Inequality and disparities in health insurance enrolment in India

Abstract

Over the years, several health insurance programmes have been launched in India to provide financial risk protection against burgeoning health expenditure. Therefore, it is essential to examine variation and inequality in health insurance enrolment over the years to identify “who is still left to be covered” and areas that require greater policy attention. The study used data from three rounds of the National Sample Survey (2004, 2014, and 2018). Descriptive statistics, bivariate and multivariable analysis, and concentration index (CI) were employed. In India, enrolment under health insurance increased from nearly 1% in 2004 to 15% in 2014 and 2018. It varied substantially across states/union territories, ranging from 0.38% in Bihar to 78.57% in Mizoram in 2018. The enrolment was consistently higher in urban areas than rural areas in 2004 (3.13% versus 0.36%), 2014 (18.02% versus 14.06%), and 2018 (19.06% versus 14.07%). Notably, enrolment under health insurance was statistically significantly concentrated among wealthier individuals in India (Erreygers CI: 0.12; Wagstaff CI: 0.22) as well as in 22/36 states/union territories in 2018. Moreover, individuals with higher educational levels, belonging to higher economic quintiles, scheduled tribes, urban areas, aged > 40 years, those earning regular wages and salaries, and following Hinduism were more likely to enrol under health insurance. The wide variations in health insurance enrolment (at inter-state, intra-state, and socio-economic levels) and the existence of inequality in insurance enrolment, emphasize the need for raising awareness, improving implementation processes, and taking into account contextual differences to increase enrolment in India.