Nuts&Bolts of CMCHIS

Nuts and Bolts of the Chief Minister’s
Comprehensive Health Insurance

Scheme (CMCHIS):
A Case Study from Tamil Nadu
FEBRUARY 2019
World Bank Team

Sheena Chhabra
Owen Smith
Ajay Tandon
Valerie Ulep
CMCHIS Team
T.S. Selvavinayagam, Government of Tamil Nadu
Sukeshini K., United India Insurance Co. Ltd.
Sainath Iyer, MDindia Health Insurance TPA Pvt. Ltd.
Ajitha Menon, Vidal Health Insurance TPA Pvt. Ltd.
T. V. Ramesh, Mediassist Health Insurance TPA Pvt. Ltd
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TABLE OF CONTENTS
Acronyms v
Preface vii
Foreword (Principal Secretary) viii
Foreword (Project Director) ix
Acknowledgements x
Summary xi
Chapter 1: Introduction 1
Chapter 2: Health in Tamil Nadu 4
Chapter 3: Covering People 12
Chapter 4: Defining Benefits 16
Chapter 5: Managing Money 21
Chapter 6: Improving Supply 29
Chapter 7: Strengthening Accountability 35
Chapter 8: Transition to PM-JAY 37
Chapter 9: Summary and Pending Agenda 43
Table of Contents iii

ANNEXES
Annex A: Key Population Health Outcomes 46
Annex B: Universal Health Coverage 47
Annex C: Burden of Disease and Risk Factor Trends for Tamil Nadu and India 48
Annex D: Key Health Financing Indicators 50
Annex E: Tamil Nadu District-Level Variables: Population and Enrollment 51
Annex F: Tamil Nadu District-Level Variables: Facilities and Beds 52
Annex G: Facilities That Provide the Maximum of Packages Across 10 Specialties and 8 53
High-End Procedures
Annex H: District-Level Utilization Rate of CMCHIS 58
Annex I: District-Level Utilization Rate of CMCHIS, by Specialty 59
Annex J: Claims Volume and Value by Age Group 60
iv Nuts and Bolts of the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS): A Case Study from Tamil Nadu
ACRONYMS
AIDS Acquired Immunodeficiency Syndrome
ANC Antenatal Care
BMI Body Mass Index
BPL Below Poverty Line
CGHS Central Government Health Scheme
CHC Community Health Center
CMCHIS Chief Minister’s Comprehensive Health Insurance Scheme
DALY Disability-Adjusted Life Year
DPT Diphtheria, Pertussis, and Tetanus
EDC Empanelment and Disciplinary Committee
ENT Ear, Nose, and Throat
ESIS Employee State Insurance Scheme
EQUAS External Quality Assessment Scheme
GDP Gross Domestic Product
GNI Gross National Income
GSDP Gross State Domestic Product
HIV Human Immunodeficiency Virus
IHME Institute for Health Metrics and Evaluation
Acronyms v
IMF International Monetary Fund
IPHS Indian Public Health Standards
IRDA Insurance Regulatory and Development Authority
LMIC Lower-Middle-Income Country
MFP Modern Family Planning
MIOT Madras Institute of Orthopedics and Traumatology
MMC Mortality and Morbidity Committee
MOU Memorandum of Understanding
MRI Magnetic Resonance Imaging
NABH National Accreditation Board of Hospitals
NFHS National Family Health Survey
NSSO National Sample Survey Organization
NQAS National Quality Assurance Standards
OOP Out-of-Pocket
PM-JAY Pradhan Mantri’s Jan Arogya Yojana
RSBY Rashtriya Swasthya Bima Yojana
SAN Sanitation
SDG Sustainable Development Goal
SECC Social-Economic Caste Census
SRS Sample Registration System
TNHSP Tamil Nadu Health Systems Project
TOB Non-Tobacco Use
TPA Third-Party Administrator
UHC Universal Health Coverage
UNICEF United Nations Children’s Fund
VAO Village Administrative Officer
VHN Village Health Nurse
WDI World Development Indicator
WHO World Health Organization
vi Nuts and Bolts of the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS): A Case Study from Tamil Nadu
PREFACE
Progressive realization of Universal Health Coverage (UHC) is one of the important aspects of the United
Nations’ Sustainable Development Goals. The Government of India is fully committed to attaining UHC
as reflected by its policies and institutional mechanisms to improve coverage and access to healthcare.
India is a highly diverse nation, and states have different approaches towards achieving UHC. Tamil
Nadu is one of the pioneer states in implementing such reforms and accumulated rich experiences
worth documenting and sharing.
The Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS), which initially began
implementation in 2009 in Tamil Nadu, provides state-financed noncontributory coverage to over
42 million poor, near-poor, and vulnerable individuals. The organizational and design features,
expenditures, potential impacts, innovative practices, and challenges of the scheme were examined
during the comprehensive study of the Scheme. The integration of the scheme with Ayushman Bharat
Pradhan Mantri Jan Arogya Yojana (PM-JAY), a centrally-financed scheme introduced in 2018 was also
documented. The implementation of PM-JAY, given its magnitude, can potentially change the landscape
of India’s Health System.
This publication is timely and relevant. In a setting constrained by low public spending for health, high
poverty rates, and complex governance and accountability issues, the Government of Tamil Nadu has
introduced a mechanism to manage public funds for health and deliver healthcare services to the poor
and vulnerable populations. The architecture of CMCHIS and the lessons learned in the last 6 years
provide important insights not only for other Indian states, but also for the central government, which
is currently at the crossroad of health financing reforms. Other countries can learn as well especially
those questing for universal healthcare and implementing pro-poor health insurance schemes with large
presence of private sector.
Preface vii
ACKNOWLEDGEMENTS
The case study on the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) was
prepared by a joint team from CMCHIS-TNHSP and South Asia Region (SAR), Global Health, Nutrition
and Population (HNP), World Bank. The team comprised of Dr. T.S. Selvavinayagam (Additional Director,
Public Health, Government of Tamil Nadu (GoTN)), Ms. Sukeshini Ramaswamy (DGM, United India
Insurance Company (UIIC)), Mr. Sainath Iyer (Project Head, MDIndia Health Insurance TPA Pvt. Ltd.),
Ms. Ajitha Menon (Project Head, Vidal Health Insurance TPA Pvt. Ltd.), Dr. T. V. Ramesh (Project Head,
Mediassist Health Insurance TPA Pvt. Ltd.), Ms. Sheena Chhabra (Senior Health Specialist, World Bank),
Mr. Owen Smith (Senior Economist, World Bank), Mr. Ajay Tandon (Lead Economist, World Bank) and
Mr. Valerie Ulep (Consultant, World Bank).
We will like to express our gratitude to Dr. J. Radhakrishnan, Principal Secretary, Department of Health
and Family Welfare, GoTN, Ms. P. Uma Maheshwari, Project Director, Tamil Nadu Health Systems
Project, GoTN, and Ms. Rekha Menon, Practice Manager, SAR, World Bank for providing constant
encouragement and guidance for documenting the case study. We also appreciate the keen interest and
enthusiasm of Dr. Indu Bhushan, CEO, National Health Authority (NHA) and Dr. Dinesh Arora, Deputy
CEO, NHA, for the case study to draw lessons for PM-JAY and promote practitioner to practitioner
learning among states.
The authors are also deeply appreciative of the extensive contributions and support provided by a large
number of officials affiliated with CMCHIS. Special gratitude to Dr. Amanda, Dr. Senthil, Dr. Kaarthika,
Dr. Parameswari, Dr. Anusha, and Dr. Devasena from TNHSP; Mr. K Shiva Kumar, Mr. S Raman,
Mr. Dinesh Reddy, Mr. Varun Kumar Sukhla, and Pream Mukilan, from UIIC; Mr. B Balamuralikrishnan,
and Mr. S Valaguru from Vidal Health Insurance TPA Pvt. Ltd; Mr. T Ambedkar, Mr. C Dinesh, and
Ms. Pratheema from Mediassist Health Insurance TPA Pvt. Ltd.; and Ms. B K Deepa Rani, Mr. B Yuvaraj,
Mr. G Ramchandran, and Dr. S Janane from MDIndia Health Insurance TPA Pvt. Ltd. for rich inputs and
engaging discussions. The team is indebted to Mr. Sainath Iyer for excellent coordination especially of
numerous requests for data.
We will also like to thank Ms. Aparnaa Somanathan, Dr. Somil Nagpal, Mr. Aakash Mohpal, Mr. George
Schieber, Mr. Adrien Dozol, Mr. Christoph Kurowski, Mr. Rajesh Jha, and Mr. Aloke Gupta from the
World Bank for the excellent peer review of the document. The World Bank technical support has been
provided under the Programmatic Advisory Services and Analytics for Universal Health Coverage in
India with financial support by the Bill & Melinda Gates Foundation Trust Fund.
x Nuts and Bolts of the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS): A Case Study from Tamil Nadu
SUMMARY
This publication summarizes the architecture Although some elements of the scheme’s
of the Chief Minister’s Comprehensive Health architecture are similar to those being implemented
Insurance Scheme (CMCHIS) which initially began across several states in India, certain modalities of
implementation in 2009, in the state of Tamil Nadu, 1 CMCHIS are also quite different in important and
in India. CMCHIS provides state-financed notable ways, serving to provide valuable lessons
noncontributory coverage to over 42 million poor, for other states and countries implementing
near-poor, and vulnerable individuals—more than similar programs. For instance, CMCHIS
half of Tamil Nadu’s population—for `100,000 includes coverage for a diagnostic package that
(~US$1,429) and up t̀o 200,000 (~US$2,858) beneficiaries can also avail of in empaneled health
for certain procedures per family per year for care facilities. This diagnostics package covers
an explicitly defined inpatient-focused benefits investigative procedures even if they do not lead
package that can be availed of at empaneled to admissions, potentially helping diagnose health
government and private facilities. CMCHIS uses a conditions before they become severe enough to
‘mixed’ implementation modality; a public sector require imminent hospitalization. Follow-up care
insurance company is paid an annual premium of for up to one year post-hospitalization is also
`699 (~US$10) per family enrolled, which forms provided for a preidentified range of conditions.
the pool of resources from which providers are Payments under CMCHIS to the public health
reimbursed using a case-based method, while insurance company are for a minimum of four years
top-up claims to providers for selected high-end and are front-loaded: 95 percent of premiums paid
procedures with a higher beneficiary coverage cap for by the government on behalf of beneficiaries
are paid for using an ‘assurance’ modality, that is, are advanced on an annual basis at the beginning
they are paid directly by the scheme-administering of the year, reducing uncertainty on the timing and
agency. regularity of financing for the scheme. Almost all
claims are settled within seven days of submission,
helping bolster provider confidence in the scheme.
1 This publication has been prepared by a team comprising CMCHIS is also notable for implementing strong
members from CMCHIS (T.S. Selvavinayagam, Sukeshini R.,
Sainath Iyer, Ajitha Menon, T. V. Ramesh) and from the World processes for ensuring provider accountability
Bank India team (Sheena Chhabra, Owen Smith, Ajay Tandon, and for preventing, detecting, and deterring fraud
and Valerie Ulep).
Summary xi
through engaging multiple TPAs and shifting remains thin and the scheme is operating on the
responsibilities over time, preauthorizations and edge with regard to its overall claims ratio, raising
claims reviews. In addition, CMCHIS mandates that concerns regarding sustainability, especially as
all empaneled private health facilities hold monthly and when utilization rates increase and to ensure
outreach ‘health camps’ to provide screening, continued engagement with the for-profit private
detection, and referrals. CMCHIS has pioneered sector.
the implementation of tiered reimbursements for
private hospitals, aimed at incentivizing quality of In looking to the future, CMCHIS can serve as an
care, in addition to implementing regular reviews important platform to consider options by which
of morbidity and mortality outcomes related to some of the gains made by Tamil Nadu’s health
admissions at both government and empaneled systems could be sustained and expanded as it
private hospitals. faces new challenges and opportunities. As has
been the experience of many countries, a longer-
As CMCHISgets integratedwith the national Pradhan term agenda could be to assess the feasibility of
Mantri’s Jan Arogya Yojana (PM-JAY) scheme, there the scheme as a mechanism to expand coverage
remains a pending agenda related to systematic for a larger set of health needs, not just those
monitoring and evaluation of the scheme’s impact around relatively infrequent hospitalizations, and
on health outcomes and on financial protection as to integrate primary and specialist outpatient
well as of finding ways for enhancing flexibility for care more systematically and holistically to
course correction during implementation. Despite enhance access to all levels and to provide
best efforts, there remain concerns that private continuum of care, a key consideration as the
providers are balance-billing some beneficiaries; state undergoes its epidemiological transition
furthermore, a related issue regarding increasing toward a predominance of Non-communicable
knowledge and awareness among beneficiaries Diseases (NCDs): improving health outcomes,
of the full range of entitlements provided by reducing financial barriers to accessing care for
the scheme remains an ongoing challenge, the poor and vulnerable, and reducing the health
especially for new additions. At 0.1 percent of the system’s overall dependence on financing from
Gross State Domestic Product (GSDP), financing Out-of-Pocket (OOP) sources.
xii Nuts and Bolts of the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS): A Case Study from Tamil Nadu
1. INTRODUCTION
This publication summarizes the architecture of million, Tamil Nadu is southernmost among India’s
the Tamil Nadu state’s government-sponsored 29 states: it is one of the four southern states
health insurance scheme. The scheme—currently in India, bordering Karnataka, Kerala, Andhra
referred to as the Chief Minister’s Comprehensive Pradesh, and the union territory of Pondicherry.
Health Insurance Scheme (CMCHIS)—was initially Tamil Nadu is also geographically close to the
launched in 2009. With a population of 79.3 island country of Sri Lanka (Figure 1). In terms
FIGURE 1: TAMIL NADU STATE IN INDIA
FIGURE 2: PER CAPITA INCOME (2017) AND ECONOMIC GROWTH (2000–2016): TAMIL NADU VER SUS
COMPARATORS
of population, it is the seventh-largest state in akin to a Lower-Middle-Income Country (LMIC)

