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Copyright © 2012. World Bank Publications. All rights reserved.

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 Government-Sponsored Health
Insurance in India
Copyright © 2012. World Bank Publications. All rights reserved.

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 Government-Sponsored
Health Insurance in India
Are You Covered?
Gerard La Forgia and Somil Nagpal
Copyright © 2012. World Bank Publications. All rights reserved.

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 © 2012 International Bank for Reconstruction and Development / The World Bank
1818 H Street NW,
Washington DC 20433
Telephone: 202-473-1000;
Internet: www.worldbank.org

Some rights reserved

1 2 3 4 15 14 13 12

This work is a product of the staff of The World Bank with external contributions. Note that The World Bank does not
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Attribution—Please cite the work as follows: La Forgia, Gerard, and Somil Nagpal. 2012. Government-Sponsored Health
Insurance in India: Are You Covered? Directions in Development. Washington, DC: World Bank. doi:10.1596/978-0-8213-
9618-6. License: Creative Commons Attribution CC BY 3.0

Translations—If you create a translation of this work, please add the following disclaimer along with the attribution: This
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World Bank shall not be liable for any content or error in this translation.

All queries on rights and licenses should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW,
Washington, DC 20433, USA; fax: 202-522-2625; e-mail: [email protected].

ISBN (paper): 978-0-8213-9618-6

Copyright © 2012. World Bank Publications. All rights reserved.

ISBN (electronic): 978-0-8213-9619-3

DOI: 10.1596/978-0-8213-9618-6

Cover photo: Suvarna Arogya Suraksha Trust, Government of Karnataka, Bangalore, India

Library of Congress Cataloging-in-Publication Data

La Forgia, Gerard M. (Gerard Martin)
Government-sponsored health insurance in India [electronic resource] : are you covered? / Gerard La Forgia, Somil Nagpal.
1 online resource. — (Directions in development)
Includes bibliographical references.
Description based on print version record and CIP data provided by publisher; resource not viewed.
ISBN 978-0-8213-9619-3 (epub) — ISBN 978-1-118-13415-3 (pbk.) (print)
I. Nagpal, Somil. II. World Bank. III. Title.

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 [DNLM: 1. National Health Programs—economics—India. 2. Delivery of Health Care—economics—India. 3. Health
Expenditures—India. 4. Insurance Coverage—India. 5. Insurance, Health—India. 6. National Health Programs—organization
& administration—India. WA 540 JI4]
362.10954—dc23

2012021079
Copyright © 2012. World Bank Publications. All rights reserved.

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 Contents

Foreword xv
Preface xix
Acknowledgments xxxv
Abbreviations xxxvii

Chapter 1 Introduction 1
Analytical Framework and Methods 6
Case Study Selection and Summaries 8
Notes 14
References 15

Understanding the Context: The Development of Health

Chapter 2 17
Insurance in India
A Brief Review of Health Finance and Delivery in India 17
Financial Burden 24
Service Delivery Issues 25
Health Insurance in India: Context and Historical Development 27
Not Cut from Whole Cloth 27
Notes 30
References 33

Chapter 3 Results and Cross-Cutting Issues 37

Population Coverage 37
Copyright © 2012. World Bank Publications. All rights reserved.

Enrolment and Beneficiaries 40

Benefits 47
Utilization 53
Expenditures and Costs 58
Rate Setting and Provider Payment 65
Provider Networks, Quality, and Patient Satisfaction 70
The Role of Public Hospitals 77
Financial Benefits and Burdens on Patients 81
Cost Containment 87

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 Institutional Arrangements and Managerial Capacity 92
The Political Economy of Demand- and Supply-Side Financing 101
Conclusion: Successes and Challenges 104
Annex 3A Statistical Annex 109
Annex 3B Methods Used for Population-Coverage Projections 110
Annex 3C Methods Used for Expenditure Projections 111
Notes 111
References 120

Chapter 4 Addressing GSHIS Operational Challenges 127

Promoting Governance and Coordination 128
Strengthening Purchasing and Contracting Practices 130
Reinforcing Cost Containment: (1) Provider Payment Systems 131
Reinforcing Cost Containment: (2) Additional Measures 138
Establishing Robust Monitoring and Data Use 140
Fixing Targeting Mechanisms 142
Introducing Quality-Based Purchasing 143
Expanding Public Hospital Autonomy 147
Strengthening the Collection and Dissemination of Consumer
150
Information
Notes 154
References 158

Chapter 5 Pragmatic Pathways to Universal Coverage 165

Building Blocks for Change 167
Pathways to Expanding Population Coverage and Benefit Coverage 169
Consolidation of CGHS and ESIS 182
How Are the Recommendations Linked to the Goals of the 12th Five
183
Copyright © 2012. World Bank Publications. All rights reserved.

