Abt Associates Inc.In collaboration with:

Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH)| Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

January 29, 2017

Sharon Nakhimovsky, Onaopemipo Abiodun,

Adam Koon (presenter), and Altea Cico

Expanding Health Coverage toInformal Workers in USAID PriorityCountries

Ending Preventable Child and MaternalDeaths (EPCMD) countries

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EPCMD Countries

Afghanistan Mozambique

Bangladesh Myanmar

Democratic Republic of the Congo Nepal

Ethiopia Nigeria

Ghana Pakistan

Haiti Rwanda

India Senegal

Indonesia South Sudan

Kenya Tanzania

Liberia Uganda

Madagascar Yemen

Malawi Zambia

Mali

Study objectives and methodology

Questions Methodology

• What % of EPCMD labor force isinformal?

• What do we know about them?

Statistics andliterature review

• How do EPCMD* governmentsexpand coverage?

• Challenges?

• How are they addressed?

34 key informantinterviews in 10EPCMD countries*

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*Bangladesh, Ethiopia, Ghana, India, Indonesia, Mozambique, Nigeria, Senegal, Tanzania, Uganda

Who are informal workers?

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People of working age whose job does not provide them withlegal social protection.

Source: International Labor Organization 2003

Ho

useh

old

inco

me

Poo

rV

ulne

rabl

eN

on-p

oor,

non-

vuln

erab

le

Unemployed

Formal Workers Informal Workers

Labor forcePopulation not employed, not looking for work

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EPCMD countries: 70% labor force is informal,higher than LMICs overall

Informal Workers in select EPCMDs as a Percentage of the Labor Force

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Indonesia

Tanzania

Ghana

Bangladesh

Haiti

India

Madagascar

Agricultural employment (informal) Non-agricultural informal employment

Formal employment Unemployment

Improving micro-level operations to expandcoverage for informal workers

Demand-side:

Use labor groups to reachmembers

Easier payment options

Supply-side:

Keep health facilities open later

More facilities in rural areas

Expanded outreach

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Good governance builds on small schemes

Isolated “grassroots”community schemes notsustainable or scalable

Policy actions

Tax subsidy

Consolidated beneficiarycontributions

Professionalizing schememanagement

8

Improving the data to expand coverage

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Insufficient survey data – informal sector stays invisible

Informal/formal dichotomy in UHC dialogue

Moving beyond ‘informality’

SHI legacy countries

Free care legacy countries

Incremental approachesbeginning with the poor

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Key takeaways

Progress towards UHC requires covering informal workers

EPCMD countries have MORE informal workers

No silver bullet

Policy solutions shaped by the past

Informal workers less visible and influential on public policy

Looking ahead

Better data on informal workers

Informed long term policy

Micro-level operational improvements

Targeting subgroups to expand coverage incrementally

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THANK YOU!

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All Study Participants, Laurel Hatt, RicardoBitran, USAID: Scott Stewart and Jodi Charles

Photos courtesy of Photoshare and A. Koon

Please see full report on our website:

www.hfgproject.org