Extending Health Financial Coverage to the Informal Non-poor and Near Poor in India

Several countries are rolling out and scaling healthcare financial coverage for the informal non-poor or the informal near poor through publicly sponsored health insurance programmes. As Indian policymakers are planning to extend the coverage of the National Health Insurance Programme (Pradhan Mantri Jan Aarogya Yojana) to the missing middle, insights from international experience are explored.

The authors acknowledge the guidance of John C Langenbrunber who kindly helped them understand the concepts of financial protection for informal non-poor and conduct the literature review.

Matny low- and middle-income countries, including India, pursued universal health coverage (UHC) by providing financial protection to the vulnerable groups. These often include the poorest of the poor families earning mostly through informal means. The formally employed are often covered by compulsory or voluntary employer-based insurance. A “missing middle” comprises non-poor informal-sector workers, middle-class workers and their families, who remain financially vulnerable due to healthcare episodes (Bonfert et al 2015). This is because of the relative difficulty of identifying and enrolling them and financing their coverage efficiently and equitably. Andhra Pradesh has envisaged to cover this “missing middle” through the Aarogya Raksha programme. Similarly, community-based health insurance programmes like SEWA (VimoSEWA 2020), ACCORD (Devadasan et al 2007), Yeshasvini (Yeshasvini Cooperative Farmers Health Care Scheme nd), and Health Insurance Scheme for Weavers aimed to provide financial coverage to a specific occupational group (GoI 2019). This article presents lessons from nations that provide insurance coverage for their informal workers.

The study is based on the review of literature on the lessons learnt by extending health insurance coverage to the informal non-poor, globally. The research has been conducted as an exploratory study as the published literature is relatively limited for extending insurance coverage for the informal workers in India, or low- and middle-income countries.