Year Plan?
What about Private Health Insurance? 184
Estimating the Costs of the Proposed Schemes 186
Research Agenda 188
Annex 5A Summary of Proposed Expansion of Services 195
Notes 196
References 200

Appendix A Employees’ State Insurance Scheme 205

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 Appendix B Central Government Health Scheme 227

Appendix C Yeshasvini Co-operative Farmers Health Care Scheme, Karnataka 253

Appendix D Rajiv Aarogyasri Community Health Insurance Scheme 275

Appendix E Rashtriya Swasthya Bima Yojana 295

Chief Minister Kalaignar’s Insurance Scheme for Life Saving

Appendix F 315
Treatments

Appendix G Vajpayee Arogyashri Scheme, Karnataka 333

Appendix H RSBY Plus Scheme, Himachal Pradesh 345

Apka Swasthya Bima Yojana (Proposed), Government of National

Appendix I 357
Capital Territory (NCT) of Delhi

Tool for Collecting Information on Government-Sponsored Health

Appendix J 365
Insurance Schemes in India

Glossary 375

About the Authors 401

Boxes
1.1 Indian Law and Health Insurance 8
2.1 India: Organizational Arrangements for Risk Pooling 22
Copyright © 2012. World Bank Publications. All rights reserved.

3.1 India: Alternative Organizational Arrangements of Public Hospitals 78

India: Constraints to Introducing Ambulatory Care Benefits in Health
3.2 87
Insurance
4.1 Thailand: Sentinel Hospitals Evidence for DRG Cost Weights 135
4.2 International Experiences with Pay-for-Quality Incentives 145
4.3 International Experience in Public Hospital Reform 149
4.4 Areas of Consumer Information and Corresponding Questions 152
Extending Coverage to the Informal Sector: Lessons from Middle-
5.1 170

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 Income Countries
5.2 Health Care Coordination in OECD Countries: Lessons for India? 174
5.3 International and Indian Experiences with Ambulatory Package Rates 179
Does India Have Fiscal Room to Finance Coverage Extension by
5.4 189
2015?

Figures
India and Comparators: Public Expenditures on Health as a Share of
2.1 19
GDP and in Relation to Income per Capita, 2008
2.2 India: Main Actors and Fund Flows in Health System, ca. 2005 21
India and Comparators: Household Spending on Health Exceeding
2.3 24
Thresholds
India: A Genealogy of Government-Sponsored Health Insurance
2.4 28
Schemes
India: Households Falling below Poverty Line due to Inpatient and
3.1 86
Outpatient Health Care Costs, Selected States, 2004
India: Estimated Health Insurance Coverage, 2003–04, 2009–10, and
3A.1 109
2015
3A.2 India: Estimated Health Insurance Expenditures 110
India: Data Infrastructure for Strengthening Package Rates, Bottom-Up
4.1 133
Approaches for the Short and Long Term
5.1 India: Evolution of Health Financing Systems, by Income Level 168
5.2 Financial and Benefit Flows of Proposed Schemes 171
A.1 ESIS Institutional Framework 208
A.2 ESIS Beneficiaries, 1994–95 to 2009–10 210
A.3 ESIC: Revenue and Expenditure Trends, FY2000–2010 214
A.4 ESIS: Per Capita Spending, Selected States, 2008–09 216
ESIS: Trends in New Outpatient Visits for Common Causes, 2000–01
A.5 to 2008–09 218
Copyright © 2012. World Bank Publications. All rights reserved.

A.6 ESIS: Trends in New Outpatient Visits, 2000–01 to 2008–09 219

A.7 ESIS: Trends in Hospital Admissions, 2000–01 to 2008–09 221
B.1 CGHS: Institutional Framework 230
B.2 CGHS: Trends in Total Estimated Expenditure, 2001–02 to 2009–10 238
GOI Spending on CGHS, by Major Expenditure Component, 2001–02
B.3 239
to 2009–10
C.1 Yeshasvini Institutional Framework 256
Yeshasvini: Trends in Number and Value of Claims, 2003–04 to
C.2 262
2009–10

