FRIEDRICH-EBERT-STIFTUNG – A majority working in the shadows Figure 4.4 Willingness of workers in informal employment(non-members) to join a health insurance scheme 4.4.1 By urban–rural location Benin 55.9% 61.1% 49.9% Zambia 58.3% 51.7% 66.6% Kenya 70.6% 70.4% 71.1% Ethiopia 72.9% 75.2% 65.9% Senegal 74.1% 74.4% 73.8% Côte d’Ivoire 80.6% 80.7% 80.5% 0 50 100% Total Rural Urban % of informal workers . interested to contribute % informal uncovered who wants to join Less than 1/2 MW 1/2 MW – MW MW– 2 MW More than 2 MW 4.4.2 Depending on individual labour income 90% 85% 80% 75% 70% 65% 60% Zambia Côte d’Ivoire Benin Kenya Ethiopia Senegal 55% 50% 45% Individual labour income % informal covered 4.4.3 Depending on household labour income 100% Kenya 90% 80% 70% 60% Côte d’Ivoire Benin Zambia Senegal Ethiopia 50% 40% Less 1/2 M 1/2 MW W–M wag in e im [M um MW W] – 2 MW 2 MW –­8 MW More than 8 MW Household income 4.3.2 Reasons for not being willing to join Another way of assessing the factors influencing people’s willingness to pay contributions is to ask directly those who do not want to join a scheme for the main reason for their lack of interest or indifference. Awareness is a precondition for assessing the influence of other factors, such as poverty or mistrust, and is strongly related to knowledge of health insurance. In fact, only a minority lack awareness of how health insurance works and how to proceed: 15 per cent or less of informal workers not interested in joining a scheme in Senegal and Kenya, around 20 per cent in Zambia or Benin, and over 25 per cent in Ethiopia and Côte d’Ivoire. The lack of financial capacity is the main reason mentioned by those not interested in joining. This category is the largest group in Ethiopia(43 per cent) and the majority(more than half) in all the other five countries(53 to 55 per cent in Côte d’Ivoire and Senegal, 60 per cent in Benin and close to 70 per cent in Kenya and Zambia). Women consider the financial issue as the main obstacle even more than men(Figure 4.5.1) and so do less-educated informal workers, for example, in Benin, Ethiopia and Senegal(Figure 4.5.3), and employees, contributing family workers and own-account workers more than employers(Table 4.A9 in Annex). The differences by area of residence do not reveal any consistent pattern across countries(Figure 4.5.2). 14 Obviously, the lack of financial ca­pacity is mentioned as the main reason by those with lower levels of labour income. Looking at the average in the six countries: 66 per cent of informal workers earning less than 14 The absence of urban-rural differences in Zambia and Kenya to some extent confirms the absence of significant differences in access to health care depending on the area of residence, as shown in Chapter 2. half of the minimum wage mention financial barriers as the main reason for not joining compared with less than 30 per cent among those earning more than twice the minimum wage(Figure 4.6.1). This sheds light on the importance of carefully designed policies to expand coverage to the informal economy, and to ensure that one does not overestimate con­tributory capacities when it comes to contributory schemes. What is required is an in-depth understanding of the diversity of situations in the informal economy, and accordingly of realistic options. Lack of trust in health insurance schemes is mentioned by less than 10 per cent of respondents in Zambia, but by as many as 24 to 26 per cent in Senegal and Ethiopia, and 15 to 19 per cent in Kenya, Côte d’Ivoire and Benin. Trust declines as the level of education increases(Figure 4.5.3). In Benin, Ethiopia and Senegal, a lack of trust in health in­surance schemes is mentioned by more than 40 per cent of those with at least a secondary level of education. Mistrust also tends to gain importance with an increase in the level of income(Figure 4.6.2). If the lack of awareness is primarily a matter of information and education(confirmed by data from Benin, Côte d’Ivoire, Kenya and Zambia, as shown in Figure 4.5.3), then more transparency and well-designed public information cam­paigns to ensure that informal workers are aware of their rights and entitlements could reduce this group significantly (Traub-Merz/Öhm 2021). Poverty and mistrust appear to be the main obstacles to extension of the coverage of social health insurance schemes. In an effort to combat poverty what is needed is a combination of financial mechanisms relying on non-contributory schemes and/or partial or full subsidization of social insurance contributions for low-­income groups. Building trust calls for institutional action to 30