India comparable in size to countries such as Iran (Figure 2).2 Within India, its income is above the
and Turkey, both of which are among the top 20 national average and it ranks 11th among states in
largest countries in the world. Tamil Nadu’s per 2 The World Bank currently classifies countries as low income if
capita income of about US$2,300—similar to that the Gross National Income (GNI) per capita is less than US$995;
LMICs are those with GNI per capita greater than US$995 and
of Nicaragua and Vietnam and comparable to less than US$3,895; Upper-Middle-Income Countries (UMIC)
that of several other Indian states such as Kerala, as those with GNI per capita greater than US$3,895 and less
than US$12,055; countries with GNI per capita greater than
Punjab, Gujarat, and Maharashtra—makes it US$12,055 are classified as high income.
2 Nuts and Bolts of the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS): A Case Study from Tamil Nadu
terms of per capita gross state domestic product scheme’s architecture are similar to those being
(GSDP).3 Per capita economic growth rates in implemented across several state schemes in
the state have been close to 7 percent over the India, certain modalities of CMCHIS are also quite
past 15 years—both before and after the 2009 different in important and notable ways, serving
launch of CMCHIS—making Tamil Nadu one of to provide valuable lessons for other states and
the fastest growing regions of the world. Strong countries implementing similar programs. In
economic growth has resulted in a decline in describing CMCHIS, the focus is on assessing
poverty rates to about 12 percent of the population key elements of its architecture, highlighting
in the state. 4 Tamil Nadu is notable for being one innovations and ‘good-practice’ elements where
of the most literate states in India (80 percent of evident, while also noting areas where there
the population is literate). 5 It has 32 districts and is remains a pending agenda for improving the
highly urbanized. 6 performance of the scheme as it gets integrated
with the national Pradhan Mantri’s Jan Arogya
CMCHIS currently provides coverage to more Yojana (PM-JAY) for continued implementation.
than half of Tamil Nadu’s population. CMCHIS
provides state-financed noncontributory coverage The remainder of the publication is organized
to over 42 million poor, near-poor, and vulnerable as follows. The framework draws on a recent
individuals—more than half of Tamil Nadu’s World Bank publication, Going Universal: How 24
population—for up to `100,000 (~US$1,429) and Developing Countries are Implementing Universal
up to `200,000 (~US$2,858) per family per year Health Coverage Reforms from the Bottom
for an explicitly defined inpatient-focused benefits Up, which identified the ‘nuts and bolts’ of pro-
package that can be availed of at both government poor Universal Health Coverage (UHC) reform
and empaneled private facilities. CMCHIS uses a implementation globally across five broad policy
‘mixed’ implementation modality: a public sector areas: covering people, defining benefits, managing
insurance company is paid an annual premium of money, improving supply, and strengthening
accountability. 7 Before doing so, the next section
` 699 (~US$10) per family which forms the pool of
summarizes health-relevant background for the
resources from which providers are reimbursed
state of Tamil Nadu to help position the state in
using a case-based method, while top-up claims
a national and global context and as a prelude to
to providers for selected high-end procedures
introducing CMCHIS. Subsequent sections outline
with a higher coverage cap are paid for using an
(a) how CMCHIS covers people, including eligibility
‘assurance’ modality, that is, they are paid directly
and enrollment; (b) how benefits are defined and
by the scheme-administering agency.
how they evolved over time; (c) how resources are
CMCHIS includes several innovative design and managed and expended; (d) how CMCHIS includes
elements for improving supply of health services,
implementation elements that can potentially
both for government and empaneled private
provide useful lessons for other states in India as
hospitals; and (e) how accountability is being
well as globally. Although some elements of the
strengthened under the scheme. The publication
3 Reserve Bank of India. 2018H . andbook of Statistics of Indian ends with an overview of integration of CMCHIS
States. Mumbai: Government of India. with PM-JAY as well as a summary of key lessons
4 Reserve Bank of India. 2018H . andbook of Statistics of Indian
States. Mumbai: Government of India. that the architecture of CMCHIS potentially offers
5 In Tamil Nadu, the literacy rates among women and men were to other states in India under PM-JAY, as well as
73 percent and 87 percent, respectively; in India, on average, the
literacy rates were much lower for both genders: 65 percent for globally.
women and 81 percent for men (Reserved Bank of India, 2018).
6 In Tamil Nadu, almost half of the population lives in urban areas, 7 Cotlear, D., S. Nagpal, O. Smith, A. Tandon, and R. Cortez. 2015.
significantly higher than less than one-third for India on average; Going Universal: How 24 Countries Are Implementing Universal
Ministry of Statistics and Program Implementation. 2017. Selected Health Coverage Reforms from the Bottom Up. Washington, DC:
Socio-economic Statistics. New Delhi: Government of India. World Bank.
2. HEALTH IN TAMIL NADU
Tamil Nadu’s population has undoubtedly average ever since. Tamil Nadu has already met
become healthier over the past several decades. the child and maternal health 2030 United Nations
Life expectancy at birth has steadily increased Sustainable Development Goals (SDGs) of an
to 71 years in 2015, up from 64 years in the late under-five mortality rate of less than 25 per 1,000
1990s and close to 50 years in 1970 (Figure 3). The live births and a maternal mortality ratio of less
infant mortality rate has declined from over 100 than 70 per 100,000 live births. Unlike the average
in the 1970s to 50 in the late 1990s to less than for India, both under-five mortality and maternal
20 per 1,000 live births in 2016. Whereas Tamil mortality ratios are far better than what might be
Nadu’s health outcomes were similar to the Indian expected for Tamil Nadu’s income level (Figure 4).
average in the early 1970s, it is notable that the Tamil Nadu’s total fertility rate of 1.6 is among the
state has consistently outperformed the national lowest in India, comparable to that of much richer,
Upper-Middle-Income Countries (UMIC) such as
China and Thailand (see Annex A).
FIGURE 3: KEY POPULATION HEALTH OUTCOMES
IN TAMIL NADU, 1970–2016 Tamil Nadu is committed to attaining UHC for
its entire population. UHC—a policy commitment
that is also part of the 2030 SDGs—is about
ensuring that all people can use the promotive,
preventive, curative, rehabilitative, and palliative
health services they need, of sufficient quality to
be effective while also ensuring the use of these
services does not expose the user to financial
hardship. The global monitoring framework of the
World Health Organization (WHO)-World Bank
recommends tracking a mix of preventive and
promotive treatment service coverage and financial
coverage indicators to assess progress toward
UHC. Recommendations under preventive and
Source: Sample Registration of India and Reserve Bank of India
promotive coverage include monitoring access
FIGURE 4: UNDER-FIVE MORTALITY RATE AND MATERNAL including the proportion of households
MORTALITY RATIO RELATIVE TO INCOME, 2015 that spend more than 10–25 percent
of their income or consumption on
health and the proportion of households
that are impoverished as a result of
high OOP spending. 8 It is notable that
recommended UHC indicators do not
include the proportion of population
that has insurance coverage as that is a
means and not an end in itself: the focus
is on effective coverage of services and
of financial protection when seeking
care.
One reason for Tamil Nadu’s relatively

good performance on population health
outcomes is due to high coverage rates
for key UHC-related service coverage
interventions. Tamil Nadu’s coverage
indicators for key health services such
as access to modern family planning
methods, ANC, skilled birth attendance,
immunization, and tuberculosis treatment
rates are greater than 80 percent, higher
than India’s and the average for LMICs
and, in some cases, better than high-
performing countries such as Sri Lanka
and Turkey (see Annex B). The areas
where Tamil Nadu shows some weakness
are in access to sanitation and for financial
protection indicators because, as also
Source: Sample Registration of India and Reserve Bank of India
discussed later, OOP remains the largest
source of financing for the health sector. Other
to modern family planning methods; Antenatal
factors that contribute to Tamil Nadu’s success in
Care (ANC) for pregnant women; skilled birth
health include training and deployment of village
attendance; diphtheria, pertussis, and tetanus
health nurses, investments in a strong network of
(DPT3) immunization coverage; non-prevalence
2,226 primary health care centers (of these, 416—
of tobacco smoking; access to improved water
almost 20 percent—are open for 24 hours), and
sources; and access to improved sanitation, among
development of institutions such as the autonomous
others. Recommended treatment interventions
Tamil Nadu Medical Services Corporation that have
include treatment rates for tuberculosis,
been critical to ensure a reliable supply of essential
hypertension, diabetes, and antiretroviral therapy
coverage for those with HIV. Recommended
8 WHO (World Health Organization) and World Bank. 2017.
financial coverage indicators include those derived Tracking Universal Health Coverage: Global Monitoring Report.
from high levels of OOP health expenditures Geneva: WHO.

medicines. 9 A range of non-health system factors lost due to morbidity and premature mortality in
also explains why Tamil Nadu has experienced 2016 (Figure 5).11 Ischemic heart disease was also
better health outcomes than other states in India. the leading cause of premature mortality in Tamil
Tamil Nadu enjoys a relatively higher level of Nadu. Other NCDs such as diabetes have more
education and women’s empowerment: the state than tripled their share of the disease burden over
has been a pioneer in the introduction of programs 1990–2016 (see Annex C). New risk factors related
to enhance school enrollment, particularly among to urbanization and lifestyle factors are growing.
girls. Even before the National Right to Education Ageing is one contributory factor—7 percent of
Act was passed in 2009, the state made major the population of the state is over 65 years of age
legislative efforts for the universalization of and this share is growing rapidly—although the
education in the early 1990s. Along with sustained prevalence of NCDs among younger age groups
programs in education and health, Tamil Nadu has in Tamil Nadu is also increasing. Unhealthy diets,
relatively good infrastructure (for example, roads high fasting plasma glucose, and hypertension
and transportation). Tamil Nadu was one of the are prominent among the top 10 risk factors
first states to achieve almost universal access to contributing to the overall disease burden in the
electricity (for example, the electrification rate in state. The share of high Body Mass Index (BMI)
rural Tamil Nadu is 85 percent compared to 40 as contributor to DALYs lost has increased more
percent in rural Uttar Pradesh). Tamil Nadu has a than fivefold and high total cholesterol has more
long history of democratized administration and than doubled over 1990–2016. Alcohol and drug
this has helped improve the responsiveness of the use in Tamil Nadu is also rising in its contribution
health system.10 to the overall burden of disease. Despite recent
reductions, the prevalence of smoking remains
Non-communicable Diseases (NCDs) now high, particularly among men, with 32 percent of
account for almost two-thirds of the burden men currently using tobacco products.
of disease in Tamil Nadu, higher than their
overall average share of 55 percent for India Despite notable progress on key population health
(Figure 5). Whereas in 1990 only about 38 percent outcomes, several challenges remain especially
of morbidity and mortality in Tamil Nadu was with regard to malnutrition, adult survival rates,
due to NCDs, by 2016, this number had risen to NCDs, and inequalities in outcomes. Although
65 percent (Figure 5). This trend is expected to the infant mortality rate in some districts such as
continue in coming years. Ischemic heart disease Kanchipuram and Erode was less than 10 per 1,000
was responsible for the largest share of the overall live births, the rate was more than double in other
disease burden in Tamil Nadu, causing 14.3 districts such as Thoothukudi and Dharmapuri.
percent of all Disability-Adjusted Life Years (DALYs) Infant mortality rates were also sharply lower among
higher socioeconomic groups. Stunting rates in
9 Balabanova, D., A. Mills, L. Conteh, et al. 2013. “Good Health at
Low Cost 25 Years On: Lessons for the Future of Health Systems children remain high, having barely improved from
Strengthening.” Lancet 381: 2118–2133. 30 percent in 2005 to 27 percent in 2015. Despite
10 Muraleedharan V., U. Dash, L. Gilson. 2011. “Tamil Nadu 1980-
2005: A Success Story in India.” In Good Health at Low Cost 25 substantial efforts, screening for NCDs remains
Years On: What Makes a Successful Health System? edited by
D. Balabanova, M. McKee, and A. Mills. London: London School
of Tropical Medicine and Hygiene; Harmer, A. 2011. “Improving 11 Whereas in India as a whole, ischemic heart disease is also
the Lives of Half the Sky: How Political, Economic, and Social responsible for the top slot, the remainder of the disease burden
Factors Affect the Health of Women and their Children.” In Good is quite different. For example, tuberculosis remains in the top 10
Health at Low Cost 25 years On: What Makes a Successful Health for India but not for Tamil Nadu, diabetes is the second-largest
System? edited by D. Balabanova, M. McKee, and A. Mills. cause of disease burden in Tamil Nadu but is not yet in the top 10
London: London School of Tropical Medicine and Hygiene; Sinha, for India, and stroke is high for India but does not appear in the
D. 2016. Women, Health, and Public Service in India. New York: top 10 for Tamil Nadu. Similar differences in rankings are notable
Routledge. for risk factors (see Annex C).
FIGURE 5: BURDEN OF DISEASE IN TAMIL NADU AND INDIA, 1990–2016 12 months were advised to quit
smoking; in comparison, in the
neighboring state of Karnataka,
80 percent of the smokers who
visited a doctor in the past
year were advised to stop
smoking. 13
Tamil Nadu has mixed public-

private provision of health
services and dual practice is
legal. Tamil Nadu is one of the
states with the highest levels
of human resources for health
relative to its population: there
are an estimated 1.6 physicians
as well as 4.1 nurses and
midwives per 1,000 population,
almost double the national
average of 0.8 physicians and
2.1 nurses and midwives per
1,000.14 There are approximately
71,000 government hospital
beds (1 per 1,000 population)
in the state, significantly higher
than the Indian average (0.5
beds per 10,000 population). 15
When asked where household
members went when they were
sick, almost two-thirds reported
using government facilities,
higher than the proportion on
average for India (Table 1). As
with the nationwide average,
the bottom 40 percent in
13 The prevalence of tobacco use among adults in Karnataka is

low—less than 30 percent of individuals 30 years 23 percent, slightly higher than in Tamil Nadu (20 percent); Tata
Institute of Social Sciences and Ministry of Health and Family
or older are screened annually for hypertension Welfare. 2017.Global Adult Tobacco Survey GATS 2 India
and diabetes and around 20 percent of women 2016–17. New Delhi: Government of India.
14 Ministry of Health and Family Welfare. 201N8a.tional Health
aged 30 years or older are screened for cervical Profile. New Delhi: Government of India.
and breast cancer. 12 Only slightly more than half 15 Number of hospital beds includes beds in primary care health
centers; reliable data on the total number of private hospital
of the smokers who visited a doctor in the past beds are not available; industry estimates indicate total beds
in India to be roughly 1 per 1,000 population. Ministry of Health
and Family Welfare. 2018.National Health Profile . New Delhi:
12 National Family Health Survey (NFHS-4) (2015–2016). Government of India.

Table 1: General utilization-related indicators
Where do people generally go for treatment when sick? (%)

Government Private
Tamil Nadu
Bottom 40% 82.7 17.1
Top 10% 20.5 79.3
All 63.3 36.5
India
Bottom 40% 48.1 46.3
Top 10% 27.7 71.3
All 44.9 51.7
Source: NFHS-4.
Tamil Nadu are far more likely—by a wide higher among the poor, whereas the share of NCDs
margin—to self-report utilization at government (such as cardiovascular diseases and cancer) was
facilities compared with the top 10 percent of the slightly higher among the rich. 18 Notably, public
population. 16 inpatient utilization rates were higher among the
poor versus richer quintiles in the state. Outpatient
Almost 6 percent of the population reported using utilization rates in Tamil Nadu are also double the
inpatient care services (excluding childbirth) national average, with the poorest quintiles more
in the previous year. As is commonly observed likely to use public facilities; richer people were far
globally, self-reported illnesses in the past 15 days more likely to use private facilities when seeking
were much higher among the rich relative to the outpatient care.
poor (Table 2).17 Although they are significantly
higher than the national average (3.7 percent), At less than 3 percent of the state’s economy,
inpatient care utilization rates vary significantly total expenditures on health are relatively low in
across economic quintiles: household survey data Tamil Nadu. Recent estimates indicate levels of per
estimates indicate that the poor had significantly capita spending of only about `4,101 (~US$57),
lower rates of hospitalization compared to the about 2.8 percent of the state’s economy. Health
rich. Infectious diseases (such as tuberculosis, spending has remained low despite increasing from
diarrhea, sexually transmitted infections, malaria, `1,703 (~US$24; 2.1 percent of the economy) a
diphtheria, and whooping cough) were the most decade earlier. Per capita health spending levels are
common reason for hospitalization, accounting for generally higher in the states of Kerala, Maharashtra,
almost a fourth of all admissions; this was followed Punjab, and Karnataka when compared with Tamil
by injuries and cardiovascular diseases. The share Nadu. This low level of spending on health is
of hospitalization related to infectious diseases was even more stark when compared to countries at
similar levels of income. In Ghana and Vietnam,
16 Among those not using government facilities in Tamil Nadu, the for example, total health spending was more than
most common reason given was that ‘waiting time was too long’
followed by ‘poor quality of care’, ‘no nearby facility’, and ‘facility 5 percent of the Gross Domestic Product (GDP).
timing not convenient’.
17 See: Tandon, A., C. J. L. Murray, J. A. Salomon, and G. King,
Globally, LMICs on average spend US$121 per
2003. “Statistical Models for Enhancing Cross-Population capita on health, about 5.4 percent of GDP (see
Comparability.” In Health Systems Performance Assessment:
Debates, Methods and Empiricism, edited by C. J. L. Murray and
D. B. Evans. Geneva: World Health Organization. 18 NSSO 71st round.
Table 2: Self-reported illness and utilization rates, Tamil Nadu versus India (%)
Tamil Nadu
India
Poorest Second Middle Fourth Richest All
Self-reported illness (last 15 days) 12.8 14.3 16.0 18.8 23.4 16.9 10.0
Outpatient (last 15 days) 11.3 12.6 13.4 17.0 22.6 15.2 8.4
Public 7.2 5.4 5.7 6.1 4.0 5.7 2.3
Private 4.9 8.1 8.8 12.6 20.2 10.7 6.7
Inpatient (last 365 days) 4.4 4.1 5.7 6.5 7.7 5.6 3.7
Public 2.3 2.2 2.0 2.1 1.1 1.9 1.5
Private 2.0 1.8 3.7 4.4 6.4 3.6 2.2
Source: National Sample Survey Office (NSSO) 71st round.
Annex D).19 Tamil FIGURE 6: PUBLIC FINANCING FOR HEALTH AS SHARE OF

Nadu’s attainment of GDP VERSUS INCOME
good health outcomes
is notable despite
relatively low levels of
financing for health.
OOP remains the

primary source of
financing for health
in Tamil Nadu. OOP
financing for health
accounted for 68
percent of total
health expenditures,
one of the highest
shares in the world,
comprising, in large
part, expenditures on
drugs and diagnostic
services.20 This was
followed by central
and state government Source: MOHFW and World Development Indicators.
expenditures,
accounting for 25 percent of total health increases in levels of health expenditures over the
expenditures. As in India, on average—despite last 10 years—the overall composition of health
financing has remained relatively unchanged in the
19 Tandon, A., J. Cain, C. Kurowski, and I. Postolovska. 2018.
“Intertemporal Dynamics of Public Financing for Universal Health state (for example, OOP was 70 percent of health
Coverage: Accounting for Fiscal Space Across Countries.” HNP expenditures in 2005). At less than 1 percent of the
Discussion Paper, World Bank, Washington, DC.
20 Tandon et al. 2018. state’s economy, public financing for health in Tamil

