back by from being able to live a healthy life and achieve their potential.
Often efforts to reduce health inequities depended on single policy measures (e.g. education) and at
times, the impact of these policies has been overestimated. Scaling up action on health equity and
enabling the conditions necessary to lead healthy and prosperous lives therefore require a combination
of policies and interventions.
The HESRi is based on five interrelated action areas in which policies can be strengthened and progress
monitored (See Fig. A1.1).
Fig. A1.1 Action areas to increase equity in health and well-being within countries
These action areas are closely interlinked, producing the key conditions needed to be able to live
a healthy life. They include: (1) health services; (2) income security and social protection, including
universal health care; (3) living conditions; (4) social and human capital, including community
capacities; and (5) employment and working conditions.
Evidence clearly suggests that a coherent basket of interventions (policies, services and programmes)
across all five of these interrelated areas may work best to level up health opportunities and outcomes
across the population (WHO Regional Office for Europe, 2014).
In addition to policy coherence, the HESRi highlights the need to tackle the underlying causes of
inequity, including participation, empowerment and accountability for health equity, with the aim
of reducing stigma, removing barriers to participating in social, economic and cultural life, as well as
increasing individual and community resilience and control over destiny.
37
Annex 2. Structured interview guideline
Annex 2. Structured interview guideline
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR EUROPE
WELTGESUNDHEITSORGANISATION
REGIONALBÜRO FÜR EUROPA
ORGANISATION MONDIALE DE LA SANTÉ
BUREAU RÉGIONAL DE L'EUROPE
ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ
ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО
Interview Guideline UBI WHO EURO page 1
The WHO European Health Equity Status Report initiative (HESRi)
Discussion paper on how Universal Basic Income Policies can contribute to accelerating
progress to reduce inequities in health within the diverse context of
the WHO European Region
Guidance for interviews contributing to the WHO Discussion paper
Introduction and Purpose of the Discussion paper
Progress to reduce health inequities across countries of the WHO European Region in the last 10 years
has been mixed. For example in more than half of Member States inequities in life-limiting illness and
poor self-reported health by quintile groups have remained the same or have increased between 2008
and 2015, infant mortality continues to follow a social gradient in transition economies and there are
worrying trends in falling life expectancy by gender and socio-economic status in some high income
countries. Against this backdrop health Policy makers and practitioners are looking for innovative
solutions and mechanisms that may help to address the structural factors or pathways to health, in
order to reduce health inequities and improve well-being for all. The WHO European Health Equity
Status Report initiative (HESRi) is taking up this challenge with the aim to
1. Set a baseline for monitoring health equity status and health equity policy progress within
Countries of the WHO European Region .
2. Set an agenda for scaling-up action to increase equity in health within countries and across
communities of practice in the European Region.
3. Create a strong voice for political advocacy for health equity in European Region
The HESRi is being led by Chris Brown and the team at the WHO European Office for Investment for
Health and Development, based in Venice Italy. Core to the work of the HESRi is to capture what is
already working to reduce health inequities and to bring forward for discussion, promising approaches
with the potential to
Create the conditions for all people to prosper and flourish, in health and in life
Remove barriers that are holding people back by from being able to live a healthy life and to
achieve their potential.
Purpose of the interviews
Within this context the aim of this policy research is to review the extent to which Universal Basic
Income Policies can contribute to accelerating progress to reduce inequities in health within the
diverse context of the WHO European Region.
The specific request of the WHO HESRi is to take a closer look at the current debate and role of UBI for
health equity as being taken up by Member States. It also relates to wider policy processes making
reference to the WHO EURO strategy Health 2020, but also to the Agenda 2030 and its core objective
The WHO European Health Equity Status Report initiative (HESRi)
Discussion paper on how universal basic income (UBI) policies can contribute to accelerating
progress to reduce inequities in health within the diverse context of the WHO European Region
Guidance for interviews contributing to the WHO discussion paper
Introduction and purpose of the discussion paper
Progress to reduce health inequities across countries of the WHO European Region in the last 10 years
has been mixed. For example: in more than half of Member States inequities in limiting illness and
poor self-reported health by quintile groups have remained the same or have increased between 2008
and 2015; infant mortality continues to follow a social gradient in transition economies; and there are
worrying trends in falling life expectancy by gender and socioeconomic status in some high-income
countries. Against this backdrop, health policy-makers and practitioners are looking for innovative
solutions and mechanisms that may help to address the structural factors or pathways to health, in
order to reduce health inequities and improve well-being for all.
The WHO HESRi is taking up this challenge, with the aim to:
1. set a baseline for monitoring health equity status and health equity policy progress within
WHO European Region Member States;
2. set an agenda for scaling-up action to increase equity in health within countries and across
communities of practice in the WHO European Region;
3. create a strong voice for political advocacy for health equity in the Region.
