The slide deck is a compilation of community based health insurance schemes in India

1. Community Based Health Insurance
Schemes in India
PGDPHM- 2019–20
Prepared By :
Ketki
Pallavi
Neetu
Sakshi
Rajeev
Trisha
Shashikant
Abhinouy

2. Community Based Health Insurance Schemes – An Overview
Limitations
• CBHI schemes suffer from poor design and management
• Often there is a problem of adverse selection as premiums are not based on assessment of individual risk status
• These schemes fail to include the poorest of the poor
• They have low membership and require extensive financial support
• Other issues relate to sustainability and replication of such schemes.
• Community based schemes are typically targeted at poorer population living in communities. Such schemes are generally run by charitable trusts or
non-governmental organizations (NGOs). In these schemes the members prepay a set amount each year for specified services. The premia are usually
flat rate (not income related) and therefore not progressive. The benefits offered are mainly in terms of preventive care, though ambulatory and
inpatient care is also covered. Such schemes tend to be financed through patient collection, government grants and donations. Increasingly in India,
CBHI schemes are negotiating with for profit insurers for the purchase of custom designed group insurance policies.

3. Models of Community Based Health Insurance
Provider + insurer
Community
Premium
Care Insurer
Community
Provider
Premium
Insurer
ProviderNGO
Community
Reimbursement
Premium
Care
Type I Type II Type III

4. Features of Community Based Health Insurance Schemes
Characteristics Provider Model Insurer Model Linked Model
Freedom to suit local needs Very free Very free Depends
Premium Set by the NGO based on affordability Set by the NGO based on affordability
Set by the insurer and based on actuarial
calculations
Benefit Package Comprehensive and meet local needs Comprehensive and meet local needs
Mediclaim policy with inclusions and
exclusions
Financial Risk With the NGO With the NGO With the insurer
Quality of Care Better No difference No difference
Community Involvement Minimal Varies Varies
Source: ‘A study of determinants influencing development of community based health insurance program with reference to morbidity patterns, health seeking behavior and out - of -
Pocket health expenditure in urban slum inhabitants in a metropolitan city’, ResearchGate (August 2015)

5. List of CBHI schemes operating in India (1/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion
Criteria
State where
active
Population
covered (N)
Students
Health Home
( for primary to
university
students)
1952
Rs 10/ student
per year
Free doctor
consultations, drugs at
Rs 5/day and hospital
stays at nominal rates
Completely
run by
students
Students
annual fee +
WB Govt grants
+ Donations
None West Bengal
23 lakh
students
Voluntary
Health Services
(low and
middle income
households)
1963
A/c to the
monthly
income of the
household
Free annual health
check-up for
household members
and out-patient and
in-patient care at
concessionary rates
Doctors /
Providers
Membership
fee graded
according to
monthly
income
None Tamil Nadu
> 1 lakh low
and middle
income
households
Source: SHH official website; ‘Community-based health insurance schemes in India’, The National Medical Journal of India (April 2003);

6. List of CBHI schemes operating in India (2/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion
Criteria
State where
active
Population
covered (N)
Sewagram,
Sorghum
Health Scheme
(Covers poorest
members of
the society)
1978
Fixed amount
of jowl crop at
harvest time/
Landowners
pay according
to the number
of hectares
they own,
while landless
laborers Rs16
/year
50% coverage of OPD
charges and 100% on
emergency services
SEWAGRAM
Trust
75% from Govt.
and rest from
service charges
and donations
Villages
with less
than 75%
enrollment
are
excluded
Maharashtra 19,500
Source: The National Medical Journal of India (April 2003); ‘Gandhian scheme provides rural health care’, Down To Earth (June 2015)
• To prevent political rivalry from undermining the scheme, villages where panchayat has been unanimously selected are considered to be eligible for the
scheme

7. List of CBHI schemes operating in India (3/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion
Criteria
State where
active
Population
covered (N)
Working
Women Forum
(WWF)
(intended for
Women
members of
Indian Co-
operative
Network for
Women
(ICNW))
2000-01
Up to 18 years
premium is Rs.
65
Between 18-45
years an
amount of Rs.
125
Between 45-60
years an
amount of Rs.
175
Between 60-75
years an
amount of Rs.
210
Inpatient expenses
upto Rs 7000/year
(maximum Rs 5000
per claim) Limits
maternity care Rs
3000 cataract Rs 2000
bed charges Rs
100/day
NGO act as an
intermediary
between the
target
population
and a private-
for-profit
insurance
scheme (LIC
&RSA)
WWF has tie-up
with Life
Insurance
Corporation of
India (LIC) and
Royal Sundaram
Alliance Pvt. Ltd
None
Andhra Pradesh,
Karnataka,
Tamil Nadu
Till now around
737235 Premium
holders have paid
a premium
amount of Rs.
2,38,65,880. And
4542 members
have benefited to
the tune of Rs.
2,53,46,423.
Source: The National Medical Journal of India (April 2003)

8. List of CBHI schemes operating in India (4/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion
Criteria
State where
active
Population
covered (N)
Mallur Milk
Co-operative
1973
Previously mandatory
enrolment of all
members of Mallur
Milk Co-operative
(1997data). Now
premiums paid from
endowment fund, for
all community
members.
Outpatient and
inpatient care:
referral services to
St Johns in
Bangalore, MCH
clinics held
monthly;
immunization
services;
emergency home
services and home
deliveries,etc
Mallur Dairy
Cooperative
Interest on
past
contribution.
None Karnataka
7000 in three
villages.
Source: The National Medical Journal of India (April 2003)
• Mallur Milk Co-operative scheme benefited from the strong economic condition of the community, the political power of the milk co-operative, supportive
political environment, strong and dynamic leadership, and the technical support provided by a nearby medical college.
• Success of the Mallur Milk Co-operative was attributed in part to community organization, ownership and participation