Table 3: Average OOP spending per hospitalization and outpatient visit in Tamil Nadu versus India (`)
Tamil Nadu
India
Poorest Second Middle Fourth Richest All
Outpatient 323 (11%) 347 (6%) 581(9%) 595 (8%) 730 (6%) 552 (8%) 721 (11%)
Public 137 (5%) 100 (2%) 127 (2%) 175 (2%) 189 (3%) 140 (3%) 557 (10%)
Private 677 (20%) 533(9%) 847 (13%) 769 (11%) 830 (7%) 763 (10%) 831 (12%)
Inpatient 9,545 (20%)11,491 (18%)14,846 (20%)19,789 (23%) 36,675(23%)20,397 (23%)20,381 (21%)
Public 2,067 (6%) 2,311 (6%) 2,686 (3%) 9,200 (3%) 5,372 (3%) 3,879 (5%) 8,615 (11%)
Private 18,213 (36%)22,215 (32%)21,175 (28%) 24,742(27%)42,056 (26%)29,047 (28%)27,674 (26%)
Note: In parenthesis: the average OOP spending as a share of total consumption expenditure. Those who did not utilized were excluded from
the mean. It is possible that an individual may have utilized both inpatient and outpatient services. In such cases, the expenditures for
inpatient and outpatient visits were calculated separately. Source: NSSO 71st round.
Source: NSSO 71st round.
Nadu is among the lowest in the world. Recent the availability of scarce resources for households
estimates indicate per capita public financing for to use toward more productive activities. In Tamil
health in the state to be `1,025 (~US$15), despite Nadu, the high levels of OOP result in almost a
having tripled in real per capita terms over the past quarter of households spending more than 10
decade, largely because of strong economic growth percent of consumption expenditure. 21 OOP
(Figure 6); public spending on health as a share payments encourage people to deter and delay
of GDP and as a share of the state government care, making it also an inefficient source of
expenditure has remained largely unchanged over financing for health because health problems are
the past 10–15 years. addressed later once they have advanced rather
than earlier when they can be prevented. OOP
Reducing OOP and improving financial financing also constrains the redistributive capacity
protection, especially for the poor and vulnerable, of health financing systems and reduces the ability
by increasing and effectively targeting public to implement pooled purchasing of health services
financing for health are key for making progress to reduce and control costs.
toward UHC. Household survey data estimates
indicate average OOP spending per hospitalization With this backdrop, CMCHIS was introduced
of `20,397 (~US$291): `3,879 (~US$55) for public by the state to provide quality health care and
and `29,047 (~US$415) for private (Table 3). Overall reduce financial hardship for poor and near-
OOP payments for inpatient care were similar in poor families. The stated objectives of CMCHIS
magnitude in the state to those in India; however, are to “…provide quality health care to eligible
OOP payments for outpatient utilization in the persons through empaneled government and
public sector tended to be much lower in Tamil private hospitals and to reduce the financial
Nadu. Interestingly, OOP payments for inpatient hardship for enrolled families and move towards
and outpatient care incurred in the public sector UHC by effectively linking with the public health
as share of total expenditure were also much lower system.” 22 As noted earlier, CMCHIS targets
in Tamil Nadu compared to the national average.
OOP financing connects access to ability to pay for 21 These numbers are likely to be inflated when compared with global
estimates as total household consumption was underestimated
services and is, therefore, inherently inequitable. in the 71st round of the NSSO.
OOP financing is a risk factor for impoverishment, 22 Government of Tamil Nadu. 2017. Tender Document to
Select Insurance Company to Implement: Chief Minister’s
pushing households into poverty while reducing Comprehensive Health Insurance Scheme.
poor and near-poor families and provides them FIGURE 7: ORGANIZATIONAL FRAMEWORK FOR
with noncontributory ‘cashless’ coverage—that CMCHIS
is, coverage without any beneficiary premium or
co-payments—for an explicitly defined inpatient-
focused benefits package in the government and
empaneled private hospitals. The Tamil Nadu
Health Systems Project (TNHSP), a registered
society under the purview of the state’s health
department that was initially set up to implement
a World Bank project, is the scheme-administering
agency for CMCHIS. From 2009–2012, the
scheme—referred to then as the Chief Minister
Kalaignar’s Insurance Scheme for Life Saving
Treatments—contracted a private insurance
company for implementation. In 2012, the name of
the scheme was changed to CMCHIS and a public
sector insurance company — the United India
Insurance Company Limited—was contracted. 23
The public sector insurance company, in turn, has
contracted three Third-Party Administrators (TPAs):
Vidal Health Insurance TPA, Mediassist Health
Insurance TPA Private Limited, and MDIndia
Health Insurance TPA Private Limited (Figure 7).24 and assurance models (the latter modality is
Settlement of claims to providers is managed by one where there is a public purchasing agency
the insurance company and the TPAs; however, that purchases services directly from providers;
settlements for selected high-end procedures the former modality uses an insurance company as
over and above an augmented beneficiary cap intermediary to purchase services from providers).
are paid for by the scheme-administering agency
directly to providers from a corpus fund which Additional details regarding the architecture
sets aside 27 percent of reimbursements to of CMCHIS are provided under five different
government hospitals. In doing so, CMCHIS can be subheadings: covering people, defining benefits,
characterized as having a ‘mixed’ implementation managing money, improving supply, and
modality—that is, a combination of both insurance strengthening accountability.
23 United India Insurance Company Limited is a public general

insurance company headquartered in Chennai.
24 All three TPAs are licensed by India’s Insurance Regulatory and
Development Authority (IRDA).

3. COVERING PEOPLE
CMCHIS targets families whose annual income they are not denied coverage even if they do not
is below `72,000 (~US$1,029). In addition, have Aadhar linking in the scheme’s database. In
irrespective of income, families who are members other terms, this requirement is for financing of the
of 26 welfare boards constituted by the state scheme but not for determining entitlement: the
government including agriculture, construction, onus is on the insurer to ensure Aadhar linking, not
manual laborers, auto rickshaw drivers, artists, the beneficiary. 25
goldsmiths, tribal persons, differently abled
persons, orphans, and refugees from Sri Lanka Administrative data indicate that the scheme
are also eligible for coverage under the scheme. provides coverage to more than half of Tamil
Families must procure an income certificate from Nadu’s population. A total of 15.7 million
the Village Administrative Officer (VAO) or from families are currently enrolled under the scheme,
revenue authorities along with a family ration more than half the total number of estimated
card to enroll in the scheme. VAOs generally have families in the state; of these, to date, 14.7 million
knowledge and awareness on the eligibility of people have also beenAadhar linked. Initially, in 2012,
dwelling in the village and their backgrounds. For almost 13.4 million families were enrolled in the
those families who are members of eligible welfare scheme; this number rose to over 15 million in
boards, membership cards must be produced at 2016 (Figure 8). Of all enrolled, two-thirds are
the time of enrollment. Migrants from other states estimated to be those living below the income
who are certified by the Labour Department that threshold of `72,000 per year; an additional 5
they have resided in the state for more than six million families are members of the agricultural
months are also eligible for coverage. At the time welfare board; the remaining 100,000 or so
of enrollment, details shared by the beneficiary are families are Sri Lankan refugees and members
verified with the database of the Food and Civil of other welfare boards. The total number of
Supplies Department. As of 2017 A,adhar card individuals —as opposed to families—covered is
linking is also required and premiums are paid to not known precisely; the average family size is
the insurance company based on the number of estimated under the scheme to be 2.7, implying
families whose enrollment in the scheme has also 25 Aadhar is the unique 12-digit identity number that can be
been Aadhar linked for at least one member of the obtained by all residents of India based on their biometric and
demographic information; as of July 2018, the government has
family. Nevertheless, as long as a family is eligible, issued an estimated 1.2 billion Aadhaar cards.
FIGURE 8: CMCHIS ENROLLMENT TRENDS, 2012–2018 The unit for CMCHIS eligibility
and enrollment is the family and
not the household. Coverage is
extended to the head of the family,
the legal spouse, dependent parents,
and dependent children (the latter if
they are unemployed, unmarried, or
below the age of 25, whichever is
earlier) as long as they are listed on
the family ration card. 26 Children who
are employed, married, or above
the age of 25 are not considered
dependents and must demonstrate
income eligibility and register
separately under the scheme as a
different family (even if they continue
to live in the same household). There
Source: CMCHIS
are no restrictions or caps on family
size, but—as explained later— the
FIGURE 9: DISTRIBUTION OF ENROLLED FAMILIES BY
annual coverage expenditure cap
DISTRICT, 2018
of `100,000 (~US$1,429) and up to
`200,000 (~US$2,858) for certain
specified procedures is determined
at the family level and is the same
regardless of family size.
Enrollment awareness under

the scheme happens through
information and education
campaigns and during monthly
outreach camps. The insurer
is responsible for awareness
generation activities, in consultation
with the scheme-administering
agency, and is incentivized to do so
given that each newAadhar-linked
enrolled family implies additional
premium transfers. Monthly health
camps, mandated for private
Source: CMCHIS
providers, are another important
part of raising awareness regarding
coverage for approximately 42 million individuals,
the scheme; the providers have an incentive to
more than half of Tamil Nadu’s current estimated
population. The distribution of enrollees across
26 This is how most government-sponsored health insurance
the state varies (Figure 9 and Annex E). schemes have implemented their coverage.
Chapter 3: Covering People 13

FIGURE 10: SPECIMEN OF CMCHIS ‘SMART CARD’
hold these camps for demand generation. 27 These selected biometric information (Figure 10). 29
health camps are also meant to provide free The card also clearly displays a number of a call
basic primary care services to attract attendance center, which is run by TPAs, that provides 24/7
by beneficiaries, in addition to identifying and access to information and grievance redressal
referring cases for hospitalization. In addition to services regarding the scheme. CMCHIS allows
health camps, some beneficiaries have reported for beneficiaries to download an e-card from
finding out about the scheme from Village Health the public portal of the scheme, searching the
Nurse (VHN). From a purely financial perspective, scheme’s online database using their family
both the insurer and provider have incentives to card number, name, village, district, and taluk
‘cream-skim’—that is, select beneficiaries who are (that is, subdistrict). The smart card also allows
at low risk for utilization (for insurers) and to select beneficiaries (and their providers) to access their
beneficiaries for high-margin procedures (for medical history and claims records online.
providers)—but there is no evidence to suggest
that this is happening under the scheme. Only a Recent survey estimates confirm administrative
relatively small number of new enrollees appear to data of CMCHIS coverage numbers. 30 Household
have been adversely selected, that is, they enrolled survey data estimates indicate 57 percent of all
just before seeking care. Despite efforts and household reporting coverage under CMCHIS,
improvements, awareness in the population about similar to the estimated coverage numbers from
eligibility and exact nature of benefit entitlements CMCHIS administrative data. This number rises
remains an ongoing challenge. 28 to 64 percent when other schemes—including the
Employee State Insurance Scheme (ESIS) and the
On enrollment, beneficiaries are provided with Central Government Health Scheme (CGHS)—are
a ‘smart card’. The card has a microprocessor included (compared to 29 percent nationally).
chip displaying a photograph of the beneficiary Based on economic deciles estimated from
family, a unique identification number that is linked household asset ownership, CMCHIS coverage
to the family’s ration card, and—in some cases— was generally higher among lower economic
27 Some government facilities also participate in these camps, 29 Even if family members are not listed in the CMCHIS database,
although it is not mandatory for them to do so. as long as other proof of family identification can be provided,
28 Karan, A., A. Chakraborti, H. Matela, et al. 2017. Process Evaluation they are eligible to receive treatment.
Report: Chief Minister's Comprehensive Health Insurance Scheme, 30 This number is based on NFHS-4 which was conducted in 2015–
Tamil Nadu. New Delhi: Public Health Foundation of India. 2016; estimates from the NSSO 71st round in 2014 are lower.
deciles (Figure 11).31 Less than 2 percent of relatively wealthy in India, so large-scale
CMCHIS card-holders reported owning a car and mistargeting does not appear to be an issue.
having an air conditioner, two markers of being
FIGURE 11: HOUSEHOLD SURVEY DATA ESTIMATES OF HEALTH INSURANCE/SCHEME

COVERAGE BY ECONOMIC DECILES
31 Economic deciles are derived based on ownership of assets

including mattress, color television, Internet, computer, washing
machine, car/tractor, and air conditioner.
4. DEFINING BENEFITS
The CMCHIS benefits package emphasizes committee to determine procedure package rates.
coverage for hospitalization for secondary It is usually benchmarked against market prices
and tertiary care. The scheme’s benefits have and other government health schemes.
evolved over time. Pre-2012, under Phase I of
the scheme, 647 procedures under 14 specialties Most providers where beneficiaries can avail
were covered and the beneficiary cap was benefits are in the private sector. Currently,
600 private facilities are empaneled under the
`100,000 (~US$1,429) per family over the course
scheme along with 225 government providers,
of four years. From 2012–2016, under Phase II of
and coverage is portable in that beneficiaries
the scheme, the number of procedures covered
can go to any empaneled government or private
almost doubled: high-end procedures including
provider within the state that offers a given
implantation surgeries and organ transplantation
procedure. 32 An Empanelment and Disciplinary
(such as renal, liver, and cochlear surgeries) were
Committee (EDC) is responsible for empanelment
included, as were a number of diagnostic and
of providers; all government hospitals—including
follow-up procedures. In addition, the beneficiary
a few Community Health Centers (CHCs)—are
cap was raised to`100,000 (~US$1,429) and up
included in the scheme. The number of empaneled
to `200,000 (~US$2,858) for certain procedures
private facilities is capped with adjustments made
per family per year. Restrictions were added such
over time, allowing for volume gains to be realized
that, to prevent abuse, some procedures such as
for those empaneled; there is usually a waiting
hearing aids and hip/knee replacements could only
list of private facilities wanting to be empaneled
be availed of in government hospitals or by using
under the scheme. Government and empaneled
government referrals. Post 2017, under Phase III of
private facilities had a combined number of beds
the scheme, additional procedures such as heart
exceeding 120,000—2.6 beds per 1,000 enrolled
and lung transplantations have been added and
under CMCHIS—with almost two-thirds in the
the number of diagnostic and follow-up procedures
private sector. However, there are wide variations
have been expanded (Table 4). The addition and
across districts, both in terms of number of facilities,
amendment of benefits over time appears to
have been done based largely on demand and 32 Reliable information on the number of private facilities in the
state is not available; estimates suggest about one-fifth of eligible
supply considerations. CMCHIS has an in-house private providers are empaneled under the scheme.
Table 4: Evolution of the CMCHIS benefits package over time
Benefits Package Pre-2012 2012–2016a Post–2017b

Secondary/tertiary care
Total number of procedures 647 1,016 1,027
Procedures reserved for government facilities 56 86
Number of specialties 14 33 43
High-end tertiary 5 8
Follow-up
Number of procedures 113 154
Diagnostic 23 38
Coverage cap per family `100,000every `100,000 per year `100,000 per year
4 years
Notes: a. High-end tertiary and follow-up procedures had a higher annual cap of 150,000.
b. Follow-up procedures had a higher annual cap of `200,000 per family per year; high-end tertiary procedures include renal, liver,
lung, heart, bone marrow/stem cell transplants, and cochlear and auditory brain stem implants and are financed on a case-by-
case basis from a corpus fund once the beneficiary cap of `200,000 is exhausted; although the tender document states that 158
procedures are reserved for government facilities, in reality only 86 are reserved.
beds, and the government-private split of providers Diagnostic procedures can also be availed of
where benefits can be availed. The districts of at private outpatient facilities. The 38 diagnostic
Viluppuram, Tiruvannamalai, Ariyalur, and the procedures—including metabolic screening,
Nilgiris had generally the lowest numbers of facilities Magnetic Resonance Imaging (MRI), and
available for the scheme, less than 1 bed per 1,000 mammograms—can also be availed at 238 private
enrolled population. Ariyalur, Nagapattinam, diagnostic facilities but only if these procedures are
Ramanathapuram, and the Nilgiris had some of referred by a government hospital (see Annex G
the lowest penetration rates of empaneled private for distribution of private diagnostic facilities by
facilities in the state (see Annex F). district); these diagnostic procedures are covered
even if they do not lead to hospitalization, and
Given the relatively large scope of benefits in these are separate from diagnostic procedures
the CMCHIS package, not all procedures and that are included as part of hospitalization. 33
specialties can be availed of at all government Follow-up coverage, subject to a higher annual
and empaneled private facilities. Some cap of `200,000, is provided from the sixth day up
empaneled private providers are single-specialty to a post-discharge period of one year—including
facilities, for example, only for ophthalmology, for consultations, follow-up investigations, and
orthopedics, genitourinary surgery, oncology, and medicines—for 154 procedures. Pre-existing
nephrology, among others. Among multispecialty conditions are covered, and coverage begins on
providers, 183 government and private facilities the day of premium payment.
provide a maximum of packages across 10
specialties and 8 high-end procedures (see About 3 percent of all enrolled families utilized
Annex G). It is notable that several big corporate CMCHIS benefits in 2017. In absolute numbers,
hospital chains—for example, Apollo, Fortis,
Madras Institute of Orthopedics and Traumatology 33 In 2017, over three-fourths of the 160,941 diagnostics claims
(MIOT), and Manipal—are also empaneled under did not lead to hospitalization; the rates of conversion to
hospitalization were slightly higher at government than in private
the scheme. facilities.

