Working paper 156
Many developing countries are considering insurance as a means of pursuing universal health coverage. A key challenge to confront is how to achieve high levels of health insurance enrolment. For voluntary schemes, this entails mass awareness- raising and promotional activity, though as schemes move to compulsory enrolment, monitoring and enforcement is required. This paper focuses on Ethiopia, which is has made state health insurance for the informal sector a central pillar of its universal health coverage strategy. The paper shows that high enrolment requires particular forms of state capacity, captured here by Michael Mann’s concept of state ‘infrastructural power’. The paper draws on detailed case studies of health insurance implementation in the Tigray and Oromiya regions of Ethiopia to illustrate variation in state infrastructural power and the implications for the promotion of health insurance. The findings suggest that the potential of state health insurance as a means of promoting health access for a broad section of the population may be limited to the minority of countries or regions within countries exhibiting high levels of infrastructural power.