State health insurance and out-of-pocket health expenditures in Andhra Pradesh, India

  • Victoria Y. FanEmail author
  • Anup Karan
  • Ajay Mahal


In 2007 the state of Andhra Pradesh in southern India began rolling out Aarogyasri health insurance to reduce catastrophic health expenditures in households ‘below the poverty line’. We exploit variation in program roll-out over time and districts to evaluate the impacts of the scheme using difference-in-differences. Our results suggest that within the first nine months of implementation Phase I of Aarogyasri significantly reduced out-of-pocket inpatient expenditures and, to a lesser extent, outpatient expenditures. These results are robust to checks using quantile regression and matching methods. No clear effects on catastrophic health expenditures or medical impoverishment are seen. Aarogyasri is not benefiting scheduled caste and scheduled tribe households as much as the rest of the population.


Health insurance Health expenditure Tertiary care Poverty India 

JEL Classification

I18 I38 G22 


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  1. Aarogyasri Health Care Trust. (2011). Quality Medicare for all, 2011. Accessed 1 June 2011.
  2. Aggarwal A. (2010) Impact evaluation of India’s Yeshasvini community-based health insurance programme. Health Economics 19(S1): 5–35PubMedCrossRefGoogle Scholar
  3. Australian Institute of Health and Welfare: (2010) Health expenditure in Australia 2008–9. Australian Government, CanberraGoogle Scholar
  4. Balarajan Y., Selvaraj S., Subramanian S. V. (2011) Health care and equity in India. Lancet 377(9764): 505–515PubMedCrossRefGoogle Scholar
  5. Berman P., Ahuja R., Bhandari L. (2010) The impoverishing effect of healthcare payments in India: New methodology and findings. Economic & Political Weekly 45(16): 65–71Google Scholar
  6. Bhalla S. (2002) Imagine there’s no country: Poverty, inequality and growth in the era of globalization. Institute of International Economics, Washington, DCGoogle Scholar
  7. Bhandari, L., & Sinha, A. (2010). Access to healthcare. In India health report 2010 (pp. 21–34). New Delhi: Business Standard.Google Scholar
  8. Das Gupta, M., Desikachari, B. R., Somanathan, T. V., & Padmanaban, P. (2009). How to improve public health systems: Lessons from Tamil Nadu. Policy Research Working paper 5073, The World Bank.Google Scholar
  9. Deaton A., Kozel V. (2005) Data and dogma: The great Indian poverty debate. Macmillan India, New DelhiGoogle Scholar
  10. Devadasan N., Criel B., Van Damme W., Manoharan S., Sarma P. S., Vander Stuyft P. (2010) Community health insurance in Gudalur, India, increases access to hospital care. Health Policy & Planning 25(2): 145–154CrossRefGoogle Scholar
  11. Devadasan N., Criel B., Van Damme W., Ranson K., Vander Stuyft P. (2007) Indian community health insurance schemes provide partial protection against catastrophic health expenditure. BMC Health Services Research 7: 43PubMedCrossRefGoogle Scholar
  12. Dror D. M., Koren R., Ost A., Binnendijk E., Vellakkal S., Danis M. (2007) Health insurance benefit packages prioritized by low-income clients in India: Three criteria to estimate effectiveness of choice. Social Science & Medicine 64(4): 884–896CrossRefGoogle Scholar
  13. Duflo E. (2001) Schooling and labor market consequences of school construction in Indonesia: Evidence from an unusual policy experiment. American Economic Review 91(4): 795–813CrossRefGoogle Scholar
  14. Ellis R. P., Alam M., Gupta I. (2000) Health insurance in India: Prognosis and prospectus. Economic & Political Weekly 35(4): 207–217Google Scholar
  15. Flores G., Krishnakumar J., O’Donnell O., Van Doorslaer E. (2008) Coping with health-care costs: Implications for the measurement of catastrophic expenditures and poverty. Health Economics 17: 1393–1412PubMedCrossRefGoogle Scholar
  16. Garg C., Karan A. (2009) Reducing out-of-pocket expenditures to reduce poverty: A disaggregated analysis at rural–urban and state level in India. Health Policy & Planning 24(2): 116–128CrossRefGoogle Scholar
  17. Grabosky P. (2001) The prevention and control of economic crime. In: Larmout P., Wolanin N. (eds) Corruption and anti-corruption. Asia Pacific Press, CanberraGoogle Scholar
  18. Government of Andhra Pradesh, Directorate of Economics & Statistics. (2009). Per capita net state domestic product at current prices. December 11.Google Scholar
  19. Government of India (GOI): (2007) Poverty estimates for 2004–2005. Press Information Bureau (PIB), Government of India, New DelhiGoogle Scholar