FIGURE 12: UTILIZATION-RELATED TRENDS, 2012–2017
Source: CMCHIS
this represented utilization of benefits by a total utilization rate under CMCHIS is comparable
of 403,890 families (a little under 1 percent of the in magnitude to other government-sponsored
total enrolled population) and overall processing schemes across India. 35
of 641,000 unique claims. This was more than
three times the volume of utilization and claims in District-level variations in CMCHIS utilization
2012 (Figure 12). On average, claim volumes have rates were notable, including in terms of the
increased steadily by about 13 percent every year government-private split and the share of families
following an initial big jump of 77 percent over utilizing out-of-district services. Districts such as
2012–2013; some of the increase in the utilization Kanyakumari and Chennai had some of the highest
rate in 2017 is due to expansion of the benefits utilization rates under the scheme: more than 4.5
package described earlier. Despite the relatively percent of enrolled families used it in 2017; in the
large number of empaneled private facilities and Nilgiris, on the other hand, less than 2 percent used
beds under the scheme, more than half of all
35 Utilization rates under selected government-sponsored health
utilization occurred in government facilities (partly insurance schemes in India: 2 percent under Karnataka’s
also because some packages are reserved for Yeshavini Cooperative Farmers Health Scheme and <1 percent
under Vajpayee Arogyashri Scheme; 2.5 percent under Rashtriya
government facilities). 34 In general, the claims Swasthya Bima Yojana (RSBY); <1 percent under Andhra
Pradesh’s Rajiv Aarogyasri Community Health Insurance
34 As expected, given the relatively low rates of utilization and program; and <1 percent under Himachal Pradesh’s RSBY Plus.
the nature of the benefits package, about 13.1 million (slightly Utilization rates were calculated using data from:La Forgia, G.,
less than 85 percent of all enrolled families) have not yet used and S. Nagpal. 2012. Government-Sponsored Health Insurance
CMCHIS benefits. in India: Are You Covered? Washington, DC: World Bank.
FIGURE 13: CLAIM VOLUME SHARES IN GOVERNMENT VERSUS PRIVA
TE FACILITIES, 2017
Source: CMCHIS
the scheme. Chennai had the highest utilization and medical oncology. Other specialties such as
rate in government hospitals, whereas Theni’s orthopedic trauma, genitourinary surgery, general
private utilization rates were the highest in the state surgery, general medicine, and neonatology
(see Annex H). About 40 percent of families used each accounted for less than 3–5 percent of
the scheme in districts other than the ones they the total claim volume in 2017, the first full year
were officially residing in. As expected, some of the when the latest iteration of the benefits package
districts with the lowest out-of-district utilization was implemented. 36 Annex I summarizes family
rates were those that had relatively good supply utilization rates by specialty across districts. One
of services: Chennai, Coimbatore, Kanyakumari, to of the biggest differences between the share of
name a few. In districts with relatively poorer supply claims volume between the government versus
of hospitals such as Tiruvallur and Ariyalur, more empaneled private providers was in nephrology
than three-quarters of utilization occurred outside (which includes dialysis, with each visit counting
of the district (see Annex H). as a different claim). It was the largest share
More than half the number of claims volume
36 Note: this refers to the volume of claims and not the value of
under CMCHIS is from diagnostics, nephrology, claims; the latter is discussed in a subsequent subsection.

of the volume of claims for private providers, radiation oncology, and interventional cardiology
followed by diagnostics. Among public providers, (Figure 13). Claims utilization varied by age and
the largest volume of claims was diagnostics, sex of beneficiary. Claims peaked among those
followed by medical oncology. Neonatology; Ear, who were 51–60 years old for men and 41–50
Nose, Throat (ENT); general medicine; cardiology; years for women. Surprisingly, across all age
and hepatology appear among the top 10 in categories, claims volumes were much lower for
government facilities. The top 10 claims volume female beneficiaries than for male beneficiaries
among private providers included genitourinary (see Annex J).37
surgery, cardiothoracic surgery, ophthalmology,
37 There are a range of factors—for example, health-seeking

behavior, benefit design, disease pattern— that might explain
higher utilization and spending among men. In developed
countries, on average, women account for higher health spending
than men; while overall health spending is skewed toward
women, men tend to account for higher proportion of spending
on hospital care. OECD (Organisation for Economic Co-operation
and Development). 2016. Focus on Health Spending: Expenditure
by Disease and Gender. Paris: OECD.
5. MANAGING MONEY
CMCHIS is financed entirely from own-state incentive to enroll as many families as possible
general government revenues. The state while reducing unnecessary utilization of benefits.
government pays a ‘premium’ on behalf of enrolled However, profit and loss stipulations are tightly
families to the insurer out of general government regulated. Premium payments are front-loaded
revenues (that is, there was no earmarked tax for with a stop-loss provision. It was agreed that
financing the scheme): this per-family premium 95 percent of the premiums would be advanced
rate was `469 (~US$6.70) pre-2012, `497 at the beginning of the year with the remaining
(~US$7.10) over 2012–2016, and`699 (~US$10) 5 percent paid at the end of the year, removing a
thereafter.38 Although the benefits packages are key source of uncertainty for the insurer. 40 If the
not strictly comparable, government-subsidized claims ratio—that is, the ratio of claim payments
premium payments for the poor and near-poor to total premiums received—goes above
families in other countries running similar schemes 110 percent, 50 percent of the loss amount above
were notably higher—ranging from US$22 in 110 percent is shared equally between the insurer
the Philippines, US$62 in Vietnam, to US$77 and the scheme-administering agency, that is,
in Indonesia; in each of these countries, most there is sharing of financial risk of larger losses
inpatient care is included in the benefits package to accord some degree of financial protection
as is outpatient primary care. for the insurer. On the flip side, if the claims ratio
falls below 90 percent, the insurance company is
The contract period with the insurer has obligated to return a proportion of this amount to
typically been four years, with the possibility the scheme-administering agency.
of a one-year extension. 39 As such, with such
an arrangement, the insurer has a financial Preauthorization and final claims settlement
are conducted by three TP As contracted by
38 Assuming an average family size of 2.7, this implies an implicit
premium of `258.89 (~US$3.70) per capita; in addition to the 40 Section 64VB of the Insurance Act 1938 requires advance payment
per-family premium payment, the state government also pays of premium to the insurer. However, in most government health
service tax to the insurer which has not been factored into the insurance schemes, premiums are paid in quarterly installments.
calculations. Often, a situation arose where the claims exceeded the quarterly
39 Most state schemes do not have long-term pricing contracts with premium installment creating a cash flow deficit with the insurer,
insurers; most contracts are annual. La Forgia, G., and S. Nagpal. which delayed claims settlement. Tamil Nadu became the first
2012. Government-Sponsored Health Insurance in India: Are You state to recognize this problem and initiated advance payment of
Covered? Washington, DC: World Bank. 95 percent premium.

FIGURE 14: TPA DISTRICT ASSIGNMENTS, 2012–2015 (LEFT) VERSUS CURRENT (RIGHT)
Source: CMCHIS
the insurer. Each of the three TPAs—MD India, insurance coordinator who serves as the first point
Mediassist, and Vidal—has responsibility for of contact for beneficiaries when they seek care.
designated districts within the state, and district
TPA assignments are rotated over time (Figure 14 Providers are paid on a bundled case basis.
shows the assignments for 2012–2015 versus Package reimbursement rates were fixed ex
current). At present, Vidal has 14 districts covering ante by the scheme-administering agency; they
5.8 million families, Mediassist covers 10 districts were the same for both government and private
with 4.5 million families, and MD India covers hospitals and were set based on previous rates,
8 districts with 4.1 million families. All claims consultation with experts as well as stakeholders,
are subject to preauthorization and claims need and were supposedly reflective of adjustments for
to be settled within seven days of their receipt; inflation. 41 Analysis of morbidity and mortality data
more than 95 percent of claims are indeed settled was also conducted to estimate the incidence rate
within seven days of receipt under the scheme. of different conditions and to help arrive at tariffs.
The insurer/TPAs employ a team of project Nevertheless, as with many other schemes in India
officers, vigilance officers, and medical officers as well as globally, many private providers are of
at the district level to oversee implementation. In 41 As discussed subsequently, payment rates for private facilities
addition, each of the empaneled hospitals has an varied depending on hospital supply-side readiness.
Table 5: Market price versus CMCHIS tariffs in selected private facilities for tracer interventions
Package Private hospital A Private hospital B Private hospital C CMCHIS tariff
Maintenance hemodialysis for 27,200 12,000 10,400 8,000

chronic renal failurea
Surgical correction of long-bone 300,000 80,000 100,000 22, 250
fracture
Percutaneous transluminal 250,000 150,000 135,000 63.000
coronary angioplasty b
Ureterorenoscopic lithotripsy 80,000 70,000 35,000 22,000
Total knee replacement 200,000 1,60,000 90,000 65,000
Coronary bypass surgery 250,000 225,000 225,000 90,000C
Note: a. Eight dialysis including seropositive; b. With stent; c. range 90,000-116,000.
the view that the tariffs are low and do not cover diagnostics and follow-up procedures generally
the full cost of providing care. 42 As can be seen had the lowest tariffs. In general, over 90 percent
in Table 5, CMCHIS tariffs for many packages of procedures had tariffs lower than `100,000
are significantly lower than the market prices for (~US$1,429). Tariffs were meant to cover (as
the same packages in private facilities. The flip needed) bed charges in a general ward, nursing
side of this argument is that the providers need and boarding charges, surgeons and anesthetists,
to view this as reimbursements of marginal costs medical practitioners, consultant fees, anesthesia,
and as a shift from a ‘low-volume high-margin’ to blood, oxygen, operating theater charges, cost of
a ‘high-volume low-margin’ regime. To date, there surgical appliances, medicines and drugs, cost of
have been no systematic assessments of private prosthetic devices, implants, x-rays and diagnostic
providers to assess the impact of the scheme on tests, follow-up medicines, and food. Beneficiaries
facility-level financial performance. The fact that a were paid a nominal amount—to cover public
large majority of private providers have remained transport costs—when using care; this amount
empaneled with the scheme—and there is a waiting was subsumed under the package rate and was
list of others wanting to join—is indicative that given to beneficiaries by providers. Diagnostics up
participation in the scheme has been beneficial, to one day before admission and five days post-
either financially or otherwise. 43 discharge were also covered under the scheme;
diagnostic procedures require prescription
The average tariff across all procedures was by a doctor at a government hospital and are
about `30,000 (~US$429). Surgical procedures reimbursed separately even if they do not lead to
had the highest average tariffs (~`35,000; admission. Multiple procedures during the same
US$500), followed by medical procedures admission have tiered payments: 100 percent for
(~`22,000; US$314) and diagnostics (~`4,000; the first diagnosis, 50 percent for the second, and
US$57). Bariatric surgery and hematology 25 percent for the third.
were the specialties with the highest tariffs;
In 2017, aggregate CMCHIS outlays amounted
42 Karan et al. (2017).
43 In some cases, private providers appear to have appealed to to `8.6 billion (~US$122.4 million). These outlays
additional philanthropic sources to augment revenues, using represented about 8 percent of the state’s overall
empanelment with CMCHIS as a signal of corporate social
responsibility. health spending, 0.4 percent of the state’s overall

a
Table 6: Key financing indicators for CMCHIS, 2009–2017
2009–2011b 2012 2013 2014 2015 2016 2017c

Premium per family (`) 469 497 497 497 497 497 699
Number of families (millions) 12.9 12.9 13.0 13.9 15.4 15.7 14.2
Amount transferred to insurer 11.7 6.4 6.4 6.6 7.6 7.8 8.6
(`,billions)
Share of state health expenditure (%) 16 13 11 9 9 9 8
Share of state government 0.8 0.6 0.5 0.4 0.5 0.4 0.4
expenditure (%)
Share of state GDP (%) 0.1 0.1 0.1 0.1 0.1 0.1 0.1
Health share of state government 5.0 5.0 5.0 5.0 5.0 4.0 5.0
expenditure (%)
Note: a. For the ratios, calculations are based on calendar year 2012 corresponding to fiscal year 2012–2013 and so on for each of the
following years.
b. This period is pre-CMCHIS, when the scheme was referred to as the Chief Minister Kalaignar’s Insurance Scheme for Life Saving
Treatments and contracted a private insurance provider for implementation.
c. As mentioned earlier, as of 2017, premiums have been paid only for the number of families that have also been Aadhar seeded: this
number totaled 13.4 million families (an estimated 36.2 million beneficiaries).
expenditure, and 0.1 percent FIGURE 15: HEALTH FINANCING FLOWS IN TAMIL NADU45
of the GSDP (Table 6).44
CMCHIS resources remain
a relatively small 2 percent
share of the overall
resources in Tamil Nadu’s
health financing system as
summarized in Figure 15.
The average claim amount
across all procedures was
about `25,000 (~US$357).
The average value of a claim
was higher in private versus
government facilities. Across
all specialties, government
facility claims averaged
`11,490 (~US$164) in 2017
and the corresponding
number for private facilities
was `16,340 (~US$233). In
44 The numbers do not exactly match

the premium rate times the number
of families because of pro-rated and
other minor adjustments.
45 The overall health financing picture for
Tamil Nadu is similar to that of India
on average.
mirroring tariffs, claims amounts were highest for cardiothoracic surgeries that accounted for the
surgical procedures (`37,502; US$536), followed largest share of claims among private providers.
by medical procedures (`12,792; US$183) and Nephrology and interventional cardiology were
diagnostics (`2,253; US$32). more prominent shares of claims among private
providers as opposed to government facilities.
Although diagnostics constituted the largest General surgery and diagnostics was a higher
share of the volume of claims, cardiothoracic share among government providers versus
surgeries claim the largest share in terms of the private ones. Time series analysis of claims over
value of claims. Other specialties that accounted 2014–2016 indicate that—although there was an
for more than 5 percent of the total claims value increase in claims value across all specialties, an
in 2017 included orthopedic trauma, nephrology, increase annually of about 6 percent—greater than
interventional cardiology, genitourinary surgery, 10 percent increases were evident for diagnostics
and general surgery. As with claim volumes, and nephrology across both government and
claim value differences are notable between private facilities; for cardiology, neurosurgery,
government and private providers (Figure 16): and orthopedic trauma in government facilities;
whereas orthopedic trauma was the largest value and for cardiothoracic surgery in private
share of claims among government facilities, it was facilities (Table 7).
FIGURE 16: CLAIM VALUE SHARES IN GOVERNMENT VERSUS PRIVA

TE FACILITIES, 2017
Source: CMCHIS

Table 7: Specialties with large changes in claim value, 2014–2016
Specialties with > 10% increase in claims value, 2014–2016

Government Private All
Diagnostics Diagnostics Diagnostics
Nephrology Nephrology Nephrology
Cardiology Cardiothoracic surgery Cardiology
Neurosurgery Cardiothoracic surgery
Orthopedic trauma
In some cases, reimbursements are lower than to-claims ratio—the difference between what the
those paid for OOP by patients who are not hospital claimed versus what was reimbursed by
covered by CMCHIS in private facilities. There the scheme (following validation)—was 66 percent
are concerns that scheme reimbursements are in 2017–2018: 78 percent for private hospitals and
low relative to the ‘market price’ for many of the only 51 percent for government facilities. There
packages; crude analysis of household data does is some volatility in the month-to-month paid-to-
suggest this to be so for some cases, although claims ratio, especially for government facilities
this is to be expected given CMCHIS’ monopsony and for medical claims, less so for surgical claims.
power. For example, using latest NSSO data, the The ratio seems to dip for the months of January
average OOP payment for heart disease (surgical) and February—toward the end and beginning of
was reported to be `132,125; the tariff for the same new year of the scheme, respectively—due to
ranged from `4,100 to `200,000 with average reconciliation of claims (Figure 17).46 A relatively
claims paid amounting to `86,611: 35 percent small number (4,304; less than 1 percent) of all
lower (Table 8). A similar lower magnitude was claims were rejected in 2017: two-thirds of claim
observed for accidental injury (surgical) compared rejections were from government facilities and the
with average claims for orthopedic trauma. On the remainder from empaneled private facilities.
other hand, for gastric and peptic ulcer (surgical),
the reported OOP payment amounts at private With claims ratios in recent years ranging
facilities were comparable to the average claims between 100 percent and 110 percent, the
paid under CMCHIS for gastroenterology surgery. scheme is operating at the edge. Since 2012, the
claims ratio under CMCHIS has never exceeded
On average, two-thirds of what was claimed 110 percent; in 2017, the claims ratio was 102
was paid out, and this ratio was higher for percent, indicating a small loss for the insurance
private versus government hospitals. The paid- company even before factoring in administrative
Table 8: Comparing OOP payments in Tamil Nadu with claim reimbursements for selected interventions (`)
Category for inpatient admission OOP at private CMCHIS package Average claim
Heart disease (surgical) 132,125 Cardiothoracic surgery 86,611
Gastric and peptic ulcer (surgical) 36,707 Gastroenterology surgery 36,108
Accidental injury (surgical) 51,730 Orthopedic trauma 38,297
Source: NSSO 71st round.
46 The increase in March–April for medical claims for government
facilities is due to payment of backed-up and pending
reimbursements.
FIGURE 17: PAID-VERSUS-CLAIMS RATIO, 2017–2018 costs. A slight increase
in utilization rate could
be catastrophic for the
scheme: for example,
at current average claim
levels, an increase in family
utilization—say from a
current rate of 3 percent
to 3.25 percent—would
increase the claims ratio to
110 percent.
CMCHIS is ‘cashless’
in that there are no
beneficiary co-payments
until the annual family cap
is reached. Any amount
under the annual cap that
is not used by any family
member by the end of the
year cannot be carried over
to the following year. Once
the annual family cap is
reached, the beneficiary
must bear the full cost
of coverage until the end
of the year. Annually, a
relatively small proportion—
about 2–3 percent of
those families that use the
scheme—reached the cap
of `100,000: for example,
only almost 12,000 families
reached this cap in 2017,
80 percent of which did
so while availing benefits
from private providers; only
Source: CMCHIS
998 families exceeded the
higher cap of `200,000 (~US$2,857). Although there is no widespread reporting of balanced billing by
providers even when the beneficiary cap has not been reached, there are sporadic reports that this is
occurring to some extent but not being captured through normal grievance mechanisms.
CMCHIS was mandated to create a corpus fund to help needy beneficiaries. The corpus fund
was used for beneficiary payments over the cap, for example, when coverage amounts exceeded the

