D o , Da id Ma k
Book Pa — Published Ve sion
Pe spec i e Chap e : Mic oinsu ance’s Ques o P o ec he
Unp o ec ed, beyond he Bisma ck and Be e idge Models
Sugges ed Ci a ion: D o , Da id Ma k (2024) : Pe spec i e Chap e : Mic oinsu ance’s Ques o P o ec
he Unp o ec ed, beyond he Bisma ck and Be e idge Models, In: Ta a es, Aida Isabel (Ed.): Heal h
Insu ance Ac oss Wo ldwide Heal h Sys ems, ISBN 978-0-85466-213-5, In echOpen, London, pp.
1-26,
h ps://doi.o g/10.5772/in echopen.1002483
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h ps://hdl.handle.ne /10419/315596
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1
Chap e
Pe spec i e Chap e :
Mic oinsu ance’s Ques o P o ec
he Unp o ec ed, beyond he
Bisma ck and Be e idge Models
Da id Ma kD o
Abs ac
This chap e o e s a de ailed analysis o mic oinsu ance (nowadays o en called
“inclusi e insu ance”), an inno a i e hyb id model combining g ass oo s ini ia i es
wi h op-down app oaches o each popula ions no co e ed by go e nmen -ope a ed
social p o ec ion sys ems. Wi h hal o he global popula ion, p ima ily in low and
middle-income coun ies, lacking social p o ec ion, he chap e ocuses on he po en-
ial o mic oinsu ance o add ess his p essing issue. The comme cial mic oinsu ance
a emp s, o en labeled as “insu ance o he poo ,” ha e been la gely insu icien . An
al e na i e lies in he “Collabo a i e and Con ibu i e” (C&C) model o mic oinsu -
ance, which ha nesses social o ces, ypically mo e compelling han ma ke o ces in
in o mal se ings, o s imula e demand. The chap e e alua es mic oinsu ance’s social
and economic impac s, d awing insigh s om 25 yea s o p og ess. I unde sco es
he need o policymake s, in e na ional de elopmen banke s, and he einsu ance
indus y o ecognize he po en ial o he C and C model in p o iding comp ehensi e
insu ance o ma ginalized popula ions.
Keywo ds: in o mal sec o , inancial p o ec ion, isk managemen , a o dable
co e age, insu ance educa ion, mic oinsu ance
1. In oduc ion
This chap e ackles a signi ican global de elopmen issue: he sys emic exclusion
o hal he wo ld’s popula ion om i al social p o ec ion sys ems [1]. Such sys ems,
encompassing c ucial se ices like heal h insu ance, social secu i y, and social
assis ance, emain inaccessible o a la ge p opo ion o he global popula ion. This
widesp ead lack o access dep i es nume ous indi iduals o uni e sal social p o ec-
ion co e age’s social and inancial bene i s. I hinde s economic g ow h and equi able
income and weal h dis ibu ion in a ious coun ies. A mul i ude o complex and
in e ela ed ac o s d i e his oubling si ua ion.
In he ea ly 1970s, Kei h Ha ’s seminal s udies ca alyzed discussions a ound
in o mal employmen [2]. Building upon his momen um, he In e na ional Labou
Heal h Insu ance Ac oss Wo ldwide Heal h Sys ems
2
O ganiza ion (ILO) soon in oduced he ‘non- adi ional insu ance’ concep . P esen ed
in hei 1972 epo [3], his ounda ional discou se on in o mal sec o s and non-
adi ional insu ance con inued o gain ac ion in he 1980s and 1990s s uc u al
adjus men e a. This idea ook a de ini i e o m in he 1990s, culmina ing in he e m
‘mic oinsu ance.’ O e ime, mic oinsu ance has u he e ol ed and is now commonly
e e ed o as ‘inclusi e insu ance’ o emphasize he aim o educing exclusion [4].
Mic oinsu ance is no con ined o heal h isks; i can add ess a ious pe ils. Howe e ,
in his chap e , he ocus is p ima ily on heal h- ela ed isks, aligning wi h he o e all
subjec o his book, which is heal h insu ance. This cla i ica ion ensu es ha he scope
o he discou se on mic oinsu ance wi hin his wo k is unde s ood. This e m e e ed o
communi y-based o ganiza ions connec ed o la ge s uc u es o acili a e isk pooling.
Gi en ha , in many con ex s, he pe cei ed incapaci y o he s a e o p o ide adequa e
social p o ec ion o speci ic segmen s o socie y, his app oach was seen as necessa y.
The chap e begins by ou lining he p oblem and i s backg ound be o e discuss-
ing how he de ini ion and applica ion o he mic oinsu ance concep can p o ide
possible solu ions.
1.1 Impac o p ede e mina ion belie s on isk analysis and p e en i e measu es
Cul u al no ms and socie al p io i ies deeply embedded a he indi idual le el
o en de e speci ic g oups om accessing insu ance mechanisms. F om he dawn
o ime, ad e se e en s ha e o en been a ibu ed o p edes ina ion, di ine will, o
he esul o pe sonal ac ions. This pe cep ion, which is s ill pe sis en in many pa s
o he wo ld, causes many o a oid isk analysis and, e en mo e, no o ake p e en-
i e measu es o coun e ac , mi iga e, o compensa e o isks ( o mo e de ails on
isk pe cep ion, see [5]). An app oach o unde s anding hose pe cep ions equi es
sus ained collec i e commi men .
