Universal Health Coverage and the Challenge of Informal Employment : Lessons from Developing Countries
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World Bank, Washington, DC
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The aim of the report is to review
existing approaches and available policy options to improve
access to health care services and financial protection
against health shocks for informal-sector workers (ISWs).
Along with their families, ISWs represent the majority of
the population in many developing countries. The report
reviews the definition and measurement of the informal
sector and the literature on efforts toward its health
insurance coverage. It also examines several country cases
based on published and unpublished reports and on structured
interviews of expert informants. Developing country efforts
to expand health coverage are characterized by a common
enrollment and financing pattern, starting with
formal-sector workers and following with
government-subsidized enrollment of the poor. Thus, ISWs are
typically left behind and have been referred to as "the
missing middle." They find themselves financially
unprotected against health shocks and with limited access to
quality and timely health care. ISWs are generally reluctant
to enroll in insurance schemes, including social health
insurance (SHI), community insurance, and other
arrangements. Further, initiatives to enroll them in
self-financed contributory schemes have generally resulted
in adverse selection, as those with high anticipated health
needs are more willing to pay and enroll than others.
Successful initiatives to cover this population group are
the ones where government has abandoned its expectations to
derive relatively substantial revenue from it. Offering this
group a benefits package that is relatively smaller than
that of formal workers and charging them a premium that is
only a fraction of that charged to formal workers is a
strategy used by some countries to limit the need for public
subsidies. While there is evidence that greater insurance
coverage has improved access to health services for ISWs and
their dependents, in several countries it has not yet
improved financial protection for this target group. A broad
set of reforms will be required to strengthen the supply
side to ensure that additional public financing translates
into improved coverage for ISWs.
Palabras clave
ABSENTEEISM, ACCESS TO HEALTH CARE, ACCESS TO HEALTH CARE SERVICES, ACCESS TO HEALTH SERVICES, ACCESS TO SERVICES, ADMINISTRATIVE COSTS, ADVERSE SELECTION, ADVERSE SELECTION PROBLEMS, AMBULATORY CARE, AVERAGE WAGE, CAPITA HEALTH SPENDING, CASUAL EMPLOYMENT, CATASTROPHIC EXPENDITURES, CATASTROPHIC HEALTH SPENDING, CHILD HEALTH, CHILD HEALTH SERVICES, CHOICE OF HEALTH FINANCING SYSTEM, CHRONIC CONDITION, CITIES, COLLECTION OF CONTRIBUTIONS, COMMUNITY HEALTH, CONTRACTUAL ARRANGEMENTS, COSTS OF HEALTH CARE, DELIVERY SYSTEM, DRUGS, ELDERLY PEOPLE, EMPLOYEE, EMPLOYER CONTRIBUTION, EMPLOYMENT EFFECTS, EMPLOYMENT STATUS, ENROLLEES, EXPOSURE, FAMILIES, FAMILY INCOME, FINANCIAL INCENTIVES, FINANCIAL PROTECTION, FINANCIAL RISK, FINANCIAL VIABILITY, HEALTH CARE, HEALTH CARE DELIVERY, HEALTH CARE PROVIDERS, HEALTH CARE REFORM, HEALTH COVERAGE, HEALTH EXPENDITURE, HEALTH EXPENDITURES, HEALTH FACILITIES, HEALTH FINANCING, HEALTH INSURANCE, HEALTH INSURANCE FUND, HEALTH INSURANCE FUNDS, HEALTH INSURANCE PLAN, HEALTH INSURANCE PROGRAM, HEALTH INSURANCE SCHEME, HEALTH INSURANCE SCHEMES, HEALTH NEEDS, HEALTH ORGANIZATION, HEALTH POLICY, HEALTH PROVIDERS, HEALTH RESULTS, HEALTH SAVINGS ACCOUNTS, HEALTH SECTOR, HEALTH SERVICES, HEALTH STATUS, HEALTH SYSTEM, HEALTH SYSTEMS, HEALTH WORKERS, HEALTH-CARE, HOSPITALS, HOUSEHOLD ENTERPRISES, HOUSEHOLD EXPENDITURE, HOUSEHOLD INCOME, HOUSEHOLD SURVEY, HUMAN DEVELOPMENT, ILLNESS, IMMIGRANTS, IMPACT EVALUATIONS, INCOME, INCOME COUNTRIES, INCOME GROUPS, INCOME HOUSEHOLDS, INFORMAL ECONOMY, INFORMAL EMPLOYMENT, INFORMAL SECTOR, INFORMAL SECTOR WORKERS, INSURANCE ARRANGEMENTS, INSURANCE CONTRIBUTIONS, INSURANCE PLAN, INTEGRATION, JOBS, LABOR FORCE, LABOR MARKET, LABOR RELATIONS, LABOR SUPPLY, LABOUR, LAID-OFF WORKERS, LAWS, LEGAL PROTECTIONS, LEGAL REQUIREMENTS, LOW INCOME, LOW-INCOME COUNTRIES, MEDICAL CARE, MEDICAL CONDITIONS, MEDICAL EXPENDITURES, MEDICAL INSURANCE, MEDICINES, MIGRANTS, MONTHLY PREMIUM, MORAL HAZARD, NATIONAL HEALTH, NATIONAL HEALTH INSURANCE, NONGOVERNMENTAL ORGANIZATIONS, NUTRITION, OUTPATIENT CARE, OUTPATIENT SERVICES, PATIENTS, PAYROLL TAX, POCKET PAYMENTS, PRELIMINARY RESULTS, PREVIOUS STUDIES, PRIVATE EMPLOYMENT, PRIVATE ENTERPRISES, PRIVATE HEALTH INSURANCE, PRIVATE INSURANCE, PRIVATE INSURERS, PRIVATE PROVIDERS, PRIVATE SECTOR, PRIVATE SECTOR WORKERS, PROBABILITY, PRODUCTION UNITS, PUBLIC HEALTH, PUBLIC PROVIDERS, PUBLIC SECTOR, PUBLIC SPENDING, QUALITY OF CARE, RISK SHARING, SAFETY NETS, SERVANTS, SOCIAL DEVELOPMENT, SOCIAL HEALTH INSURANCE, SOCIAL SECURITY, SOCIAL SECURITY BENEFITS, TOTAL EMPLOYMENT, UNEMPLOYED, UNEMPLOYMENT, UNEMPLOYMENT INSURANCE, UNINTENDED CONSEQUENCE, UNIVERSAL HEALTH INSURANCE COVERAGE, UNPAID WORKERS, URBAN WORKERS, WAGE GAP, WORKER, WORKERS, WORKING CONDITIONS, YOUNGER WORKERS