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The ‘Missing Middle’: How to Provide 350 Million Indians with Health Coverage?

Author

Listed:
  • Ajay Mahal

    (Ajay Mahal (corresponding author) is at the National Council of Applied Economic Research, Delhi, India, and University of Melbourne, Australia. E-mail: ajay.mahal@unimelb.edu.au)

  • Vivek Panwar

    (Vivek Panwar is at P4H India Desk, Delhi, India.)

  • Arun Tiwari

    (Arun Tiwari is at the National Council of Applied Economic Research, Delhi, India.)

  • Rahul Reddy

    (Rahul Reddy is at AMREF, Joint Learning Network, Delhi, India.)

  • Sumit Kane

    (Sumit Kane is at the National Council of Applied Economic Research, Delhi, India, and University of Melbourne, Australia.)

Abstract

Despite recent expansion in its population covered by public-funded insurance, a large section of India’s population remains at major financial risk from health shocks. This segment of the population, sometimes referred to as the ‘missing middle’, typically consists of population groups that are, or have been, engaged in informal sector work, and are not poor enough to be eligible for state-subsidised contributions to insurance premiums; and potentially includes many even among those who satisfy the eligibility criteria. We estimate that the missing middle number is at least 300–350 million in India, with large variations in their economic circumstances. Using extensive international and India-based evidence, we assess two approaches to cover the missing middle: an expansion in public sector health delivery and a contributory demand-side financing system, that is currently popular in India. We conclude that a mix of the two approaches appears to be the most feasible in the short run, given limited regulatory and management capacity and resource constraints, with a longer-run emphasis on integrated systems. The approach proposed in the paper is also likely to help address the problem of shallow coverage of existing health insurance coverage that concerns large numbers of people extending beyond the group comprising the missing middle. JEL codes: I13, I14, I18

Suggested Citation

  • Ajay Mahal & Vivek Panwar & Arun Tiwari & Rahul Reddy & Sumit Kane, 2024. "The ‘Missing Middle’: How to Provide 350 Million Indians with Health Coverage?," Margin: The Journal of Applied Economic Research, National Council of Applied Economic Research, vol. 18(1-2), pages 43-73, February.
    • Handle: RePEc:sae:mareco:v:18:y:2024:i:1-2:p:43-73
    DOI: 10.1177/00252921241284190
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    References listed on IDEAS

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    1. Krishna, Anirudh, 2007. "For Reducing Poverty Faster: Target Reasons Before People," World Development, Elsevier, vol. 35(11), pages 1947-1960, November.
    2. Malhotra, Shefali & Patnaik, Ila & Roy, Shubho & Shah, Ajay, 2018. "Fair play in Indian Health Insurance," Working Papers 18/228, National Institute of Public Finance and Policy.
    3. Roman-Urrestarazu, Andres & Yang, Justin C. & Ettelt, Stefanie & Thalmann, Inna & Seguel Ravest, Valeska & Brayne, Carol, 2018. "Private health insurance in Germany and Chile: two stories of co-existence, segmentation and conflict," LSE Research Online Documents on Economics 90055, London School of Economics and Political Science, LSE Library.
    4. Besley, Timothy & Coate, Stephen, 1991. "Public Provision of Private Goods and the Redistribution of Income," American Economic Review, American Economic Association, vol. 81(4), pages 979-984, September.
    5. Rao, Krishna D. & Sheffel, Ashley, 2018. "Quality of clinical care and bypassing of primary health centers in India," Social Science & Medicine, Elsevier, vol. 207(C), pages 80-88.
    6. Sonia Bhalotra, 2007. "Spending to save? State health expenditure and infant mortality in India," Health Economics, John Wiley & Sons, Ltd., vol. 16(9), pages 911-928, September.
    7. Cheng, Terence C. & Haisken-DeNew, John P. & Yong, Jongsay, 2015. "Cream skimming and hospital transfers in a mixed public-private system," Social Science & Medicine, Elsevier, vol. 132(C), pages 156-164.
    8. Nga Lê & Wim Groot & Sonila M. Tomini & Florian Tomini, 2019. "Effects of health insurance on labour supply: evidence from the health care fund for the poor in Vietnam," Applied Economics, Taylor & Francis Journals, vol. 51(58), pages 6190-6212, December.
    9. Krishna, Anirudh & Shariff, Abusaleh, 2011. "The Irrelevance of National Strategies? Rural Poverty Dynamics in States and Regions of India, 1993-2005," World Development, Elsevier, vol. 39(4), pages 533-549, April.
    10. Kane, Sumit & Joshi, Madhura & Mahal, Ajay & McPake, Barbara, 2023. "How social norms and values shape household healthcare expenditures and resource allocation: Insights from India," Social Science & Medicine, Elsevier, vol. 336(C).
    11. Gerard La Forgia & Somil Nagpal, 2012. "Government-Sponsored Health Insurance in India : Are You Covered?," World Bank Publications - Books, The World Bank Group, number 11957.
    12. Karan, Anup & Yip, Winnie & Mahal, Ajay, 2017. "Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out of pocket spending for healthcare," Social Science & Medicine, Elsevier, vol. 181(C), pages 83-92.
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    More about this item

    Keywords

    India; Health Financing; Missing Middle; Insurance;
    All these keywords.

    JEL classification:

    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private
    • I14 - Health, Education, and Welfare - - Health - - - Health and Inequality
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health

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