The HESRi is being led by Chris Brown and the team at the WHO European Office for Investment for
Health and Development, based in Venice, Italy. Core to the work of the HESRi is capturing what is
already working to reduce health inequities and bringing forward for discussion promising approaches,
with the potential to:
• create the conditions for all people to prosper and flourish, in health and in life;
• remove barriers that are holding people back from being able to live a healthy life and achieving
their potential.
Purpose of the interviews
Within this context, the aim of this policy research is to review the extent to which UBI policies can
contribute to accelerating progress to reduce inequities in health within the diverse context of the WHO
European Region.
38
Universal basic income policies and their potential for addressing health inequities
The specific request of the WHO HESRi is to take a closer look at the current debate and role of UBI for
health equity as being taken up by Member States. It also relates to wider policy processes, making
specific reference to: the WHO European health policy framework Health 2020; the 2030 Agenda for
Sustainable Development and its core objective of leaving no one behind; and the European Pillar of
Social Rights (2017), which emphasizes the role of social rights for the creation of efficient employment
and better social outcomes, along with an inclusive and fair growth model.
As part of this research, the WHO HESRi, based at the Venice Office, is carrying out qualitative interviews
with health practitioners, experts working in the field of health inequities, and policy-makers concerned
with inclusion and well-being, who are all engaged in the debate around UBI and its potential for
reducing health inequities and/or are involved in UBI pilots and experiments already under way. The
aim of the interviews is to get a better insight into the debate around health inequities and UBI in
your country/region/city, including the major drivers behind the debate, stakeholders involved, the
perceived potential of UBI for health inequities and the perceived challenges, as well as the wider
political and societal debates that are ongoing.
Interview style
• The interview is based on a structured interview guideline and should last around 45 minutes.
• To aid a smooth process and analysis, with your permission we would like to record the interview.
• The interview will be partly transcribed and analysed and will constitute a major source for informing
the discussion paper; however, the information obtained will remain strictly confidential and will be
anonymized.
• Any consented recording of the interviews will be destroyed after transcription.
Interview questions
1. Before discussing UBI, please could you tell us more about health equity in your country. What
are the major issues around health equity/ inequity? How is it currently “positioned” within the
priorities of government and wider society? Are any specific goals and approaches being pursued?
Who/what is the motivation or drivers behind the priorities/goals and approaches?
2. How did UBI get onto the political agenda in your country/region/city?
3. What are the drivers behind the debate on UBI? What are the major issues that have nurtured the
debate on UBI?40
4. Does health in general, and health equity/reducing inequities specifically feature in the debate
around UBI? If yes, in what ways? If not, what do you think are the reasons for this?
5. Who is driving the UBI process in your country and what do you consider to be the underlying
interests, motivations and goals?41
6. Looking at people’s health and well-being, evidence suggests that the classical welfare approaches
that have dominated the post-war period – being based on a specific employment and labour
market model – are no longer in the position to address existing health inequities. Do you agree
with this statement, or not? Please tell us more about this. If you agree, in your opinion what are
40 Suggestion: probe for wider debates in society and politics that touch upon issues of well-being, social justice and
sustainable development.
41 This could include stakeholders, groups and institutions that play a key role in moving these issues forward.
39
Annex 2. Structured interview guideline
the major challenges/reasons why things are not working out?
7. UBI has three core features that are all important, and should be set together: individuality of the
benefit; no conditions applied to the basic benefit, such as work tests on health or education/
training measures; and no means testing.42 There is also the issue of the size of the benefit, as
people should be allowed to make a decent living. Compared to current social and health policies,
what advantages would you see with the introduction of a UBI for tackling pathways to health?
What are your expectations for UBI in terms of improving health equity? What does it offer/what
role can UBI play in tackling health inequities?
8. WHO’s position is not to substitute other policies for UBI; it is understood as a package of several
policies that create the conditions for good health and well-being for all, used to tackle multiple
inequities which hold people back in health and in life. What is the debate in your country? What
kind of UBI is debated and what role does it play in relation to other policies and services?43
9. How does this match your perspective/position on UBI from a health equity perspective?
10. There is a lot of debate around UBI at political and societal levels, but only a few countries/regions
have started to implement pilots. From the health point of view, what would you consider the most
important challenges with regards to implementing UBI approaches?
11. We have talked a lot about UBI, which is currently receiving much attention and is widely debated.
What could be alternative approaches/measures, if any?
12. What role could WHO HESRi play to support countries, with respect to:
• UBI in particular;
• promoting equity in health, generally;
• supporting policy-makers with common challenges and interests? Specifically, this means
encouraging them to implement, share and innovate in best practices (in terms of both policies
and approaches) to increase equity in health and well-being as part of their broader development
agendas and plans.
13. Additional comments/reflections/information are welcome.
42 For probing/clarification: not setting a means test is argued for in order to avoid stigma and work disincentives that arise
if benefits are clawed back with earnings. Individuality is argued for as it protects rights; for example, those of women in
households. Finally, having no work tests is argued for to encourage individuals to search for jobs they are motivated to do
and keep.