9. List of CBHI schemes operating in India (5/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion
Criteria
State where
active
Population covered (N)
Association for
Community
Cooperation &
Rural
Development
(ACCORD)
1991
Rs
20/person/
year
All hospitalizations to
a maximum of Rs
1500 Covers care at
one trust hospital (or
others if referral
required)
ACCORD ,
ASHWINI
Hospital staffs
and Adivasi
Munnetra
Sangam
(AMS)leaders
New India
Insurance
Only two
admissions
for delivery
covered per
woman
Gudalur, Tamil
Nadu
Scheduled tribes of
Gudalur taluk who are
members of Adivasi
Munnetra Sangam
(AMS)the tribal union
Company 1992 (N =
13,070 individuals)
Bharat Agro
Industries
Foundation
(BAIF)
2001
Rs 131+
25(administ
rative fee)
for a year
Covered
hospitalization up to
INR 5,000 and
concessionary prices
for primary care at a
BAIF center
A committee of
members from
community and
BAIF settles
claims, monitors
financial
performance,
and determines
strategic
direction
United India
Insurance
company
None
Pune (rural
outpost),
Maharashtra
Poor women members
of the community
banking and living in the
22 villages around Uruli
Company Kanchan
town.(N= 1,500 women
Source: The National Medical Journal of India (April 2003);

10. List of CBHI schemes operating in India (6/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion Criteria
State where
active
Population
covered (N)
SEWA
Self-employed
women’s
association
(Vimo SEWA)
Established-
1972
Started
working in
health care
area – 1992
Rs 85 is paid
by woman
Rs 55 can be
paid for
insurance of
her husband.
Rs 20 per
member paid
to NIC
Inpatient costs 2000/-
per person per year for
first
hospitalization ;
Fixed deposit
members receive one-
time flat payment for
maternity care,
dentures and hearing
aid
NGO
intermediate
GIC
Self Financed
NIC
Presently
working with
NIC
Normal delivery;
Pre-existing disease;
>1hospitalization for
newly developed chronic
disease;
HIV/AIDS and its
complications; diseases
resulting from
drug/alcohol use;
Outpatient service.
Ahmedabad,
Gujarat
Voluntary
Individual 92 000
(2001-2002)
Self-Employed
women+
husband+ child(if
any)
RAHA
Jashpur
(community
health
protection
scheme)
1974
Cash Rs.30 or
2 Kg of rice
per person
annually
Health services up to
Rs. 100/- at Rural
Health Center (RHC)
level and in the
Referral Hospital Rs.
2500/-
Managed by a
team with a
Coordinator
NGO-owned None
Chhattisgarh
(Raigarh
Jashpur
Surguja
Balrampur
Surajpur
Korea)
(2018-19)
over 100,000
members
Source: The National Medical Journal of India (April 2003)

11. List of CBHI schemes operating in India (7/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion Criteria
State where
active
Population covered
(N)
TF-old
Established
1993-94
Discontinued
1999
Rs.10 per
household
per year
Discount on
inpatient care
(inversely
proportional to
their wealth) at
single trust hospital
in district*
NGO- owned NGO
People deemed
sufficiently wealthy (as
adjudged by doctor or
social worker)were not
provided with benefit
Anand,
Gujarat
Residents of one rural
district Voluntary
Household 16%–20% of
the target population of
800 000
TF-new
(Sardar Patel
scheme)
Estabished
2001
Rs.1 per
household
per annum in
addition to
3paise per L
of milk
deposited
Covers 100% of
direct cost of
hospitalization at
any of 8 trust
hospitalization*
NGO-owned NGO
Costs of ‘special’(v.
standard) hospital
rooms Heart surgery,
cancer, HIV/AIDS, major
orthopedic surgeries,
kidney transplants
DOES NOT cover
medicines
Anand,
Gujarat
Enrolment >100,000
households, membership
restricted to members of
the AMUL Dairy
Cooperatives, acting as a
third-party insurer;
Members of dairy co-
operative, depositing at
least 300 L/year
*Benefits are available at the time of discharge.
Source: The National Medical Journal of India (April 2003); Social Health Insurance, WHO (June 2003)

12. List of CBHI schemes operating in India (8/8)
Name of the
plan
Established
(Year)
Premium Package Management
Financing
Source
Exclusion Criteria
State where
active
Population covered
(N)
Navsarjan
Trust
1999
Discontinued
in 2000
Rs 159 per
individual
Hospitalizations to
a maximum of Rs
15000
NGO
intermediated
GIC as
insurer
Normal delivery, pre-
existing disease, >1
hospitalization for
newly developed
chronic disease,
HIV/AIDS and its
complications,
diseases resulting
from drug/alcohol
use
Patan,
Gujarat
Dalits(SC), 5-80 years
of age
Voluntary individuals
of 574
Seba 1982
Rs 105 per
member
per annum
Hospitalization
expenses upto Rs
8000
NGO
intermediated
GIC as
insurer
None
Calcutta,
West Bengal
Voluntary Family
<3000 families
Source: The National Medical Journal of India (April 2003)

13. Thank You