Publication: Social Health Insurance Reexamined
Loading...
Published
2007-01
ISSN
Date
2012-06-01
Author(s)
Editor(s)
Abstract
Social health insurance (SHI) is enjoying something of a revival in parts of the developing world. Many countries that have in the past relied largely on tax finance (and out-of-pocket payments) have introduced SHI, or are thinking about doing so. And countries with SHI already in place are making vigorous efforts to extend coverage to the informal sector. Ironically, this revival is occurring at a time when the traditional SHI countries in Europe have either already reduced payroll financing in favor of general revenues, or are in the process of doing so. This paper examines how SHI fares in health care delivery, revenue collection, covering the formal sector, and its impacts on the labor market. It argues that SHI does not necessarily deliver good quality care at a low cost, partly because of poor regulation of SHI purchasers. It suggests that the costs of collecting revenues can be substantial, even in the formal sector where nonenrollment and evasion are commonplace, and that while SHI can cover the formal sector and the poor relatively easily, it fares badly in terms of covering the nonpoor informal sector workers until the economy has reached a high level of economic development. The paper also argues that SHI can have negative labor market effects.
Link to Data Set
Citation
“Wagstaff, Adam. 2007. Social Health Insurance Reexamined. Policy Research Working Paper; No. 4111. © World Bank. http://hdl.handle.net/10986/6886 License: CC BY 3.0 IGO.”
Associated URLs
Associated content
Other publications in this report series
Publication The Economic Value of Weather Forecasts: A Quantitative Systematic Literature Review(Washington, DC: World Bank, 2025-09-10)This study systematically reviews the literature that quantifies the economic benefits of weather observations and forecasts in four weather-dependent economic sectors: agriculture, energy, transport, and disaster-risk management. The review covers 175 peer-reviewed journal articles and 15 policy reports. Findings show that the literature is concentrated in high-income countries and most studies use theoretical models, followed by observational and then experimental research designs. Forecast horizons studied, meteorological variables and services, and monetization techniques vary markedly by sector. Estimated benefits even within specific subsectors span several orders of magnitude and broad uncertainty ranges. An econometric meta-analysis suggests that theoretical studies and studies in richer countries tend to report significantly larger values. Barriers that hinder value realization are identified on both the provider and user sides, with inadequate relevance, weak dissemination, and limited ability to act recurring across sectors. Policy reports rely heavily on back-of-the-envelope or recursive benefit-transfer estimates, rather than on the methods and results of the peer-reviewed literature, revealing a science-to-policy gap. These findings suggest substantial socioeconomic potential of hydrometeorological services around the world, but also knowledge gaps that require more valuation studies focusing on low- and middle-income countries, addressing provider- and user-side barriers and employing rigorous empirical valuation methods to complement and validate theoretical models.Publication The State of Global Services Trade Policies: Evidence from Recent Data(Washington, DC: World Bank, 2025-10-28)The economic environment for services trade has changed dramatically over the past 15 years, driven by rapid technological progress that has expanded the possibilities for exchanging services. How has trade policy responded to these changes? How do policy stances in a wide range of service sectors compare across economies? With its unprecedented global coverage, the Services Trade Policy Database and the associated Services Trade Restrictions Index, developed jointly by the World Bank and the World Trade Organization, help address these questions. This paper makes three principal contributions. First, it offers an in-depth discussion of the current state of services trade policies and their differences across 134 economies and 34 services subsectors. Second, the paper reveals how recent (2016–22) changes in policy stances have seen progressive liberalization by lower-income economies but stabilization or even slight policy reversals in high-income economies. This dynamic differs fundamentally from the trend that unfolded after the Great Recession over 2008–16. Third, the paper shows the implications of policy changes over the past six years on services trade costs, and it showcases how the Services Trade Policy Database’s regulatory information can inform trade negotiations, regulatory analysis, and policy making. Alongside these contributions, the paper documents updates to the Services Trade Policy Database’s economy and sector coverage and explains the latest methodological improvements made to the World Bank–World Trade Organization Services Trade Restrictions