1.2 Role o insu ance in add essing un o eseen e en s and inancial consequences
Insu ance is a p oac i e ool designed o mi iga e inancial consequences om
unp edic able e en s. While he b oade pa e ns o hese e en s a e known, he exac
iming, loca ion, se e i y, and speci ic indi idual o asse a isk a e unce ain [6]. A
i s co e, insu ance ope a es on he p inciple o isk pooling.
Wilkie’s seminal wo k [7] ap ly di e en ia es be ween wo p ima y o ms o isk
pooling:
Risk-based pooling: He e, con ibu ions o p emiums a e de e mined by he speci ic
isk le el each pa icipan (indi idual o g oup) in oduces o he pool. This app oach
is commonly seen in p i a e insu ance.
Solida i y-based pooling: This model conside s b oade socie al ac o s when de e -
mining con ibu ions, epi omizing he p inciples o social insu ance sys ems.
In insu ance and mu ual o ganiza ions, “mu uali y” adi ionally deno es
membe s’ sha ed bene i s and bu dens. Con e sely, “solida i y” ep esen s he
ounda ional e hos o social insu ance, whe e socie al o g oup membe s collec i ely
shoulde he cos o isk p o ec ion, i espec i e o he indi idual isk hey in oduce.
Howe e , many indi iduals, pa icula ly hose less a luen , less educa ed, o
employed in he in o mal sec o , pe cei e insu ance as beyond hei g asp, e med
as “lack o agency.” This sen imen is especially s ong owa ds comme cial insu -
ance among economically disad an aged popula ions [8]. Simila sen imen s a e
3
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echoed in s udies on mic oinsu ance [9] and mic o inance [10], whe e indi iduals
eel challenged o manage p edic able isks o main ain ela ionships wi h insu ance
p o ide s.
1.3 His o ical app oach o go e nmen in e en ion in heal h insu ance
Go e nmen s i s en u ed in o (heal h) insu ance egula ion in he mid-nine-
een h cen u y. They expanded hei in ol emen o include inancing and p o ision
in he wen ie h cen u y. We de ail he ou models [11] and hen discuss he wo ha
ha e p o en mo e in luen ial.
Bisma ckian Model: Named a e he Ge man s a esman O o on Bisma ck, his
model connec s he igh o heal hca e co e age o obliga o y insu ance inanced
h ough con ibu ions. I is common in indus ialized coun ies like Ge many, F ance,
Swi ze land, and Japan, whe e employe s and employees und he heal h insu ance
sys em [12].
Be e idgean Model: The Be e idgean model, named a e William Be e idge,
p o ides heal hca e co e age igh s based on esidency o ci izenship. P ima ily
unded h ough gene al axa ion, his model s esses uni e sal co e age, i espec i e
o income o employmen s a us. I is mani es ed in he Uni ed Kingdom’s Na ional
Heal h Se ice (NHS), Sweden, Spain, Canada, India, China, I aly, and o he s [13, 14].
USA Model: The US heal hca e sys em is a hyb id model, combining ax-based
unding o speci ic popula ions (like Medica e and Medicaid ecipien s and some
A o dable Ca e Ac en ollees) wi h p i a e insu ance. This model lacks a coo dina ed
app oach o heal hca e co e age, leading o signi ican a iabili y in accessibili y and
a o dabili y. Fu he mo e, many people ac oss di e en socioeconomic le els o
employmen s a uses emain uninsu ed [15].
The Semashko Model, named a e Nikolai Semashko, was a heal hca e sys em used
in he o me So ie Union and o he socialis na ions. Funded by s a e subsidies, i
p o ided heal hca e se ices h ough local public cen e s o designa ed wo kplace
acili ies, o en accessible mainly o he “p i ileged” class, like go e nmen ins i u-
ions, he mili a y, he police, and majo ac o ies in c i ical sec o s. This model
allowed a ying ca e le els, e lec ing So ie socie y’s in o mal class dis inc ions,
om he in luen ial “nomenkla u a” o hose in employmen , educa ion, e i emen ,
o wi h disabili ies, and he ma ginalized “social ma gin” o “pa asi es” [16].
The ini ial e o s o Eu opean go e nmen s in insu ance egula ion in he nine-
een h cen u y we e p edominan ly gea ed owa ds wha can be e med as “p i a e”
insu ance, based on he p inciple o mu uali y, e en i hey we e no always con-
duc ed h ough mu ual associa ions in he mode n sense. Howe e , by he second
hal o he wen ie h cen u y, hese models in oduced mo e comp ehensi e sys ems,
ep esen ing he nascen s ages o wha we now ecognize as social insu ance. As
such, i ’s c ucial o di e en ia e be ween hese ea ly egula o y in e en ions and he
mo e holis ic, s a e-d i en models o social insu ance ha ollowed.
1.4 Limi a ions and exclusions in hese models, especially o he in o mal sec o
The Bisma ckian and Be e idge models a e in luen ial in many coun ies wo ld-
wide because hey ep esen wo dis inc , well-es ablished app oaches o s uc u ing
social secu i y and heal h insu ance sys ems [17]. By con as , he USA model is
c i icized o i s complexi y, high cos s, and gaps in co e age [18]. And he Semashko
model, accommoda ing he no ion o unequal quali y and quan i y o ca e o igina ing
Heal h Insu ance Ac oss Wo ldwide Heal h Sys ems
4
om he social o de o he o me So ie Union, is now conside ed i ele an o
cu en deba es on heal hca e sys ems [16].
Why is he e a p essing need o an addi ional model? The c ux o he issue
p ima ily lies in he op-down go e nance embedded in he ou adi ional models.
