**4. Single-payer National Health Insurance Scheme**

In most LMICs where tax-funded system is not the option taken by the political leadership, SHI schemes can be a good choice to ensure equitable access to essential health care in LMICs. The SHI model can be gradually implemented for employed population for partial health benefits that the population can afford. Indonesia started SHI for civil servants in 1968 and then for private employees in 1993 and finally for everybody in 2014 [7]. China also introduced this social insurance model starting for employed groups. The challenges in implementing SHI for whole population are collecting contributions for the informal sector. The informal sector or non-waged earners do not have a regular monthly income. In LMICs, the proportion of non-waged earners is generally very high, more than 50%. Therefore, scaling up to cover the whole population to achieve UHC in LIMCs may take decades. One option is to subsidize the informal sector from the government budget, integrated to the NHI. When a country implementing SHI became a high-income country, normally the SHI model is continued to be implemented as happened in Germany, Korea, Japan, the Philippines, and Taiwan.

The choice of administrators of the SHI can be implemented by special SHI fund for special groups such as civil servants, private employees, teachers, farmers, etc. Multiple payer systems create possibility that some groups will have more coverage with higher contribution levels than others. Different SHI and different groups of population create oligo- or multi-payer systems that may provide problems in negotiating prices of health care from various providers. The Japan employer-based health insurance system creates a virtual single payer by forcing all SHI plans to purchase health care organized by Central Administrative Offices. Regardless of the plans, all

*The Advantage of Single-Payer National Insurance DOI: http://dx.doi.org/10.5772/intechopen.105692*

Japan's residents could go to the same health care providers. Implementing different SHI for different groups may create unequal benefits across different population groups and may not be acceptable in some countries. On the other hand, some small differences of contribution or preventive services like implemented in Japan are socially accepted [25]. Germany once had more than 5000 sickness funds; they now have less than 100 sickness funds. To ensure equity across different employment groups, Germany requires equalizing funds across different sickness funds [26]. South Korea once followed the German and Japan SHI model with multiple plans then in early 2000 integrated all SHI schemes into a single NHI model [14].

The politics, cultural values, social norms, and the national constitutions of countries play crucial roles in determining single- or multi-payer system of NHI. Indonesia also followed the Korean model, integrating SHI and social assistance schemes into a single NHI. The fight to establish a single NHI in Indonesia involved union strikes, extensive academic debates, and legal battle in the parliament and in the constitutional court [7]. Despite of the very high health expenditures, the USA has not achieved UHC. Only the elderly population is covered by the public fund of SHI model, called Medicare. The poor are covered by sharing of federal and state funds. The Obama Care is basically providing tax incentive for the informal sector to purchase CHI. Turkey integrates all SHI plans into a single NHI in 2008 by reforming the social security system [27].
