Social Health Protection and Publicly Funded Health Insurance Schemes in India: The Right Way Forward?

This paper presents an assessment of publicly funded health insurance (PFHI) schemes as a measure of social health protection (SHP) in the country. The study uses secondary data from the nationally representative large-scale survey data on household social consumption related to health from three National Sample Survey (NSS) rounds—60 (2004), 71 (2014), and 75 (2017–18). The analysis of PFHI schemes is done on three metrics—population coverage, service coverage, and financial coverage. The analytical framework of the paper is based on the conceptual framework of the universal health coverage (UHC) cube of the World Health Organization (WHO) (“UHC cube” exhibits three dimensions of coverage: i.e., breadth of the cube—the population [who is covered?], depth of the cube—services [which are covered], and height of the cube—cost sharing [what proportion of costs are covered?]). To achieve the long-standing goal of UHC, improvements need to be made across each dimension in order to help fill the cube (Van Leberghe 2008). From the available data on population coverage, the national estimates of PFHI coverage in the country show a limited proportion of rural and urban population being covered in 2017–18. PFHI schemes provide coverage for only selective secondary and tertiary care, and not comprehensive care as per the design of the schemes. Outpatient care including diagnostics, and medicines are not covered under these schemes. High out-of-pocket expenditures (OOPEs) despite PFHI schemes are observed with disproportionately higher expenditures in private hospitals. This raises serious concerns with the direction of public policy that prioritises the national PFHI, PMJAY (Pradhan Mantri Jan Aarogya Yojana) to solve the social health protection (SHP) problem for the workforce of the country. The existing social health insurance ESIS (Employees’ State Insurance Scheme) which only covers a small section of the labour force is, however, relatively better in terms of its benefits cover (second arm of the UHC cube) and financial protection (third arm of the UHC cube) as seen in the OOPE per hospitalisation case as compared to PFHI schemes and might offer useful lessons for expanding social security to the country’s workforce.