| This month, PRS Legislative Research is 5 years old! The objective when we started out was to make the legislative process in India better informed, more transparent and participatory. From what started off as an idea, we believe we have made some progress towards our objective. - About 250 MPs across political parties have reached out to PRS for inputs on a range of issues that have come up in Parliament. In addition, there are a number of MPs who use PRS material for their preparation in Parliament, even though they have not contacted PRS for further inputs. - PRS has increasingly become a resource for the media as well. Over the past year, PRS has been cited on nearly 400 occasions by leading newspapers and websites as the source of information about legislation and Parliament. These are some of the milestones that we feel happy to have reached. But I want to really share are some of the learnings that we have had over these years. The first thing that we have learned is that many of us carry so many wrong perceptions about our MPs. Most of us don’t know that more than 80 percent of our MPs have college degrees. Most of us don’t know that the average attendance rate in Parliament is close to 80 percent in the past year. Most of us don’t know that Parliament has worked for more than 90 percent of the scheduled time in recent sessions, despite the undesirable disruptions in Parliament. There is a lot that is wrong with our politics, but we hope that some of these facts throw light about some lesser known aspects about our MPs. Laws are made for the really long term! That seems obvious, when we see examples such as our Indian Penal Code which was made in 1860, and the Land Acquisition Act that has haunted our country in recent years was passed in 1894. And these are just some examples. The fact is that if we do not debate our laws when they are being made, and citizens do not engage and provide inputs to this process, then we will be stuck with any issues that these laws might have for the next 100 years or more. So it is critical to get the laws as close to ‘right’ as possible when they are being passed. It is not obvious to most people that so many MPs put in significant effort to engage effectively in Parliament. Clearly, there is a selection bias, statistically speaking – I am talking of MPs who have reached out to us. Despite this selection bias, the point is that there are a number of MPs who take their work in Parliament seriously, even though they know that much of the work they do in Parliament has almost no bearing on their re-election prospects. (By the way, in most informal polls that I have done when I meet with groups of people, most do not know the role of an MP – even amongst some of the well educated groups.) Why do so many MPs still work hard to prepare for their work in Parliament, despite knowing that this work has no bearing on their re-election prospects? On this, we can only hypothesize. There are many MPs who understand their role as legislators and take it very seriously. There are MPs who feel that making a good point on an issue on the floor of Parliament is a way to establish their grasp of a certain issue to their colleagues in Parliament, but also to the larger world. For some others, it is a signalling device to their party colleagues about their interest and expertise in a certain subject area. And we have had MPs who have said, that they feel very good when other MPs, especially from other parties, compliment them for making a good point. All of these sound like good positive reasons for many MPs to want to be well prepared to speak in Parliament. We have begun to appreciate that the role of the MP in Parliament is very challenging. I can point to at least three reasons, which are independent of how educated or capable an MP might be: (a) The range of subjects in Parliament is so wide that no individual, however intelligent, can be fully conversant with all the subjects being discussed. (b) MPs have no research staff whatsoever, and are expected to do all of their preparatory work on their own, and (c) The constituency pressure on the MPs is often very high, making it difficult for them to pay adequate attention to their work in Parliament. We most certainly want more from our MPs and our Parliament. We want our MPs to meet for more days, find better ways to raise issues in Parliament than to disrupt proceedings, debate in more detail the laws that they pass. But what we have learned is that we cannot throw the baby out with the bath water. So, I am not suggesting that we can’t do better or that our MPs or our Parliament are perfect. The only way we will have a better Parliament is if we engage. And more people engage – from all walks of life. Policy making is not the exclusive preserve of either the expert or the policy maker. The policy process can be greatly strengthened if we participate in the process and ensure that our MPs know that we want effective laws to govern us and our children. Parliament can be made more effective by addressing some of the current bottlenecks. And some of these issues are not even difficult to fix. For example, can we have more people in the committee staff to support the work of the standing committees in Parliament so they can cover more ground in any given year? Can we have qualified research staff working for MPs so that they can go better prepared for Parliament? (Our Legislative Assistants to MPs – LAMPs programme has shown that it is hugely rewarding for young legislative assistants and the MPs if such a platform is created.) Can we have recorded voting on all legislative votes, instead of voice votes – the electronic button system is already in place to do this! These are just some examples… and we at PRS have a laundry list of ideas for strengthening Parliament – with varying degrees of difficulty. We have raised some of these issues in our Annual Conference of Effective Legislatures, and will continue to do so in the years ahead. A very BIG thanks to each of you for making PRS possible over these past five years… We hope that you will continue to bless and support us in the years ahead to help shape a more robust policy making process in India. | PRS PRODUCTS The Legislative Briefs are our flagship product. Each Brief analyses one Bill pending in Parliament. These are no longer than 6 pages and are sent to all MPs. We then get calls from MPs asking for more information/ clarification. Since earlier this year PRS has begun a Wednesday morning Policy Dialogue series exclusively for MPs. These are widely attended by MPs across parties. PRS is the knowledge partner to brief MPs in the Thursday morning Bill briefing sessions organised by the Constitution Club. PRS has reached out to about 1000 journalists across the country, through journalist workshops and direct engagement. PRS has started the Legislative Assistants to MPs (LAMPs) programme as a pilot initiative. Under the programme, participating MPs get a trained legislative assistant for a period of three Parliament sessions. PRS produces Primers to demystify Parliamentary process for citizens. These are widely used in our interactions with civil society groups. The Vital Stats series is a crisp two page document that often highlights interesting aspects of Parliament. They are very popular with journalists. PRS has nearly 1000 fans on Facebook and 2000 followers on Twitter, including some MPs. PRS has a Session Alert at the beginning of each session of Parliament. On the last day of each session, PRS releases two reports on the just concluded session: Parliament Session Wrap and Plan vs. Performance. PRS hosts an Annual Conference of Effective Legislatures each year to highlight certain aspects of the functioning of Parliament. PRS has compiled a free online database of all state laws across the country. This effort www.lawsofindia.org is the first effort of its kind in India. The PRS website www.prsindia.org has become an important resource for anyone tracking the Indian Parliament both within the country and abroad. |
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.
