In 1986, the Ottawa Charter changed the way the world thinks about health. It reminded us that health is created in the conditions of everyday life, where people live, learn and work.
Health is often discussed as a responsibility of the health system. But it is also shaped by income security, access to care, safe work and support when illness or disability changes lives.
This is why social security must be part of creating a healthier future. Health promotion without social protection is an incomplete promise.
A changing challenge
Social security protects people throughout the life course. It provides health care and income protection, and also supports prevention, rehabilitation, return to work, healthy ageing and long-term care. Strong systems therefore contribute to healthier and more resilient societies.
There has been progress. More than half of the world’s population is now covered by at least one social protection benefit. Yet 3.8 billion people remain without any social protection.
The challenges are also changing. People are living longer, and chronic diseases and mental health conditions place increasing demands on health and social security systems. At the same time, the world of work is changing. Informal employment, platform work and other non-standard forms of employment challenge traditional approaches to social security coverage. Fiscal pressures are also increasing, while citizens expect institutions to provide accessible, efficient and high-quality services.
These developments require us to think differently. We cannot build sustainable systems by concentrating mainly on paying for the consequences of poor health. We must invest in preventing those consequences.
From protection to prevention
Prevention should therefore become an increasingly important part of modern social security. A study by the International Social Security Association found that a single dollar invested in occupational safety and health prevention can potentially generate $2.20 in return.
I have long believed in a simple sequence: prevention before rehabilitation, rehabilitation before compensation.
Compensation remains essential when loss occurs. But first, we should prevent avoidable harm. When harm occurs, we should restore function, independence and participation as early as possible.
Rehabilitation, when started early and delivered well, can prevent illness or injury from becoming long-term disability, unemployment, dependency and poverty. ISSA research estimates that, for social security systems, investment in work reintegration and rehabilitation can generate an average return of 2.9 times the investment. This is where health policy, social security and employment policy must meet.
This shift is an investment in people and in the future sustainability of social security.
Technology must serve people
Digital transformation provides another important opportunity. Telemedicine, digital health services, artificial intelligence and better use of data can improve access, identify risks earlier and make services more efficient.
But technology itself is not the objective. A digital service that excludes an older person, a rural worker or somebody without digital skills has not achieved its purpose. Technology must make social security more accessible and more human, not create another barrier.
Health care, social security, employment services, rehabilitation, disability management and long-term care are often administered separately. For the person who needs support, these boundaries have little meaning.
A worker recovering from serious illness may need treatment, income support, rehabilitation and help to return to employment. A healthy system should make this journey easier, not require the person to navigate several disconnected systems.
People experience one life. Our systems must respond with the same coherence.
The political choice ahead
Ultimately, the choices before us are political choices.
Governments must treat social security and health as investments, not just costs. Social protection must keep pace with the changing forms of work. Health, rehabilitation, employment and long-term care should be better connected. Digitalisation must make services easier to access, while keeping them human.
For almost a century, social security institutions have adapted to profound changes in society. As the ISSA approaches its centenary, our responsibility is not only to protect what has been achieved, but to prepare social security for the next generation.
Forty years after Ottawa, the political choice is whether we build societies that help people stay healthy, recover early, continue participating and age with dignity.
A healthy future requires more than a health system. It requires security throughout life.