Index.Publication It’s Not (Just) the Tariffs: Rethinking Non-Tariff Measures in a Fragmented Global Economy(Washington, DC: World Bank, 2025-10-22)As tariffs have declined, non-tariff measures (NTMs) have become central to trade policy, especially in high-income countries and regulated sectors like food and green technologies. Although NTMs may serve legitimate goals, they could also sort countries and firms into or out of markets based on compliance capacity and differences in product mix. Documenting recent advances in the estimation of ad valorem equivalents (AVEs), this paper uncovers new patterns of use and exposure of NTMs. High-income countries rely more heavily on NTMs relative to tariffs, while low- and middle-income countries face steeper AVEs on their exports. Firm-level evidence shows that NTMs disproportionately affect smaller firms, leading to market exit and concentration. Poorly designed NTMs can harm productivity and welfare, while coordinated, capacity-aware use can deliver inclusive outcomes. Policy design, transparency, and diagnostics must evolve to reflect the growing role—and risks—of NTMs in a fragmented global trade landscape.Publication The Marshall Plan: Then and Now(Washington, DC: World Bank, 2025-10-14)This paper is a product of the Development Policy Team, Development Economics. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://www.worldbank.org/prwp.Publication The Macroeconomic Implications of Climate Change Impacts and Adaptation Options(Washington, DC: World Bank, 2025-05-29)Estimating the macroeconomic implications of climate change impacts and adaptation options is a topic of intense research. This paper presents a framework in the World Bank's macrostructural model to assess climate-related damages. This approach has been used in many Country Climate and Development Reports, a World Bank diagnostic that identifies priorities to ensure continued development in spite of climate change and climate policy objectives. The methodology captures a set of impact channels through which climate change affects the economy by (1) connecting a set of biophysical models to the macroeconomic model and (2) exploring a set of development and climate scenarios. The paper summarizes the results for five countries, highlighting the sources and magnitudes of their vulnerability --- with estimated gross domestic product losses in 2050 exceeding 10 percent of gross domestic product in some countries and scenarios, although only a small set of impact channels is included. The paper also presents estimates of the macroeconomic gains from sector-level adaptation interventions, considering their upfront costs and avoided climate impacts and finding significant net gross domestic product gains from adaptation opportunities identified in the Country Climate and Development Reports. Finally, the paper discusses the limits of current modeling approaches, and their complementarity with empirical approaches based on historical data series. The integrated modeling approach proposed in this paper can inform policymakers as they make proactive decisions on climate change adaptation and resilience.
Journal
Journal Volume
Journal Issue
Collections
Related items
Showing items related by metadata.
Publication Bosnia and Herzegovina : Policy Notes for the BH Governments(Washington, DC, 2007-03)Bosnia and Herzegovina (BH) has made substantial progress in economic reconstruction since the end of the war, but much more remains to be done to establish conditions for sustainable private sector-led growth, curtail risks to hard-won fiscal stability, and create an efficient government. The high level of government spending remains supported by a larger than optimal tax burden, primarily reflecting onerous social security contributions, bankruptcy or liquidation. The operational independence of the privatization agencies should be ensured, and transparent methods must be used for divestiture. This paper also notes that deteriorating rural infrastructure, including roads, electricity, village water supply, and irrigation, all constrain rural development. Recommendations are proposed for improving conditions in the agriculture, health, transport, and education sectors.Publication Vietnam : Learning from Smart Reforms on the Road to Universal Health Coverage(World Bank Group, Washington, DC, 2014-08)Universal Health Coverage is a powerful framework for a nation aiming to protect their population against health risks. However, countries face multiple challenges in implementing, achieving and sustaining UHC strategies. Sharing and learning from diverse country experiences may enable to foster global and country progress toward that goal. The study seeks to contribute to the global effort of sharing potentially useful lessons to address policy concerns on the design and implementation of UHC strategies in LMICs. Vietnam is one of the LMICs that have taken relatively quick and effective actions to expand health coverage and improve financial protection in the last two decades. The country study, first, takes stock of UHC progress in Vietnam, examining