These sys ems h i e on cen alized decision-making and con ol, cul i a ing dis inc
command chains and po en ial e iciencies. Bu his cen aliza ion o en p opels hese
sys ems owa ds one-size- i s-all solu ions, less sui able o con ex -speci ic go e -
nance [19]. Mo eo e , such sys ems a e ela i ely ola ile unde uns able mac oeco-
nomic condi ions [20]. And hey s i e o apply ‘one-size- i s-all’ solu ions ha may
be unsui able in nume ous se ings [21].
Mo eo e , many low- and middle-income coun ies ha e adop ed a policy o
a ac ing o eign in es o s o s imula e expo -o ien ed manu ac u ing. These
economies depend on expo ing low-cos goods, which equi es low-cos p oduc-
ion, o en leading o minimum wages o wo ke s and slim business p o i ma gins.
Consequen ly, hese coun ies equen ly elax he equi emen s o o eign i ms o
p o ide social bene i s, u he lowe ing ope a ing cos s [22]. This app oach s imu-
la es expo -o ien ed manu ac u ing wi h minimal wo ke s’ wages and p o ec ion
and can gene a e jobs and spu sho - e m economic g ow h. Howe e , i o en esul s
in dec eased ax e enues o he go e nmen . This s a egy can be execu ed and
scaled wi hou equi ing go e nmen s o implemen ex ensi e social p o ec ion mod-
els, no o men ion he mo e comp ehensi e Bisma ckian o Be e idgean sys ems.
1.5 Applicabili y o in e na ional labo s anda ds on uni e sal social p o ec ion
co e age
The ques ion may a ise whe he in e na ional labo s anda ds migh bind coun-
ies o p o ide a leas minimal social p o ec ion. Al hough hese ma e s ha e been
acknowledged a a ious in e na ional con e ences, he e is no binding solu ion
ye . The UN’s agency championing he e olu ion o social p o ec ion sys ems is he
In e na ional Labou O ganiza ion (ILO). Be o e 2000, he ILO’s social secu i y
p omo ion ocused on he o mal economy [23]. The c ux o he ILO’s s a egy lay in
ad oca ing o he a i ica ion and implemen a ion o he Social Secu i y (Minimum
S anda ds) Con en ion, 1952 (No. 102) [24]. This con en ion, which ou lines mini-
mum s anda ds o he p incipal b anches o social secu i y, e lec s a Bisma ckian
app oach, emphasizing con ibu ion-based social insu ance schemes.
E en be o e 2000, he ILO ecognized ha many na ions could no apply he
s anda ds o eseen in Con en ion No. 102. Consequen ly, i suppo ed a g adual
expansion o co e age, conside ing na ional ci cums ances and s essing public
consul a ion’s impo ance in de e mining sui able implemen a ion s a egies [25].
By he la e wen ie h cen u y, i also became clea ha a subs an ial segmen o
he global popula ion emained excluded, pa icula ly hose in de eloping coun ies’
in o mal economies [26, 27].
Subsequen ly, he ILO began ad oca ing o mo e lexible social p o ec ion
models o each unde se ed popula ions [28]. This shi esul ed in he ILO’s 2012
Recommenda ion No. 202 [29], which p omo ed he idea o na ional Social P o ec ion
Floo s (SPFs)—basic social secu i y gua an ees aiming o comba po e y, ulne -
abili y, and social exclusion [30]. In addi ion o ad oca ing o he ealiza ion o SPFs,
he ILO suppo s o malizing in o mal employmen and conside ing gende -speci ic
isks in social p o ec ion design and implemen a ion.
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The Wo ld Heal h O ganiza ion (WHO) ad oca ed o Uni e sal Heal h Co e age
(UHC), as well as mic oinsu ance [31]. Bu i s ac ions ha e been mo e decla a-
i e han p ac ical. The 58 h Wo ld Heal h Assembly (WHA) passed Resolu ion
WHA58.33 in 2005, eques ing membe s a es o de elop heal h inancing sys ems
capable o achie ing and main aining UHC. The 2010 Wo ld Heal h Repo also
ocused on heal h inancing, p o iding ad ice on aising unds, educing dependence
on di ec se ice paymen s, and enhancing e iciency and equi y.
Addi ionally, he Uni ed Na ions Gene al Assembly adop ed a esolu ion in 2012
(A/RES/67/81), encou aging membe s a es o p og ess owa ds p o iding UHC. This
esolu ion has been ein o ced by subsequen WHA esolu ions and he inclusion o
UHC as a a ge o he Sus ainable De elopmen Goals (SDGs) in 2015.
Consequen ly, while he UN and o he in e na ional bodies ha e ad oca ed o
expanded heal h insu ance access o ma ginalized popula ions, hey ha e ye o
enac any legally binding ins umen s o gua an ee he ealiza ion o his objec i e.
Fu he mo e, he e is a lack o consensus on which en i y should spea head his mission.
2. Mic oinsu ance: ex ending co e age o he in o mal sec o
Mic oinsu ance is a dis inc insu ance app oach designed o mee he demand
o o en ma ginalized, unde se ed communi ies, ocusing on needs iden i ied and
p io i ized locally [32] (mic o co esponds o local, meso o egional, and mac o o
na ional). Gi en ha mos uninsu ed indi iduals a e engaged in he in o mal sec o in
Figu e 1.
Hidden wo k o ce: In o mal employmen in labo -in ensi e indus ies.
Heal h Insu ance Ac oss Wo ldwide Heal h Sys ems
6
Low and Middle-Income Coun ies (LMICs) and ha many labo -in ensi e indus ies
in o mally employ a signi ican po ion o hei wo k o ce [ILO da a; g aph sou ce
[33]], i ’s impe a i e o unde sco e he necessi y o ailo ing solu ions o he unique
ci cums ances o he in o mal sec o (Figu e 1).
