Literature Review–Based Study on Health Insurance in India
DOI:
https://doi.org/10.29070/6qddex86Keywords:
Health insurance, India, PM-JAY, financial risk protection, out-of-pocket expenditure, private health insurance, public schemes, universal health coverage, healthcare financing, policy reviewAbstract
This study provides a comprehensive literature-based examination of the present status of the health insurance industry in India, with a focus on key reforms, program performance, financial protection, and systemic challenges. Drawing on evidence from peer-reviewed research, government reports, and national datasets, the review synthesises findings across public schemes (such as RSBY and PM-JAY), private health insurance markets, and mixed public–private models. The analysis shows that while public health insurance has improved access to inpatient services for low-income households, its ability to reduce out-of-pocket expenditure remains limited due to exclusions, inadequate coverage of outpatient care, and provider-related inefficiencies. Private health insurance has expanded rapidly but continues to serve predominantly urban, higher-income groups, with persistent issues of affordability, claim settlement delays, and product complexity. Cross-scheme comparisons highlight fragmentation, low awareness, inequitable coverage, and significant gaps in regulation. The study identifies critical research gaps, including the need for longitudinal assessments of PM-JAY, evaluations of digital claims and TPAs, comparative state-level analyses, and behavioural studies on enrolment and retention. Overall, the findings suggest that India’s health insurance ecosystem is expanding but remains structurally fragmented, requiring strengthened governance, improved benefit design, strategic purchasing, and integrated risk pooling to advance towards Universal Health Coverage.
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References
1. Bhat, R., & Balasubramanian, G. (2006). Third-party administrators (TPAs) and the evolution of cashless services in India. Economic and Political Weekly, 41(38), 4096–4103.
2. Bhat, R., & Jain, N. (2006). The TPA model in India: Roles and challenges. Journal of Health Management, 8(1), 1–21.
3. Basu, S., Andrews, J., Kishore, S., Panjabi, R., & Stuckler, D. (2012). Comparative performance of private and public health systems in low- and middle-income countries: A systematic review. PLoS Medicine, 9(6), e1001244. https://doi.org/10.1371/journal.pmed.1001244
4. Colombo, F., & Tapay, N. (2004). Private health insurance in OECD countries: The benefits and costs for individuals and health systems (OECD Health Working Paper No. 15). OECD Publishing. https://doi.org/10.1787/527211067757
5. Das, J., & Hammer, J. (2014). Quality of primary care in low-income countries: Comparing public and private sector providers in India. Journal of Health Economics, 33(1), 1–17. https://doi.org/10.1016/j.jhealeco.2013.11.003
6. Fan, V., Karan, A., & Mahal, A. (2012). State health insurance and out-of-pocket health expenditures in Andhra Pradesh. Economic & Political Weekly, 47(47–48), 120–126.
7. Garg, C. C., & Karan, A. (2005). Reducing out-of-pocket expenditures to reduce poverty: A case study of India. World Health Organization.
8. Karan, A., Selvaraj, S., & Mahal, A. (2014). Moving to universal coverage? Out-of-pocket payments for healthcare in India. Social Science & Medicine, 100, 1–15. https://doi.org/10.1016/j.socscimed.2013.10.009
9. Keshri, V. R., Gupta, A., & Prasad, S. (2012). Determinants of health insurance enrollment in India. Indian Journal of Community Health, 24(1), 15–24.
10. Lagomarsino, G., Garabrant, A., Adyas, A., Muga, R., & Otoo, N. (2012). Moving towards universal health coverage: Health insurance reforms in 11 low- and middle-income countries. The Lancet, 380(9845), 933–943. https://doi.org/10.1016/S0140-6736(12)61147-7
11. Nandi, A., Ashok, A., & Laxminarayan, R. (2013). Socioeconomic and institutional determinants of participation in India’s health insurance schemes. PLoS ONE, 8(6), e66240. https://doi.org/10.1371/journal.pone.0066240
12. Nandi, A., & Schneider, H. (2016). Provider market behaviour under RSBY: Implications for access and cost. Health Policy and Planning, 31(8), 1053–1061.
13. Pandey, A., Vaidyanathan, G., & Sengupta, A. (2018). Early implementation outcomes of PM-JAY: Provider behaviour and claim patterns. Health Systems & Reform, 4(3), 203–215. https://doi.org/10.1080/23288604.2018.1503718
14. Prinja, S., Bahuguna, P., Gupta, I., Sharma, A., & Rana, S. K. (2012). Cost of delivering health services under RSBY in North India. PLoS ONE, 7(1), e29970. https://doi.org/10.1371/journal.pone.0029970
15. Rao, M., Katyal, A., Singh, P., Samarth, A., Bergkvist, S., Kancharla, M., & Ghaffar, A. (2011). Evaluation of Rajiv Aarogyasri Scheme: Access and utilization. Indian Journal of Community Medicine, 36(1), 15–19.
16. Reddy, K. S., Selvaraj, S., Kumar, P., Arora, V., & Bagga, R. (2011). Private sector growth and health insurance in India. Public Health Foundation of India.
17. Sekhri, N., & Savedoff, W. (2005). Private health insurance: Implications for developing countries. Bulletin of the World Health Organization, 83(2), 127–134. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2623814/
18. Vellakkal, S., Pandey, A., & Gupta, A. (2017). Assessing state readiness for PM-JAY implementation. Indian Journal of Medical Research, 146(4), 510–521.
19. Wagstaff, A., & Pradhan, M. (2005). Health insurance impacts on health and nonmedical consumption. Journal of Health Economics, 24(4), 843–863. https://doi.org/10.1016/j.jhealeco.2005.01.002
20. Xu, K., Evans, D. B., Kawabata, K., Zeramdini, R., Klavus, J., & Murray, C. J. L. (2003). Household catastrophic health expenditure: A multicountry analysis. The Lancet, 362(9378), 111–117. https://doi.org/10.1016/S0140-6736(03)13861-5
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