43 For probing/clarification: there are four basic approaches to basic income security which involve all, some or none of
the components of UBI. For example, some people argue that a partial UBI is best, combined with other means-tested and
contributory policies, as a “top-up” for groups that need or have paid into insurances to attain additional support. This means
keeping many existing benefits, but making a basic benefit floor that is universal to all, to avoid stigma, etc. A second approach
entails UBI replacing most means-tested benefits. Finally, a third (and fourth) approach involves no universal benefit – no UBI
– but retains the current approach of tailoring benefits only to need. Within this there are two options (constituting the fourth
approach): assessing only need but not setting behaviour conditions; or, assessing need and setting behaviour conditions.
From a health and a practical perspective, which do you think would work best?
40
Universal basic income policies and their potential for addressing health inequities
Annex 3. The equality paradox: public finance
conditions for human development and a healtheffective basic income reform
It is broadly recognized that various conditions shape the positive health benefits of basic income
reform. Several welfare scholars have linked effective welfare policies to the scale effect, with both
the level of public finance and the reach of services across populations playing a role (Hills, 2015;
Rothstein, 1998; Korpi & Palme, 1998; Haagh, 2002, 2012; Kangas & Blomgren, 2014). This is highly
relevant for basic income because it is wide-reaching by definition. On the other hand, the depth of
this reach – for example, whether it extends beyond mere subsistence to generate conditions for active
inclusion – depends on other human development-sustaining policies, and ultimately on the reach and
scale of the whole system of public finance (Haagh, 2012, 2015). In this context, although interviews
with stakeholders highlight concerns about the connection between basic income and contributive
systems, a positive case can be made for how basic income supports a rebuilding of contributory and
employment systems in the context of a more active welfare state (Haagh, 2019b).
Fig. A3.1 and Fig. A3.2, derived from Haagh (2019b, 2019d44), set the level of inclusiveness of public finance
systems against the level of public investment in select core human development-promoting policies;
in particular, education, support for employment training, and care/family benefits. A propensity to
support higher levels of human development investment in inclusive tax states with correspondingly
high levels of economic formalization of employment reaffirms a core hypothesis elaborated by Korpi &
Palme (1998), to the effect that redistributive (targeted) welfare policies tend to coincide with low levels
of welfare financing, and vice versa. Comparing tax systems and human development spending preand post-austerity, the illustrations show a propensity to sustain human development investments,
despite a tendency towards erosion of the level and inclusiveness of tax systems during the period
of austerity, especially within European countries. This presents a challenging policy scenario, which
explains the tendency to favour caseload reduction within income security provision in the period after
the onset of the financial crisis in 2007. However, a policy to promote deregistration from public income
security support systems is counterproductive in a context of rising job insecurity. Paradoxically, basic
income may seem less urgent in countries in which basic income is fiscally feasible (known as the
equality paradox, as discussed in Haagh (2019c)). However, it is important to think beyond short-term
fiscal constraints to consider how the design of income security institutions can be improved. The role
of universal basic income (UBI) reform in this context is pivotal because, even as countries recover
fiscal capacity, an inclusive design of income security institutions will be crucial in order to derive the
best return to investment in other areas of social provision (such as education and health) and to build
capability for effective employment promotion.45
44 More in-depth understanding of the data can be gained from the online appendix to Haagh (2019b) (http://politybooks.
com/bookdetail/?isbn=9781509522958&subject_id=4).
45 Research which looks at long-term employment effects of alternative income security designs shows better sustained
employment outcomes under systems with more stable (long-term) income security provision (Tatsiramos, 2006; Griggs &
Evans, 2010). Even cases of so-called moral hazard, e.g. where recipients of unemployment insurance remain covered after
taking employment, suggest external sources of income security act as a springboard for employment integration (Chahad,
2004; Haagh, 2011b).
41
Annex 3. The equality paradox: public finance conditions for human development and a health-effective basic income reform
Fig. A3.1 Trends in fiscal capacity and human development spending, 2000 (plus available data trends)
PUBLIC REVENUE
LOW HIGH
HIGH
PUBLIC
SPENDING ON
HUMAN
DEVELOPMENT
LOW
United Kingdom
Sweden
Denmark
Czechia
United States
Finland
Poland
Austria
Ireland
New Zealand
Italy
Hungary
Germany
South Korea
Netherlands
Norway France
Belgium
Spain
Australia
Mexico Japan
Portugal
Notes. Available data trends range from 1975 to 2015. The diagram is intended to give a representation of
welfare state structure by setting different measures together, presenting an overall picture of the level of and
trends in public fiscal capacity (tax on various types of revenue), on the one hand, and human development
spending on child care, education and training (social spending in GDP, share of social expenditure, etc.), on the
other hand. Details of the data points and measures can be found in Haagh (2019b), in the online appendix.