La e , we examine h ee in e p e a ions o he e m ‘inclusi e insu ance.’ In i s
o iginal concep ion, he bene icia ies ac i ely de e mine he insu ed isks based
on hei abili y and willingness o pay p emiums. Addi ionally, he insu ed g oup
should pa icipa e in managemen and claim adjudica ion p ocesses. This in ol e-
men educes adminis a i e cos s, inc eases anspa ency, and nu u es us . These
unique cha ac e is ics dis inguish i signi ican ly om he ope a ional models o
adi ional comme cial o public insu ance schemes.
2.1 In oduc ion o mic oinsu ance as a non-manda o y social p o ec ion model
The In e na ional Labou O ganiza ion (ILO) in oduced non- adi ional co e age
o o e social p o ec ion o in o mal and ag icul u al wo ke s, o en excluded om
adi ional pension and social secu i y sys ems. This concep eme ged du ing he
s uc u al adjus men e a o he Wo ld Bank’s ea ly explo a ion in o index insu ance
[34]. Howe e , a emp s o expand social secu i y o non- adi ional wo ke s du ing
he 1970s and 1980s encoun e ed signi ican unding challenges due o he wi hd awal
o go e nmen subsidies unde s uc u al adjus men policies [35–37].
Du ing ha pe iod, he w i ings o Ama ya Sen became pa icula ly signi ican .
His Capabili y App oach unde sco ed he impo ance o indi idual agency and
eedom in achie ing de elopmen al ou comes [38, 39]. Sen and Jean D èze high-
ligh ed he impo ance o public pa icipa ion in policymaking, ad oca ing agains
op-down, o e ly simpli ied solu ions o complex social p oblems [40].
By he la e 1980s, he ILO, in luenced by Sen’s emphasis on pa icipa o y de elop-
men , sugges ed a no el app oach: ad oca ing o communi y-based social p o ec ion
schemes using ‘ adi ional’ ins i u ions [41]. This idea gained u he ac ion in he
1990s, p opelled by Elino Os om’s g oundb eaking wo k on managing common
pool esou ces (CPR) [42]. Os om’s p inciples, ad oca ing o local communi ies’
au onomy in managing common esou ces, esona ed wi h he e hos o communi y-
based social p o ec ion schemes ha he ILO endo sed.
In luenced by Sen’s and Os om’s ideas, he ILO launched a p ojec ocusing on he
in o mal sec o in h ee majo de eloping ci ies [43]. This p ojec laid he g oundwo k
o ‘mic oinsu ance,’ in oduced in 1999 [44]. D o ’s mic oinsu ance model encap-
sula ed communi y-d i en o ganiza ions linked o la ge s uc u es o isk pooling.
The model e ec i ely me ged Os om’s gene al app oach o collec i e ac ion and CPR
managemen and Sen’s emphasis on pa icipa o y decision-making and eedom.
D o ’s model en isions communi ies collec i ely managing and dis ibu ing isks
[45], suppo ing a locally o ganized and inanced sys em ha allows collec i e esou ce
pooling and isk managemen . The model allows cus omiza ion o insu ance p oduc s
o i speci ic communi y needs and le e ages exis ing social dynamics among he unin-
su ed, o e ing a o dable, con ex -speci ic, and demand-d i en insu ance packages.
Howe e , du ing he ea ly de elopmen o mic oinsu ance, in o mal sec o
wo ke s’ oices we e o en unde ep esen ed, and consul a ion was insu icien ,
wi h empi ical e idence o implemen a ion lacking. The discou se was ins ead
domina ed by ex e nal pa ies om weal hie na ions keen o pinpoin he de ining
ea u es o mic oinsu ance. Th ee p incipal pe spec i es eme ged: one ocused on
he a ge popula ion—“ he poo ” [46, 47]; ano he highligh ed he p oduc ’s na u e,
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cha ac e ized by “low cos and low co e age” [48, 49]; he hi d pe spec i e cen e ed
on he ype o insu ance p o ide , whe he mu ual, social, o o -p o i en i ies [50].
Comme cial insu e s ound alida ion o hei p e e ence o sell insu ance o
indi iduals h ough agen s in Thale and Suns ein’s “nudge” concep [51], which
ad oca es mino in e en ions o guide decision-making. While his concep aligns
wi h Sen’s emphasis on eedom o choice [38], i lacks his emphasis on public discus-
sion o enhance a ionali y [52]. Fu he mo e, i con as s wi h Os om’s pe spec i e
on he capaci y o local communi ies o sel -go e n common esou ces [42].
The blu ed lines be ween “insu ance o he poo ” and “low-cos & low-co e age
p oduc s” o en esul ed in bo h pe spec i es de ia ing om he o iginal p oposi-
ion o ha nessing social dynamics [53, 54]. Addi ionally, low-cos p oduc s did no
gua an ee ha “che y-picking “p ac ices1 would no lea e p o ec ion gaps among he
clien s o hese new p oduc s [55]. Se e al “low p emium p oduc s” we e de eloped
wi hou cus omizing o local isk exposu e o su icien ly explo ing he p ice sensi i -
i y o he uninsu ed [56]. Howe e , he lack o empi ical e idence o implemen a ion
and clea e idence o bene i s o a ge popula ions mean insu icien consul a ion
among he poo es popula ions hwa ed comme cial success. The Mic o Insu ance
Academy ( ounded by Da id D o in New Delhi in 2007) ocused on implemen a ion
suppo o he Mic o Insu ance Uni concep , emb acing Sen’s and Os om’s heo e i-
cal ounda ions bu wi h no el acili a ion o ‘insu ance educa ion’ unde he banne
o he Collabo a i e and Con ibu i e (C&C) mic oinsu ance model, which unde -
sco es Sen’s emphasis on communi y pa icipa ion, eedom, and collec i e engage-
men in ailo ing solu ions o speci ic local esou ce managemen [57, 58].