beneficiary cap of `200,000 for selected high-end Under CMCHIS, the insurer reimburses up to
procedures. Payments over this capped limit are `200,000 for these selected procedures; any
made from a corpus fund on a case-by-case basis amount above this is paid for directly to the
by the scheme-administering agency directly. All provider by the scheme-administering agency
government hospitals are required to set aside 27 making CMCHIS a ‘mixed’ model in using both the
percent of the value of claims for this corpus fund. insurance and assurance modality. The number of
These funds cover top-up reimbursements for high-end claims handled through the assurance
liver transplantation, renal transplantation, bone mode is low: only 1,213 high-end procedure claims
marrow transplantation, cochlear implantation, were reimbursed in 2017 for a total amount of `0.3
stem cell transplantation, heart transplantation, trillion (~US$3.3 million), less than 3 percent of the
lung transplantation, combined transplantation total amount reimbursed by the insurer in the same
procedures, and auditory brainstem implantation. year (Figure 18).
FIGURE 18: VOLUME AND VALUE OF HIGH-END PROCEDURES, 2012–2017
Source: CMCHIS
6. IMPROVING SUPPLY
Elements of CMCHIS have been consciously as part of implementation of UHC schemes. Some
designed to instigate supply-side improvements. of these elements for improving supply are also
Across countries, UHC schemes are often designed notable under CMCHIS.
and implemented in ways to serve as instruments
not only to improve access and financial CMCHIS, by empaneling private providers in
protection but also to nudge reforms in health care addition to government hospitals, expands
provision. 47 For example, flexibility to retain and access of health services for the poor and
use demand-side scheme reimbursement funds vulnerable. Almost all government-sponsored
for salary incentives, infrastructure improvements, health insurance schemes in India have empaneled
operating costs, and to bypass traditional public private providers, so this is not unique to CMCHIS.
financial management rigidities in public systems Hospitals under the scheme are required to have a
have been noted in many countries. In Thailand, minimum of 30 beds; in addition, they need to be
additional funds from the UHC scheme have equipped with a microbiologically-safe operation
been used to hire contractual staff in hospitals theater and have minimum staffing levels of
to cope with additional demand without violating doctors, nurses, and other human resources to
the government’s zero-growth policy for civil be eligible under the scheme. 48 CMCHIS’ contract
servants. In Argentina’s Plan Nacer Program that with the insurer requires the latter to make sure
provided coverage for maternal and child services that a minimum number of private providers are
to vulnerable groups, reimbursements to facilities empaneled. In the district of Chennai, the insurer
from the insurer have been retained to provide staff is required to empanel a minimum of 50 private
incentives. In addition, insurance schemes have hospitals, 30 each in districts of Coimbatore and
actively been used to integrate private provision Madurai, and 10 each in other districts of the
to help ease the burden on government providers. state. The EDC is charged with the process of
Other supply-side improvements—for example, empanelment and de-empanelment for private
through use of accreditation for empanelment and providers. 49 Some facilities in neighboring states are
requirements for tightening referral chains—have
48 In some cases, exemptions may be given, for example, for single-
also been used as mechanisms to improve supply specialty hospitals and for those serving remote communities.
49 The EDC is composed of officials from the Tamil Nadu Health
47 Cotlear et al. 2015. Systems Project and United India Insurance Company Limited.

also empaneled. For example, 13 private hospitals private facilities in the state are not empaneled
in neighboring states and union territory—3 in under the scheme; they either do not meet the
Karnataka, 4 in Kerala, 1 in Andhra Pradesh, and minimum standards, do not offer packages offered
12 in Pondicherry—are also empaneled under the under CMCHIS, or have chosen not to empanel
scheme as in some cases these may be closer to because the reimbursements are too low. About
beneficiaries than in-state facilities. These out-of- 40 percent of empaneled private facilities reported
state private hospitals have the same tariffs and having initiated operations less than 10 years
other stipulations to provider coverage under the ago—about the time the scheme was launched in
scheme. In addition, beneficiaries have access to 2009—and 15 percent began operations less than
238 in-state private diagnostic outpatient services, 5 years ago (Figure 20). Clearly, a lot of new private
although the distribution of these facilities varies hospitals have entered Tamil Nadu’s health sector;
widely across the state; more than 15 such facilities however, without additional follow-up research, it
are empaneled in districts such as Chennai, is not possible to assess to what extent market
Madurai, and Kanyakumari but only one each was entry of new private providers was a direct result
empaneled in the districts of Ariyalur, Perambalur, of CMCHIS.
and Thiruvannamalai.
Some facilities only provide coverage for a
What sets CMCHIS apart from many other subset of benefits in the package, and the entire
schemes is that private providers are mandated benefits package is not available at all facilities.
to hold monthly outreach camps that provide Nevertheless, many of the same benefits can be
free primary care services. Government facilities availed of at multiple providers —both government
are also encouraged to hold these monthly camps and private—which introduces an element of
but are not mandated to do so. These monthly choice for beneficiaries and of competition among
camps also provide information and education providers, although the impact of the latter on
about the scheme and help identify potential provider behavior and outcomes has not been
candidates for hospitalization. Except for some assessed systematically. This multiplicity of
relatively isolated instances and in a few districts, options is particularly evident in urban areas. 51
these health camps do not seem to have been a
vehicle for large-scale immediate demand creation CMCHIS proactively incentivizes quality
or for supply-induced care. For example, less than improvements among private providers. All
1 percent of admissions in government hospitals private providers under the scheme are required
and less than 2 percent of admissions in private to have ‘entry-level’ accreditation by the National
hospitals in 2017 were a direct result of camp- Accreditation Board of Hospitals (NABH) within
referred hospitalizations of CMCHIS beneficiaries. 12 months of empanelment. 52 At present, 90
percent of all empaneled private facilities have
Access to private facilities has increased
under CMCHIS. Despite some de-empanelment 51 All districts have at least one hospital that offers the complete
set of specialties covered under the scheme. However, the total
over time, the total number of private facilities number of such facilities varies across districts. The following
contracted by CMCHIS has steadily increased are districts with the largest number of hospitals with complete
specialties: Tirunelveli (19), Chennai (15), Tiruchirappalli (11),
over time, more than 200 additional facilities have and Coimbatore (11). These districts are also among the most
signed-on for the scheme from the number in populous in Tamil Nadu.
52 The NABH has developed pre-accreditation entry-level certification
2012 (Figure 19).50 However, some of the smaller standards as a stepping stone for enhancing quality of patient
care and safety; once entry-level certification is achieved, the
health provider can then prepare and move to full accreditation
50 This amounts to more than 8,000 private beds added under the status. Hospitals need to attain 167 domain objectives (mostly
scheme since 2012. process quality indicators) to get entry-level accreditation.
FIGURE 19: NUMBER OF EMPANELED PRIVATE FACILITIES WITH
graded from a high of ‘S1’ to
CMCHIS, 2012–2018
a low of ‘S2’. 53 A hospital with
more than 100 beds is given
3 points compared to 1 point
to hospitals with less than
30 beds. Hospitals meeting
other quality standards are
also given a higher score.
Hospitals meeting the Indian
Public Health Standards
(IPHS) of doctor-to-bed ratio
of 1:6 and nurse-to-bed ratio
of 1:2 are given 3 points. The
same is the rating for hospitals
with quality and professional
certifications. Likewise, a
hospital laboratory service with
External Quality Assessment
Source: CMCHIS Scheme (EQAS) certification,
a microbiology lab headed by
FIGURE 20: DISTRIBUTION OF YEARS OF OPERA
TION FOR a microbiologist with master’s
EMPANELED PRIVATE HOSPITALS degree, and a pharmacy with
a licensed pharmacist all
have correspondingly higher
points. A hospital can get a
maximum of 100 points, and
this assessment is conducted
annually.54
Higher-tiered private
hospitals are entitled to
higher reimbursement
rates for some procedures.
Table 9 shows reimbursement
differences to private hospitals
by grade for selected conditions.
As can be seen, tariffs for some
Source: CMCHIS
procedures—for example,
dengue hemorrhagic fever,
this accreditation. In addition, payment rates for
private providers are tiered based on availability 53 From 2012–2016, CMCHIS used a different set of criteria as basis
of grade level. The criteria focused mainly on the availability of
of infrastructure and expertise: multispecialty limited set of hospital equipment. In 2017, CMCHIS adopted new
private hospitals are graded from a high of ‘A1’ to criteria with a more extensive list of hospital equipment including
various quality assurance and professional certification.
a low of ‘A6’; single-specialty private hospitals are 54 Additional details are available at the CMCHIS website.

diabetic ketoacidosis, FIGURE 21: DISTRIBUTION OF PRIVATE PROVIDERS BY GRADE, 2018
and acute severe asthma
with ventilation—are
almost half for ‘A6’
facilities relative to ‘A1’
facilities. In other cases,
the differences are not
that large. For some
procedures, such as
total knee replacement,
there are no differences
in reimbursements
by grade. In 2018, 19
percent of all private
providers were graded
‘A1’ and 29 percent
of private beds were
graded ‘A1’ (the facilities
graded ‘A1’ also tended
to have more beds). Source: CMCHIS
Although 84 percent
of all private facilities Government hospitals are automatically
that have been in the scheme for multiple years graded in the highest category but are required
did not change grade over 2012–2016, 12 percent to use a portion of reimbursements for quality
moved down at least one grade in the past five improvements. NABH accreditation is not
years (only the remaining 4 percent moved up at required for government hospitals, although the
least one grade) (Figure 22). This needs further process of introducing this is under way, and they
study to better understand the dynamics behind are currently automatically accorded a grade of
this: factors other than reimbursement levels could ‘A1’. However, unlike private facilities, government
equally well explain the observed intertemporal hospitals are required to set aside 17 percent of
grade transitions. all CMCHIS reimbursements for ‘institutional
Table 9: Variations in CMCHIS tariffs by hospital grade for selected procedures
Procedure A1 A2 A3 A4 A5 A6 S1 S2
Dengue hemorrhagic fever 18,000 16,200 14,580 13,122 11,810 10,629 18,000 13,122
Diabetic ketoacidosis 30,000 27,000 24,300 21,870 19,683 17,715 30,000 21,870
Acute severe asthma with 51,200 46,080 41,472 37,325 33,592 30,233 51,200 37,325
ventilation
Coronary bypass surgery 100,000 100,000 90,000 90,000 90,000 90,000 100,000 90,000
Total knee replacement 65,000 65,000 65,000 65,000 65,000 65,000 65,000 65,000
Hearing aid 8,000 8,000 8,000 8,000 8,000 8,000 8,000 8,000
Total hip replacement (cemented) 66,750 60,075 60,075 60,075 60,075 60,075 66,750 60,075
Source: CMCHIS
FIGURE 22: GRADE TRANSITIONS FOR PRIVA
TE PROVIDERS, 2012–2016
Source: CMCHIS
development/hospital upgradation’ (in addition, 40 CMCHIS stipulates that continued provider

percent can be used for consumables; 15 percent empanelment is dependent on quality metrics.
as incentives for operating teams; 27 percent for There is a contractual stipulation that states that
a corpus fund to finance high-end procedures; quality parameters such as hospital mortality
and 1 percent for information, education, and rates and infection rates may be considered
communication activities). 55 In 2017, on average, as parameters for continuation of providers in
total reimbursements per bed in government the scheme. As mentioned above, at present,
hospitals were `21,000 (~US$290). However, as government hospitals are not required to undergo
expected, it appears that CMCHIS reimbursements NABH accreditation but are expected to undergo
were a more significant source of financing in a ‘facility assessment’ and follow National Quality
smaller government hospitals compared to bigger Assurance Standards (NQAS). To date, almost
government hospitals (Figure 23). For example, 300 private providers have been suspended under
hospitals in the bottom quintile in terms of bed the scheme. None of the government facilities
size (number of beds between 11 and 56) received have been de-empaneled. De-empanelment
reimbursements per bed of̀38,000 (~US$510), has occurred for a variety of reasons, the most
much higher than the top quintile of hospitals that prominent being low performance especially on
had beds above 200 (`15,400; ~US$210). the requirement that facilities conduct monthly
outreach camps. A few private providers were
55 Government Order No. 331 of 2014. also de-empaneled because they did not receive

NABH accreditation within the FIGURE 23: CMCHIS REIMBURSEMENT PER BED IN GOVERNMENT
requisite 12-month period. A FACILITIES
few private facilities voluntarily
de-empaneled themselves
56
from the scheme.
CMCHIS adopts a simplified

protocol for medical and
surgical packages to
ensure health providers
do not overprovide or
underprovide care. Although
these protocols are not very
detailed, they specify for each
package, the bare minimum
signs adnd symptom that
indicate need for admission,
the minimum and types of
tests and treatment that
should rendered (including,
in some cases, the minimum Source: CMCHIS
number of days of admissions). of every month, is composed of consultants from
Compliance is monitored and enforced through various medical colleges and hospitals in the
the preauthorization approval and claims payment state. The review process of the committee is
process, and noncompliance may lead to reduction standardized; guidelines are in place to ensure
of claim payment. To preauthorize coronary bypass the investigations are conducted in a transparent
surgery, the patient needs to have symptoms fashion. If the committee finds the hospital to have
of angina and hospitals are required to perform ‘unacceptable’ mortality or morbidity outcomes,
an angiogram. If the surgery is conducted, the they can be given warnings, show-cause notices,
full settlement amount is paid. If the surgery is or even suspension. Hospitals, however, can
abandoned (that is, initiated but not completed), appeal against the decision of the committee. 57
only 25 percent of the tariff is settled.
Empaneled hospitals are also required to
A special committee regularly monitors quality submit information on notifiable diseases. As
of care. The Mortality and Morbidity Committee part of the state’s effort to strengthen an integrated
(MMC) was established under CMCHIS to disease surveillance system, CMCHIS mandates
investigate all deaths as well as a sample of all government and empaneled private hospitals
morbidity cases. The goal of the committee is to to report on 24 notifiable infectious diseases that
ensure quality standards are being met, deaths are may pose serious public health concern. These
reported, and morbidity cases do not occur due are mostly outbreaks of infectious diseases (for
to unsafe clinical practice and negligence. The example, AH1N1) and re-emergence of infectious
committee, which convenes on the last Wednesday diseases (for example, malaria and tuberculosis).
56 About 6-7 private facilities have voluntarily de-empaneled to date;
the primary reason for voluntary de-empanelment appears to have 57 In 2017, out of 108 cases submitted for possible investigation, 35
been the relatively low levels of reimbursements under CMCHIS. were acted upon by the MMC.
7. STRENGTHENING
ACCOUNTABILITY
Changes introduced through CMCHIS include scheme. As noted earlier, part of the financial
a fundamental alteration in the roles and risk for the scheme is borne by the insurer. The
responsibilities of key stakeholders. As in other contract between the scheme-administering
states and countries, expansion of government- agency and the insurance company specifies the
financed coverage in Tamil Nadu was not simply overarching financing envelope for the scheme
a case of doing ‘more of the same’; CMCHIS for four years and benefits to be provided. The
introduced different roles and responsibilities for contract also includes actions and metrics by
the Department of Health, insurance providers, which both parties must adhere and be held
TPAs, and health care providers. Instead of accountable. The insurance company is chosen
purchasing services from government hospitals through a bidding process and, under current
through traditional line-item financing without guidelines, only public sector insurance companies
a clear separation between the payer (the state can bid for the scheme. Currently, the insurance
government) and providers, CMCHIS introduced company only signs service agreement contracts
several arm’s-length separations with explicit with private providers, and there are plans to do
responsibilities. Public financing is now being the same with government providers. In addition,
used to purchase some health services from both the insurer separately contracts three private TPAs
government and empaneled private providers on that manage the nuts and bolts of implementation
behalf of beneficiaries using insurance and TPAs from enrollment to claims processing to day-to-
through case-based bundled payments. The day management of the scheme. Each district in
decision to use an insurance company appears the state is handled by one TPA only, and TPA
to have been made to protect the integrity of district assignments are rotated over time, and this
the process from political and other forms of appears to have fostered a healthy competitive-
interference, something that would likely have been collaborative relationship between them.
far more difficult to realize had Tamil Nadu chosen
to use a trust model with the state government Guidelines and memorandums of
directly administering the scheme. understanding (MO Us) are also used to
specify accountabilities. For example,
Legal contracts specify accountability provision of services in government hospitals
arrangements among the larger actors in the is outlined in MOUs with the insurer. The
Chapter 7: Strengthening Accountability 35