Source: adapted from Appendix tables A.1 and A.2 in Haagh (2019b).
Fig. A3.2 Trends in fiscal capacity and human development spending, 2015 (various years) (plus available
data trends)
United Kingdom
Sweden
Denmark
Czechia United States
Finland
Poland
Austria
Ireland
New Zealand
Italy
Hungary
Germany
South Korea
Netherlands
Norway
France
Belgium
Spain
Australia
Japan Mexico
Portugal
PUBLIC REVENUE
LOW HIGH
HIGH
PUBLIC
SPENDING ON
HUMAN
DEVELOPMENT
LOW
Notes. Available data trends range from 1990 to 2016. The diagram is intended to give a representation of
welfare state structure by setting different measures together, presenting an overall picture of the level of and
trends in public fiscal capacity (tax on various types of revenue), on the one hand, and human development
spending on child care, education and training (social spending in GDP, share of social expenditure, etc.), on the
other hand. Details of the data points and measures can be found in Haagh (2019b), in the online appendix.
Source: adapted from Appendix tables A.1 and A.2 in Haagh (2019b).
42
Universal basic income policies and their potential for addressing health inequities
Fig. A3.3, A3.4 and Fig. A3.5 (based on Haagh, 2019a, 2019c) show countries’ administration and training
expenditure during pre- and post-austerity employment transitions. Although policies emphasizing
benefits sanctions became more common before the 2008 crisis, this event deepened the use of benefits
sanctions and caseload reduction targets to implement fiscal retrenchment goals. The illustrations
show rising investment in benefits administration, but without a uniform level of response in spending
on education and training in employment transitions. This suggests countries with a similar level of
sanctions within benefits systems (such as the United Kingdom and Denmark) administer employment
transitions and sanctions very differently (Haagh, 2019a, 2019c). Negative health outcomes of sanctions
are a direct result not of the level of state investment in benefits administration, but rather of the level
of marketization of the labour market and the effects this has on both the application and effect of
sanctions on social exclusion and health outcomes (Haagh, 2019a, 2019c). For example, in Denmark
negative health impacts of sanctions policies are cushioned by protective legislation and education
investments.
Fig. A3.3 Public support for employment transitions, 2007
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0
BENEFIT ADMINISTRATION AND PLACEMENT SERVICES
(% of GDP spend)
TRAINING
AND OTHER
ACTIVE MEASURES
(% of GDP spend)
South Korea
Sweden
Denmark
Austria
United States
Finland
Portugal
Australia
Spain
Ireland
New Zealand
Italy
Hungary
Germany
Netherlands
Norway
France
Canada
Belgium
J Czechia apan
Chile
United Kingdom
Poland
0 0.1 0.2 0.3 0.4 0.5 0.6
Notes. Other active measures include: employment incentives, supported employment and rehabilitation,
direct job creation, and start-up incentives. Details of the data points and measures can be found in Haagh
(2019b), in the online appendix.
Sources: adapted from Haagh, 2019b; data elaborated from Organisation for Economic Development (OECD)
Employment Outlook 2010 (OECD, 2010).
43
Annex 3. The equality paradox: public finance conditions for human development and a health-effective basic income reform
Fig. A3.4 Public support for employment transitions, 2010
South Korea
Sweden
Denmark
Austria
United States
Finland
Portugal
Australia
Spain
Ireland
New Zealand
Italy
Hungary
Germany
Netherlands
Norway
France
Canada
Belgium
Czechia Chile
Slovakia
Poland
BENEFIT ADMINISTRATION AND PLACEMENT SERVICES
(% of GDP spend)
Japan
TRAINING
AND OTHER
ACTIVE MEASURES
(% of GDP spend)
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0
0 0.1 0.2 0.3 0.4 0.5 0.6
Notes. Other active measures include: employment incentives, supported employment and rehabilitation,
direct job creation, and start-up incentives. Details of the data points and measures can be found in Haagh
(2019b), in the online appendix.
Sources: adapted from Haagh, 2019b; data elaborated from OECD Employment Outlook 2013 (OECD, 2013).
Fig. A3.5 Public support for employment transitions, 2014
Sweden
Denmark
Austria
Finland
Portugal
Australia
Spain
Ireland
New Zealand
Italy
Hungary
Germany
Netherlands
Norway
France
Belgium
Chile
Poland
BENEFIT ADMINISTRATION AND PLACEMENT SERVICES
(% of GDP spend)
South Korea
United States
Canada Japan
Slovakia
Czechia
TRAINING
AND OTHER
ACTIVE MEASURES
(% of GDP spend)
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0
0 0.1 0.2 0.3 0.4 0.5 0.6
Notes. Other active measures include: employment incentives, supported employment and rehabilitation,
direct job creation, and start-up incentives. Details of the data points and measures can be found in Haagh
(2019b), in the online appendix.