Howe e , p emiums had o be a o dable. This begs he ques ion: A e he unin-
su ed in e es ed in pu chasing “cheap insu ance o he poo ”? [59]. The analysis o
his i al issue o ms he nex poin o discussion.
2.2 P ice sensi i i y: ailo ing insu ance plans based on economic s a us
De ining mic oinsu ance as “insu ance o he poo ” insinua es wo condi ions:
i s ly, ha such co e age exis s ou side he s uc u e o a uni e sal social p o ec ion
sys em and, hus, con ibu o y, bu wi hou go e nmen manda es. And secondly,
he p emiums should be low o sui he limi ed esou ces o poo people [60]. The
i s condi ion implies ha mic oinsu ance mus be p iced o compensa e o he pu e
ac ua ial p emium wi hou subsidy [61]. Consequen ly, he cos o mic oinsu ance
could po en ially exceed egula (subsidized) insu ance, an ou come ha is no ypi-
cally deemed p o-poo . The second condi ion implies ha low p emium “insu ance
o he poo ” could succeed i p ice sensi i i y is high among he a ge g oup [62].
So, wha conc e e e idence is he e o suppo his assump ion?
Empi ical e idence e eals ha lowe ing he p ices o mic oinsu ance inc eases
demand, bu o e all up ake is minimal [63–65]. Households wi h highe liquidi y
and easie access o c edi a e mo e likely o buy insu ance, i.e., sligh ly less p ice
sensi i e [63, 66], and adjus ed p emium paymen s uc u es can ease liquidi y
1 Che y-picking in insu ance e e s o he p ac ice whe e insu ance companies selec i ely p o ide
co e age only o low- isk indi iduals o g oups, while a oiding o excluding hose pe cei ed as high isk.
This p ac ice, also known as “c eam-skimming,” allows insu e s o minimize hei po en ial liabili ies and
maximize hei p o i s. Howe e , i can lea e highe - isk indi iduals wi hou a o dable insu ance op ions,
mos no ably hose who ha e become high- isk a e many yea s o ha ing been insu ed when hey we e
conside ed low- isk.
Heal h Insu ance Ac oss Wo ldwide Heal h Sys ems
8
cons ain s [67, 68]. S udies ha e highligh ed he impac s o compound isk a e sion
and ambigui y a e sion on insu ance up ake [69, 70]. These s udies sugges ha he
a ge popula ion’s isk a e sion and o e all weal h le el lead i o o ego subs an ial
p emium discoun s when he o e is insu icien ly sensi i e o speci ic demand d i -
e s like income, educa ion, age, household size, and heal h s a us. The e ec o hese
demand d i e s can a y signi ican ly ac oss di e en ypes o insu ance [71, 72].
A c ucial ac o in luencing demand is insu ed indi iduals’ ou -o -pocke
expenses on op o p emiums when accessing heal hca e. A quali a i e s udy om
Ghana [73] e ealed ha e en insu ed clien s o Ghana’s NHIS incu addi ional cos s
o consul a ions and medica ions, which should be co e ed by he scheme, p ima ily
because o d ug sho ages and adminis a i e ees. The s udy ecommends elimina -
ing hese ex a cha ges o enhance us in he NHIS ac oss all egions and acili ies. A
quali a i e in es iga ion in he USA [74], which has se e al laws o deli e “insu ance
o he poo ,” poin s ou ha he lowe ou -o -pocke spending, he mo e likely he
posi i e e ec o p emium subsidies2.
In he comme cial mic oinsu ance space, “insu ance o he poo ,” i.e., p oduc s
ha o e es ic ed co e age o main ain low p emiums and p o i abili y, o “ ee-
mium” co e age ha conceals he insu ance p emium wi hin he cos o mobile
se ices bu igno es o he demand d i e s, ha e s uggled o achie e widesp ead
accep ance and consis en enewal a es [53, 75, 76].
This si ua ion is o en encapsula ed in he ph ase “insu ance o he poo is poo
insu ance.” Fi s ly, “mic oinsu ance o he poo ” only has one p ac ical pa hway o
s imula e demand: i mus be appealing enough o uninsu ed g oups. The adi ional
ma ke ing e o aims o each indi idual clien s. Howe e , e idence shows ha
people end o con o m o wha o he s a e doing and ely on o he s’ opinions and
expe iences when making decisions. This idea is widely accep ed and is oo ed in
mul iple psychological and sociological s udies [77]. We’ e ga he ed e idence indica -
ing ha ou a ge audience p io i izes sha ed expe iences and g oup consensus o e
p ice o package composi ion. Speci ically, hey alue expe iences ha co obo a e
hei collec i e unde s anding o he g oup’s pe cei ed p io i ies [78].
