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Government-Sponsored Health Insurance in India
population coverage over the last decade was due to increases in the wage ceiling, thereby bringing previously uncovered groups of the formal sector under the ESIS umbrella. The impact of a recent 50 percent hike in the wage ceiling will similarly contribute to ESIS membership expansion in the near future.8 CGHS is limited to civil servants, a group that has experienced a decline in numbers in recent years. According to the Census of Central Government Employees (2009), the total number of regular central government employees (including railways but not including defense) in 2006 was 3.1 million compared with 3.2 million in 2004, a drop of about 1.5 percent. However, as CGHS also covers retirees and is an attractive proposition for retiring civil employees,9 it is assumed that the number of employees retiring (and thus exiting CGHS at the end of their service career) will be offset by new pensioners joining the scheme. Also, new recruitments (capped at an annual 2 percent of the existing base) are also likely to be offset by members exiting the scheme due to death, keeping the member base for CGHS more or less constant in the foreseeable future. To summarize, if current trends of coverage expansion continue, at least one half of the Indian population will be enrolled in a health insurance scheme by 2015. GSHISs (as well as private insurers) are currently focusing on expanding the breadth of coverage. As will be seen below, the depth of benefit cover will vary considerably, with a large majority receiving very limited coverage and a small minority enjoying comprehensive benefits. Coverage will continue to expand in a segmented manner with different risk pools according to labor status, socioeconomic status, and enrolment in central- or state-sponsored schemes. Segmentation has important implications in terms of equity (of financial protection) and efficiency (of service purchasing and delivery).
Enrolment and Beneficiaries Successful coverage extension requires robust enrolment processes and targeting mechanisms. These measures contribute to equity while avoiding issues of adverse selection (by both insurers and beneficiaries). Simple eligibility requirements, innovative outreach mechanisms, and use of smart technologies have facilitated enrolment, allowing schemes to reach targeted beneficiaries. To identify the poor, most schemes use the BPL list, a proxy means test applied nationally by the central government (and implemented by states). It is used primarily for targeting food and other