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making any definitive statement on the top-off model and overcoming the aforementioned constraints. In the context of multiple federal schemes (e.g., ESIS, CGHS, RSBY, and other smaller federal schemes), the system is already fragmented. This can lead to inefficiencies and inequities such as overlapping administrative arrangements and provider empanelment/certification. Varying package rates (or provider payment mechanisms) would send mixed signals to providers, leading them to gravitate toward higher-paying schemes and resulting in insufficient leverage to control costs. Lack of portability is another issue (Baeza and Packard 2006). Although CGHS and ESIS are mandated for specific groups, they have several common features. However, these functions are performed in parallel and with separate management structures, resulting in duplication of effort and costs. The federal government is losing an opportunity to aggregate purchasing systems for achieving economies of scale. Similarly, the GOI Ministry of Labor runs two separate schemes for formal and informal sector workers, ESIS and RSBY, with few lines of communication between the schemes. At the very least, shared use of the ESIS facilities by RSBY could be a way of improving utilization of several underutilized ESIS facilities, and ESIS facilities could be a mechanism for RSBY to foray into ambulatory care, where they exist.
Conclusion: Successes and Challenges The major operational and design features of the GSHISs and their implications for future and sustained performance were analyzed in this chapter. The focus was on the new wave of schemes launched in the late 2000s. These schemes introduced a demand-side purchasing approach to public financing while embracing several innovative features—in the Indian context. GSHISs are well-positioned to become key stakeholders in policy decisions regarding health financing and delivery arrangements. This final section summarizes major operational successes and challenges emerging from GSHIS implementation.
Successes Building upon the lessons learned from earlier rounds of SHI and government-subsidized health insurance as well as managerial knowhow of private insurers, a new genre of schemes emerged after 2007 with a “bottom-up� focus on covering the poor. Together, these schemes represented a new of way of doing business for government in terms of