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.
On March 22, Bihar registered its first two cases of the new coronavirus disease (COVID-19), one of whom died the same day. Since then, the number of cases has increased steadily. As of April 19, Bihar has 86 confirmed cases of COVID-19, of which 47 are active cases and 37 have recovered. 33 new cases have been registered since last week. One more death has been registered since March 22.
Given the highly contagious nature of the disease, on March 22, the Government of Bihar announced a state-wide lockdown till March 31. This was followed by a nation-wide lockdown enforced by the central government between March 25 and April 14, now extended up to May 3. During the lockdown, severe restrictions have been placed on the movement of individuals. Establishments have remained closed, except those providing essential goods and services. Restrictions are likely to be relaxed in less-affected districts post-April 20.
In this blog, we look at key measures taken by the state government in response to COVID-19 so far.
Early-stage: screening of travellers, awareness on precautionary measures
The initial responses from the state government were aimed towards: (i) raising awareness about precautionary measures to be taken against the disease, and (ii) screening of international travellers. In this context, on February 25, the Bihar State Health Society issued advisories for: (i) measures to be taken in schools and colleges, and (ii) reporting of airline passengers and tourists with symptomatic cases to the district health administration. On March 11, 104 Call Centre was designated as the COVID-19 control room, to address public queries related to the disease.
Prior to lockdown: limiting mass gatherings, mobilisation of the public health system
Limiting mass gatherings
Between March 13 and March 18, the state government issued orders to shut down various premises until March 31. These include Anganwadi centres, educational institutions, and commercial establishments such as cinema halls, parks, and shopping malls. The government staff was directed to come to office on alternate days. Gathering of more than 50 persons at one place was prohibited including any mass family gathering (except marriages). The transport department was asked to restrict both public and private transport.
Healthcare measures
On March 13, the government issued directions to: (i) ensure availability of 100 extra ventilators in the government hospitals, (ii) arrange for testing of COVID-19 in AIIMS, Patna and PMCH, Patna hospitals, and (iii) cancel leaves of all employees of the Health Department, and (iv) strengthen screening of travellers entering through the Bihar-Nepal border.
On March 17, the Health Department issued The Bihar Epidemic Diseases, COVID-19 Regulation 2020 under The Epidemic Diseases Act, 1897. The Act provides for better prevention of the spread of dangerous epidemic diseases. These regulations specify the protocol to be followed in both private and government hospitals for screening and treatment of COVID-19 patients. It also empowers the district administration to take containment measures including sealing of specific areas and conducting surveillance for COVID-19 cases. It makes spreading of rumour or unauthenticated information with mala fide intent a punishable offence.
Welfare measures
On March 16, the Chief Minister announced that treatment costs for COVID-19 for residents of Bihar will be sponsored from the Chief Minister Medical Assistance Fund. Moreover, the state government will provide assistance of four lakh rupees to the family of a person dying due to COVID-19.
The government issued directions to provide direct cash transfer in place of the food provided under the Mid-Day Meal scheme in schools, and at Anganwadi centres.
Essential goods and services
On March 21, the Food and Consumer Protection Department directed the district administration to ensure implementation of the Bihar Essential Article (Display of Prices and Stocks) Order, 1977. The Order requires sellers of specified items to display stock and price for the public’s reference. The specified items include food items, edible oilseeds, and petroleum products. The Department also directed the district administration to send proposals for adding any new items to the list of specified items.
During lockdown: strengthening medical response, welfare measures
Upon announcement of the lockdown on March 22, state-level and district-level coordination committees were set up. During the lockdown, the state government’s measures have been aimed towards: (i) strengthening the medical response in the state, (ii) providing relief to various sections of society from issues being faced during the lockdown, and (iii) addressing difficulties with the supply of essential goods and services.
Healthcare measures
On March 25, the Health Department constituted the Bihar COVID-19 Emergency Response Team which is responsible for the control and coordination of all health-related response.