both the breadth and the depth of health coverage and assessing financial protection and equity outputs (chapter one). Chapter two includes an in-depth analysis of some of the major success strategies and policy actions that the country took to expand health coverage and financial protection for all, including for the poor. Chapter three focuses on some of the UHC-related challenges that the country faces in pursuing expansion and sustaining UHC. Vietnam s experience suggests that, moving toward greater UHC outputs, the system must be constantly adjusted, and that UHC strategies must be adaptive, those used in the past to cover the formal sector and the poor may turn out inadequate to reach the uninsured in the informal sector.Publication Europe and Central Asia's Great Post-Communist Social Health Insurance Experiment : Impacts on Health Sector and Labor Market Outcomes(World Bank, Washington, DC, 2007-10)The post-communist transition to social health insurance in many of the Central and Eastern European and Central Asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax-financed health systems. This paper employs a regression-based generalization of the difference-in-differences method and instrumental variables on panel data from 28 countries for the period 1990-2004. The authors find that, controlling for any concurrent provider payment reforms, adoption of social health insurance increased national health spending and hospital activity rates, but did not lead to better health outcomes. The authors also find that adoption of social health insurance reduced employment in the economy as a whole and increased unemployment, although it did not apparently increase the size of the informal economy.Publication Social Health Insurance vs. Tax-Financed Health Systems—Evidence from the OECD(2009-01-01)This paper exploits the transitions between tax-financed health care and social health insurance in the OECD countries over the period 1960-2006 to assess the effects of adopting social health insurance over tax finance on per capita health spending, amenable mortality, and labor market outcomes. The paper uses regression-based generalizations of difference-in-differences and instrumental variables to address the possible endogeneity of a country's health system. It finds that adopting social health insurance in preference to tax financing increases per capita health spending by 3-4 percent, reduces the formal sector share of employment by 8-10 percent, and reduces total employment by as much as 6 percent. For the most part, social health insurance adoption has no significant impact on amenable mortality, but for one cause-breast cancer among women-social health insurance systems perform significantly worse, with 5-6 percent more potential years of life lost.Publication Universal Health Coverage and the Challenge of Informal Employment : Lessons from Developing Countries(World Bank, Washington, DC, 2014-01)The aim of the report is to review existing approaches and available policy options to improve access to health care services and financial protection against health shocks for informal-sector workers (ISWs). Along with their families, ISWs represent the majority of the population in many developing countries. The report reviews the definition and measurement of the informal sector and the literature on efforts toward its health insurance coverage. It also examines several country cases based on published and unpublished reports and on structured interviews of expert informants. Developing country efforts to expand health coverage are characterized by a common enrollment and financing pattern, starting with formal-sector workers and following with government-subsidized enrollment of the poor. Thus, ISWs are typically left behind and have been referred to as "the missing middle." They find themselves financially unprotected against health shocks and with limited access to quality and timely health care. ISWs are generally reluctant to enroll in insurance schemes, including social health insurance (SHI), community insurance, and other arrangements. Further, initiatives to enroll them in self-financed contributory schemes have generally resulted in adverse selection, as those with high anticipated health needs are more willing to pay and enroll than others. Successful initiatives to cover this population group are the ones where government has abandoned its expectations to derive relatively substantial revenue from it. Offering this group a benefits package that is relatively smaller than that of formal workers and charging them a premium that is only a fraction of that charged to formal workers is a strategy used by some countries to limit the need for public subsidies. While there is evidence that greater insurance coverage has improved access to health services for ISWs and their dependents, in several countries it has not yet improved financial protection for this target group. A broad set of reforms will be required to strengthen the supply side to ensure that additional public financing translates into improved coverage for ISWs.
