Date of Award

January 2026

Document Type

Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Kaakpema Yelpaala

Abstract

Background and Objective. Across LMICs, a large share of the population falls outside both public subsidy and private coverage: neither poor enough for government insurance nor wealthy enough for reliable private care. This "missing middle" faces catastrophic expenditure and foregone care. Existing literature frames this as a financing/insurance design gap, yet barriers extend beyond price to delayed first contact, weak triage, incomplete referral, fragmented follow-up, travel costs, and lost wages, making the access gap organizational as well as financial. This paper examines whether cross-subsidized, distributed care delivery models can serve missing-middle populations in India, and the organizational conditions under which cross-subsidization supports operating sustainability.Methods. Desk-based qualitative design integrating structured literature review, a derived analytical framework, and comparative case analysis of two mature Indian cross-subsidy models in contrasting clinical verticals: L V Prasad Eye Institute and Narayana Health. Findings. Both organizations demonstrate access gains and sustain core services without continuous external subsidy, but solve for different parts of the patient pathway. LVPEI extends first-contact and routine care via community network, sustaining ~50% free care alongside 15-18% operating margins; referral non-compliance of 24-38% across tiers is a key limitation, which breaks pathway completion. Narayana Health compresses high-acuity care costs (open-heart surgery at ~$2,000 vs >$100,000 in the US) and subsidizes over half of inpatients while sustaining >20% India EBITDA margins, but its access mechanism activates only after patients reach the hospital. Cross-subsidy follows from delivery performance rather than driving it, and clinical vertical determines what can be distributed: first-contact care in ophthalmology, access infrastructure around a central hub in cardiac care. Limitations and Implications. The analysis is limited by reliance on two specific organizations, secondary evidence, and no patient-level disaggregation by missing-middle status. Within these constraints, it suggests that cross-subsidized distributed care can extend competent, affordable care where public financial protection remains incomplete, but is not a substitute for universal health coverage and cannot be assumed to transfer across clinical verticals. Evaluation is better served by disaggregating access into geographic, financial, and informational components rather than collapsing them into a single metric.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 09/16/2027

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