Universal health coverage: an informal worker’s perspective

Health care is a hot topic all over the world. Universal Health Coverage (UHC) has become a banner for the global health movement. It has been adopted by the World Bank and the World Health Organization as a key objective, and is included in the United Nations’ Sustainable Development Goal 3.8.

The increasing inclusion of the need for CSUs in key global platforms has been a major change, but there are still many gaps in the understanding of the reality of informal workers in this debate.

On the one hand, the CSU is seen as a universal provision of social protection, defined as a citizen’s right or a human right, and not as an employment-related issue. Workers tend to be considered a “special group”, within which workers in informal employment are considered vulnerable.

On the other hand, these workers are only targeted when ways are sought to include those with atypical employment relationships in contributory health insurance systems, on the assumption that health care is something that must be paid for.

Health financing to support workers in informal employment

One of the most contested areas around the CSU is the question of how poorer countries can finance quality health care systems that are costly.

Many countries have instituted contributory health care coverage systems (e.g. Ghana, Kenya and Vietnam), where workers in formal employment are required to contribute through wage taxes, including an employer contribution. However, self-employed workers in informal employment have to pay for it on their own, even though they are generally poorer than their counterparts in the formal economy.

As a result, the same systems are not able to achieve their “universal” goals. Oxfam research has shown how unfair these schemes are, concluding that they suffer from low coverage (registration) rates, adverse selection, inadequate risk pooling and the exclusion of the poorest workers.

Health systems that are free at the point of access and dependent on public funding, which can be covered through general taxation, are better able to provide accessible health services to self-employed workers in informal employment.

Thailand, for example, provides fair and accessible health care without the need to pass on additional costs to workers in informal employment who are often exempted by being below the tax threshold and who are already contributing substantially to government coffers through various fees, taxes and licenses.

However, a deeper understanding of health financing for the informal economy needs additional nuance. More than half of the world’s workforce is self-employed, but there are also many workers with opaque or deliberately hidden employment relationships.

Revision of the International Labour Organization’s International Classification of Status in Employment to include “dependent worker” status will mean that more workers in informal employment will be able to move out of the self-employed category and into a category with clearer employment relationships with the owners of capital.

For example, certain homeworkers working in a supply chain may be classified as dependent workers, rather than as self-employed workers. This change in classification may have real implications for who should be held responsible for providing worker protections.

It is important that these employment developments are not ignored. Financing health is a battle that can be fought on multiple fronts, and a commitment to universalism should not mean that employers/owners of capital are “liberated”, particularly in countries where informal wage labour represents a higher proportion of informal employment.

Using direct contributions from employers and capital owners towards health and social protections, which have so far eluded (or are attempting to), can contribute to the well-being of workers and can be an additional way of expanding public resources for health, in addition to the work being done to increase public revenues through general taxation and tax justice.

Health services that meet the needs of workers in informal employment

While it is important that the CSU be financially viable, it is also necessary to recognize that the provision of adequate health services is critical. Most adults are workers, and in the developing world, most workers are in informal employment. These workers are not a residual or “special” category of citizen: they are the norm.

However, many social services, including health services, are not designed with the needs of working people in mind, particularly those who do not have employment protections such as sick leave.

In a previous blog, we pointed out the specific barriers to accessing health services faced by workers in informal employment, including registration linked to the home rather than and/or in addition to the workplace, inconvenient hours, and the loss of income that workers experience if they are not able to access health services promptly.

Health services that are not designed around workers’ lives transfer risks and costs to those who already have financial problems. For example, workers in employment may seek expensive private health care in order to return to work more quickly, or they may delay seeking treatment for health conditions until their health status has deteriorated to the point that they cannot work.

If the CSU is to include workers in informal employment, the barriers that make affordable health care inaccessible to them must be addressed.