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The President addressed the Parliament after the 2009 Lok Sabha Elections on 4th June 2009. She also addressed Parliament on 22nd February 2010, as well as on 21st February 2011. The tables below highlight some items from the agenda of the central government as outlined in these speeches, as well as the initiatives undertaken with respect to these agenda items. Table 1: Some Items from the President’s Address to Parliament on 4th June 2009
Agenda Items outlined in the President’s Speech | Current Status |
Establishment of National Counter-Terrorism Centre | Proposed launch of NCTC in March 2011 on hold |
Enactment of legislation for prevention of communal violence | Communal Violence Bill 2005 pending in Parliament. New bill drafted by NAC but not introduced in Parliament |
Unique Identity Card scheme to be implemented in three years | Unique Identification Authority of India created under Planning Commission on 28 January 2009. Bill to give statutory status pending in Parliament |
Establishment of a regulator for the pension sector | Bill introduced in Lok Sabha on 24 March 2011 |
Convergence of NREGA with other programs; expansion of works permitted; independent monitoring and grievance redressal | |
Rashtriya Swasthya Bima Yojana to cover all families below the poverty line in five years | |
Enactment of Right to Free and Compulsory Education Bill | Bill passed in 2009 and brought into force on 1 April 2009 |
Madhyamik Shiksha Abhiyan to universalize access to secondary education | Rashtriya Madhyamik Shiksha Abhiyan launched in March 2009 |
National Mission for Female Literacy to make every woman literate in five years | National Literacy Mission recast in 2009 to focus on female literacy |
Construction of 1.2 crore rural houses under Indira Awas Yojana in five years | |
Introduction of Rajiv Awas Yojana for slum dwellers and urban poor | Phase I approved by Cabinet on 2 June 2011 |
Enactment of National Food Security Act | Introduced in Lok Sabha on 22 December 2011 |
Enactment of Amendment Bill to Land Acquisition Act and Rehabilitation and Resettlement Bill | Land Acquisition, Rehabilitation and Resettlement Bill 2011 introduced in Lok Sabha on 7 September 2011 |
Enactment of Women’s Reservation Bill | Passed by Rajya Sabha, pending in Lok Sabha |
Constitutional Amendment for 50 percent reservation for women in panchayats and urban local bodies | Two Bills introduced in Lok Sabha in November 2009; both pending in Parliament |
Amendment of RTI to provide for disclosure by government in all non-strategic areas | |
Model Public Services Law to be drawn up in consultation with states | Right of Citizens for Time Bound Delivery of Goods and Services and Redressal of their Grievance Bill, 2011 introduced in Lok Sabha on 20 December 2011 |
Introduction of Goods and Services Tax | Constitutional Amendment Bill introduced in Lok Sabha on 22 March 2011 |
National Council for Human Resources in Health | Introduced in Rajya Sabha on 22 December 2011 |
National Council for Higher Education | Bill introduced in Rajya Sabha on 28 December 2011 |
*Note: Blank cells indicate that PRS has not been able to find official information in the public domain. Table 2: Some Items from the President’s speech to Parliament on 22nd February 2010
Agenda Items outlined in the President’s Speech | Current Status |
Introduction of legislation to ensure food security | Introduced in Lok Sabha on 22 December 2011 |
Rural teledensity of 40 percent by 2014 | Rural teledensity of 33% as of February 2011 |
Introduction of Rajiv Awas Yojana for urban poor and slum dwellers | Phase I approved by Cabinet on 2 June 2011 |
Disposal of remaining claims under the Scheduled Tribes and Other Traditional Forest Dwellers Act | |
Introduction of amendment to the Wakf Act | Passed by Lok Sabha; pending in Rajya Sabha |
Enactment of Communal Violence (Prevention, Control and Rehabilitation of Victims) Bill, 2005 | Pending in Rajya Sabha since 2005 |
Enactment of Women’s Reservation Bill | Passed by Rajya Sabha; pending in Lok Sabha |
Constitutional amendments for 50 percent reservation for women in panchayats and urban local bodies | Two Bills introduced in Lok Sabha in November 2009; both pending in Parliament |
Establishment of National Council for Higher Education and Research | Higher Education and Research Bill, 2011 introduced in Rajya Sabha on 28 December 2011 |
Legislation for facilitating participation of foreign academic institutions in the education sector | Foreign Educational Institutions Bill, 2010 introduced in Lok Sabha on 3 May 2010 |
Voting rights for Indian citizens living abroad | Bill passed. NRIs can vote at the place of residence that is mentioned in their passport |
Table 3: Some Items from the President’s speech to Parliament on 21st February 2011
Agenda Items outlined in the President’s Speech | Current Status |
Enactment of Food Security Law | Introduced in Lok Sabha on 22 December 2011 |
Whistleblower Bill | Bill passed by Lok Sabha; pending in Rajya Sabha |
Enactment of Judicial Standards and Accountability Bill | Introduced in Lok Sabha on 1 December 2010 |
Enactment of new Mines and Minerals Bill | Introduced in Lok Sabha on 12 December 2011 |
Rural teledensity of 40 percent by 2014 | Rural teledensity of 33% as of February 2011 |
Construction of 1.2 crore rural houses during 2009-14 | |
Enactment of Women’s Reservation Bill | Passed by Rajya Sabha; pending in Lok Sabha |
Introduction of Bill regarding protection of children from sexual offences | Introduced in Rajya Sabha on 23 March 2011 |
Introduction of Biotechnology Regulatory Authority of India Bill | Not introduced till date |
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.