Health insurance coverage and non-coverage 4 HEALTH INSURANCE COVERAGE AND NON-COVERAGE WILLINGNESS TO JOIN AND PAY FOR A HEALTH INSURANCE SCHEME – REASONS FOR NOT JOINING Florence Bonnet 4.1 INTRODUCTION Despite laudable progress globally, barriers to access health care remain in the form of out-of-pocket payments on health services, physical distance, range, quality and cultural ac­ceptability of services provided, long waiting times, as well as opportunity costs, such as income loss. Collective financing, broad risk pooling and rights-based entitlements are key con­ditions to ensure effective access to health care for all. The principles provided by international social security standards on medical care are essential on the road to universal health coverage(UHC)(ILO, 2021a). Across countries there are a variety of mechanisms to this end: national health insurance and social health insurance mandated by the state; national health-care services guaranteed free of charge or for a small, regulated user fee; and targeted social assistance for health services(user fee waivers, vouchers, and so on), which may be categorical or be means-tested. The focus of the first section is financial protection against health-care costs through social health insurance among workers 1 in informal employment. 2 The second section pre­sents a broad overview of coverage taking into consideration the multiplicity of mechanisms before focusing on the extent of social health insurance(SHI) 3 and private health insurance (PHI) coverage among informal workers. The third section focuses on the majority of workers in informal employment, who are not affiliated to a social health insurance scheme. It assesses their willingness to join such a scheme, and the preferred frequency and level of contribution they would be ready to pay. For those not interested in joining, it looks at the main reasons for this choice. The chapter closes with some concluding remarks. The accessibility, availability and quality of health care services form part of UHC and also influence the level of trust in formal institutions and, associated with that, the willingness to join of those not yet covered. Being covered by social insurance or by public tax-financed health services does not necessarily mean that one has effective access to quality health care services without hardship. The findings presented below should be considered in view of the findings presented in Chapter 2 concerning the need for and use of health services. 4.2 SOCIAL HEALTH INSURANCE COVERAGE AMONG WORKERS IN INFORMAL EMPLOYMENT 4.2.1 Financial health protection against health care costs ILO standards allow for a plurality of approaches to ensure effective access to medical care. 4 They recognize the diversity of arrangements that can exist for the financing, purchasing and provision of health care – social health insurance, na­tional health service or a combination of such models – as long as they comply with key principles(ILO, 2020). In prac­tice, most countries use a combination of such mechanisms to extend coverage. The survey carried out in the six countries provides an over­view of membership in social health insurance or in private health insurance, including micro-insurance schemes. This will be the focus of the following sections. For a more com­prehensive picture of health coverage in terms of health care costs, however, a rough estimate of the coverage of workers in informal employment by tax-financed(free) national health services(NHS) is added. 5 Furthermore, the 1 In line with statistical practices, the term»worker« is used here to refer to all people in employment: employees, employers(independ­ent workers with employees), own-account workers(independent workers without employees) and contributing family workers. 2 Workers in informal employment, together with their families, repre­sent the majority of the population in the six countries under review. The percentage of workers in informal employment ranges from 69 per cent in Zambia to 90 per cent or more in Benin, Senegal or Côte d’Ivoire(ILO, 2018). 3 The term»social health insurance«(SHI) corresponds to public health insurance schemes. 4 See ILO Medical Care Recommendation No. 69, 1944 and Recommen­dation No. 202, 2012. 5 Access to free medical care is only partially assessed through the available questions. It considers situations in which, during the past 12 months, at least one household member in need of medical care went for treatment and obtained it free of charge. It is based on two questions: Q49. In the last 12 months have you or has any member of your household received regular benefits in cash or in kind?, ­ selecting those who answered(f) free medical services; and Q57 How did you or your family find the money to pay for this treatment? No fee was charged/ paid by another source. The estimates provided in Figure 1 refer to the selected worker in informal employment and should be understood as:»workers living in households where at least one household member in need of medical care over the last 12 months had access to free medical care«, on the assumption that this free ­access could benefit them as well. 25