Fu he mo e, i ’s signi ican o hem ha hei choices lead o widesp ead bene i s
o many g oup membe s. This unde sco es he desi e o join olun a y and con ibu-
o y Communi y-Based Heal h Insu ance schemes (CBHIs) [78]. Th ough i e a i e
ounds o an exe cise named ‘Choosing Heal hplans All Toge he ’ (CHAT), we
obse ed an enhanced le el o consensus among pa icipan s. This epea ed cycle o
consul a ion and p icing adjus men s led us o desc ibe he p ocess as ‘Collabo a i e
and Con ibu i e.’ Impo an ly, ou e idence unde sco es ha g oup consensus does
no eme ge spon aneously bu necessi a es a ca alys , as e e enced in he sou ce [79].
This no ion esona es wi h he hypo hesis sugges ing ha mic oinsu ance becomes
a iable business model ailo ed o ma ch he a o dabili y, needs, and p io i ies o
g oups wi hin he in o mal sec o [80]. The insu ance indus y is ye o ully accep
2 This ecen in es iga ion assessed he a o dabili y o heal hca e o indi iduals pe cei ed as poo ( hose
ecei ing unemploymen bene i s) wi hin he con ex o Cali o nia. U ilizing da a om adul pa icipan s
in on- and o -Ma ke place indi idual plans in Cali o nia in 2021, he s udy disco e ed ha 41 pe cen o
esponden s decla ed incomes a o below 400 pe cen o he ede al po e y le el. Addi ionally, 39 pe cen
li ed in households ecei ing unemploymen compensa ion. S ikingly, 72 pe cen o pa icipan s epo ed
ha ing no ouble a o ding p emiums, and 76 pe cen s a ed ha ou -o -pocke expenses did no de e
hem om seeking medical ca e. These indings imply ha ARPA (Ame ican Rescue Plan Ac o 2021)
ex ended access o insu ance plans conside ed a o dable, e en hough a o dabili y conce ns pe sis ed.
15
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4.1.5 Risk pooling and sus ainabili y
Small o homogeneous isk pools can jeopa dize he sus ainabili y o he mic o-
insu ance p og am. The pooling o a ious g oups, in oducing di e si ied p oduc s,
and including einsu ance [112] can help b oaden and di e si y he isk pool.
4.1.6 Regula o y en i onmen
A suppo i e egula o y en i onmen can p opel he g ow h o mic oinsu ance. I
is incumben upon go e nmen s o de elop egula ions ha encou age inno a ion in
he mic oinsu ance sec o while ensu ing consume p o ec ion.
4.1.7 Da a a ailabili y and p icing
The lack o eliable g anula da a o local isk assessmen and p icing can dimin-
ish he e ec i eness o mic oinsu ance. Collabo a ions be ween implemen e s and
esea ch ins i u ions and using ad anced echnologies o local da a collec ion and
analysis can imp o e da a managemen .
4.1.8 P oduc design
Mic oinsu ance p oduc s mus align wi h he speci ic needs o a ge popula ions.
This necessi a es a use -cen ic design p ocess and ongoing eedback mechanisms o
p oduc e inemen .
4.1.9 Low claims a io
A low claims a io may sugges he insu ed g oup is no eaping bene i s commensu-
a e wi h hei p emium paymen s. This migh be due o es ic i e policy condi ions, a
lack o awa eness abou he claims p ocess, high deduc ibles ha discou age indi iduals
om making claims, and o e ly conse a i e isk assessmen s. Add essing hese issues
equi es a eassessmen o he e ms o ensu e hey a e ai and no o e ly es ic i e and
enhance anspa ency and simplici y in he claims p ocess.
4.1.10 Dependence on con inued ex e nal echnical assis ance
As highligh ed by Schmid e al. [113], dependency on ex e nal echnical assis-
ance p esen s a signi ican challenge. Ensu ing a smoo h ansi ion o sus ainable
solu ions wi hou comp omising echnical pe o mance s anda ds cons i u es a
subs an ial ask.
Add essing hese challenges necessi a es coo dina ed ac ion om mul iple s ake-
holde s, including go e nmen s, mic oinsu ance p o ide s, NGOs, local communi y
o ganiza ions, and insu ed g oups. By con on ing hese issues, we can mo e e ec-
i ely unlock he po en ial o he C&C Mic oinsu ance model, he eby b oadening i s
impac in ex ending social p o ec ion o hose who need i mos .
4.2 Long- e m in es men and einsu ance o scaling mic oinsu ance
In he ea ly s ages o mic oinsu ance de elopmen , p oponen s ecognized
ha he ad an ages o small mu ual aid g oups also p esen ed challenges in isk
Heal h Insu ance Ac oss Wo ldwide Heal h Sys ems
16
di e si ica ion and co a iance. The solu ion sugges ed was “Social Reinsu ance,” a
concep o p o ide einsu ance o Mic o Insu ance Uni s (MIUs) [112].
The p ima y ad an age o einsu ance is i s abili y o o e sol ency p o ec ion. By
dis ibu ing isk among mul iple en i ies, einsu ance sa egua ds insu ance p o ide s
om insol ency due o signi ican claim e en s, such as na u al disas e s [114].
In addi ion o his i al ole, einsu ance’s alue p oposi ion lies in i s capaci y o
ex end co e age beyond insu e s’ isk-bea ing abili ies, p o ec ing a b oade pool
o clien s [114]. In a comme cial con ex , he s abilizing impac o einsu ance on
unde w i ing esul s—achie ed by educing he a iabili y o an insu e ’s loss a io—
ende s inancial ou comes mo e p edic able and appealing o in es o s [115].
Reinsu ance also plays an essen ial ole in capaci y enhancemen . By p o iding
access o global einsu ance ma ke s, insu e s, pa icula ly hose ope a ing in de el-
oping coun ies, can o e p oduc s and se ices ha migh o he wise exceed hei
isk-bea ing capaci y [116].