Sources: adapted from Haagh, 2019b; data elaborated from OECD Employment Outlook 2016 (OECD, 2016).
44
Universal basic income policies and their potential for addressing health inequities
Annex 4. UBI initiatives in Europe and Canada Country Name Size Aims and objectives Research design Effects measured Canada Ontario’s basic income trial (stopped due to change of government in July 2018) 6000 people Randomly selected from among the eligible population:
• aged between 18
and 64 years
• resident in one
of the locations
for more than 12
months
• living on a low
income
The pilot will test
whether a basic
income can better
support vulnerable
workers, improve
health and education
outcomes for people
on low incomes and
help to ensure that
everyone shares in
Ontario’s economic
growth.
4 000 people will receive will
receive:
• up to $16 989 per year for a
single person, less 50% of any
earned income;
• up to $24 027 per year for
a couple, less 50% of any
earned income;
• up to $6 000 additionally for a
person with a disability.
Randomly selected control
group of 2000 eligible people
who will not get the transfer.
The basic income will be
decreased by 0.50 cents for
every dollar earned through
work.
People who receive money
from employment insurance
or a pension plan will have a
reduced basic income. All the
other benefits will be exempted.
• Food security
• Stress and anxiety
• Mental health and health care
usage
• Housing stability
• Education and training
• Employment and labour
market participation
Source: Government of Ontario,
2017.
45
Annex 4. UBI initiatives in Europe and Canada
Country Name Size Aims and objectives Research design Effects measured
Finland The Basic Income
Experiment (trial)
1 January 2017 –
31 December 2018
2000 participants
randomly selected
from recipients of
unemployment
benefits.
The basic income is
intended to:
(a) reduce the amount
of work involved in
seeking financial
assistance;
(b) free up time and
resources for other
activities, such as
working or seeking
employment.
The aim of the pilot
is to:
(a) evaluate whether a
basic income could
help to simplify
the social security
system; and
(b) associate it with
stronger work
incentives.
Target group was residents of
Finland aged between 25 and
58 years who were on paid basic
unemployment allowance or
other labour market subsidy as
of November 2016.
Size of transfer: 560 Euro/
month
The basic income is paid
unconditionally and without
means testing.
Recipients get it automatically
once a month.
How could the social security
system be redesigned to
address the changing nature of
work?
Can the social security system
be reshaped in a way that
promotes active participation
and gives people a stronger
incentive to work?
Can bureaucracy be reduced
and the complicated benefits
system simplified?
Source: Kela FPA, 2016.
46
Universal basic income policies and their potential for addressing health inequities
Country Name Size Aims and objectives Research design Effects measured
Netherlands Research project:
Weten wat werkt/
What works
900 participants
(randomized trial)
June 2018 –
October 2019
Research project with
the City of Utrecht
and the University of
Utrecht, studying the
effects of fewer rules in
social assistance.
The current rules in
social assistance under
the Participation Act
(Participatiewet) are
complex and strict. The
City of Utrecht wants
to know whether
social assistance
can be administered
differently.
Four groups were considered.
“Self-activiation”
(unconditional transfer): no
obligation to apply for a certain
number of jobs per week or
other reintegration activities.
“Supported activation” (psychosocial support): participants
receive extra help and guidance
from the municipality.
“Work pays off”, in that
beneficiaries who work
alongside their benefits may
keep more of the money they
earn (up to 50%, or a maximum
of €202/month).
“Measuring what works”
(comparison group):
beneficiaries continue to
receive their benefits under the
current Participation Act.
Assessing:
1.whether people find
work more quickly and/
or participate in society
more actively (e.g. through
volunteer work);
2.the effect on participants’
health;
3.the financial situation;
4.the satisfaction of welfare
recipients with their own
situation.
Sources: City of Utrecht, 2018;
Hoeijmakers, 2016.
47
Annex 4. UBI initiatives in Europe and Canada
Country Name Size Aims and objectives Research design Effects measured
Spain Pilot:
B-MINCOME
project (started
September 2017)
Accompanying
research project
that measures
effects and
efficiency
1000 households
randomly selected
from eligible
households.
Eligibility criteria:
• residents of the
Besòs Axis;
• rent below the
minimum to
guarantee having
a member aged
between 25 and
60 years.
Amount: 100 €
(minimum) and
1.676 € (maximum,
double the poverty
line in Catalonia),
depending
on household
composition and
income.
The project aims
to directly invest in
people through a
guaranteed minimum
income (IMS –
inclusion municipal
support), while
seeking to improve
their immediate
surroundings, their
neighbourhoods and
districts by engaging
people in active
social and workplace
inclusion policies.
Together with IMS,
the objectives
included testing
a range of active
policies incentivizing
training, sharing and
creating cooperative
economies, mutual
support, public
participation at
neighbourhood level
and (last but not least),
the creation of a local
currency.
