According to news reports (see here and here), the Cabinet approved four Bills for discussion in Parliament. The Bills cleared for consideration and passing are: the Copyright (Amendment) Bill, 2010; the National Accreditation Regulatory Authority for Higher Educational Institutions Bill, 2010 and the Protection of Women against Sexual Harassment at Work Place Bill, 2010. It cleared the Universities for Research and Innovation Bill, 2012 for introduction in Parliament. In this post, we discuss the key provisions of the Bills and the recommendations made by the Standing Committee on Human Resource Development (HRD). The Copyright (Amendment) Bill, 2010 The Bill was introduced on April 19, 2010 in the Rajya Sabha and referred to the Standing Committee on HRD, which tabled its report on November 23, 2010. The government had attempted to pass it in the Winter session twice. However, the Opposition raised the issue of conflict of interest. The Rules of the Ethics Committee state that a MP has to declare his personal or pecuniary interest in a matter, which is under discussion in the Rajya Sabha. The MPs contended that the HRD Minister, Kapil Sibal, could not pilot the Bill without declaring his interest. They argued that his son was the lawyer for a music company which is party to a legal dispute with TV broadcasters to which the amendment would apply (see here for debate on the issue in Parliament). The Copyright Act, 1957 defines the rights of authors of creative works such as books, plays, music, and films. Two key amendments proposed in the Bill are: - Copyright in a film currently rests with the producer for 60 years. The Bill vests copyright in a director as well. - The Bill makes special provisions for those whose work is used in films or sound recordings (e.g. lyricists or composers). Rights to royalties from such works, when used in media other than films or sound recordings, shall rest with the creator of the work. (See here for PRS analysis of the Bill) Key recommendations of the Standing Committee: (a) Drop the provision that makes the principal director the author of a film along with the producer; and (b) Keep the provisions for compulsory licensing in line with the terms of international agreements. (See here for PRS Standing Committee Report summary) The National Accreditation Regulatory Authority for Higher Educational Institutions Bill, 2010 The Bill was introduced on May 3, 2010 in the Lok Sabha and referred to the Standing Committee on HRD, which tabled its report on August 12, 2011. This Bill is part of the government’s attempt to reform the higher education sector. The key objective is to provide an effective means of quality assurance in higher education. Presently, accreditation is voluntary. Higher educational institutions are accredited by two autonomous bodies set up by the University Grants Commission and the All India Council of Technical Education. The Bill makes it mandatory for each institution and every programme to get accredited by an accreditation agency. The agencies have to be registered with the National Accreditation Regulatory Authority. Only non-profit, government controlled bodies are eligible to register as accreditation agencies. (See here for PRS analysis of the Bill) The Standing Committee made some recommendations: (a) assessment for accreditation should start after two batches of students have passed out of the institution; (b) there should be specific provisions for medical education; and (c) registration to accreditation agencies should initially be granted for five years (could be extended to 10 years). (See here for PRS Standing Committee Report summary) The Protection of Women against Sexual Harassment at Work Place Bill, 2010 The Bill was introduced on December 7, 2010 in the Lok Sabha and referred to the Standing Committee on HRD, which tabled
its report on December 8, 2011. The Indian Penal Code covers criminal acts that outrage or insult the 'modesty' of women. It does not cover situations which could create a hostile or difficult environment for women at the work place. The Supreme Court in 1997 (Vishaka judgment) laid down guidelines to protect women from sexual harassment. This Bill defines sexual harassment and provides a mechanism for redressing complaints. The protection against sexual harassment is applicable to all women at the workplace. However, the Bill does not cover domestic workers working at home. (See here for PRS analysis of the Bill) The Standing Committee recommendations addressed issues of gender neutrality, inclusion of domestic workers and the modified definition of sexual harassment. (See here for PRS Standing Committee Report summary) The Universities for Research and Innovation Bill, 2012 The Bill was cleared by the Cabinet and is likely to be introduced in Parliament this session. It seeks to provide for the establishment and incorporation of Universities for Research and Innovation. These universities shall be hubs of education, research and innovation. Although an official copy of the Bill is not yet available, newspaper reports suggest that this is an omnibus law under which innovation universities (focused on specific research areas such as environment, astrophysics and urban planning) shall be established. In India, a university can only be set up through an Act of Parliament or state legislature. The Planning Commission’s Working Group on Higher Education report stated that these universities could be funded by the private sector as well. The government aims to create 14 innovation universities, which would be world class.
