All people, no matter where they live, no matter what their age, have

a right to access high quality and affordable healthcare.

POPULATION COVERAGE CHALLENGES

THE INDIAN EXPERIENCE
JAIDEV SINGH ANAND
Disclaimer: The views expressed in this paper/presentation are the views of the
author and do not necessarily reflect the views or policies of the Asian Development
Bank (ADB), or its Board of Governors, or the governments they represent. ADB does
not guarantee the accuracy of the data included in this paper and accepts no
responsibility for any consequence of their use. Terminology used may not
necessarily be consistent with ADB official terms.

Summary
Snapshot: India
Government Social Insurances in India
What is Effective Coverage?

What are the issues related to effective coverage under Social Insurance?
Effective Universal Health Coverage?
Aadhar An Opportunity?
2

Snapshot: India
Population

1.33 billion (2015)

Per capita income $ 6020 (PPP)

% under poverty
line

21.9% (2012)

% rural

67% (2015)

Life expectancy

68.3 (2015)

Health
expenditure

4.7% of GDP (2014)

1.4% of govt.
expenditures
$75 per capita (2015)

MMR

174 / 100,000 (2015 est.)

U5MR

48 / 1,000 (2015)

GINI Coefficient

33.6 (2012)
3

Government Social Insurances in India

What is social
insurance in the
context of India?
Primarily focused on
those below official
poverty line
What are the issues
faced in covering the
poor?

Percentage

Health Financing Mix as Percentage of Total Health Expenditure

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Others
Social Insurance
Non-Governmental
Organizations
State Government
Central Government
Local Bodies

Household Out of Pocket

2004 (In percentages)

2013 (In percentages)

8
1.1

6.2
4.02

0.07

1.6

11.9
6.8
0.9
71.1

10.9
6.6
1.6
69.1
Source: National Health Accounts 2004-05 and 2013-14

What is Effective Coverage?

Need

Effective Coverage

Use

Quality

What does evidence

suggest about
effective coverage of
poor under
Government Social
Heath Insurance
Schemes?

Source: Ng M, et al. (2014). Effective Coverage: A Metric for Monitoring Universal Health Coverage 5

What are the Issues Related to Effective

Coverage under Social Insurance?
Metric

Meaning

Issue

Implication

Need

Population in need
of a particular
service

Poverty Census Periodic

Better targeting needed

to prevent leakages,
including a more dynamic
method of means testing

Use

Use of services

50% enrolees not officially poor

(Ghosh S. 2014)
Limited information given to
beneficiaries on enrolment by
insurers (Trivedi et al. 2013, Thakur
2016)

Beneficiaries not aware

of scheme, potentially
affecting utilization

Falling utilization. Higher cost of

outpatient care (Sinha et al. 2014)
Quality

Actual health
benefit received

Inconclusive

Inconclusive

Effective Universal Health Coverage?

Claims of limited impact of social health insurance on incidence of catastrophic health
expenditures (Selvaraj and Karan, 2012; Ghosh S. 2014)
Lack of coverage for near poor overlooks their financial vulnerability, further driving
overall inequities
Focus on inpatient care results in cost escalation for the system and the user (Sinha, et
al. 2014). Outpatient care a large cost driver (National Health Accounts 2014)
Concerns over quality of health services and their impact (National Health Policy, 2015)
Is it possible to provide Effective Universal Health Coverage?
7

Aadhar - An Opportunity?
Unique Identification number for Indian citizens, launched in 2010 by the Government of
India.
Presents an opportunity to move towards universal coverage through unified national pool
and data architecture. Chance to drive efficiency gains and promote governments role as:
Enabler
Steward

Integrated care systems

to aid in treatment
decisions (Electronic
Medical Records)

Targeted subsidies and

asset based premiums

Purchaser
Data architecture to
prioritize spending and
rationalize provider
payments

A Means not a Way

8

Thank You
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jaidev.anand@accessh.org