Four beneficiary groups were
considered.
With conditions
Receiving aid is conditional
upon mandatory participation
in one of the four active
inclusion policies (training and
employment, social economy,
help in renting out rooms,
and fostering community
participation).
Unconditional
Benefits are granted
unconditionally (no
participation in active labour
market policies).
Limited
Benefit levels will vary with the
variation in the computable
income of the household (with
a limit).
Unlimited
The income that is generated by
the household will only partially
reduce the aid (without a limit).
Overall condition: 25% of
the transfer is paid in social
currency to promote proximity
commerce.
Qualitative community impact
assessment on active social
policy measures (beneficiaries
and non-beneficiaries).
Programme evaluation
(operations, finances,
administration).
Impact on beneficiaries and
impact on co-creation of
solutions.
Impact on happiness and
subjective well-being, including
analysis of factors such as:
age, sex, civil and labour
status, state of physical and
mental health, educational
achievement, income and
income fluctuation, emotional
stability, social capital and
trust, community relationships
(sharing), entrepreneurship,
consumption and community/
policy participation practices.
Sources: Colini, 2017; The Young
Foundation, 2017.
48
Universal basic income policies and their potential for addressing health inequities
Country Name Size Aims and objectives Research design Effects measured
Scotland Informing
Interventions to
reduce health
Inequalities (Triple
I)
Triple I provides
national and local
decision-makers
with practical tools
and interpreted
research findings
about investing
in interventions
to reduce health
inequalities in
Scotland (e.g.
taxation policies,
benefits policies,
various forms of
UBI, minimum
wage, negative
income tax (NIT),
and increasing
benefits uptake
through psychosocial support.
The aim is to model
the potential impact of
different interventions
and policies on overall
population health and
health inequalities.
The tools can be used to
produce detailed results for
different geographical entities:
• Scotland
• Council areas
• health boards
• city regions
• integrated joint boards.
Three outcomes are measured:
• premature mortality
• years of life lost
• hospital stays.
Source: ScotPHO, 2018.
49
Annex 5. Case countries
Annex 5. Case countries
A5.1. Finland
In the Finnish case, a move to simplify the benefit systems at their foundation has been progressing for
some time; it is not dissimilar to the developments accompanying the move to universal credit in the
United Kingdom. The main difference is that in the United Kingdom, administration of universal credit
has remained linked with testing of work conditionalities; greater market administration of benefits
in line with labour market fluctuations is in evidence in the use of in-work conditionality regimes,
which entail adjusting benefits with job changes, as well as asking beneficiaries to change jobs to
satisfy requirements relating to working hours. In Finland, potential public savings from streamlining
administration by easing conditionalities – along with the potential for bringing an end to poverty
traps by allowing claimants to retain their income grants when working – have entered into experiment
design. The aim to retain fiscal neutrality led to a partial version of basic income, below the subsistence
level. The aim of general system simplification can be seen in the national-level administration of
the experiment. The general political debate in Finland, however, has remained tied to reinforcing
employment participation, including with the increased use of conditionalities. Hence, the Finnish
experiment represents a contribution within a more complex debate about the direction of income
security systems.
It should be noted that in terms of health, the experiment does not relate directly to the health
sector, despite the ongoing broad health equity debate in the country.46 Evaluation and monitoring
frameworks include health indicators, the number and nature of which vary widely and tend to be
rather unspecific. Health is also considered a secondary outcome, sometimes more driven by research
than policy interest, which tends to centre on work/workfare/employability in the context of changing
economies and labour markets, as well as cost-efficiency of welfare states.
A5.2. Denmark
In the Danish case, local experimentation in lifting conditions on unemployed groups’ receipt of
assistance has been occurring in response to various developments, including government initiative,
and with the support of private foundations. Practical failings in sanctions systems that were identified
in a series of public reports contributed to the impetus for experimenting with lifting conditions on
claimants. As was the case in Finland, an important driver was testing a different model to motivate
the social integration of excluded groups, in particular the long-term unemployed population.
Support in the form of education and development grants has featured in the experiments. Emphasis
on the autonomy of beneficiaries has been strong and built into the design and the form of social
support for beneficiaries during the experiments. The Danish experiments are very small in scale, but
significantly different from other ongoing experiments. They involved self-direction in allocating time
for job searches, and voluntary workshops among social workers and unemployed people, along with
obligations for those without work and, in Aarhus, a self-budgeting arrangement (Haagh, 2019b, 2019d,
46 Increasing inequalities in accessing health care services are currently being broadly discussed in Finnish politics. Evidence
suggests that this is likely the result of socioeconomic differences, including in employment, education and gender, resulting
in large differences in mortality rates (Kangas & Blomgren, 2014; and qualitative data from an interview carried out by the
author). As a response, broad-based reforms of the primary health care sector and in particular health insurance schemes are
being discussed.
