Understanding public health insurance in India: A design perspective

Abstract

Summary It is broadly accepted that health policy is crucially affected by contextual conditions. Yet, little is known about how the context limits the effectiveness of public health insurance (PHI) programs and the extent to which these limitations could be overcome. The objective of the paper is to address these issues on the basis of the examination of 17 PHI schemes introduced by federal and state governments in India since independence. Faced with the challenge of simultaneously expanding insurance coverage while containing costs, governments have overwhelmingly favored the latter. At the same time, governments have lacked the capacity to monitor performance, which has led providers to compromise quality in return for low payment rates. While there have been modest improvements in recent years, reform efforts have been hindered by contextual conditions that constrain the use of measures to control profiteering by for‐profit agencies. The paper argues that system‐wide data on the quality of providers (system‐level operational capacity) and the ability of public agencies to monitor quality and link it with payment (organizational‐level operational capacity) critically determined the program effectiveness. We demonstrate the interaction between contextual variables, program design elements, and policy capacity linking to performance, arguing for a broader approach to understand PHI performance. We extend the present frameworks on PHI effectiveness that have narrowly focused on the design of health financing functions without factoring unfavorable context and limited policy capacity in developing countries. The paper contributes to improving PHI performance operating in unfavorable contextual conditions in India and elsewhere.

Is health insurance really benefitting Indian population? Evidence from a nationally representative sample survey

“…9 Traditionally till 2007, India's healthcare financing was confined to the supply-side mechanism (i.e., strengthening of infrastructure). 10,11 With a paradigm shift towards the demand-side financing mechanism, India has given a special impetus to GSHI schemes, [11][12][13] as done by several other low and middle-income countries. 14,15 Over the years, a number of GSHI schemes have been launched to improve the accessibility of healthcare services and to safeguard people against associated financial catastrophes.…”

“…In India several health insurance programmes have been launched to reduce the financial burden of healthcare expenditure, (i) Central Government Health Scheme (CGHS) 1954 (covering employees of central government, both current and retired, and their dependents) and Employees' State Insurance Scheme (ESIS) 1952 (covering the workers of factories and other enterprises) 12,13 are two social health insurance schemes with a large package of services, albeit available to only a small proportion of population who are engaged in the formal sector. 12,13 (ii) GSHI schemes such as central level schemes (e.g., Rashtriya Swasthya Bima Yojana (RSBY) 2008, Pradhan Mantri Jan Arogya Yojana 2018) 11,12 and state-specific schemes (e.g., Rajiv Aarogyasri Health Insurance Scheme (2007) in Andhra Pradesh, Vajpayee Arogyasri Scheme (2009-10) in Karnataka, Chief Minister's Comprehensive Health Insurance scheme (2012) in Tamil Nadu) 11,26 were launched to provide coverage mainly to the poor and vulnerable population. The government pays premium for GSHI schemes on behalf of the insured, and the enrolled families pay only a nominal amount each year to enrol or renew membership.…”

“…Our analysis for various outcomes was restricted to hospitalization incidence, because most of the health insurance schemes in India are mainly limited to cover hospitalization. 11,13 We analysed outcomes for overall insured (in any type of scheme) in general, and GSHI schemes and private voluntary health insurance, in particular. The employer-provided health insurance schemes (such as CGHS and ESIS) were not studied separately, because these schemes are mandatory (social) health insurance schemes and are available only to formal sector employees.…”

“…The employer-provided health insurance schemes (such as CGHS and ESIS) were not studied separately, because these schemes are mandatory (social) health insurance schemes and are available only to formal sector employees. [11][12][13] To check the effectiveness of GSHI schemes, the analysis was first done for the entire sample (irrespective of economic status), and then the analysis was carried out separately for the poor persons because GSHI schemes are primarily meant to provide access and financial protection to economically disadvantaged population. 11,12 We have used the inflation-adjusted official poverty line, as suggested by the Tendulkar Committee (Planning Commission) 38 to identify poor and non-poor individuals.…”

Unintended Effects of Policy Interactions in the Health Sector: A Case of Kerala, India

“…In the last decade, central and various state governments launched seventeen publicly financed social health insurance programmes covering low-income families that provided hospital-based care up to certain limits (Maurya, 2019). In 2016, nearly 214.3 million persons were covered under these programmes and eligible for hospital-based services at public and private hospitals (Insurance Regulatory Development Authority [IRDA], 2015[IRDA], -2016.…”