A/67/302 contribution schemes prevent wealthy and healthy members from opting out of the programme and diluting the size of the pool at the expense of poorer and sick members. Compulsory schemes also prohibit individuals from buying into the programme only during times of medical need. 48 While voluntary contributions may help raise funds in the absence of widespread payment and pooling, familiarize individuals with the benefits of insurance, and serve as an intermediate funding mechanism that eases the transition towards a more inclusive compulsory contribution scheme,48 they do not necessarily increase rates of insurance coverage because enrolment is not compulsory. Voluntary schemes are thus ineffective in increasing access to health facilities, goods and services for the poor because they do not generate large enough pools to facilitate robust cross-subsidization. 44. According to the right to health approach, the design and scope of social health insurance programmes should be informed by the health needs, financial capacity and employment status of target populations. Social health insurance programmes should therefore ensure that a minimum set of health goods and services are available and universally accessible based on need. Benefits packages must be responsive to the disease burden and health needs of the population, comprise effective and community-centred primary health-care services that address the particular needs of each community, and include essential medicines and generic drugs in order to ensure access to safe, effective and affordable medicines, as required under the right to health. Contribution schemes must be designed to ensure universal access to good quality health facilities, goods and services. Mechanisms meant to contain programme costs that limit enrolments, such as caps on the percentage of individuals allowed to receive absolute exemptions, must be consistent with realities of poverty and ability to pay. 49 The right to health approach thus requires, at a minimum, that contributions be structured progressively, based on individuals’ ability to pay, and that programmes may provide absolute exemptions for the poor. 45. Social health insurance programmes often rely on compulsory wage-based contributions, which may fail to identify and include those whose incomes are not formally reported or easily assessed, such as informal workers, self-employed persons and workers in rural and remote areas. For example, informal workers who may qualify for absolute exemptions or reduced contributions are difficult or impossible to identify through compulsory wage-based social health insurance programmes and thus may not be enrolled in these programmes. Such individuals may be unable to access good quality health facilities, goods and services owing to unaffordable out-of-pocket payments. Under the right to health approach, States should use innovative strategies to include the informal sector in social health insurance programmes. For example, associational taxes, in which an association representing a particular group of workers collects funds and pays into the tax system, have been shown to increase the participation of informal sector employees in formal benefits programmes. 50 __________________ 48 49 50 12-46101 WHO, World Health Report (2010), “Health Systems Financing: The path to universal coverage”, pp. 88-89. See Patrick Apoya and Anna Marriot, “Achieving a Shared Goal: Free Universal Health Care in Ghana” (Oxfam International, March 2011). Anuradha Joshi and Joseph Ayee, “Associational taxation: a pathway into the informal sector?”, Taxation and State-Building in Developing Countries: Capacity and Consent, eds. Deborah Brautigam, Odd-Helge Fjeldstad and Mick Moore (Cambridge University Press, 2008), p. 186. 17