50
Universal basic income policies and their potential for addressing health inequities
2019e). In the latter case, the experiment was supported by a private foundation, which allowed the
council to “go further than would [otherwise] be possible in law” (essentially to spend more money).
The unemployed individuals selected for the experiment were given their usual benefits and allowed
to spend up to 50 000 kroner or (about €5000) according to their own self-designed support plan. This
plan involved assistance and monitoring, but was based on self-selection of needs.
A5.3. Netherlands
As in Finland and Denmark, experiments in the Netherlands have been driven by interest in testing
models of delivering income security that are driven by motivation rather than demanding social
contributions, underpinned by threat of sanctions. In contrast with Denmark, the experiments in
the Netherlands were under discussion for a long time before proceeding, and have been motivated
to a much greater degree by experimental design. The concern has been to compare exactly how
beneficiaries would behave under different motivational conditions, and faced with different financial
incentives. Participation grants, namely a top-up transfer for voluntary participation in communityoriented work, are one such incentive. These experiments are highly localized. The background to this
is on the one hand the highly decentralized structure of the Dutch welfare state, coupled with extensive
fiscal decentralization. Faced with rising caseloads under stable resources, local communities had a
strong incentive to look for innovative solutions. The decentralized character of welfare policy in the
country enabled communities to do this within the established legal framework.47 Similarly to Finland,
health specifically does not play a significant role, except where a correlation can be drawn with
motivational effects, such as stress related to economic scarcity.
A5.4. Canada
In contrast to Finland, Denmark and the Netherlands, the experiment in Canada was driven by a strong
anti-poverty agenda, which was closely linked to a debate on health inequities. While motivational
issues played a role, there was a strong focus on the (working) poor population, which also determined
the design of the UBI trial, being based on an NIT model (see Section 4.1). Under the common agenda of
social justice, the political pressure for the income grant was essentially a bottom-up movement firmly
rooted at the local level and based on a broad-based coalition, including civil society, the public health
sector and local government. Health as a poverty trap at the individual level, but also at a broader
social, economic and fiscal level was a core dimension of the campaign, which was also favoured by the
positive political climate of a liberal government. The recent change in government has put a quick end
to the only recently started programme.
A5.5. Scotland
The Scottish experiment stands out from the others because it does not involve field experiments, but
is essentially a broad-based feasibility study to test different income policies with regard to their impact
on health outcomes, in particular premature mortality, years of life lost, and hospital stays. A microsimulation tool, which includes a variety of design options (taxation policies, benefits policies, various
forms of UBI, a minimum wage approach, NIT, and an increase in benefit uptake through psycho-social
support) allows different stakeholders and government levels to model potential health impacts.
47 Qualitative data gathered from an interview carried out by the author.
51
Annex 5. Case countries
Similarly to Canada, in the Scottish debate poverty and health take centre stage as social justice issues.
The initiative is firmly rooted at the local level and is based on a strong coalition of the public health
sector and local government, pressurizing government to explore innovative solutions in the face of
rising inequality that is resulting in increased poverty and social exclusion, with negative outcomes for
health and well-being. Concerns about administrative effectiveness with regards to accessing welfare
services are another key aspect, in particular in light of the scaling up of universal credit, which – against
its core objectives – appears to foster exclusionary processes.
A5.6. Spain
Similarly to the Netherlands, Denmark and Scotland, the Spanish model is firmly rooted at the local
administrative level and has been initiated as a reaction to rising local demand and an inadequate
response by central welfare schemes. Rising economic inequality is a key political aspect of the Spanish
experiment, while core objectives encompass the motivational aspect, participation grants, as well as
strengthening employability by supporting beneficiaries in creating local employment opportunities.
The programme thus has a broader focus oriented towards poverty reduction – while testing different
motivational aspects – which is unique to the project. Health is not expressly considered, except where
it factors in as an inherent poverty issue.
52
Universal basic income policies and their potential for addressing health inequities
Annex 6. Example of the effects of taxes and
benefits
Fig. A6.1 Summary of the effects of taxes and benefits on all households by quintile groups, United
Kingdom, financial year ending 2017
Average per household (£ per year)
Quintiles
Bottom 2nd 3rd 4th Top All households
25 000
0
-25 000
-50 000
■ Cash benefits ■ Benefits in kind ■ Direct taxes ■ Indirect taxes
● Net position
Source: ONS, 2018.
53
Annex 7. How to make it work for health equity – success factors
Annex 7. How to make it work for health equity –
success factors
Several aspects emerge from the case studies and the debates with health practitioners and policymakers involved in the UBI experiments, which seem to be crucial for establishing UBI as a health
equity issue.
• The health sector needs to make health inequities a priority theme, and to take action; not
only within its own sectoral boundaries, but also beyond them, by persuading other sectors and
stakeholders to take action on social determinants that influence health inequities, in particular
income security measures.