In comme cial insu ance con ex s, addi ional bene i s o einsu ance include
capi al managemen . I o e s a o m o con ingen capi al ha can be mobilized in he
e en o subs an ial losses, hus educing he amoun o money equi ed o unde -
w i e insu ance [115]. Fu he mo e, einsu e s o en p o ide unde w i ing, p icing,
and claims managemen expe ise and suppo , which is pa icula ly aluable o
p ima y insu e s in niche sec o s whe e such expe ise may be limi ed [116].
The p oposed concep o Social Reinsu ance in ended o bols e Mic oinsu ance
Uni s (MIUs) did no ma e ialize. A subsequen p oposal abou he ole o einsu -
ance in mic oinsu ance [117] also did no p og ess. A p ima y eason o his lack
o ad ancemen lies in he egula ions go e ning einsu ance businesses in many
coun ies, which pe mi only licensed insu ance companies o cede isks o einsu -
ance, lea ing communi y-based mic oinsu ance en i ies unable o do so. This es ic-
ion aises an impo an ques ion: how much capi al is necessa y o such schemes o
scale hei se ices? The answe o his ques ion was sough in a 2019 esea ch pape
[118]. The esea che s used algo i hms o calcula e capi al equi emen s o expand-
ing heal h mic oinsu ance o poo u al popula ions.
They ound ha o o se ea ly losses, a p o o ype plan se ing 40,000 people
in India would need an ini ial unding o USD 62,477 i long- e m ope a ing cos s
would no exceed 20% o he p emium and he claims a io would s abilize a
a ound 70%.
No su p isingly, when he con idence le els we e dec eased below 99.9%—mean-
ing a g ea e le el o isk was accep ed ha he p o o ype plan migh no s ay sol en
h oughou a yea — he capi al equi emen s diminished signi ican ly. Based on he
esea che s’ calcula ions, a g ace pe iod o 5 yea s would be ollowed by a 15-yea
epaymen pe iod o compensa e he in es o s who p o ided he ini ial unding
en i ely wi h an annual in e es a e o 5% in USD.
Based on hese indings, he s udy sugges s ha heal h mic oinsu ance p og ams
can achie e sus ainabili y by p o iding he necessa y ini ial capi al as a loan and
closely moni o ing i e key pa ame e s: en ollmen , p emiums, ope a ing cos s,
enewal a es, and he claims a io.
The pe -pe son, pe -yea capi al equi emen is s ikingly low. The s udy’s
assump ions o a 15-yea loan pe iod and a comme cial in e es a e imply ha i
in es o s could be a ac ed, i would be easible o signi ican ly scale up mic oinsu -
ance as a de elopmen p ojec , e en wi hou einsu ance. Howe e , he ideal way o
scale mic oinsu ance o a mo e signi ican impac would be h ough einsu ance,
which o e s he ad an age o capaci y enhancemen and o he bene i s. Ye , his
17
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oppo uni y likely depends on he suppo o go e nmen s o de elopmen banks like
he Wo ld Bank and he engagemen o he einsu ance indus y o ag ee o ansac
wi h small insu ance en i ies like MIUs.
5. Conclusion
The gla ing issue ha spu ed he de elopmen o mic oinsu ance is uni e sally
ecognized: app oxima ely hal o he global popula ion is be e o access o social
p o ec ion. The adi ional op-down Bisma ckian and Be e idgean models ail o
make s ides in mos low- and middle-income coun ies due o e iden and jus i i-
able easons. As he in o mal sec o bu geons and se e al labo -in ensi e indus ies
become hubs o in o mal employmen , he call o an inno a i e ope a i e model
ings mo e u gen han e e .
While i ’s e iden ha pas e o s o ame and deli e mic oinsu ance as “insu -
ance o he poo ” o “low-cos , low co e age” insu ance ha e allen sho o hei
in ended goals, hese a emp s ha e p o ided aluable lessons. They e ealed he
complex dynamics ha shape he demand o mic oinsu ance and i s e ec i eness,
om inancial cons ain s o cus ome s’ isk p io i ies and o he demand d i e s,
claims a ios, and enewal a es.
Despi e he limi a ions o mul ila e al and in e na ional o ganiza ions in es ab-
lishing obus insu ance in as uc u e in in o mal se ings, hei ole in ga he ing
insigh s om a ious pilo s—success ul o o he wise—canno be unde s a ed. E en
hough such e o s, including he p o ision o ‘dis ance insu ance li e acy,’ ha e no
ye ully eached o impac ed he in o mal sec o , hey a e s eps in he igh di ec ion.
Each e o b ings us close o ealizing he po en ial o mic oinsu ance in con ibu -
ing o wel a e gains a he g ass oo s le el. The weal h o da a and expe ience o e s a
signi ican ounda ion o building new s a egies.
This s a egic app oach o scaling mic oinsu ance, aka ‘an icipa o y ma ke iza-
ion,’ should include es ablishing mo e g anula da a sou ces, insu ance educa ion a
he g ass oo s le el, and adap ing business p ac ices by comme cial insu e s o be e
align wi h he needs o he communi y-based ma ke .
Mo eo e , he ew ini ia i es aken by some dono s and philan h opic bodies ha e
exposed a c i ical insigh : mic oinsu ance is mo e han jus a inancial ansac ion. I
ope a es wi hin a nexus o poli ical and social dynamics, which mus be conside ed
o success ul implemen a ion.
