**5. Conclusion**

The study explored the issues related to the planning and inclusion of the informal labour sector into national health insurance schemes. While universal health coverage (UHC) may have raised this as a non-issue, with its coverage 'for all', resources flowing to the same structures for implementation will encounter the same problem of high transaction costs. A re-framing analysis that pushed the issue of transaction costs into the discussion showed that hierarchical or government structures wielding tight command and control are not informal sector—friendly. Informal sector participants may not fall within the strict proxy variable means tests for the poor. Thus, their non-inclusion in the no-balance-billing thrust of the UHC still creates high user charges which minimise the benefits of health insurance against any contribution on premiums they make.

The ability of the system to provide universal financial protection will still depend on subsidies managed through mediating institutions, including facilities, that need to be brought in as part of the new social contract. There will be widespread subsidies as the impetus for the universal health care Act itself is the anticipated fiscal space provided by the passing of new tax laws that included a tax on the sugar content of beverages. The pandemic has seen increased fiscal flows to the health sector; but more importantly, it surfaced the inefficiencies and corruption of the implementing

*National Health Insurance, the Informal Sector, and Elements of a New Social Contract… DOI: http://dx.doi.org/10.5772/intechopen.103720*

agencies. The protection required in the new social contract is safeguarding the health insurance funds and the balancing of current expenditures and future funds sustainability. The rights and responsibilities implicitly pressed on citizens, providers, implementers by the new Act are directed towards ensuring the social insurance funds are protected. This is only possible if payments are made in terms of ability to pay, pay-outs designed based on needs, incomes drawn from the fund (by providers and other vendors) are fair, and systems and safeguards are in place for greater accountability. Universal health coverage is possible with better governance and undertaken in the spirit of a new social contract.