• Closely related to this argument is the importance of developing a narrative on health equity
as a social justice issue, which should be broadened beyond health impacts and outcomes. It is
important to show the pathways between income security and health, but it is equally important to
develop a narrative on the role of health in strengthening and maximizing other sectors’ outcomes
(such as employment through sustained productivity), as well as broader societal objectives, goals
and values (such as social justice, inclusive growth, reducing poverty and leaving no one behind).
In order to gain credibility and create consensus, the health sector has to take the health debate
forward and out of purely the health domain.
• Consensus needs to be built around health equity as a social justice issue. This whole-of-government
approach involves both horizontal and vertical dimensions. The local level of government seems
to play a key role in pushing for reform processes, laying the groundwork for a bottom-up reform
process for social justice. This has been seen in Canada, where the health sector and povertyfocused civil society coalitions came together to promote basic income ideas. In Scotland, too, the
role of local government was essential for bringing to the fore the health equity debate, pushing
central government to recognize and take action on health as a social justice issue (Box A7.1).
• Political will cannot be engineered. A complex mix of various stakeholders’ interests and specific
overall political, social and economic conditions (policy windows) make government take action.
However, some things may help: for example, in Canada and Scotland empirical evidence that
underpinned the pathways between health and poverty was central to creating awareness about
the link between poverty and health and well-being. What was even more important – including
in winning over the various tiers of government – was to show through disaggregated data the
impact of poverty on health at the local level. International and regional debates about the role of
social determinants of health for health equity (led by international or regional organizations, such
as WHO Regional Office for Europe) provided an important additional input and support for national
health sectors to act and increase the pressure on their respective governments.
• These processes are not happening overnight, but need time, and change will be necessary in
the mindset of many politicians and practitioners. A stable political environment supporting the
case for health equity as a policy priority lasting beyond one legislative period only seems to be
conducive.
• Finally, as with almost all reform endeavours, policy champions play a critical role, lending a voice
to the cause, which in turn can provide an important contribution to improving public and political
acceptance.
54
Universal basic income policies and their potential for addressing health inequities
Box A7.1: From health as a lifestyle issue to health as a life circumstance issue – the case of
Scotland
The debate on health inequalities in Scotland is very much framed as a health equity and social
justice issue. However, this was not always the case and it took around 20 years to change it. In
1999 a White Paper was produced in Scotland (entitled Towards a healthier Scotland (The Scottish
Government, 1999)) that for the first time framed health as part of a life circumstance agenda,
whereas before it had been very much framed as a lifestyle issue (as was the traditional approach).
The language therefore also changed, focusing less on health disparities and moving towards a
discourse on issues of equity.
In 2007 a Ministerial Task Force on Health Inequalities was established in Scotland. The Task Force’s
published report, entitled Equally well (The Scottish Government, 2008), looked into the root
causes of health inequalities. It marked a turning point in the debate on health inequalities, as it
started for the first time delve into the health equity issue, looking at the root causes and, in this
way, moving the agenda away from purely lifestyle factors to take into account life circumstances
and examine social justice issues.
Initially it was mainly the health directorate that promoted the issue, albeit referring to the role
of other sectors in dealing with the problems: it did refer to the life circumstances element, such
as early years and employment, along with social justice issues, such as drugs, alcohol, violence
and environment/transport. However, it was still seen mainly as an agenda, and did not penetrate
throughout government. Some local authorities understood the significance of this subtle change,
identifying the issues as being cross-sectorally important, which allowed the health sector to move
them forward out of the health domain, changing the direction and fostering appreciation for the
issue among other sectors.
Reducing health inequalities is a government priority and has become iconic on the Scottish
Government’s agenda. The coalition with the local government level was important initially,
to initiate moving the issue out of only the health domain. The Government now publishes
monitoring reports on the reduction of health inequalities twice yearly (The Scottish Government,
2017), assessing progress in tackling health inequalities by monitoring not only health policies, but
also policies in other sectors. This really facilitates the promotion of health inequalities as a social
justice issue that concerns all sectors.
55
Annex 8. Example of the effect of social transfers on child poverty rates
Annex 8. Example of the effect of social transfers
on child poverty rates
Fig. A8.1 Child poverty rates before and after social transfers, 2009
0 10 20 30 40 50 60
Poverty rate
■ Before social transfers ■ Aer social tranfers
Iceland
Norway
Denmark
Slovenia
Cyprus
Finland
Sweden
Czechia
Austria
Germany
Netherlands
Belgium
France
Slovakia
Ireland
Switzerland
Estonia
Malta
United Kingdom
Hungary
Luxembourg
Portugal
Poland
Spain
Greece
Italy
Lithuania
Bulgaria
Latvia
Romania
Note. Child poverty rates are based on <60% median income.
Source: WHO Regional Office for Europe, 2014.
56
Universal basic income policies and their potential for addressing health inequities
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