Main aining a posi i e ou look in he ace o challenges is c ucial. In an e a whe e
public us in “ he sys em” is e oding, he answe is no me ely o p each ai h in he
bene olence o op-down o p o i -d i en insu e s. The g owing inequali y in weal h,
income, poli ical in luence, and access o jus ice unde sco es ha simply decla ing
noble in en ions is insu icien . Manda o y en olmen , a hallma k o he Bisma ckian
model, has no been well- ecei ed in many coun ies, p o ing i ’s no he ul ima e
solu ion. Despi e his, each ield expe ience, whe he ailed o success ul, has yielded
aluable insigh s, shaping a mo e inclusi e and e ec i e mic oinsu ance sec o . This
is indeed p og ess. Ye , much mo e mus be done o s imula e app op ia e in es men s
in ‘an icipa o y ma ke iza ion.’
The way o wa d lies in he ealiza ion ha when social o ces a e mo e po en
and ac ionable han ma ke o ces, he i ing pa h o wa d in ol es le e aging hese
social dynamics o ca alyze demand. Mic oinsu ance, oo ed in mu ual aid, h i es
in small g oup se ings, os e ing open dialog and consensus on isk insu ance and
Heal h Insu ance Ac oss Wo ldwide Heal h Sys ems
18
esou ce alloca ion o isk managemen . The i eless e o s o pionee s and NGOs
o a gene a ion o alida e an uncon en ional demand heo y ha e led o an abun-
dance o ield pilo s and e idence-backed publica ions. Wha does his collec i e
wisdom ell us? A iable al e na i e pa h o eaching he uninsu ed does exis , one
pa ed wi h he powe o collabo a ion, coope a ion, consul a ion, and consensus-
building, ueling willingness o join and pay. Scaling his ans o ma i e model
necessi a es esou ces, egula o y backing, and ins i u ional suppo , much like any
g oundb eaking de elopmen p ojec . I ’s high ime we ally poli icians, banke s, and
einsu e s o pool hei esou ces and ambi ions and e he hem o his pionee ing
social p o ec ion model.
The pu sui o de eloping mic oinsu ance ma ke s and he pe sis en e o s o
oubleshoo and e-enginee hose ma ke s ep esen complex a emp s o de elop
o ms o social p o ec ion ha do no necessi a e subs an ial edis ibu ion. Is his a
deal-b eake ?
The e idence sugges s ha he excluded g oups nei he expec no demand ha
insu ance deli e s subs an ial income edis ibu ion. Howe e , hey insis on pa ici-
pa o y decision-making. This expec a ion can be me by applying he “Collabo a i e
and Con ibu i e” (C&C) mic oinsu ance model. This app oach emphasizes inclu-
sion and empowe men o e e yone—whe he employed o no , engaged in o mal
o in o mal wo k, and esiding in u ban o u al a eas— o pa icipa e in insu ance
decision-making. This ep esen s a d ama ic depa u e om he au ho i a ian s yle
o s a e-owned schemes o he igid and ob usca ed ope a ions o comme cial
insu ance.
Despi e i s po en ial, he C&C model encoun e s se e al obs acles, including
egula o y impedimen s like limi a ions on ans e ing isks o einsu ance and
insu icien poli ical and inancial backing needed o gene a e impac on a la ge scale.
Howe e , he pas qua e -cen u y has seen signi ican s ides in e ol ing demand
heo y and es ablishing ope a ional amewo ks o mu ual aid mic oinsu ance
schemes, such as Communi y-Based Heal h Insu ance (CBHI). Thanks p ima ily o
NGOs, pionee ing p ac i ione s, and a hand ul o coun ies ha ha e adop ed CBHI
as he na ional sys em, hese expe imen s ha e ca alyzed a willingness o join, pay
ac ua ially ai p emiums, and pa icipa e in go e nance and adminis a ion. Now, i ’s
ime o he academic communi y o examine mic oinsu ance’s social and economic
impac s, including i s po en ial con ibu ion o GDP g ow h by insu ing in o mal
wo ke s and he wel a e gains o he insu ed. Mos impo an ly, i ’s ime o ‘de elop-
men poli icians’, p uden banke s—pa icula ly in e na ional de elopmen bank-
e s—and he einsu ance indus y o back he C&C mic oinsu ance model’s po en ial
o ex end insu ance o all, using models ha anscend Bisma ck and Be e idge’s
models.
Acknowledgemen s
The au ho would like o since ely acknowledge he in aluable e iew commen s
o e ed by P o . Ma in Eling, D . Niha Jangle, and M . John Woodall. Thei con-
s uc i e eedback has signi ican ly enhanced he quali y o his wo k. Howe e , any
asse ions o conclusions d awn in his a icle a e he sole esponsibili y o he au ho .
Pe spec i e Chap e : Mic oinsu ance’s Ques o P o ec he Unp o ec ed, beyond he Bisma ck...
DOI: h p://dx.doi.o g/10.5772/in echopen.1002483
19
Au ho de ails
Da id Ma kD o 1,2,3
1 Mic o Insu ance Academy, NewDelhi, India
2 E asmus School o Heal h Policy and Managemen , E asmus Uni e si y, Ro e dam,
Ne he lands
3 ILO/UN, Gene a, Swi ze land
*Add ess all co espondence o: da idd o @social e.o g
© 2023 The Au ho (s). Licensee In echOpen. This chap e is dis ibu ed unde he e ms o
he C ea i e Commons A ibu ion License (h p://c ea i ecommons.o g/licenses/by/3.0),
which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided
he o iginal wo k is p ope ly ci ed.
Heal h Insu ance Ac oss Wo ldwide Heal h Sys ems
20
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