Current Affairs Nov 18 , 2021

     Health Insurance for India’s Missing Middle”


  • The central government’s flagship health insurance scheme, the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), aims to extend hospitalization cover of up to ₹5 lakh per family per annum to a poor and vulnerable population of nearly 50 crore people.
  • Apart from AB-PMJAY and State-level government health insurance schemes, small segments of the Indian population are covered under social health insurance schemes and private health insurance
  • Covering the left out segment of the population, commonly termed the ‘missing middle’ sandwiched between the poor and the affluent, has been discussed by the Government recently.
  • NITI Aayog recently published a road map document entitled “Health Insurance for India’s Missing Middle”.
  • The report proposes voluntary, contributory health insurance dispensed mainly by private commercial health insurers as the prime instrument for extending health insurance to the ‘missing middle’.
  • Government subsidies, if any at all, will be reserved for the very poor within the ‘missing middle’ and only at a later stage of development of voluntary contributory insurance.
  • “Health Insurance for India’s Missing Middle”. (NITI AAYOG Report)
  • Highlights the need for health insurance coverage for all and says, “Significant challenges will need to be overcome to increase the penetration of health insurance.”, “The government and the private sector will need to come together in this endeavour.
  • Private sector ingenuity and efficiency is required to reach the missing middle and offer compelling products.
  • The government has an important role to play in increasing consumer awareness and confidence, modifying regulation for standardized product and consumer protection, and potentially offering a platform to improve operational efficiency.”
  • It outlines the current landscape, existing gaps and articulates broad recommendations and pathways to increase health insurance coverage.”
  • The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana a flagship scheme towards Universal Health Coverage, and State Government extension schemes provides comprehensive hospitalization cover to the bottom 50% of the population.
  • Around 20% of the population is covered through social health insurance, and private voluntary health insurance primarily designed for high-income groups.
  • The remaining 30% of the population, devoid of health insurance, is termed as the “missing middle”. The missing middle contains multiple groups across all expenditure quintiles and is spread across both urban and rural areas.
  • The report highlights the need for designing a low-cost comprehensive health insurance product for the missing middle.
  • It primarily recognizes the policy issue of low financial protection for health for the missing middle segment and highlights health insurance as a potential pathway in addressing that.
  • In doing so, the report offers a starting point for broader discussions on solutions, and specific products, to improve insurance coverage for the missing middle.
  • The report proposes wider industry and government stakeholder consultations, and discussion with consumer groups to delve deeper into the specifics of the problem, and potential solutions.


  • For instance, consider countries such as Switzerland.
  • Despite relying predominantly on private insurers and a competitive model of insurance, certain important checks and balances exist.
  • It is important to remember that even free-of-cost government health insurance for the poor has little penetration in the country, despite a nearly two decade-long legacy.
  • The possible destiny of contributory private health insurance with modestly lower premiums, for a target group that is not significantly well off, is obvious.
  • The report proposes an out-patient department (OPD) insurance with an insured sum of ₹5,000 per family per annum, and again uses average per capita OPD spending to justify the ability to pay.
  • However, the OPD insurance is envisaged on a subscription basis, which means that insured families would need to pay nearly the entire insured sum in advance to obtain the benefits.
  • The National Health Policy 2017 envisaged increasing public health spending to 2.5% of GDP by 2025.

Pollution in Delhi

  • The pollution from construction, industry, road transport, hitherto being masked through the year, becomes more visible.
  • However, the period also coincides with a unique practice in northern India where farmers in Punjab, Haryana and eastern Uttar Pradesh, in a bid to hurriedly clear their fields of rice straw to make space for wheat, set fire to the chaff.
  • This long-standing practice is now facing criticism because of its emerging link to Delhi’s noxious air quality.
  • The stubble smoke carries over into Delhi through long-range wind transport.
  • Finally, the third element during the season is Deepavali and the bursting of crackers.
  • The season is also marked by more social gatherings such as weddings or related celebrations that again see a demand for crackers.
  • While there is an official ban on crackers, except so-called ‘green crackers’ that are not widely available, the additional smoke from all of these add to the bad air, spiking air quality meters into the ‘very poor’ and ‘severe’ categories. Pollution crisis is not a problem that can be solved overnight.
  • The lockdown last year provided compelling evidence that taking vehicles off the road and a cessation in industrial and construction activity led to clearer skies.
  • Source apportionment studies by various institutions have shown that the contribution of stubble burning varies significantly, from as low as 4% on some days in October-November to as much as 40%.
  • But the running of power plants and construction are also necessary activities that cannot be shut at a moment’s notice.
  • The move to ban the entry of trucks too is not any more effective than waiting for the wind to blow over, and has consequences for the economy.
  • The way forward is to view winter air pollution as a natural disaster and target root causes.
  • Road dust is the dominant source of particulate matter and the most significant impediment to clean air, and unfortunately the least amenable to an easy fix.


Global climate risk index

  • The Intergovernmental Panel on Climate Change (IPCC), under the aegis of the United Nations, defines climate risk as the likelihood of unfavourable impacts occurring as a result of severe climate events interacting with vulnerable environmental, social, economic, political or cultural conditions.
  • Quantitatively, it is the product of the probability of a climate event occurring and its adverse consequences.
  • Recent discussions around climate risk assessment and management have been based on the “Global Climate Risk Index” (GCRI), published annually by German Watch, a non-profit organization.
  • The latest version of the GCRI, published in January 2021, ranked 180 countries based on the impact of extreme weather events and associated socio-economic data from 2000-2019.
  • According to the publishing agency, the rankings are meant to forewarn countries about the possibility of more frequent and/or severe climate-related events in the future.
  • This index uses historical data to provide insights on exposure to extreme events.
  • It cannot be used for linear forecasts about future climate impact.
  • There are deep fault lines in the methodology and interpretation of the country rankings.
  • First, the GCRI ranks countries based on four key indicators: number of deaths; number of deaths per 1,00,000 inhabitants; sum of losses in Purchasing Power Parity (in U.S. dollars); and losses per unit of the Gross Domestic Product (GDP). Of these indicators, two are absolute while the other two are relative.
  • However, the GCRI report does not provide a rationale for the selection of these macro indicators.
  • Second, the index suffers from exclusion errors and selection bias. Composite indicators are better constructed using micro indicators instead of macro indicators, which measure loss because isolating the effect of the loss of elements on GDP is fraught with errors.
  • Instead, a number of key micro indicators such as the total number of people injured, loss of livestock, loss of public and private infrastructure, crop loss and others are better candidates for assessing the composite loss resulting from climate change events.
  • Third, the index accounts for information on weather-related events like storms, floods, temperature extremes and mass movements.
  • However, it omits geological incidents like earthquakes, volcanic eruptions or tsunamis, which may be potentially triggered by climate change and can have economic and humanitarian impact.
  • Fourth, the ranking under the GCRI is done based on data collected by Munich Re’s NatCatService, which is not validated at the ground-level.
  • India’s latest module on the National Disaster Management Information System (NDMIS) captures damages and losses caused by disasters and monitors the targets of the Sendai Framework for Disaster Risk Reduction.
  • The NDMIS captures details on parameters like death, injury, affected population by categories as well as economic losses in social and infrastructure sectors due to weather and geological events on a daily basis.
  • The data captured by the NDMIS includes all major climatic events.