The Union Cabinet recently approved the launch of the National Health Protection Mission which was announced during Budget 2018-19. The Mission aims to provide a cover of five lakh rupees per family per year to about 10.7 crore families belonging to poor and vulnerable population. The insurance coverage is targeted for hospitalisation at the secondary and tertiary health care levels. This post explains the healthcare financing scenario in India, which is distributed across the centre, states, and individuals.
How much does India spend on health care financing vis-à-vis other countries?
The public health expenditure in India (total of centre and state governments) has remained constant at approximately 1.3% of the GDP between 2008 and 2015, and increased marginally to 1.4% in 2016-17. This is less than the world average of 6%. Note that the National Health Policy, 2017 proposes to increase this to 2.5% of GDP by 2025.
Including the private sector, the total health expenditure as a percentage of GDP is estimated at 3.9%. Out of the total expenditure, effectively about one-third (30%) is contributed by the public sector. This contribution is low as compared to other developing and developed countries. Examples include Brazil (46%), China (56%), Indonesia (39%), USA (48%), and UK (83%) (see Figure 1).
Who pays for healthcare in India? Mostly, it is the consumer out of his own pocket.
Given the public-private split of health care expenditure, it is quite clear that it is the private expenditure which dominates i.e. the individual consumer who bears the cost of her own healthcare. Let’s look at a further disaggregation of public spending and private spending to understand this.
In 2018-19, the Ministry of Health and Family Welfare received an allocation of Rs 54,600 crore(an increase of 2% over 2017-18). The National Health Mission (NHM) received the highest allocation at Rs 30,130 crore and constitutes 55% of the total Ministry allocation (see Table 1). Despite a higher allocation, NHM has seen a decline in the allocation vis-à-vis 2017-18.
Interestingly, in 2017-18, expenditure on NHM is expected to be Rs 4,000 crore more than what had been estimated earlier. This may indicate a greater capacity to spend than what was earlier allocated. A similar trend is exhibited at the overall Ministry level where the utilisation of the allocated funds has been over 100% in the last three years.
State level spending
A NITI Aayog report (2017) noted that low income states with low revenue capacity spend significant lower on social services like health. Further, differences in the cost of delivering health services have contributed to health disparities among and within states.
Following the 14th Finance Commission recommendations, there has been an increase in the states’ share in central pool of taxes and they were given greater autonomy and flexibility to spend according to their priorities. Despite the enhanced share of states in central taxes, the increase in health budgets by some states has been marginal (see Figure 2).
Consumer level spending
If cumulatively 30% of the total health expenditure is incurred by the public sector, the rest of the health expenditure, i.e. approximately 70% is borne by consumers. Household health expenditures include out of pocket expenditures (95%) and insurance (5%). Out of pocket expenditure dominate and these are the payments made directly by individuals at the point of services which are not covered under any financial protection scheme. The highest percentage of out of pocket health expenditure (52%) is made towards medicines (see Figure 3).
This is followed by private hospitals (22%), medical and diagnostic labs (10%), and patient transportation, and emergency rescue (6%). Out of pocket expenditure is typically financed by household revenues (71%) (see Figure 4).
Note that 86% of rural population and 82% of urban population are not covered under any scheme of health expenditure support. Due to high out of pocket healthcare expenditure, about 7% population is pushed below the poverty threshold every year.
Out of the total number of persons covered under health insurance in India, three-fourths are covered under government sponsored health schemes and the balance one-fourth are covered by private insurers. With respect to the government sponsored health insurance, more claims have been made in comparison to the premiums collected, i.e., the returns to the government have been negative.
It is in this context that the newly proposed National Health Protection Mission will be implemented. First, the scheme seeks to provide coverage for hospitalisation at the secondary and tertiary levels of healthcare. The High Level Expert Group set up by the Planning Commission (2011) recommended that the focus of healthcare provision in the country should be towards providing primary health care. It observed that focus on prevention and early management of health problems can reduce the need for complicated specialist care provided at the tertiary level. Note that depending on the level of care required, health institutions in India are broadly classified into three types: primary care (provided at primary health centres), secondary care (provided at district hospitals), and tertiary care institutions (provided at specialised hospitals like AIIMS).
Second, the focus of the Mission seems to be on hospitalisation (including pre and post hospitalisation charges). However, most of the out of the pocket expenditure made by consumers is actually on buying medicines (52%) as seen in Figure 3. Further, these purchases are mostly made for patients who do not need hospitalisation.
