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Background PhilHealth, the social health insurance (SHI) agency of the Philippines, still does not sufficiently cover the informal sector workers (ISWs) - or the “missing middle”. Previous approaches had limited success. The impetus for finding solutions to protect the missing middle still remains. Methods A multi-component action research was done to address the complex social problem. Literature review and interviews were conducted to understand the nature of ISWs. National survey data was analyzed for factors affecting the ISWs' membership and retention in SHI. Findings were triangulated to construct evidence-based and context-rich marketing personas to understand PhilHealth's target clients. Using Human-Centered Design Thinking (HCDT), solutions that aim to address the low retention of ISWs in health insurance (HI) were proposed. Results The exact nature of ISWs is still unknown. Costly insurance premiums, poor knowledge of SHI, low perceived value of SHI, and inconvenient payment mechanisms contribute to low participation in SHI. Every additional 1000 PHP (∼20 USD) income increases odds of being an active member by 4%. Those who access private facilities are 2.8 times more likely to be active members. Those who perceive themselves to be sickly were 52% more likely to drop-out of the insurance. The results were fed into the HCDT process producing four prototypes: 1) solutions that explore partnership of PhilHealth with other organizations, 2) use of mobile application platforms for payment and member status updates, 3) automated algorithm to identify and calculate fair premiums, and 4) integration of money-saving strategies. Conclusions The government needs to step-up current efforts to extend health financial risk protection for the ISWs. PhilHealth can take advantage of the research results by testing the prototypes produced, and by adopting the HCDT process to improve their service and coverage for the informal sector. Key messages This government-funded project integrated principles of public health, epidemiology, health financing, participatory governance, and implementation research to address a complex social problem. The results provide a better understanding of the informal sector workers’ nature and needs with regards health insurance and can help PhilHealth improve coverage of informal sector workers.

An action research to improve social health insurance coverage of Philippines’ informal sector