ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846

Articles by Rajeev AhujaSubscribe to Rajeev Ahuja

The Impoverishing Effect of Healthcare Payments in India: New Methodology and Findings

The paper reflects the personal views and analysis of the authors and not the official views of the World Bank or its affiliates. The authors gratefully acknowledge the financial support of the World Bank and Department for International Development for this work.Peter Berman ( is with the Health Nutrition and Population Unit of the World Bank, Washington DC, Rajeev Ahuja ( is with HNP Unit of the World Bank, New Delhi and Laveesh Bhandari ( is with the Indicus Analytics, New Delhi. High private healthcare spending as well as high out of pocket spending in India are placing a considerable financial burden on households. The 60th national morbidity and healthcare survey of the National Sample Survey Organisation provides an opportunity to examine the impoverishing effect of healthcare spending in India. This paper presents an analysis of the nsso survey data with some new approaches to correcting some of the biases in previous assessments of the "impoverishing" effect of health spending. Despite these corrections, the results suggest that the extent of impoverishment due to healthcare payments is higher than previously reported. Furthermore, outpatient care is more impoverishing than inpatient care in urban and rural areas alike. The analysis of the extent of impoverishment across states, regions (urban and rural areas), income quintile groups, and between outpatient care and inpatient care yields some interesting results.

Government Health Spending in India

Although the government of India has set a goal of increasing government health spending to 2-3 per cent of gross domestic product over the next five years, even with optimistic assumptions, it cannot meet the stated goal. After analysing the recent trends in government health spending by the centre and states, this paper notes that sound fiscal targets for health spending should be based on goals for outcomes and the resources needed to achieve them, which are largely lacking. It suggests that large and sustainable increases in government health spending will require more focus on the states' own spending as well as improving the capacities of states and districts to use resources for health effectively.

Emerging Trends in Health Insurance for Low-Income Groups

This paper provides a brief overview of the existing forms of and emerging trends in health insurance for the low-income segment in India. Three conditions essential for extending health insurance to low-income groups are presented. Based on the early evidence of universal health insurance as well as on the UNDP-sponsored health insurance pilots, some lessons on design of insurance are drawn. Finally, the current debate on micro-insurance is summarised and some relevant lessons for policy are drawn.

Health Insurance for the Poor

Interstate variation in demand for the universal health insurance scheme for the poor is explained by the variation in healthcare infrastructure. In order to build demand for health insurance it is necessary to address the supply-side as well as design an insurance scheme based on a realistic assessment of the paying capacity of the poor.

Insurance: Over the Transition

Notwithstanding the impressive record of the regulatory authority, there remain several areas in which the regulator needs to quickly move forward. A lot more still needs to be done before the Indian public can take full advantage of a competitive insurance market. Besides developing specific lines of the insurance business, the regulator needs to fine-tune the rules of the game. The success of competition in financial sector ultimately depends on the efficiency of regulation.

Health Insurance for the Poor

Health insurance is emerging as an important financing tool in meeting the health care needs of the poor. Community based health insurance, rather than market mediated or government provided insurance is an appropriate way of reaching the poor. The development of private health insurance has potential risks and benefits in terms of health care access for the poor and regulatory changes can be used to maximise gains. However, even the private health insurance market lacks development due to the want of regulatory decisions on the supply of health services and the demand for health insurance.

Government Pensions

The central government expenditure on pensions has increased sixfold between 1990-91 and 1999-2000. Various bodies have estimated the extent of the pension liability over the coming decades and proposed reforms. This essay examines the assumptions made in these estimates and points to the additional considerations that merit attention while judging the viability of reforms.

New Pension System

The new pension system that has only been partially introduced awaits the necessary legislative approval to become fully operational. Recognising the needs of low-income and non-organised workers before they are drawn into the system and ensuring safeguards for the regulatory authority to function with some autonomy are some areas that need attention.

Micro-Insurance for the Poor: Policy Choices

Having a clear idea of what choice to follow and, based on that, devising appropriate macro policies is extremely important to achieve the objective of extending the reach of insurance to the poor. Other steps include building capacity (creating information tools, setting up the knowledge base, imparting training to the NGOs, etc) at various levels. The kind of capacity to build depends very much on what particular policy is chosen, which calls for some capacity building at the government level to weigh different policy choices.

Old-Age Income Security for the Poor

While the new pension system that is being promoted in the country is appropriate for those who can save for their retirement, there is need for an alternative approach for low-income people who cannot fully provide for their retirement, for which reason a significant proportion of workers may not be able to benefit from the new system.

Shrimp-Turtle Decision in WTO

This paper looks at the shrimp-turtle dispute between the US and shrimp exporting countries, including India. The US imposition of a ban on import of shrimps caught using methods endangering sea turtles has not affected Indian exports adversely. However, the ruling of the appellate body of the WTO has far-reaching implications as it virtually mainstreams environment in the world trade regime. It also legitimises the imposition of unilateral trade sanctions and process-related requirements to protect the environment.

Issues in Regulation of Insurance

In the Indian insurance market, the regulator must assure new entrants of a level playing field vis-a-vis hitherto monopoly incumbents. The initial focus of the regulator must be on financial soundness and prior experience of entrants. Tariff and contract standardisation must also be done in the initial stage. The objective of serving the weaker sections of society will be better served with a separate instrument.


Back to Top