Given the poor performance of public healthcare and the perceived high quality of private healthcare, the private health sector occupies more than 70 percent of the market share and is expanding with a growing preference even among the low income groups.  However, such an expansion will not be costless. Due to the high cost of skilled manpower along with huge capital investment and the thriving profit motive, the price is expected to increase further. Not only there are hardly any pricing criteria for healthcare services but also no benchmark as to how much care is required by patients for each category of illness. Additionally, there is high probability for supplier-induced-demand; for an ideal healthcare manager a vacant bed has to be occupied and CT scan equipments fully utilized. In a country where 72 percent of the health expenditure is Out-of-Pocket spending, people at the bottom of the pyramid will be severely hit by such a cost escalation. In fact, access to healthcare is not only a problem for below poverty line (BPL) but also for above poverty line (APL) categories.
Much discussion has been evolving around the Private�Public partnership (PPP) paradigm for an inclusive healthcare system; let�s elaborate the same with Community participation and Health Insurance (HI). The concept is not alien to India and already several community organizations are experimenting with different delivery models. Nobody can deny the importance of HI however, only around 3 percent of Indians, mostly belonging to the formal sector, have some forms of HI coverage. Community can play a vital role here. The added advantage of community involvement is that a group of people acting as a cohesive social unit can relate, better than any outsider, to the needs and priorities of the target population, location-specific conditions, prevalent activities and level of resources. Each community can be organized at the village level in coordination with other stakeholders such as NGOs, SHGs and PRIs; form an independent village healthcare committee with sub-committees to deal with various issues: negotiation with insurance companies and healthcare providers, premium collection and utilization, monitoring and claim settlement. Each community can negotiate with the insurance companies to design �tailor-made� HI schemes reflecting their health risk profiles, prevailing healthcare infrastructure and affordability of premium incorporating seasonal fluctuations in income. Further, to make the partnership sustainable, communities and insurance companies can enter into mutual agreements on sharing the profit or loss arising out of the insurance contract. Nevertheless, a community can negotiate with private healthcare providers to ensure quality care at reasonable price, and also with the stakeholders of public healthcare system to get quality services. From a government perspective, it can implement not only the various government HI programmes for the poor, for e.g., UHI for the BPL, but with a strong decentralized component by integrating initiatives like NRHM & NUHM with community participation.
The fundamental issues for the low level of HI penetration in India like low awareness, poor trust on insurance companies over reimbursement, inability to deal with insurance company etc. can be overcome to some extent by the community centered-public-private partnership. Moreover, the inherent problem of asymmetric information on relevant parameters for relations among the stakeholders in HI business resulting in �adverse selection� (tendency of relatively more unhealthy people buying HI) and �moral hazards� (over utilization of healthcare due to HI coverage) can also be controlled. Above all, the practice of considering HI as something on the top of the health pyramid can be revoked and transformed into an integral part of the existing healthcare system through active community involvement.