Providing non-contributory public health insurance to the below-poverty line (BPL) population is critical to achieving universal health coverage (UHC). To increase access to healthcare and reduce associated out-of-pocket expenditures (OOPE) for BPL households, the government of India implemented a tax-funded national health insurance scheme (RSBY) in 2008. Even though RSBY has increased health insurance coverage from less than 1 per cent in 2008 to 14 per cent in 2018, it failed to lower the associated OOPE.
To address gaps in the coverage of BPL households and financial protection mechanisms, the government of India launched Pradhan Mantri Jan Arogya Yojana (PM-JAY) in 2018 to provide publicly financed health insurance to around 500 million individuals comprising the bottom 40 per cent of the population. PM-JAY aimed to address gaps in RSBY with an increased ceiling of Rs 5,00,000 (a substantial increase from the previous sum of Rs 30,000) and an expanded service package for secondary and tertiary healthcare. In addition, it also aimed to address the gaps in beneficiary enrollment by employing the criteria of deprivation and occupation from the Socio-Economic and Caste Census (SECC) 2011.
The question after five years since the introduction of this programme is, to what extent has it helped to address the coverage gap? An analysis of the recently released household consumption expenditure survey (HCES) data (2022-23) indicates that while the coverage of public health insurance (PMJAY and state-specific insurance) programmes for the first two quintiles (poor and poorest) has increased since 2018, it remains low at less than 30 per cent of the population in this category. HCES data shows that of the 50 crore eligible people from the bottom 40 per cent population, about 13 crore are reported to be covered. The share of people from higher quintiles is reported to be more than 50 per cent of the overall coverage of public health insurance programs.
Further, about 25 per cent of the population in the first two quintiles who utilised hospitalisation services had public health insurance. Thirty-four per cent of those enrolled and who utilised the healthcare system received insurance benefits. In contrast, 36 per cent from the higher quintiles received benefits. Therefore, even though the increase in utilisation by covered people has doubled since 2017-18, the overall healthcare utilisation under the health insurance scheme remained low. Clearly, the overall increase in population coverage and consequent distribution of health insurance benefits for in-patient services also remained low in the last five years preceding the survey. The reasons for this need further examination.
A quintile-wise analysis of survey data revealed that the cumulative participation of middle and upper-middle-income groups in public health insurance programs continues to be higher than low-income groups. This could be due to public insurance being extended to the entire population in several states but it is worth probing.
A detailed analysis of HCES data revealed that 68 per cent of the total hospitalisation cases were treated in government facilities, which shows that people covered by public health insurance mainly relied on government health facilities for in-patient care. This remained unchanged since 2017-18. A considerable percentage of the population (>50 per cent) who did not have public health insurance also utilised government facilities. Thus, irrespective of public health insurance, people rely on government health facilities for in-patient care.
Achieving UHC requires the provision of financial protection to prevent households from incurring high OOPE. Household Social Consumption: Health survey (NSSO 75th round) 2018 showed that people in the first two quintiles were incurring a higher burden of OOPE than the people in the last two quintiles for both in-patient and out-patient care. However, HCES data 2022-23 indicates a shift of burden from lower income group to higher income group for in-patient services. This indicates a positive impact of public health insurance on OOPE due to hospitalisation in low-income groups. However, the financial burden for out-patient care remained the same as the low-income groups still incur a higher burden of healthcare expenditure.
Even though the HCES data indicates a lowering of the burden of healthcare expenditure for hospitalisation for the first two quintiles, they are still incurring a considerable amount while utilising in-patient services. As per HCES data, people across all quintiles are incurring significant expenditures, an average of Rs 6,700 for the first two quintiles while receiving treatment for in-patient care. Aligned with the findings of the Comptroller and Auditor General of India (CAG) report 2023, public health insurance beneficiaries had to pay from their pocket for the treatments received.
The findings of the HCES data for 2022-23 suggest that progress on UHC through targeted public health insurance in India is lagging in two crucial aspects: One, coverage of the targeted population; and two, financial protection to people in the first two quintiles. Even though HCES 2022-23 is not strictly comparable with NSSO 75th Survey 2017-18 due to the differences in questionnaire and recall periods, a broad comparison of population coverage and medical expenditure shows that the progress towards UHC is slow. The coverage of the target population in the two lowest income quintiles also remains low. In addition, the participation of middle and upper-middle-income groups in targeted public health insurance schemes is reported to be higher. All these show that drawbacks in the erstwhile National Health Insurance Scheme, such as in the identification and enrollment of targeted beneficiaries, low population coverage, and weaker financial protection mechanisms, have not been addressed fully.
The writer is research associate in the health vertical at CSEP