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 C.3 Yeshasvini: Trends in Specialty Claim Shares of Total Claims, by 263
Value, 2003–04 to 2009–10
Yeshasvini: Trends in Number of Claims, by Specialty, 2003–04 to
C.4 264
2009–10
Yeshasvini: Trends in Average Claim Values, Different Districts,
C.5 265
2006–07 to 2009–10
Yeshasvini: Contribution, Subsidy, and Expenditure, 2003–04 to
C.6 267
2009–10
D.1 Rajiv Aarogyasri: Institutional Framework 277
Rajiv Aarogyasri: Monthly Volume of Authorized Claims for
D.2 284
Surgeries and Therapies, 2007–July 2010
D.3 Rajiv Aarogyasri: Frequency of Hospitalization, by District and Year 286
E.1 RSBY: Institutional Framework 298
F.1 Kalaignar: Institutional Framework 318
F.2 Kalaignar: Utilization Trends since Inception, August 2010 324
F.3 Kalaignar: Share of Claim Costs, by Specialty, July 2009 to July 2010 326
Kalaignar: Average Claim Costs, by Age and Gender, July 2009 to
F.4 328
July 2010
G.1 VA: Institutional Framework 335
H.1 RP: Institutional Framework 348
H.2 RP: Monthly Trend in Claim Value, March through December 2010 353
I.1 ASBY Institutional Framework 360

Tables
1.1 Analytical Framework Applied to Case Studies 7
Summary of Salient Characteristics of the Government-Sponsored
1.2 10
Health Insurance Schemes, 2010
2.1 India: Estimated Distribution of Health Expenditure, by Source 20
India: Average Out-of-Pocket Expenditure for an Inpatient Stay, 1996
Copyright © 2012. World Bank Publications. All rights reserved.

2.2 25
and 2004
India: Population Coverage and Projected Growth, 2003–04, 2009–
3.1 38
10, and 2015
India: BPL Card Distribution and Economic Status, by Income
3.2 45
Quintile, 2005
India: Number of Covered Treatment “Packages” and Maximum
3.3 49
Benefit Coverage, 2009–10
India: Packages Classified by Major Disease Group and by Surgical
3.4 50
and Medical Treatment, 2010

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 3.5 India: Hospital Utilization Rates Nationally and for Selected Schemes 54
India: Estimated Expenditures on Health Insurance and Projected
3.6 59
Growth, 2003–04, 2009–10, 2015
India: Government Contributions to GSHISs and Public Delivery,
3.7 62
2008–09
India: Average Central and State Government Spending per
3.8 63
Beneficiary per Admission, 2009–10
3.9 India: Average Hospital Charges by City Size, 2009 66
India: Variation in Package Rates for Similar Procedures, 2009–10,
3.10 68
Selected Schemes
India: Number of Scheme-Networked Public and Private Hospitals,
3.11 71
2010
India: Minimum Number of Hospital Beds Required for Empanelment,
3.12 73
by Scheme, 2010
India: Share of Top 20 Network Hospitals in Preauthorized Claims,
3.13 89
Selected Schemes
3.14 India: Features of GSHIS Governing and Executing Agencies, 2010 95
India: Options for Expanding Ambulatory Care to BPL Population
5.1 176
under GSHISs
5.2 India: Estimated Incremental Costs of Recommended Schemes, 2015 187
5A.1 Indicative List of Services Covered in the Proposed Packages 195

A.1 ESIS Summary Matrix 205

ESIS: Provision of Ambulatory Medical Services in ESIS Medical
A.2 211
Facilities
A.3 ESIS: Financial Position, 1960–61 to 2008–09 213
ESIS: Total Beneficiaries and Medical Care Expenditure, 2001–02 to
A.4 214
2009–10
A.5 ESIS: Number of Outpatient Visits 219
ESIS: Most Common Conditions for Outpatient Consultation, 2007–08
A.6 220
Copyright © 2012. World Bank Publications. All rights reserved.

and 2008–09
A.7 ESIS: Coverage and Utilization Statistics, Selected States, 2009 222
A.8 ESIS: Expenditure on Drugs and Dressings 224
B.1 CGHS: Summary Matrix 227
CGHS: Number of Cardholders, by City and Category, December
B.2 232
2009
B.3 CGHS: Network of Own Facilities, by City and Type, 2009 235
CGHS Outpatient Utilization, by City and Type of Facility, 2007 and
B.4 236
2009