Protocols for containment and treatment: Directions have been issued to implement several guidelines related to containment and treatment measures. These include: (i) set up and operationalization of isolation centres and quarantine centres, (ii) containment plan to address local transmission and community transmission through cluster containment strategy, (iii) surveillance program for Influenza-like Illness (ILI) and Severe Acute Respiratory Illness (SARI), (iv) handling of waste generated during treatment/diagnosis/quarantine, and (v) sanitation of residence and nearby areas of a COVID-19 positive person.
Door-to-door screening campaign: On April 14, the Chief Minister issued directions to start door-to-door screening campaign for suspected cases in affected districts including Siwan, Begusarai, and Nalanda. Such screening campaign will also be run in districts in border-areas, and an area within 3 km radius of the residence of COVID-19 positive patients.
Increasing manpower: The government invited medical professionals including doctors, nurses, and paramedics to volunteer. It also directed the district administration to engage retired doctors, nurses, and paramedics from defence services for volunteer work. Leaves of all employees of the Health Department were cancelled until April 30. The Health Department deputed AYUSH practitioners to assist at isolation and quarantine centres.
Dedicated infrastructure for COVID-19: On April 5, certain government hospitals were designated as exclusive hospitals for treatment of COVID-19 patients. The Health Department also directed certain big private hospitals in Patna to stop OPD services.
Other health-related measures: On March 23, the state government announced payment of one-month basic salary as an incentive to all doctors and health workers. On April 13, the Health Department issued an order prohibiting spitting in public places by tobacco, cigarette, and Pan users. Further, the state government announced that it will procure test kits from the private sector.
Welfare measures
Relief package: On March 23, the state government announced a relief package for people affected due to lockdown. Key features of the relief package are:
ration of one-month to all ration cardholders for free,
one-time cash transfer of Rs 1,000 per family to ration cardholders,
payment of pensions for three months in advance to all pensioners including pension for old age persons, widows, and physically challenged, and
release of pending scholarships to all students.
Help for migrants: On March 26, Rs 100 crore was allocated from the Chief Minister Relief Fund to provide aid to the migrants from Bihar stuck in other parts of the country due to the lockdown. On April 2, the state government announced that a one-time cash transfer of Rs 1,000 will be provided to the migrants. On April 13, an additional Rs 50 crore was allocated from the Relief Fund for this purpose. State-wise nodal officers have been appointed for coordination of relief efforts for migrants. The state government is running 10 food centres in Delhi to help migrants from Bihar.
Relief camps: On March 28, the state government decided to start relief camps along the border (including Nepal border) offering food, shelter, and medical help to persons coming in the state. Community kitchens and relief camps have been started in government school campuses to provide food and shelter.
Electricity tariff: On April 8, the State Cabinet approved the proposals for: (i) reducing electricity tariff for domestic and agricultural consumers by 10 paise per unit and (ii) waiving the monthly meter fee.
Measures for businesses and agricultural activities
The state government provided certain relaxations to businesses in matters related to taxation. These include:
extension in the deadline for payment of GST from March 31 to June 30, no interest or penalty charges to be levied for late payment in certain cases,
three-month extension in the deadline for one-time settlement scheme for pre-GST tax disputes, and
cancellation of orders regarding attachment of bank accounts of certain tax defaulters.
On April 16, the Chief Minister issued directions to start procurement of wheat through the Primary Agriculture Credit Society (PACS).
Essential goods and services
Various departments issued guidelines to the district administration to facilitate operational continuity of essential goods and services including (i) food items, (ii) seeds, fertilisers, and other agriculture-related items, (iii) livestock fodder, and (iv) petroleum products.
On March 27, the Food and Consumer Protection Department brought certain new items under the purview of The Bihar Essential Article (Display of Prices and Stocks) Order, 1977. These include: (i) wheat and wheat products, (ii) masks and hand sanitisers, and (iii) potato and onion.
Other Measures
Education: On April 8, the cabinet approved the proposal to promote students of Class I to XI (except class X) without annual examination.
Legislature: Salaries of MLAs and MLCs have been reduced by 15% for one year. The amount will be donated to the state’s Corona relief fund.
Labour and employment: On April 16, the Chief Minister issued directions to resume public works under the Saat Nischay Programme, Jal Jeevan Hariyali Yojana, and MNREGA.
For more information on the spread of COVID-19 and the central and state government response to the pandemic, please see here.
