Governments Come Together to Improve Health in India | World Bank Institute (WBI)

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  • Unexpected emergency care drives poor families in India further into debt and poverty. 
  • Health insurance has recently emerged in India to improve citizens’ access to health care, but there are many challenges in institutional structures, quality of services, reforms in provider contracting, and lack of capacity in monitoring and evaluation.
  • WBI and the World Bank’s Health team in India organized a workshop for the various implementing agencies to share challenges, experiences and a chance to collaborate moving forward.


April 7, 2011—India is the world’s second most populated country with 1.2 billion citizens. Like many developing countries, the major causes of poor health are inadequate prevention, lack of access to basic health care, poor nutrition, and unclean water.

Around 41% of India lives below the poverty line of US$1.25 per day. For millions of these people, illness can lead to serious consequences. Lack of resources and fears of financial strains often discourage poor families from seeking treatment until it is too late. Those who do seek treatment often do so at a high cost, driving them further into debt and extinguishing any dream of escaping poverty. The World Health Organization (WHO) estimates that more than 150 million people worldwide suffer financial ruin every year, from unexpected emergency care.

Insurance in India has emerged in the past decade as a response to the insufficient access and impoverishing effects of household out of pocket payments. Health insurance improves access and use by making health care more affordable, and improves financial protection for families. Health insurance is also viewed as a strategy for mobilizing more resources for health, pooling risk, providing more equitable access to health care for the poor, and delivering better quality health care.

India’s Foray into Health Insurance

Health insurance benefit plans mostly cover inpatient care (e.g., hospitalization and surgeries) as well as transportation costs while outpatient care is still provided by publically funded hospitals. Public-private partnerships are increasingly used to deliver services in India.

There are currently two types of health insurance schemes in India, private and government funded. Both types are growing in coverage and to date, 25% of Indians have some form of health insurance though the depth of coverage is far from comprehensive. Among the approximately ten government-sponsored plans, each covers a specific geographical region and most target families below the poverty line. The majority of these plans were launched within the last ten years.

While no scheme will fit the needs of every individual, each must address the larger issues of poor governance, fraud, lack of payment to hospitals, and affordability. Other challenges to health insurance schemes include institutional structures, quality of services, reforms in provider contracting, and lack of capacity in monitoring and evaluation.

Beginning a Dialogue

To help the various implementers understand challenges and share experiences, the World Bank Institute (WBI) and the World Bank’s India Health team organized a forum on ‘Government Sponsored Health Insurance Schemes in India’ in Delhi on January 20 and 21. Government officials from seven states, officials from the Department of Economic Affairs, and the Ministries of Health and Labor, shared their views around the design and implementation aspects of health insurance schemes. The World Bank’s India Health, Nutrition, and Population (HNP) team moderated the discussions.

The main topics discussed were:

  • Institutional Structure and Internal Controls,
  • Benefits Plans, Provider Payment and Package Rates,
  • Cost Containment and,
  • Quality in the Delivery of Health Care. 

"Having this opportunity to come together and speak about the real challenges we face in our different schemes is invaluable. The collaboration will certainly help us move forward,” said one participant. This was the first time that representatives from all government sponsored health insurance schemes in the country came together to share their experience with health schemes, leveraging their combined strengths and to meet with the donor community and international experts from India Public Health Foundation, Access International, and The World Bank.

The forum also presented two international experiences on insurance. The first case study was on Social Insurance Reform in Colombia and the reform process that characterized the health insurance evolution in the country over the last two decades as well as its current challenges and initiatives. The second case study was on the Pay for Quality model implemented in Brazil and the challenges it addressed, specifically in terms of quality, inequity, structural and clinical processes and outcomes. 

Moving Forward to Improve Health Insurance Schemes

These activities allowed a better understanding of the Indian context and proved to be a successful model to further improve practitioner exchanges and South-to-South activities on both the design and implementation on health policy topics, particularly health insurance.

Moving forward, an 18-month Practitioner-to-Practitioner Exchange program, on how to improve health insurance schemes in India, will be co-delivered by WBI and India HNP team.

The WBI Health team will continue developing practitioner exchanges between health insurance schemes and practitioners across countries and regions.