VAO or revenue authorities are responsible for their claims to be processed. 58 In addition, a
for verifying the income-related eligibility of sample of claims is subject to a comprehensive
beneficiaries. Although theAadhar card is not post-claim audit. CMCHIS employs a team of
used for verification as such, the system links the doctors and retired police officers (also known
beneficiary’s Aadhar number if this is available as district vigilance officers) to handle fraud
and, as of 2017, premium payments have been management at the district level. When fraud is
tied to Aadhar -linked families. suspected, the EDC directs retired officers to
conduct the initial investigation.
The insurer can de-empanel private providers
resulting from poor performance or if evidence CMCHIS uses several mechanisms for routine
of fraud is found. Fraud by providers is not clearly monitoring of the scheme. The scheme-
defined but is specified as “…where any fraudulent administering agency (TNHSP) holds a weekly
claim, negligence, not rendering cashless open-door meeting with stakeholders where
treatment, not following the norms and guidelines anyone with a grievance or query can walk in or
related to implementation of scheme including poor connect through Skype. In addition, as mentioned
performance, etc. becomes directly attributable to above, the scheme has a toll-free number,
the hospital.” As noted earlier, almost 300 private website, district review meetings, and regional
hospitals have been suspended by the scheme review meetings for logging complaints and
to date. All claims are subject to preauthorization grievances. Complaints from beneficiaries can
to prevent fraud. Once admitted, the hospital lead to de-empanelment from the scheme. The
submits documents for preauthorization to the call center logs about 500 calls per day; analysis
TPA; preauthorization is typically completed by reveals that calls registering complaints such as
the TPA within 24 hours. Once the beneficiary has unsatisfactory treatment or denial of benefits are
been discharged, the provider submits a claim to relatively rare.59 There is regular monitoring of
the insurer; claim settlement needs to occur within facilities, including surprise visits. Once admitted,
seven days following which the insurer makes an the liaison officer of the scheme is expected to
electronic payment to the provider. Providers are visit the beneficiary patient at least once per
required to submit paperwork, upload photographs day; in addition, the officer also monitors bed-
and videos, and provide detailed information occupancy rates.
58 The IT system of CMCHIS has built-in triggers that flag

potentially fraudulent claims. The following are some examples
of triggers used: claims coming from family with the same illness,
‘anatomically-impossible claims’ (for example, claims from an
adult submitting pediatric claims), sudden surge of claims in a
particular district, and so on.
59 In 2017, less than 1 percent of calls were registered as complaints.
Emergency intimation and queries on diagnostics, enrollment,
benefits, and about the scheme in general were the top calls
registered.
8. TRANSITION TO
PM-JAY
India is implementing several major reforms for on—has been the expansion of noncontributory
progressively realizing UHC for its 1.3 billion coverage for the poor using general government
population. Ayushman Bharat or ‘Long Live India’— revenues, either through bolstering traditional
the umbrella term for health sector reforms in the supply-side financing for public facilities or
country—comprises two primary components: through insurance-style demand-side financing
(a) creation of ‘health and wellness centers’ that will that provides access to both government and
provide diagnostic tests, free essential medicines, empaneled private facilities. Similar to India, many
and other comprehensive primary care services at countries—including China, the Philippines, and
sub-health centers that cater to a catchment area Turkey—initially expanded demand-side coverage
population of 5,000 in rural plains areas versus only for inpatient care, later expanding benefits
3,000 in hilly/desert/tribal areas and are generally to include outpatient primary and specialist
the first point of contact for India’s public sector care services. Nevertheless, what sets India’s
health system and (b) implementation of PM- reforms apart from reforms in other countries is
JAY that was launched in September 2018 to the sheer scale of population coverage under a
provide government-sponsored health insurance single program: with an estimated 500 million
coverage for a package of inpatient secondary and beneficiaries, PM-JAY is often referred to as the
tertiary care that can be availed of at government largest government-sponsored health insurance
and empaneled private hospitals to 100 million scheme in the world.
poor and near-poor families (an estimated total
of 500 million individuals, roughly 40 percent Over the past decade, states such as Tamil
of the country’s population) up to a maximum Nadu have amassed significant experience
annual limit of ` 500,000 (~US$7,143) per family. with implementing government-sponsored
In launching PM-JAY, India is following in the health insurance schemes similar in design
footsteps of many other developing countries that to PM-JAY. Health is a state subject in India.
have recently implemented and expanded pro- PM-JAY—which almost all states have agreed to
poor UHC reforms. A key common element across implement—is a centrally sponsored scheme that
many of these UHC reforms—in China, Indonesia, is co-financed by the center and the states for a
Mexico, the Philippines, Thailand, Vietnam, and so minimum standard benefits package of secondary

FIGURE 24: OVERLAP OF BENEFITS PACKAGES: PM-JAY VERSUS CMCHIS
and tertiary health care services. 60 However, states 2008, several additional states have implemented
can expand own-financed coverage—in terms of the central government-sponsored RSBY that
who they cover, what they cover, and how much provided inpatient secondary care coverage
they cover—beyond what is stipulated under PM- to Below Poverty Line (BPL) families up to a
JAY should they choose to do so. States can also maximum annual amount of̀ 30,000 (~US$429)
choose different implementation modalities: they per year. Subsequently, many states have financed
can contract private or public sector insurance additional coverage and benefits beyond what
firms to implement the scheme (the so-called was stipulated under RSBY or implemented their
‘insurance’ mode), use a state department or own schemes in place of RSBY. As a result, many
state implementation agency (‘assurance’ mode), states have amassed knowledge and experience
or use a mix (‘mixed’ mode). In its design, PM- in designing and implementing a variety of
JAY builds upon several central and state-level government-sponsored health insurance schemes:
government-sponsored health insurance schemes experiences which can and should be tapped to
that have been implemented in the country over provide lessons for maximizing the effectiveness
the past decade. For example, in 2007, one of the of PM-JAY.
first-ever government-sponsored health insurance
schemes in India was launched in the state of As with other government-sponsored health
Andhra Pradesh (the Rajiv Aarogyasri scheme) that insurance schemes in India, CMCHIS is merging
provided inpatient tertiary care coverage to over with PM-JAY. There is significant overlap between
20 million poor and near-poor families. 61 Since the benefits packages of CMCHIS and PM-JAY. In
many ways, this makes the transition to PM-JAY
60 The center-state co-financing split is 60:40 except for eight north-
eastern and three Himalayan states where it is 90:10; for union
easier for a state such as Tamil Nadu as compared
territories with legislatures (Delhi and Pondicherry) co-financing to introduction of the scheme in ‘greenfield’ states
is 60:40 and for other union territories it is entirely financed from
the center. such as Uttar Pradesh, Madhya Pradesh, and
61 Nagpal, S. 2013. “Expanding Health Coverage for Vulnerable Bihar which do not have existing government-
Groups in India.” Universal Health Coverage Studies Series
No. 13, Washington, DC: World Bank. sponsored health insurance schemes. There are a
total of 1,342 secondary and tertiary care packages Tariffs for overlapping packages are, for the
under PM-JAY, included one that is classified most part, similar across CMCHIS and PM-J AY.
as ‘unspecified’ which can be reimbursed at a There is no systematic tendency for rates to be
recommended tariff of`100,000 (~US$1,429): of higher for CMCHIS (which are range depending
these, roughly 72 percent are already covered on supply characteristics for private facilities)
under CMCHIS; this leaves roughly 28 percent of versus PM-JAY. In some cases—laparoscopic
the total number of packages (424) that are covered cholecystectomy, hernia (epigastric), and temporal
under PM-JAY but are reserved for government bone excision/resection—CMCHIS tariffs are higher
facilities. In addition, CMCHIS covers additional than those proposed under PM-JAY; in others, the
diagnostics and high-end packages that are not reimbursements for CMCHIS are at the lower end
covered by PM-JAY (Figure 24). from those proposed under PM-JAY (Figure 25).
FIGURE 25: TARIFF COMPARISONS, CMCHIS VERSUS PM-JAY
Source: CMCHIS

Table 10 summarizes some of the ways in which stipulations, the benefits package and tariffs are
CMCHIS will transition to PM-JAY, under the as per the national package list are applicable. The
same broad themes of covering people, defining payment of claims to hospitals is to be made by the
benefits, managing money, improving supply, and trust or insurance company that is implementing
strengthening accountability. PM-JAY in the home state to which the beneficiary
belongs. Processing of claims and payment
PM-JAY allows for national portability, that is, to hospitals need to be made within 30 days of
beneficiaries from any part of the country are receiving the claim. In the case of any disputes,
entitled to seek care at empaneled hospitals standard grievance redressal processes are to be
anywhere in the country. Under portability followed.
Table 10: CMCHIS-PM-JAY transition
CMCHIS PM-JAY guidelines PM-JAY-CMCHIS

Covering Primary target: families with Primary target: Poor families identified Primary target: CMCHIS
people annual income less than in 2011 Social-Economic Caste enrollees plus any
`72,000 Census (SECC) based on deprivation additional families
criteria in rural areas and occupational identified under SECC
categories in urban areas. not currently enrolled in
CMCHIS.
Number of families: Number of families: 7,770,986 Number of
15,724,432 families:15,724,432
Enrollment required. Smart Entitlement based on validation, no Enrollment required.
card issued on enrollment. enrollment recommended. Smart card issued on
enrollment; for all families
an additional e-card
may be provided on
validation.
Defining 1,027 packages, no Minimum 1,342 packages, including 1,451 packages,
benefits ‘unspecified’ package one ‘unspecified’ package. States can including one
add additional packages. ‘unspecified’ package:
including 533 common
packages, 494 packages
exclusive to CMCHIS,
and 424 packages
covered under PM-JAY
but not under CMCHIS
for all.
38 stand-alone diagnostics No stand-alone diagnostics packages CMCHIS stand-alone
packages included in minimum. diagnostics packages will
continue for all.
154 follow-up packages No specific follow-up packages CMCHIS follow-up
included in minimum. packages will continue.
8 high-end packages No high-end packages included in CMCHIS high-end
minimum. packages will continue.
Managing Premium: `699, own-state Premium varies by state; 60:40 Premium: `699, 60:40
money financed co-financed between center and center-state co-financed
state except for northeastern for 7,770,986 families
states, Himalayan states, and and own-state financed
Union Territories where the center for 7,953,446.
co-finances 90–100% of the
premium. 62
Annual family cap: `100,000 Annual family cap: `500,000/family Annual family cap:
per family; cap of `200,000 `500,000/family for all.
per family for 154 follow-
up packages; corpus-
funded reimbursements for
>`200,000 for 8 high-end
packages.
‘Mixed’: Public sector Public or private insurance mode, or CMCHIS ‘mixed’ mode
insurance company with assurance mode, or ‘mixed’, with or will continue.
multiple TPA support, without TPAs.
assurance mode for
reimbursements above
`200,000 for 8 high-end
packages.
Four-year contract, with Recommended minimum of three CMCHIS practices will
one-year extension years contract. continue.
Provider payment: Provider payment: Case based, tariffs CMCHIS tariffs for
Casebased, tariffs set recommended by the center. overlapping benefits;
by state government; PM-JAY recommended
27% of reimbursements tariffs for non-CMCHIS
to government hospitals packages.
mandated for corpus fund.
Improving Network of in-state National portability for empaneled 424 PM-JAY packages
supply government facilities and government and private facilities. to be provided only by
empaneled private facilities, empaneled government
some empaneled facilities facilities for now.
in neighboring states
Private providers No such recommended mandate. CMCHIS practices will
mandate to conduct continue.
monthly outreach health
camps for provision of
free primary care; for
information, education, and
communication activities.
62 In 2018, the central government imposed a 4 percent ‘cess’ on payable income tax (that is, on total tax liability). This 4 percent ‘cess’ is
made up of a 2 percent education ‘cess’, 1 percent is for a senior secondary education ‘cess’ (a total 3 percent education ‘cess’), and a new
1 percent for a health ‘cess’. For formal salaried employees, the tax liability and ‘cess’ are deducted automatically from payroll. For non-
formal workers (non-salaried) workers, the tax liability and ‘cess’ are reflected in annual income tax returns. The government is anticipating
raising US$1.5 billion ((`107 billion), which will be used to finance PM-JAY.

Six-tiered reimbursements 10–15% over and above the CMCHIS reimbursements
for multi specialty private recommended PM-JAY package will continue.
providers depending on tariff depending on the level NABH
infrastructure and staffing; accreditation, whether serving
two-tiered reimbursements ‘aspirational’ districts, or whether
for single-specialty private offering postgraduate courses
facilities
Total number of empaneled No specific guidelines for total CMCHIS practices will
private hospitals is number of private hospital enrollment continue.
controlled.
Regular review of mortality No specific recommendations CMCHIS practices will
and morbidity outcomes continue.
For government hospital No specific recommendations CMCHIS practices will
reimbursements: 17% for continue.
infrastructure/upgradation,
15% for staff incentives
Strengthening Legal contracts, guidelines, Legal contracts, guidelines, and CMCHIS practices will
accountability and MOUs with different MOUs with different actors with continue.
actors with explicit explicit accountability arrangements
accountability arrangements
Strong anti-fraud orientation Recommendations outlined in anti- CMCHIS practices will
through 100% pre- fraud guidelines continue.
authorization, claims review,
and sample post-claim
audits
9. SUMMARY AND
PENDING AGENDA
Several innovative design elements in significantly helped reduce premium

implementation of Tamil Nadu’s CMCHIS payments under CMCHIS. Advancing of
are notable. As India embarks on nationwide payments reduced a significant source of
financial protection reforms under PM-JAY, there uncertainty and could be encouraged when
are important lessons to be learned from similar contracts are made with insurance agencies
reforms implemented in states such as Tamil or even with providers.
Nadu over the past decade or soS . ome notable
 Use of multiple TP As. Use of multiple
aspects of the experience from CMCHIS include
TPAs, including cross-mixing district
the following:
allocations over time, has led to a spirit of
 Inclusion of diagnostics. One of the most competitive collaboration for day-to-day
important characteristic of CMCHIS that sets implementation of the scheme. TPAs can
it apart from PM-JAY is on the diagnostic have the opportunity to learn from each
benefits front, namely inclusion of a separate other and this can stimulate efficiency and
diagnostics package—which can be availed encourage experimentation with alternatives
of also at private primary care facilities on to implementation; competition among TPAs
an outpatient basis—is an important step can act as a check, while enabling exploitation
forward toward expanding the reach of of scale economies where possible. Shifting
benefits beyond narrowly defined secondary district responsibilities every couple of years
and tertiary inpatient care, something that removes incentives for entrenchment and
PM-JAY may consider encouraging states to reduces the potential of fraud.
incorporate. Although diagnostics accounted
 Incentivizing quality. CMCHIS proactively
for more than one-fifth of the overall volume
uses financial levers to incentivize quantity
of claims under CMCHIS, they represented
and quality of health care; although
less than 5 percent of the total claim values.
preliminary analysis suggests this is not
 Flexibility in advancing payments. having the intended effect on improving
Longer-term contracts with and flexibility quality, the attempt to do so is what sets the
in advancing payments to the insurer scheme apart from PM-JAY. The scheme’s

MMC is another mechanism by which  Primary health care outreach camps.
quality enhancements are implemented, with CMCHIS mandated monthly proactive
feedback loops and regular assessments outreach camps by providers, both to raise
of clinical quality of care. Setting aside 17 awareness among beneficiaries as well
percent of reimbursements under the scheme as to serve as a first point of contact for
for improving supply of government facilities routine primary health care and for helping
is notable; these resources have been set beneficiaries identify needs and navigate the
aside for infrastructure improvements and system if further interventions are needed;
are separate from the resources for financing although in some ways this is not an ideal
consumables. 63 arrangement—some form of seamless
 Strong governance and fraud inclusion of primary health care and specialty
management. Despite lack of an explicit outpatient services under the scheme would
fraud management policy or guidelines, obviate the need for such camps—it can
CMCHIS appears to have an extremely robust and does serve to improve access to health
fraud prevention, detection, and deterrence services for vulnerable population groups.
mechanism. There is strong leadership This element of CMCHIS is potentially
and governance of the scheme, vigilant efficiency-enhancing, as it can help the
monitoring systems in place, and a very strong system catch diseases early, before severe
technological infrastructure implemented symptoms appear that might necessitate
by a highly committed team comprising the immediate hospitalization.
scheme-administering agency, the public In looking forward, as CMCHIS is implemented
insurer, and the three TPAs. in conjunction with PM-JAY , it is an opportune
 Corpus funds for needy beneficiaries. time to flag some pending agenda issues and
Beneficiary welfare improvements, over challenges for the state. Systemically, high
and above what is provided by the scheme, levels of OOP spending remain in both Tamil Nadu
have been implemented by helping provide and nationally and are unlikely to be influenced
top-up financing for high-end procedures, significantly by PM-JAY: the scheme covers
accessories, and follow-up procedures. interventions that are of fairly low frequency; over
Although this has come at the expense of time, the scheme could consider adding more
lowering payments to government facilities, benefits to the package; expansion of population
the principle is laudable. coverage will help make a dent in moving the
dependence of the health financing system on
63 In developed countries, more sensitive indicators of hospital
quality (for example, readmission rates and infection rates) OOP spending.64 At present, CMCHIS amounts
are routinely collected and used as basis for incentivizing to only 2 percent of all health resources in the
performance. We attempted to estimate readmission rates
of specific conditions: pneumonia, COPD, and hip and knee system. With a relatively small resource outlay,
replacement. For pneumonia cases, 30 hospitals had their CMCHIS is operating at the edge: even small
patient readmitted at the same facility or other facility within 90
days after discharge. Of the 30 hospitals, 24 were government increases in utilization will render the scheme to
facilities. The share of readmitted cases to total pneumonia cases
were <1 percent to 9 percent. For COPD cases, 16 hospitals had
become financially unsustainable. Lack of systemic
their patients readmitted at the same facility or other facility with integration of primary care with the scheme is a key
90 days after discharge. Of the 16 hospitals, 11 were government
facilities. The shares also vary from <1 percent to 11 percent. bottleneck, especially critical given the continuum-
No readmission case was noted for knee and hip replacement.
These estimates, however, should be taken with a grain of salt. 64 This is even more critical as global experience has shown that
Standard method of readmission rate estimation uses ICD10 to sometimes when similar schemes are introduced they lead to
classify conditions and includes all hospitals cases. Here, only increase in both utilization and OOP payments, at least in the
CMCHIS patients were used. beginning.
of-care needs of NCDs and of integrated care facilities that do not empanel, understandingwhy
more generally.65 A strong primary care system they do not do so; assessing impact on beneficiary
that works in conjunction with—not in parallel to— health outcomes and financial protection; examining
CMCHIS will go a long way to ensure sustainability. and reducing hospitalizations for ambulatory-
In addition, the two-tiered treatment of facilities sensitive conditions (such as diabetes and asthma,
could be slowly removed. Government hospitals for example); emphasizing and incentivizing
should be required to adhere to the same quality prevention over curative services; and tracking
guidelines and metrics that private providers are referrals from lower levels of care, among others.
required to adhere to. The scheme should also CMCHIS can serve as an important platform to
move beyond focusing on traditional monitoring consider options by which some of the gains made
and evaluation metrics to those that provide by Tamil Nadu’s health systems could be sustained
additional information about systemic weaknesses and expanded as it faces new challenges and
that could be addressed: tracking private opportunities to do so in coming years.
65 Approximately 13 percent of claims submitted to CMCHIS were

from patients referred from lower-level facilities. There is no
significant difference in the referral rates between government
and private hospitals.

