2014年-世界发展银行全球_Universal_Health_Coverage_and_the_Challenge_of_Informal_Employment___Lessons_from_Developing_Countries_86页_2mb

报告摘要

Universal Health Coverage and the Challenge of Informal Employment: Lessons from Developing Countries

Core Content

This report examines the challenges of achieving Universal Health Coverage (UHC) in developing countries, with a particular focus on the informal sector workers (ISWs), who are often excluded from traditional health insurance systems. The informal sector is defined as those engaged in unregistered or small, unincorporated private enterprises, and these workers typically lack formal contracts and social protections. ISWs represent a significant portion of the population in many developing countries and are often referred to as "the missing middle" due to their exclusion from health coverage.

The report highlights that UHC involves extending health insurance to all citizens, improving access to health services, and providing financial protection against health shocks. However, the informal sector presents a major challenge to achieving UHC due to its lack of formal registration, limited contribution to social health insurance (SHI), and difficulty in collecting taxes. This makes it hard for governments to finance health coverage for ISWs through conventional means.

Main Points and Key Information

1. Informal Employment Trends

Informal employment is widespread in developing countries, particularly in Latin America and Sub-Saharan Africa.
The proportion of informal employment varies by region, with some countries experiencing growth and others decline.
In Latin America, informal employment increased from 54.2% in the late 1990s to 57.7% in the late 2000s.
In Sub-Saharan Africa, the share of informal employment in nonagricultural GDP ranged from 22% (Burkina Faso) to 36% (Cameroon).
The informal wage penalty — the phenomenon where informal workers earn less than formal ones — is more pronounced for younger workers and those with higher education, particularly in Brazil and South Africa.

2. Informal Sector Characteristics

The informal sector is not a deliberate effort to evade taxes, but rather a lack of formal structures.
Informal sector workers are not registered, and thus not subject to income or social security taxes.
The informal sector contributes significantly to GDP, but its economic significance varies across regions.

3. Challenges of Health Insurance for ISWs

ISWs are typically left out of government-subsidized health insurance schemes, as these schemes often target the formal sector first.
They are reluctant to enroll in insurance schemes, including social health insurance (SHI), community-based health insurance (CBHI), and self-financed contributory schemes.
Adverse selection is a common problem in schemes targeting ISWs, as those with higher health needs are more likely to enroll, which can threaten the financial sustainability of these programs.

4. Strategies to Cover ISWs

Some countries have adopted smaller benefits packages and lower premiums for ISWs to reduce the need for public subsidies.
Others have shifted to tax-financed health systems, which can provide broader coverage without relying on user fees.
Ghana, Vietnam, and the Dominican Republic are examples of countries that have implemented targeted health insurance schemes for ISWs, though the effectiveness varies.

5. Financial and Structural Considerations

Achieving UHC requires increased public financing, which is difficult to secure due to the limited tax base from the informal sector.
User fees can be discriminatory, particularly for the poor, and may deter access to health services.
Reallocating public resources and increasing taxes are potential sources of additional revenue for health financing.
Reforms on the supply side are essential to ensure that additional public financing translates into improved health coverage for ISWs.

6. Role of Economic Growth

Large and sustained economic growth is crucial for achieving UHC, as it generates public resources that can be used to subsidize coverage for the poor and informal workers.
The report emphasizes that the definition of UHC varies by country, and that achieving UHC depends on each country's specific context and policy choices.

Conclusion

The report concludes that while UHC is a global priority, informal employment poses a significant challenge to its implementation. Informal sector workers are often excluded from existing health insurance systems, leading to limited access to health services and financial vulnerability. To address this, targeted policies such as smaller benefits packages, tax-financed systems, and community-based insurance have been explored. However, financial sustainability and equitable access remain key concerns. Economic growth and policy innovation are essential to ensure that UHC can be achieved for all, including informal workers.

Key Recommendations

Governments should abandon expectations of substantial revenue from informal workers.
Tailored health insurance schemes that offer limited benefits and lower premiums can help increase coverage.
Tax-financed health systems may be a more equitable and sustainable option for covering ISWs.
Reforms on the supply side and increased public financing are necessary to improve access and ensure financial protection.
Sustained economic growth is essential to support UHC initiatives and subsidize coverage for the poor and informal workers.

References and Data Sources

The report includes country-specific case studies and data from various sources, including the International Labour Organization (ILO), World Bank, and local governments.
Tables and figures are used to illustrate the size and scope of informal employment, health insurance coverage, and economic trends.
Key abbreviations are provided for clarity, including SHI, CBHI, GSHIS, and UHC.

Summary of Findings

Informal employment is a major challenge for achieving UHC.
Informal sector workers are often financially unprotected and have limited access to health services.
Strategies such as tax-financed systems, community-based insurance, and targeted subsidies have been used to improve coverage.
Financial sustainability and equitable access are key concerns in designing health insurance schemes for ISWs.
Economic growth is indispensable for achieving UHC and subsidizing coverage for the poor and informal workers.