Strengthening Health Coverage in Karnataka, India

In Karnataka, India, more than ninety percent of the population have health insurance coverage for tertiary care. The National Health Mission, Karnataka, works to improve access to primary healthcare. Secondary healthcare coverage is provided through a mix of health insurance programs, from both state and central government. Despite these multiple forms of insurance, there are still many people who are not adequately covered. For them, they often face high out of pocket expenditure. There is an understanding that primary healthcare must be strengthened to increase access, quality, and equitability of healthcare. The Government of Karnataka recently announced a convergence of all health insurance programs which will drive cost effectiveness by preventing duplication of beneficiaries, promoting continuity of care, and increasing awareness and decreasing confusion.

A one day state level consultation was organized by the Department of Health and Family Welfare, Karnataka and NITI Aayog in Bangalore on August 29, 2017 to address some of the questions around how to redefine existing service delivery levels and delineate types of health services for each level of healthcare. The goal is to ensure continuity and harmonized referrals and move more rapidly toward universal health coverage.

I was invited to be on a panel “Achieving Universal Health Coverage and Assurance Through Convergence Across Health Schemes” to share experiences from the Joint Learning Network that may be of interest to Karnataka.  The panel session was chaired by Mr. I.S.N Prasad, Additional Chief Secretary, Government of Karnataka and moderated by Dr. Rathan Kelkar, Mission Director National Health Mission and Executive Director, Suvarna Arogya Suraksha Trust, Government of Karnataka. The other two panelists were Dr. Devi Shetty, Chairman and Founder, Narayana Health and Jorge Coarasa, Senior Economist, World Bank.

Joint Learning Network

The Joint Learning Network for Universal Health Coverage is a practitioner to practitioner learning network that helps low and middle income countries learn from one another, jointly solve implementation problems, and collectively produce and use new works of knowledge and innovative approaches to accelerate their country’s progress toward universal health coverage. India has been a member of this network since its inception in 2011. Today, twenty seven countries are part of the network. India benefits tremendously from the network and Karnataka in particular has much to learn from examples from other countries.

South Korea

South Korea had an amazing journey to build their healthcare system. They managed to go from hardly any healthcare coverage to universal health coverage in twelve years. Their  journey started when the National Health Insurance was made compulsory for workers in the formal sector. The program was extended to the entire population in 1989. Korea adapted its model from Japan’s national health insurance system. The Korean program is based on three central principles: mandatory coverage, payment of contribution on the basis of ability to pay, and receipt of benefits according to need.  The first principle ensures universality and the latter two promote equity. One major reform took place in 2000 when they merged several existing insurance programs to a single payer.

The insurance revenues consist of contributions from employers, employees, self employed, and government subsidies. They have found innovative and effective ways to collect premiums.

While today the financial protection against availing health services is universal in South Korea, even their system had its share of challenges. They, just like India, have a very large private sector and thus difficulties to control costs and quality of care. The Ministry of Health created a separate agency, the Health Insurance Review and Assessment Service (HIRA). This government agency is independent from the government insurance and is responsible for data analysis, claims processing, and control of quality of care. It is estimated that this agency saves the government about twenty percent of the annual healthcare budget through fraud and quality control. The benefit package includes curative services, but also biannual health checks and vaccinations from public health centers. The country has also introduced a capitation based outpatient treatment reimbursement mechanism.


In 2004, Indonesia mandated the establishment of a National Social Protection System. Indonesia had five insurance programs. In 2011, a new law was established which called for their integration. This integration kicked off in January 2014. The Ministry of Health, in collaboration with health practitioners, universities, and other related ministries, developed a road map to National Health Insurance. Total coverage would be achieved by 2019, after the harmonization of existing schemes and the expansion of coverage to currently uninsured people. The target seems quite ambitious for a low to middle income country like Indonesia, especially considering it took South Korea a dozen years to achieve full health insurance coverage.

Karnataka has a long association with the Joint Learning Network in seeking support and being part of the various technical exchanges. Sharing the Joint Learning Network experiences at the Bangalore event was another level of exchange and collaboration that will eventually lead to improved health coverage and health outcomes.