FRIEDRICH-EBERT-STIFTUNG – A majority working in the shadows Monthly amount of premium (USD current) % uncovered ready to pay at least X for a monthly premium (SHI) Figure 4.8 Level of contributions suggested by non-members in relation to various benchmarks 2.5 2.0 1.5 $0.91 1.0 14.9% 0.5 7.5% 1.3% 0.0 Zambia 20 ZMK/mth $1.78 $1.15 $1.15 8.2% 3.7% 2.0% Ethiopia 31 ETB/mth 13.8% 12.7% 4.0% Benin 628 FCFA/mth 18.3% 17.6% 8.9% Senegal 967 FCFA/mth $1.95 30.2% 22.8% 3.5% Kenya 235 KES/mth 50 $2.15 45 40 35 30 21.8% 25 20 19.1% 15 10 9.7% 5 0 Côte d'Ivoire 1171 FCFA/mth Average monthly premium(Current USD) Proportion ready to pay at least USD 3 /month Proportion ready to pay at least USD 2 /month Proportion ready to pay at least USD 5 /month ployment status, 20 to 25 per cent of workers in informal employment are not yet covered, but are interested in joining and would be ready to pay the full amount of the National Health Insurance Fund(NHIF). Furthermore, 32 to 40 per cent provide a spontaneous amount corresponding to half of the current value of contributions. In Senegal, 57 per cent of informally employed workers sug­gested an amount above the current annual contribution of 3,500 CFA francs 15 to join the CMU. The readiness and ability to pay a certain level of premium raises the issue, for the extension of coverage to employees, of the shared contribution of both employer and employee, complemented – or not – by the state. Employees are not supposed to cover the full cost of health insurance, including in the absence of state subsidies. 16 This is not the case for employees in formal employment, so there is no reason for those in informal wage employment to do so. It is essential that employers be involved and willing and able to pay, and that this be sustainable. Table 4.1 Values of contributions in existing schemes and com­parison of»spontaneous amounts« provided in Benin BENIN Mutual health insurance Contribution Percentage ready to pay the full amount Percentage ready to pay half the amount 1,200 13.6 27.4 Caisse Mutuelle de Prévoyance Sociale (CMPS) 850 Régime d’Assurance Maladie Universelle (RAMU) 1,000 21.0 20.9 35.0 35.0 4.4 CONCLUDING REMARKS Workers in informal employment and their family members are disproportionately affected by health coverage gaps, even in relation to national health systems that provide access to free health care. On average, over the six countries, 14.5 per cent of workers in informal employment are members of a social health insurance scheme and an additional 1.9 per cent are covered by private health insurance, including micro insurance. Including access to free medical care, still more than 72 per cent of workers in informal employment are either not covered by health insurance or cannot access free medical care when needed. Informality is not desirable either for workers(no access to decent work), or for a country’s ability to generate sufficient revenues to actually redistribute wealth and counter inequalities. Facilitating the transition to formality should also be pursued as a means of ensuring better access to protection, including social health protec­tion. The extension of social protection is a key element of gradual processes of formalization. It contributes – together with other measures – to ensure a basic level, stability and predictability of income and to improve productivity. By doing so, it helps to reduce exposure to poverty, enhance access to health care and enable the informally employed to seize economic opportunities(ILO, 2021d). In countries that 15 The contribution per beneficiary is 7,000 CFA francs per year, subsi­dised at 50 per cent by the state(ILO, 2021b). 16 See Social Security(Minimum Standards) Convention, 1952(No. 102), Art. 71 about cost sharing:»The cost of the benefits provided in com­pliance with this Convention and the cost of the administration of such benefits shall be borne collectively by way of insurance contribu­tions or taxation or both in a manner which avoids hardship to per­sons of small means and takes into account the economic situation of the Member and of the classes of persons protected. The total of the insurance contributions borne by the employees protected shall not exceed 50 per cent of the total of the financial resources allocated to the protection of employees and their wives and children.« 34