Annex A
KEY POPULATION HEALTH OUTCOMES
Country/state Population TFR Life Adult Under-five Infant Maternal Stunting

expectancy survival mortality mortality mortality (%)
Andhra Pradesh 47.9 1.7 70 71 37 34 74 31
Bangladesh 164.9 2.1 72 76 34 28 176 36
Brazil 209.2 1.7 76 79 15 14 44 7
Chhattisgarh 28.9 2.5 65 49 39 173 38
China 1,397.0 1.6 76 86 10 9 27 8
Ghana 29.0 4.0 63 62 59 41 319 19
Goa 1.6 76 8 20
Gujarat 68.6 2.2 70 75 33 30 91 39
India 1,334.2 2.3 69 71 43 35 174 38
Indonesia 265.3 2.4 69 72 26 22 126 36
Karnataka 68.5 1.8 69 73 29 24 108 36
Kerala 36.3 1.8 75 82 11 10 46 20
Meghalaya 3.5 67 40 30 44
Maharashtra 127.2 1.8 72 78 21 19 61 34
Malaysia 32.5 2.0 75 81 8 7 40 21
Philippines 107.4 2.9 69 70 27 22 114 33
Punjab 31.0 1.7 73 76 24 21 122 26
Russia 144.0 1.8 72 70 8 7 25 13
South Africa 57.4 2.5 63 55 43 34 138 27
Sri Lanka 21.7 2.0 75 80 9 8 30 17
Thailand 69.2 1.5 75 79 12 11 20 11
Turkey 81.9 2.1 76 84 13 11 16 10
Tamil Nadu 79.3 1.6 71 75 19 17 66 27
Vietnam 94.6 2.0 76 81 22 17 54 25
West Bengal 102.4 1.6 71 77 27 25 101 33
Lower-middle-income 2,969.5 3.2 68 70 41 31 194 27
Sources.Countries: Population (2018) using International Monetary Fund (IMF), total fertility rate (2016), life expectancy (2016), under-five
mortality rate (2016), infant mortality rate (2016), adult survival rate (2016), and maternal mortality rate (2016) using World Development
Indicators; Stunting rates: United Nations Children’s Fund (UNICEF)/WHO/World Bank joint malnutrition rates (latest available years), no
data provided for Russia but estimate by Lunze et al. (2015) was 13 percent; States: Population (2018) using authors’ projection using five
rounds of decadal census, TFR (2015), life expectancy (2014), under-five mortalityrate (2016), infant mortalityrate (2016), adult survival rate,
and maternal mortalityrate (2016) using Sample Registry System (SRS) infant mortality rate and under-five mortality ratefor Meghalaya using
NFHS 2015–2016; life expectancy for Meghalaya and Goa using Institute for Health Metrics and Evaluation (IHME) estimates. Sample Registry
System (SRS)only provides life expectancy for big states; stunting rates using NFHS 2015–2016.
Annex B
UNIVERSAL HEALTH COVERAGE
UHC TRACER INDICATORS (%)
Country/state MFP ANC DPT SAN TOB CHI HIV TBT PPE CAT10 CAT25
Andhra Pradesh 93 76 89 54 80 91 38 92 22 71 83
Bangladesh 74 31 97 47 77 42 13 93 28 86 95
Brazil 88 90 96 86 86 50 57 71 72 74 97
Chhattisgarh 77 59 91 33 61 78 12 92 42 88 94
China 95 74 99 75 75 79 41 94 68 82 95
Ghana 43 87 88 14 96 56 28 85 64 97 100
Goa 56 89 94 78 90 — 46 93 — 84 91
Gujarat 78 71 73 64 75 79 29 93 47 83 93
India 72 45 87 44 88 77 44 72 35 83 96
Indonesia 81 84 78 68 61 75 10 85 50 96 100
Karnataka 83 70 78 58 77 92 48 84 48 74 86
Kerala 74 90 90 98 87 — 33 89 26 57 80
Meghalaya 45 50 74 60 53 76 19 82 — 92 98
Maharashtra 84 72 75 52 73 89 54 84 40 77 89
Malaysia 53 80 99 100 78 87 26 78 64 99 100
Philippines 54 84 60 75 75 64 27 91 46 99 99
Punjab 80 69 95 82 87 92 40 93 21 67 82
Russia 73 78 97 89 59 83 28 71 64 95 99
South Africa 84 87 75 73 79 65 49 81 92 99 100
Sri Lanka 74 93 99 94 86 58 23 85 62 97 100
Thailand 91 93 99 95 79 83 61 79 88 97 99
Turkey 60 89 97 96 72 85 28 87 83 97 100
Tamil Nadu 83 81 85 52 80 89 57 80 34 76 87
Vietnam 77 74 97 78 76 81 43 92 57 — —
West Bengal 73 77 93 51 67 77 13 90 — 67 82
Lower-middle-income 61 68 84 62 80 63 34 85 49 91 98
Sources. Countries: World Bank and WHO UHC Monitoring Report (2017); States: MFP using estimates of New et al. (2017); ANC, DPT, SAN,
CHI using NFHS 2015–2016; TOB using GATS India Survey (2016); HIV estimates using data from National Aids Council (2018); TBT using
data from India TB Report (2018). OOP using data from India’s Ministry of Health and Family Welfare CAT10 and CAT25 estimates using
NSSO 71st round.
Note. MFP: Demand satisfied for modern family planning; ANC: at least four prenatal care visits; DPT: DPT3 vaccination; SAN: basic
sanitation; TOB: non-tobacco smoking; CHI: care-seeking behavior of children with pneumonia; HIV: people living with HIV/AIDS under anti-
retro viral therapy; TBT: tuberculosis treatment success rate; PPE: prepaid/pooled expenditures; CAT10: households not spending 10 percent
of total expenditures; CAT25: households not spending 25 percent of total expenditures.
CAT10 and CAT25 for states and countries should compared with caution. In NSSO 71st round, the survey used monthly reported expenditures,
which grossly underestimates the total household expenditures and the potential reason for higher catastrophic expenditure estimates.
Annexes 47
Annex C
BURDEN OF DISEASE AND RISK FACTOR TRENDS
FOR TAMIL NADU AND INDIA
TAMIL NADU
DALYs lost share (%)

Rank in 2016 Top 10 diseases/conditions in 2016
1990 2000 2010 2016
1 Ischemic heart disease 6.6 8.8 12.2 14.3
2 Diabetes 1.4 2.4 3.9 4.9
3 Self-harm or violence 3.4 4.3 4.3 4.1
4 Chronic obstetric pulmonary disorder 2.5 3.3 3.4 3.7
5 Dietary iron deficiency 2.4 3.0 3.4 3.6
6 Diarrheal diseases 10.8 6.2 3.8 2.8
7 Falls 1.8 2.1 2.5 2.4
8 Migraine 1.2 1.7 2.1 2.4
9 Neonatal prenatal birth 6.8 4.8 3.3 2.2
10 Lower respiratory tract infection 6.9 5.0 3.1 2.1
DALYs (millions) 33.6 29.1 27.0 25.4
DALYs per 100,000 55.9 44.1 36.4 33.5
Sources. Institute for Health Metrics and Evaluation (IHME) (2016)
INDIA
DALYs lost share (%)

Rank in 2016 Top 10 diseases/conditions in 2016
1990 2000 2010 2016
1 Ischemic heart disease 3.7 4.8 7.0 8.7
2 Chronic obstetric pulmonary disorder 3.1 3.7 4.0 4.8
3 Diarrheal disease 12.4 9.2 6.2 4.1
4 Lower respiratory tract infection 9.8 7.9 6.1 4.4
5 Stroke 2.0 2.4 3.0 3.5
6 Dietary iron deficiency 2.1 2.7 3.2 3.5
7 Neonatal preterm birth 5.5 5.0 4.3 3.4
8 Tuberculosis 5.0 4.5 3.7 3.2
9 Sense organ 1.4 1.8 2.4 2.9
10 Road injuries 1.5 2.0 2.6 2.9
DALYs (millions) 537.4 527.3 495.1 466.3
DALYs per 100,000 62.2 50.6 40.4 35.4
TAMIL NADU
Rank in 2016 Top 10 risk factors in 2016 DALYs lost share (%)
1990 2000 2010 2016
1 Dietary risk 7.7 9.6 12.7 14.4
2 High fasting blood glucose 4.9 8.4 10.6 13.0
3 High systolic blood pressure 5.9 7.9 10.7 12.3
4 High BMI 1.5 3.5 6.3 8.1
5 Child and maternal nutrition 31.1 19.3 11.9 8.0
6 Air pollution 9.6 9.1 8.0 7.2
7 High total cholesterol 3.2 4.4 6.2 7.2
8 Tobacco 4.9 5.7 6.2 5.6
9 Impaired kidney function 2.7 3.5 4.1 4.6
10 Alcohol and drug use 1.8 2.8 3.5 3.8
DALYs (millions) 18.5 14.6 13.2 12.2
DALYs per 100,000 31.2 22.2 17.9 16.1
INDIA
Rank in 2016 Top 10 risk factors in 2016 DALYs lost share (%)
1990 2000 2010 2016
1 Child and maternal nutrition 35.5 28.1 20.9 14.6
2 Air pollution 11.1 10.5 10.1 9.8
3 Dietary risk 4.5 5.4 7.4 8.9
4 High systolic blood pressure 3.9 5.0 7.0 8.5
5 High fasting plasma sugar 2.3 3.6 4.8 6.0
6 Tobacco 4.4 4.8 5.6 5.9
7 Unsafe water, sanitation, handwashing 12.5 9.5 6.3 4.7
8 High total cholesterol 1.7 2.3 3.3 4.1
9 High BMI 0.8 1.5 2.5 3.6
10 Alcohol and drug use 1.7 2.4 3.1 3.6
DALYs (millions) 292.1 271.8 244.6 219.0
DALYs per 100,000 33.8 25.9 20.0 16.6
Annexes 49
Annex D
KEY HEALTH FINANCING INDICATORS
Country/state Total health Total health Public health Public health OOP spending
expenditure expenditure expenditure expenditure share of
per capita share of GDP per capita share of GDP total health
(US$) (%) (US$) (%) spending (%)
Andhra Pradesh 58 4.3 9 0.7 78
Bangladesh 32 2.6 6 0.5 72
Brazil 780 8.9 338 3.9 28
Chhattisgarh 49 3.6 14 1.0 58
China 426 5.3 254 3.2 32
Ghana 80 5.9 41 3.1 36
Goa
Gujarat 48 2.1 16 0.7 53
India 63 3.9 16 1.0 65
Indonesia 115 3.4 38 1.5 50
Karnataka 68 3.0 15 0.7 52
Kerala 106 4.5 19 0.8 74
Meghalaya
Maharashtra 70 3.0 12 0.5 60
Malaysia 377 3.9 199 2.0 36
Philippines 127 4.4 41 1.5 54
Punjab 81 4.1 14 0.7 79
Russia 524 5.6 320 3.4 36
South Africa 471 8.2 252 4.4 7.7
Sri Lanka 118 3.0 64 1.6 38
Thailand 220 3.8 166 2.9 12
Turkey 455 4.1 355 3.2 17
Tamil Nadu 64 2.8 16 0.7 66
Vietnam 117 5.7 51 2.5 44
West Bengal
Lower-middle-income 132 5.7 71 3.0 40
Sources. Countries: Global Health Expenditure Database (2015). States: Ministry of Health and Family Welfare (2017)
Annex E
TAMIL NADU DISTRICT-LEVEL VARIABLES:
POPULATION AND ENROLLMENT
District Population a Families enrolled Individuals enrolled b

Enrollment rate c (%)
Ariyalur 813,014 181,073 488,896 60.1
Chennai 5,404,072 663,083 1,790,323 33.1
Coimbatore 3,918,339 705,207 1,904,059 48.6
Cuddalore 2,873,026 606,491 1,637,526 57.0
Dharmapuri 1,720,502 395,922 1,068,989 62.1
Dindigul 2,357,113 474,778 1,281,901 54.4
Erode 2,503,447 624,535 1,686,245 67.4
Kancheepuram 4,787,249 794,061 2,143,964 44.8
Kanyakumari 2,038,957 446,722 1,206,149 59.2
Karur 1,159,651 298,239 805,245 69.4
Krishnagiri 2,153,888 447,147 1,207,296 56.1
Madurai 3,409,010 649,342 1,753,223 51.4
Nagapattinam 1,739,912 349,737 944,290 54.3
Namakkal 1,898,602 409,806 1,106,477 58.3
Perambalur 622,054 145,533 392,940 63.2
Pudukkottai 1,808,974 417,416 1,127,023 62.3
Ramanathapuram 1,467,461 301,208 813,262 55.4
Salem 3,889,354 829,456 2,239,531 57.6
Sivaganga 1,458,741 305,199 824,037 56.5
Thanjavur 2,619,248 555,318 1,499,359 57.2
The Nilgiris 801,674 166,300 449,011 56.0
Theni 1,364,486 298,489 805,920 59.1
Tiruchirappalli 3,016,328 572,328 1,545,286 51.2
Tirunelveli 3,350,490 605,186 1,634,002 48.8
Tiruppur 2,837,502 539,000 1,455,299 51.3
Tiruvallur 4,509,658 753,096 2,033,358 45.1
Tiruvannamalai 2,697,961 527,796 1,425,050 52.8
Tiruvarur 1,367,726 318,954 861,176 63.0
Tuticorin 1,867,315 311,614 841,358 45.1
Vellore 4,387,467 820,721 2,215,945 50.5
Viluppuram 3,820,189 811,590 2,191,293 57.4
Virudhunagar 2,145,860 399,088 1,077,539 50.2
Tamil Nadu 79,263,612 15,724,432 42,455,968 53.6
Source. Families enrolled from CMCHIS.
Note: a. Estimated using decadal census
b. Estimated, assuming average family size of 2.7.
c. Estimated individuals covered divided by estimated population.
Annexes 51
Annex F
TAMIL NADU DISTRICT-LEVEL VARIABLES:
FACILITIES AND BEDS
Government Private Beds per

District
Facilities Beds Facilities Beds Diagnostics 1,000 enrolled
Ariyalur 2 222 0 — 1 0.5
Chennai 16 6,255 54 6,413 16 7.1
Coimbatore 11 2,309 67 8,398 12 5.6
Cuddalore 9 2,525 17 6,335 10 5.4
Dharmapuri 5 1,297 10 362 3 1.6
Dindigul 5 1,014 28 1,965 15 2.3
Erode 7 1,661 42 2,434 10 2.4
Kancheepuram 8 476 27 6,195 8 3.1
Kanyakumari 5 1,179 30 4,542 22 4.7
Karur 5 699 11 444 10 1.4
Krishnagiri 4 791 12 1,394 4 1.8
Madurai 7 1,807 53 5,408 21 4.1
Nagapattinam 10 1,260 3 93 3 1.4
Namakkal 6 1,020 17 836 6 1.7
Perambalur 1 105 6 626 2 1.9
Pudukkottai 8 875 7 579 1 1.3
Ramanathapuram 10 1,156 3 177 8 1.6
Salem 6 1,954 52 5,539 2 3.3
Sivaganga 7 1,260 10 603 8 2.3
Thanjavur 6 2,690 24 2,077 3 3.2
The Nilgiris 4 742 3 136 9 2.0
Theni 4 284 12 666 5 1.2
Tiruchirappalli 11 2,261 35 3,479 3 3.7
Tirunelveli 19 1,786 15 1,068 1 1.7
Tiruppur 4 969 23 1,119 3 1.4
Tiruvallur 8 510 16 1,442 10 1.0
Tiruvannamalai 5 286 5 395 6 0.5
Tiruvarur 4 1,099 5 268 14 1.6
Tuticorin 10 1,036 8 484 5 1.8
Vellore 10 2,292 18 1,443 4 1.7
Viluppuram 7 440 10 568 4 0.5
Virudhunagar 11 1,310 15 509 9 1.7
Tamil Nadu 235 43,570 638 65,997 238 2.6
Sources.CMCHIS
Annex G
FACILITIES THAT PROVIDE THE MAXIMUM OF PACKAGES
ACROSS 10 SPECIALTIES AND 8 HIGH-END PROCEDURES
District Type Name of Facility