Users also downloaded
Showing related downloaded files
Publication Mining Royalties : A Global Study of Their Impact on Investors, Government, and Civil Society(Washington, DC: World Bank, 2006)Mineral sector regulatory and fiscal systems have been undergoing major reforms across the globe. This book focuses on information and analysis relating to mineral royalties. It provides a general discussion of the concepts behind mining taxation, a guide to royalties, examples of royalty calculations and the ways in which these interact with other forms of taxation, as well as financial effects on investments under varying conditions. Primary information includes royalty legislation from over forty nations. The book discusses implications for investors and governments of various tax regimes and provides specific country case examples. A chapter is included on transparency, governance, and management of revenue streams. The appendices, in the second volume, contain brief summaries and selected statutes relating to royalties in a broad cross-section of nations around the world; sample spreadsheets of the results of mine models that were analyzed; and examples of administrative and distributional approaches to collecting royalties.Publication International Financial Reporting Standards : A Practical Guide, 5th Edition(World Bank, 2009)The publication of this fifth edition coincides with the convergence in accounting standards that has been a feature of the international landscape since the global financial crisis of 1998. The events of that year prompted several international organizations, including the World Bank and the International Monetary Fund, to launch a cooperative initiative to strengthen the global financial architecture and to seek a longer-term solution to the lack of transparency in financial information. A conscious decision has been made to focus on the needs of executives and financial analysts in the private and public sectors who might not have a strong accounting background. This publication summarizes each standard so managers and analysts can quickly obtain a broad overview of the key issues. Detailed discussion of certain topics has been excluded to maintain the overall objective of providing a useful tool to managers and financial analysts. In addition to the short summaries, most chapters contain basic examples that emphasize the practical application of some key concepts in a particular standard. This text provides the tools to enable an executive without a technical accounting background to: (1) participate in an informed manner in discussions relating to the appropriateness or application of a particular standard in a given situation, and (2) evaluate the effect that the application of the principles of a given standard will have on the financial results and position of a division or of an entire enterprise.Publication Social Protection and Jobs Responses to COVID-19(Washington, DC: World Bank, 2022-02-07)As of January 2022, a total of 3,856 social protection and labor measures were planned or implemented by 223 economies. This constitutes a net increase of 523 measures, or 15.6 percent since the last update in May 2021. While noteworthy, such increase is the lowest among net additions observed over previous semesters. In fact, the global pace of measures’ introduction over January 2020-January 2022 has been slowing down. This report focuses on the real-time review of country measures in terms of social protection and job responses to Coronavirus (COVID-19).Publication Global Economic Prospects, June 2025(Washington, DC: World Bank, 2025-06-10)The global economy is facing another substantial headwind, emanating largely from an increase in trade tensions and heightened global policy uncertainty. For emerging market and developing economies (EMDEs), the ability to boost job creation and reduce extreme poverty has declined. Key downside risks include a further escalation of trade barriers and continued policy uncertainty. These challenges are exacerbated by subdued foreign direct investment into EMDEs. Global cooperation is needed to restore a more stable international trade environment and scale up support for vulnerable countries grappling with conflict, debt burdens, and climate change. Domestic policy action is also critical to contain inflation risks and strengthen fiscal resilience. To accelerate job creation and long-term growth, structural reforms must focus on raising institutional quality, attracting private investment, and strengthening human capital and labor markets. Countries in fragile and conflict situations face daunting development challenges that will require tailored domestic policy reforms and well-coordinated multilateral support.Publication Commodity Markets Outlook, October 2025(Washington, DC: World Bank, 2025-10-29)Commodity prices are expected to decline by about 7 percent overall this year, reflecting subdued global economic activity, elevated trade tensions and policy uncertainty, ample global supply of oil, and weather-related supply shocks. In 2026, commodity prices are forecast to fall by a further 7 percent, a fourth consecutive year of decline, as global growth remains sluggish and the oil market oversupplied. Energy price movements are envisaged to continue contributing to global disinflation in 2026. Metals and minerals prices are expected to remain stable in 2026, while agricultural prices are projected to edge down, primarily due to strong supply conditions. Precious metals prices are expected to rise another 5 percent, after a historically large, investment-driven rally of about 40 percent in 2025. Risks to the commodity price projections are tilted to the downside. Key downside risks include weaker-than-expected global growth, a longer-than-assumed period of economic policy uncertainty, and additional oversupply of oil. Upside risks include intensifying geopolitical tensions, the market impact of additional oil sanctions, supply reductions stemming from additional trade restrictions, unfavorable weather conditions, faster-than-expected rollout of new data centers. Commodity price volatility in recent years has revived interest in supply management via international commodity agreements. Historical experience, however, shows that the most effective policy is to promote diversification, innovation, transparency, and market-based pricing—measures that build lasting resilience to commodity price volatility.