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 B.5 MOHFW Expenditure on CGHS, by Accounting Heads, 2001–02 to 240
2009–10
B.6 CGHS: Sources of Funds, 2007–08 to 2009–10 242
B.7 CGHS: Monthly Contribution by Beneficiaries 243
C.1 Yeshasvini: Summary Matrix 253
Yeshasvini: Enrolment Growth, Contributions, and Claims, 2003–04
C.2 257
to 2009–10
Yeshasvini: Number and Value of Claims Paid to Top 20 Hospitals,
C.3 260
2009–10
Yeshasvini: Number and Value of Rejected Claims, 2007–08 to 2009–
C.4 264
10
Yeshasvini: Summary of Trust Finances and Expenses, 2004–05 to
C.5 268
2009–10
Yeshasvini: Reasons for Disempanelment of Network Hospitals, since
C.6 270
Inception
Yeshasvini: Trends in Number of Claims, by Specialty, 2003–04 to
C.7 271
2009–10
D.1 Rajiv Aarogyasri: Summary Matrix 275
Rajiv Aarogyasri: Distribution of Procedures, by Institution, 2007–
D.2 283
August 2010
Rajiv Aarogyasri: Phased Rollout, Premiums, Claims, and Claim
D.3 Ratio, 2007–10 287

E.1 Rashtriya Swasthya Bima Yojana: Summary Matrix 295

E.2 RSBY: Districts and Hospitals, by Type and by State 304
RSBY: Hospitalization and Claims, by State, Inception to January
E.3 308
2011
F.1 Kalaignar Summary Matrix 315
Kalaignar: Top 25 Network Hospitals by Claim Value, July 2009 to
F.2 322
July 2010
Copyright © 2012. World Bank Publications. All rights reserved.

Kalaignar: Share of Claims in First Year of Policy, July 2009 to July

F.3 325
2010
Kalaignar: Approved Claims, by Gender and Age, July 2009 to July
F.4 327
2010
F.5 Kalaignar: Claim Distribution, by District, July 2009 to July 2010 329
G.1 Vajpayee Arogyashri Scheme: Summary Matrix 333
VA: Top 20 Hospitals, by Value of Authorized Claims, to November
G.2 339
15, 2010
G.3 VA Financial Status, August 2010 340
G.4 VA: Claim Distribution, by Specialty, to November 15, 2010 340

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 G.5 VA: Claim Distribution, by District, to November 15, 2010 341
H.1 RP: Summary Matrix 345
RP Hospital Network and Its Utilization, March 1, 2010, to February
H.2 351
15, 2011
I.1 ASBY: Summary Matrix 357
Copyright © 2012. World Bank Publications. All rights reserved.

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
 Foreword

Ever since assuming the position of Additional Secretary and Director General, Central
Government Health Scheme, in the Ministry of Health and Family Welfare in September 2010,
I have observed firsthand the opportunities and challenges facing health financing in India.
Despite recent gains, the country still struggles with low levels of population coverage and
financial protection, poor outcomes, but rapidly rising costs. Since Independence, the health
financing scenario in the public sphere has not changed much. It consists of mostly central
government public health programs, state-financed service delivery systems, and insurance
schemes for formal sector workers and civil servants. Reflecting low levels of public
spending, out-of-pocket spending at the point of service surpasses all other sources of
financing, suggesting that much more needs to be done to ensure more equal access to health
care and suitable financial protection.
This book fills a critical knowledge gap by providing an in-depth analysis of a relatively
new, but promising health financing modality: government health insurance schemes. La Forgia
and Nagpal dissect the nine largest schemes with considerable detail and accuracy, focusing on
a new crop of schemes that emerged in the last few years and are directed toward protecting
the poorest segments of Indian society. The authors finely probe these schemes, uncovering
their progress, potential, and shortcomings. Arguably, these recent arrivals represent a
pioneering—at least in the Indian context—but still emerging platform that can be one of the
key tools for achieving India’s stated goal of universal health coverage. However, finishing the
job started will be more difficult. In this respect, the authors make a significant contribution by
specifying the operational changes that will be required to transform them into more robust
platforms for contributing to universal coverage. Policy makers and planners should pay close
attention to these recommendations.
The road ahead will not be easy. In preparation for the 12th Five Year Plan (2012–17), the
central government is planning to significantly increase public spending on health to spearhead
the march toward universal coverage. This is certainly a welcome initiative, considering the
Copyright © 2012. World Bank Publications. All rights reserved.

historically low levels of government financing for health. But it is not only a question of
giving the health system more money. How best to spend these new resources to secure more
effective services is also an issue that needs to be addressed. These health insurance schemes
can spearhead changes in the broader system of finance and delivery at the tertiary and
secondary levels in the march toward universal coverage. How to direct the new funding is
already the subject of intense debate. For example, some call for expanding public delivery
systems operated by the states while others call for extending coverage through government-
sponsored health insurance. This may be a false dichotomy, and the authors intelligently avoid
this trap. What is clear is that the country can ill afford to move ahead on parallel tracks—

Forgia, Gerard La, et al. Government-Sponsored Health Insurance in India : Are You Covered?, World Bank Publications, 2012. ProQuest Ebook Central,
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