Chennai Government Government Royapettah Hospital
Chennai Government Government Stanley Medical College Hospital
Chennai Government Government Kilpauk Medical College Hospital
Chennai Government Government Kasturba Gandhi Hospital
Chennai Government Madras Medical College
Coimbatore Government Coimbatore Government Medical College
Kanchipuram Government Chengalpattu Medical College
Kanyakumari Government Kanyakumari Medical College Hospital
Madurai Government Government Rajaji Hospital
Madurai Private Meenakshi Mission Hospital and Research Center
Salem Government Government Mohan Kumaramangalam Medical College
Sivagangai Government Government Sivagangai Medical College and Hospital
Theni Government Theni Government Medical College and Hospital
Tirunelveli Government Tirunelveli Medical College Hospital
Trichy Government KAP Viswanathan Government Medical College
Vellore Government Government Medical College Hospital
Cuddalore Private Mahatma Gandhi Medical College
Cuddalore Private Manakula Vinayagar Medical College
Cuddalore Private PIMS
Cuddalore Private Jipmer Hospital
Kanyakumari Private Sri Mookambika Inst of Med Sc. Hospital
Madurai Private Velammal MC Hosp and Research Institute
Trichy Private Chennai Medical College and Hospital
Cuddalore Private A G Padmavathys Hospital Pvt Limited
Kanyakumari Private C.S.I Mission Hospital
Kanyakumari Private Dr.Jeyasekharan Medical Trust
Kanyakumari Private Holy Cross Hospital
Kanyakumari Private Siva Hospital
Kanyakumari Private M L Hospital
Karur Private Amaravathi Hospital
Annexes 53
Madurai Private Guru Multispeciality Hospital
Madurai Private Meenakshi Mission Hospital and Research Centre
Madurai Private Saravana Hospital
Madurai Private SKG Hospital
Madurai Private VMC Speciality Hospital
Madurai Private BGM Hospital
Madurai Private Bala Hospitals
Madurai Private Harshitha Hospitals
Pudukottai Private Muthu Meenakshi Hospitals
Sivagangai Private Senthil Hospital
Sivagangai Private Kauvery Medical Centre
Thanjavur Private Meenakshi Multispeciality Hospital
Thanjavur Private KG Multi Specialty Hospital
Tirunelveli Private Shifa Hospital
Tiruvarur Private Thiruvarur Medical Centre
Trichy Private Dr. G. Viswanathan Specialty
Trichy Private Kavery Medical Centre and Hospital
Trichy Private A. J. Hospital
Trichy Private G V N Hospital
Trichy Private KMC Specialty
Trichy Private Maruti Hospital
Trichy Private Apollo Hospitals
Trichy Private GKM Hospital
Trichy Private Gitanjali Medical Centre
Coimbatore Private Abinand Hospital
Coimbatore Private Alwa Hospital
Coimbatore Private Arun Hospital
Coimbatore Private Ashwin Polyclinic
Coimbatore Private Deepam Hospital
Coimbatore Private K.G.M. Hospital
Coimbatore Private K.R. Health Care
Coimbatore Private Kalpana Medical Centre
Coimbatore Private Karpagam Hospital
Coimbatore Private KG Hospital
Coimbatore Private Kongunad Hospital
Coimbatore Private Kovai Medical Center and Hospital
Coimbatore Private Kurinji Hospital
Coimbatore Private Manu Hospital
Coimbatore Private N.G. Hospital
Coimbatore Private Pills Hospitals
Coimbatore Private PSG Hospitals
Coimbatore Private Ram Polyclinic
Coimbatore Private Royal Care Super Specialty Hospital
Coimbatore Private S.P.T Hospital
Coimbatore Private Shree Sivaa Hospital
Coimbatore Private Sree Abirami Hospital
Coimbatore Private Sree Resmika Hospital
Coimbatore Private Sri Bala Medical Centre
Coimbatore Private Sri Lakshmi Hospital
Coimbatore Private Sri Ramakrishna Hospital
Dharmapuri Private DNV Polyclinic
Dharmapuri Private K.S. Hospital
Dharmapuri Private Om Sakthi Hospital
Erode Private Care 24 Medical Centre and Hospital
Erode Private City Hospital
Erode Private CK Hospital
Erode Private Erode Medical Centre
Erode Private KGR Surgical Nursing Home
Erode Private KMCH Specialty Hospital
Erode Private Lotus Hospitals Research Centre
Erode Private Maaruthi Medical Center and Hospitals
Kerala Private DM Wayanad Institute of Medical Science
Krishnagiri Private ARK Nursing Home
Krishnagiri Private Arogya Seva Hospital
Krishnagiri Private Chandrasekara Hospital
Krishnagiri Private P.E.S.I.M.S.R Hospital
Krishnagiri Private Vijay Hospital
Nilgiris Private Ashwini Gudalur Tribal Hospital
Nilgiris Private Nankam Hospital
Salem Private Aishwaryam Speciality Hospital
Salem Private Appu Venkatachalam Medical Research Centre
Salem Private Aravind Hospital
Salem Private Deepam Hospital
Salem Private Dharan Hospital
Salem Private Dr. Suraksha Specialty Medical Centre
Salem Private Dr. Thiru Neuro Multi Specialty
Annexes 55
Salem Private Dr. Sundararajan Neuro Hospital
Salem Private Kamala Hospital Agraharam
Salem Private Karthik Media Centre
Salem Private Kiruba Hospital
Salem Private Kurinji Hospital
Salem Private Manipal Hospital
Salem Private Nathan Super Specialty Hospital
Salem Private Neuro Foundation Three Roads
Salem Private Nitish Ge and Multispeciality Hospital
Salem Private Priyam Speciality Hospital
Salem Private Salem Polyclinic
Salem Private Saravana Hospital
Salem Private Shanmuga Hospital Cancer Institute
Salem Private Shanthi Nursing Home
Salem Private SIMS Chellum Hospital
Salem Private SKS Hospital
Salem Private SPMM Hospital
Salem Private Sri Gokulam Hospital
Salem Private Sri Shellappa Hospital
Salem Private Sundaram Multispecialty Hospital
Salem Private Universal Cancer Hospital
Salem Private Vinayaga Mission Kirubananda Medical College
Salem Private Vinyaga Mission Hospital Hi-Tech
Tirupur Private Aresta Medical Centre
Tirupur Private Deepa Hospital
Tirupur Private L.G. Medical Centre
Tirupur Private Malar Priya Medical Centre
Tirupur Private Rams Multispecialty Centre
Tirupur Private Revathi Medical Centre
Tirupur Private Sri Kumaran Hospital
Tirupur Private Sri Saran Hospital
Tirupur Private Sugan Sugaa Medical Centre
Vellore Private Arun Hospital
Vellore Private Christian Medical College and Hospital
Vellore Private Indira Nursing Home
Vellore Private Kafeel Emergency Care
Vellore Private Sri Narayani Hospital and Research Centre
Chennai Private Billoroth Hospitals
Chennai Private Chennai National Hospital
Chennai Private Dr Mehtas Hospitals
Chennai Private Faith Multispecialty Hospital
Chennai Private Kavery Hospital
Chennai Private Kumaran Hospital
Chennai Private Medway Hospital
Chennai Private Murugan Hospital Kilpauk
Chennai Private New Hope Medical Centre
Chennai Private Prashanth Hospital
Chennai Private Public Health and Welfare Society
Chennai Private Vijaya Hospital
Kanchipuram Private Chettinad Super Specialty Hospital
Kanchipuram Private Dr Kamakshi Memorial Hospital
Kanchipuram Private Hindu Mission Hospital
Kanchipuram Private Karpaga Vinyaga Institute
Kanchipuram Private Meenakshi Medical College
Kanchipuram Private Saveetha Medical College
Kanchipuram Private Sri Balaji Hospital
Kanchipuram Private Sri Ramachandra Medical Center
Kanchipuram Private SRM Medical College Hospital
Kanchipuram Private St. Thomas Hospital
Kanchipuram Private Tagore Medical College and Hospital
Namakkal Private Aravinth Hospital
Namakkal Private Thangam Hospital
Namakkal Private Vivekanandha Medical Care Hospital
Perambalur Private Dhanalakshmi Srinivas Hospital
Theni Private NRT Hospital
Thiruvallur Private K.V.T. Specialty Hospital
Thiruvallur Private Sugam Hospital
Villupuram Private E. S. Nursing College Hospital
Villupuram Private E. S. Hospital
Source: CMCHIS
Annexes 57
Annex H
DISTRICT-LEVEL UTILIZATION RATE OF CMCHIS
Families Utilization rate (%) Out-of-district utilization

District
utilizing Total Government Private share (%)
Ariyalur 4,327 2.4 1.1 1.3 76.6
Chennai 23,930 3.6 2.7 0.9 8.0
Coimbatore 15,071 2.1 0.9 1.2 7.9
Cuddalore 11,788 1.9 0.8 1.1 65.8
Dharmapuri 9,718 2.5 1.1 1.3 37.8
Dindigul 11,516 2.4 0.9 1.5 52.8
Erode 13,518 2.2 0.8 1.4 31.0
Kancheepuram 18,758 2.4 1.4 1.0 48.9
Kanyakumari 18,225 4.1 2.1 2.0 3.8
Karur 5,811 1.9 0.8 1.1 53.1
Krishnagiri 8,221 1.8 0.8 1.1 44.2
Madurai 18,017 2.8 1.4 1.4 13.7
Nagapattinam 7,734 2.2 1.3 0.9 58.5
Namakkal 12,447 3.0 0.9 2.2 46.9
Perambalur 5,797 4.0 1.8 2.2 37.8
Pudukkottai 8,709 2.1 0.9 1.2 60.5
Ramanathapuram 10,300 3.4 1.9 1.5 41.6
Salem 17,828 2.1 1.0 1.2 24.9
Sivaganga 8,805 2.9 1.7 1.1 41.4
Thanjavur 11,048 2.0 1.2 0.8 26.5
The Nilgiris 2,684 1.6 0.7 0.9 68.9
Theni 11,462 3.8 1.4 2.4 23.1
Tiruchirappalli 11,898 2.1 0.9 1.2 29.0
Tirunelveli 17,165 2.8 1.7 1.2 25.2
Tiruppur 11,796 2.2 0.7 1.5 61.7
Tiruvallur 21,460 2.8 2.0 0.8 89.7
Tiruvannamalai 14,509 2.7 1.8 0.9 69.7
Tiruvarur 6,106 1.9 1.1 0.8 55.4
Tuticorin 11,762 3.8 2.4 1.3 36.5
Vellore 20,589 2.5 1.5 1.1 42.5
Viluppuram 19,769 2.4 1.1 1.3 59.3
Virudhunagar 13,122 3.3 1.6 1.7 42.5
Tamil Nadu 403,890 2.6 1.3 1.2 40.3
Source: CMCHIS
Annex I
DISTRICT-LEVEL UTILIZATION RATE OF CMCHIS, BY SPECIALTY
Medical (%) Surgical (%) Diagnostics (%)

District
Government Private Government Private Government Private
Ariyalur 0.4 0.3 0.5 0.6 0.3 0.5
Chennai 1.0 0.3 1.0 0.5 1.0 0.3
Coimbatore 0.4 0.4 0.3 0.8 0.3 0.2
Cuddalore 0.4 0.4 0.3 0.6 0.3 0.4
Dharmapuri 0.5 0.2 0.3 0.7 0.4 0.6
Dindigul 0.5 0.4 0.3 0.8 0.2 0.5
Erode 0.2 0.3 0.2 0.8 0.4 0.5
Kancheepuram 0.5 0.3 0.6 0.5 0.5 0.3
Kanyakumari 0.5 0.4 0.5 0.6 1.3 1.5
Karur 0.4 0.2 0.3 0.7 0.2 0.4
Krishnagiri 0.3 0.2 0.2 0.5 0.3 0.6
Madurai 0.6 0.7 0.6 0.6 0.4 0.3
Nagapattinam 0.6 0.2 0.5 0.4 0.2 0.5
Namakkal 0.4 0.3 0.2 1.1 0.3 1.1
Perambalur 0.5 0.7 0.5 1.0 0.9 0.9
Pudukkottai 0.5 0.2 0.3 0.5 0.2 0.7
Ramanathapuram 1.2 0.5 0.4 0.5 0.4 0.8
Salem 0.4 0.3 0.4 0.9 0.3 0.1
Sivaganga 0.5 0.5 0.6 0.5 0.8 0.3
Thanjavur 0.5 0.2 0.5 0.5 0.2 0.3
The Nilgiris 0.4 0.2 0.3 0.5 0.1 0.3
Theni 0.5 0.3 0.5 0.8 0.5 1.7
Tiruchirappalli 0.4 0.3 0.4 0.7 0.2 0.4
Tirunelveli 0.8 0.2 0.6 0.5 0.5 0.7
Tiruppur 0.3 0.4 0.2 0.9 0.2 0.5
Tiruvallur 0.8 0.2 0.8 0.4 0.7 0.3
Tiruvannamalai 0.6 0.2 0.8 0.6 0.6 0.3
Tiruvarur 0.5 0.2 0.5 0.3 0.1 0.4
Tuticorin 1.0 0.2 0.7 0.5 1.0 0.9
Vellore 0.7 0.2 0.5 0.5 0.4 0.5
Viluppuram 0.4 0.4 0.5 0.7 0.4 0.3
Virudhunagar 0.7 0.3 0.5 0.6 0.5 1.1
Tamil Nadu 0.5 0.3 0.5 0.6 0.4 0.5
Source: CMCHIS
Annexes 59
Annex J
CLAIMS VOLUME AND VALUE BY AGE GROUP
Source: CMCHIS
Source: CMCHIS

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Nuts and Bolts of the Chief Minister’s

Comprehensive Health Insurance

World Bank Team

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Foreword (Principal Secretary) viii

Foreword (Project Director) ix

Chapter 2: Health in Tamil Nadu 4

Chapter 3: Covering People 12

Chapter 4: Deﬁning Beneﬁts 16

Chapter 5: Managing Money 21

Chapter 6: Improving Supply 29

Chapter 7: Strengthening Accountability 35

Chapter 8: Transition to PM-JAY 37

Chapter 9: Summary and Pending Agenda 43

Table of Contents iii

Annex A: Key Population Health Outcomes 46

Annex B: Universal Health Coverage 47

Annex D: Key Health Financing Indicators 50

Annex E: Tamil Nadu District-Level Variables: Population and Enrollment 51

Annex F: Tamil Nadu District-Level Variables: Facilities and Beds 52

Annex H: District-Level Utilization Rate of CMCHIS 58

Annex I: District-Level Utilization Rate of CMCHIS, by Specialty 59

Annex J: Claims Volume and Value by Age Group 60

AIDS Acquired Immunodeﬁciency Syndrome

ANC Antenatal Care

BMI Body Mass Index

BPL Below Poverty Line

CGHS Central Government Health Scheme

CHC Community Health Center

CMCHIS Chief Minister’s Comprehensive Health Insurance Scheme

DALY Disability-Adjusted Life Year

DPT Diphtheria, Pertussis, and Tetanus

EDC Empanelment and Disciplinary Committee

ENT Ear, Nose, and Throat

ESIS Employee State Insurance Scheme

EQUAS External Quality Assessment Scheme

GDP Gross Domestic Product

GNI Gross National Income

GSDP Gross State Domestic Product

HIV Human Immunodeﬁciency Virus

IHME Institute for Health Metrics and Evaluation

IPHS Indian Public Health Standards

IRDA Insurance Regulatory and Development Authority

LMIC Lower-Middle-Income Country

MFP Modern Family Planning

MIOT Madras Institute of Orthopedics and Traumatology

MMC Mortality and Morbidity Committee

MOU Memorandum of Understanding

MRI Magnetic Resonance Imaging

NABH National Accreditation Board of Hospitals

NFHS National Family Health Survey

NSSO National Sample Survey Organization

NQAS National Quality Assurance Standards

PM-JAY Pradhan Mantri’s Jan Arogya Yojana

RSBY Rashtriya Swasthya Bima Yojana

SDG Sustainable Development Goal

SECC Social-Economic Caste Census

SRS Sample Registration System

TNHSP Tamil Nadu Health Systems Project

TOB Non-Tobacco Use

TPA Third-Party Administrator

UHC Universal Health Coverage

Nuts&Bolts of CMCHIS

Nuts&Bolts of CMCHIS