  20. Hirway I. (2003) Identification of BPL households for poverty alleviation programmes. Economic & Political Weekly 38(45): 4803–4808Google Scholar
  21. Iacus, S.M., King, G., & Porro, G., (2011). Multivariate matching methods that are monotonic imbalance bounding. Journal of the American Statistical Association 106 (2011): 345–361.Google Scholar
  22. Joint Learning Workshop. (2010). Country case study—India (Aarogyasri). Moving towards universal health coverage. Accessed February 24, 2010, from
  23. Jowett M., Deolalikar A., Martinsson P. (2004) Health insurance and treatment-seeking behavior: Evidence from a low-income country. Health Economics 13(9): 845–857PubMedCrossRefGoogle Scholar
  24. Kijima Y. (2006) Caste and tribe inequality: Evidence from India, 1983–1999. Economic Development & Cultural Change 54(2): 369–404CrossRefGoogle Scholar
  25. Krishna A. (2004) Escaping poverty and becoming poor: Who gains, who loses, and why?. World Development 32(1): 121–136CrossRefGoogle Scholar
  26. Krishna A. (2006) Pathways out of and into poverty in 36 villages of Andhra Pradesh. World Development 34(2): 271–288CrossRefGoogle Scholar
  27. Mahal A., Rajaraman I. (2010) Decentralisation, preference diversity and public spending: Health and education in India, economic and political weekly: A journal of current economic and political affairs. The Economic and Political Weekly, India 45(43): 57–63Google Scholar
  28. Mahamallik M., Bihari Sahu G. (2011) Identification of the poor: Errors of exclusion and inclusion. Economic and Political Weekly 46(9): 70–77Google Scholar
  29. Meenakshi J. V., Ray R., Gupta S. (2000) Estimates of poverty for SC, ST and female-headed households. Economic & Political Weekly 35(31): 2748–2754Google Scholar
  30. Ministry of Finance. (2012). Prices and monetary management. In: Economic survey 2011–12. New Delhi: Government of India.Google Scholar
  31. Mitchell A., Mahal A., Bossert T. (2011) Healthcare utilization in rural Andhra Pradesh. Economic and Political Weekly 46(5): 15–19Google Scholar
  32. National Health Systems Resource Centre. (2010). 264 High focus districts including RCH and LWE new—Proposed allocation for 2010–11. Accessed 1 June 2011.
  33. Planning Commission. (2002). National human development report. Planning Commission, Government of India, New Delhi.Google Scholar
  34. Prasad, S. K. (2012, January 8). GVK-government standoff derails ‘108’. Times of India, Hyderabad edition. Accessed April 15, 2012, from
  35. Preker A. S., Carrin G., Dror D., Jakab M., Hsiao W. C., Arhin-Tenkorang D. (2004) Rich-poor differences in health financing. In: Preker A. S., Carrin G. (eds) Health financing for poor people: Resource mobilization and risk sharing. The International Bank for Reconstruction and Development (The World Bank), Washington, DCGoogle Scholar
  36. Ranson M. K. (2002) Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: Current experiences and challenges. Bulletin of the World Health Organization 80(8): 613–621PubMedGoogle Scholar
  37. Sastry, N. S. (2004). Estimating informal employment and poverty in India. United Nations Development Programme (UNDP) India and Human Development Resource Center (HDRC), Discussion Paper Series 7, December.
  38. Sengupta, K. (2011). Risk aversion in rural India. Social Impact Research Experience Journal, Wharton School, University of Pennsylvania. Accessed 1 June 2011
  39. Tarozzi A. (2007) Calculating comparable statistics from incomparable surveys, with an application to poverty in India. Journal of Business & Economic Statistics 25(3): 314–336CrossRefGoogle Scholar
  40. Vaidyanathan A. (1986) On the validity of NSS consumption data. Economic & Political Weekly 21(3): 129–137Google Scholar
  41. van Doorslaer E., O’Donnell O. et al (2007) Catastrophic payments for health care in Asia. Health Economics 16(11): 1159–1184PubMedCrossRefGoogle Scholar
  42. Wagstaff, A. (2008). Measuring financial protection in health. Policy Research Working paper, No. 4554. The World Bank, Development Research Group, Human Development and Public Services Team, Washington DC, March.Google Scholar
  43. WHO. (2011). Global health expenditure database. Accessed August 6, 2011, from
  44. Xu K., Evans D. B. et al (2003) Household catastrophic health expenditure: A multi-country analysis. Lancet 362(9378): 111–117PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Center for Global DevelopmentWashingtonUSA
  2. 2.Oxford UniversityOxfordUK
  3. 3.Public Health Foundation of IndiaNew DelhiIndia
  4. 4.Monash UniversityMelbourneAustralia

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