FRIEDRICH-EBERT-STIFTUNG – A majority working in the shadows Figure 4.1 Membership of health insurance schemes, free access to national health services and direct financing by the employer % workers in informal employment 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% . 44.3% 1.9% 0.8% 40.2% 1.3% Zambia 2.3% 1.2% 1.1% Benin** 19.3% 4.6% 2.8% 6.5% 5.3% Senegal 22.2% 3.9% 2.9% 8.0% 7.3% Côte d’Ivoire 32.1% 3.5% 6.5% 22.1% Kenya 37.7% 1.0% 2.0% Employer pays for health expenditure* PHI- Private health insurance(including micro-insurance) NHS- National Health Service (tax-financed) SHI- Social(public) health insurance 34.8% Sum of SHI+ PHI+ NHS (Financial health coverage against health care costs) Ethiopia Notes: Proportions can be added as each additional mechanism is assessed to take into consideration workers not yet covered by other arrangements to avoid any double counting. The assessment of coverage by(tax-financed) national health services should be read as»workers in informal employment living in households where at least one household member, in need of health care, had access to free medical care«. * The question on direct payment of health expenditure by the employer was not available in Benin and Kenya and not usable in Ethiopia. ** No additional coverage by national health services was captured in Benin. direct payment of health expenditure by the employer is also considered for employees who do not benefit from any of the abovementioned public or private mechanisms. Taking these multiple mechanisms into account – social health insurance, private health insurance and national health services – Zambia ranks first with an estimated 44.5 per cent of workers in informal employment being either covered by social health insurance(1.3 per cent), accessing health care services free of charge(40.2 per cent) or being covered by private health insurance(one per cent) or another private mechanism, namely the direct payment of health expendi­ture by their employer(1.9 per cent). Taking all mechanisms into consideration leads to proportions that range from around one in five informally employed workers benefiting from some forms of health protection in Senegal and Côte d’Ivoire, to 32 to 38 per cent in Kenya and Ethiopia, and the abovementioned, 44.3 per cent in Zambia(see Figure 4.1). 6 4.2.2 Coverage by social health insurance(SHI) of workers in informal employment Focusing on social health insurance coverage, the six coun­tries covered reveal a critical social health insurance coverage gap for the majority of workers in informal employment. 7 The proportions of workers in informal employment who are members of social health insurance schemes range from 1.1 to 1.3 per cent in Benin and Zambia, to five to seven per cent in Côte d’Ivoire and Senegal, and to as much as 22.1 per 6 The three countries identified in Chapter 2 as showing the most ­extensive use of health care services when needed are also the coun­tries where the extent of health coverage(social insurance or tax­based) is the highest: Zambia, Ethiopia and Kenya. 7 This chapter draws on Traub-Merz, Öhm(2021: Section 6). cent in Kenya and 34.8 per cent in Ethiopia(Figure 4.1). The share of workers in informal employment affiliated to social health insurance tends to be higher among women than among men(Table 4.A2 in Annex); and with the exception of Ethiopia, to be higher in urban than in rural areas(Table 4.A3 in Annex). Informal workers with higher levels of education and higher individual labour income are also more likely to be covered than others(Tables 4.A4 and A5). Country schemes As far as affiliation to social health insurance is concerned, Kenya and Ethiopia are likely to be the runaway two countries among the six countries reviewed. The Kenyan government has made a commitment to achieve universal health cover­age by 2022 based on the opening up of the long-standing National Health Insurance Fund(NHIF) to v­ oluntary affiliation with proactive measures to enrol workers operating in the informal economy(Health Economics Research Unit 2019). The country’s strong political commitment to universal health coverage is embodied in the government’s big four agenda, which includes health care for all as one of the key develop­ment priorities. The fairly high number of insured persons may be an additional factor helping the dissemination of information on joining the scheme and the procedures for doing so(Traub-Merz/Öhm 2021; S­ chwettmann 2022). The Community-based Health Insurance(CBHI) scheme was introduced in Ethiopia in 2011, aimed at people who work in the informal sector in both urban and rural areas. Like in Rwanda, this is a government-led programme with a national public agency in charge of it(the Ethiopian Health 26