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As of May 5, Assam has 43 confirmed cases of COVID-19. Of these, 32 have been cured, and 1 person has died. In this blog, we summarise some key decisions taken by the Government of Assam until May 5 for containing the spread of the pandemic in the state.
Movement Restrictions
For containing the spread of COVID-19 in the state, the Government of Assam took the following measures for restricting the movement of people in the state. On March 19, the Department of Health and Family Welfare issued an order for closure of all museums, libraries, coaching centers among others until March 31.
Lockdown: To further restrict the movement of individuals, in order to contain the spread of the disease, the state government enforced a state-wide lockdown from March 24 to March 31. The lockdown involved: (i) sealing the state borders, (ii) suspension of public transport services, (iii) closure of all commercial establishments, offices, and factories, and (iv) banning the congregation of more than five people at any public place. Establishments providing essential goods and services were excluded from the lockdown restrictions. Limited rituals were allowed in places of worship without any community participation.
This was followed by a nation-wide lockdown enforced by the central government between March 25 and April 14, now extended till May 18. Starting from May 4, based on the Ministry of Home Affairs guidelines, the state government has allowed certain activities with restrictions in green zones of the state. Activities such as e-commerce for all commodities, construction activities in urban areas, functioning of government and private offices among others are being allowed in green zones.
Health Measures
The Assam COVID-19 regulations, 2020: On March 18, the government issued the Assam COVID-19 regulations, 2020. These regulations are valid for one year. Key features of the regulations are as follows:
All government and private hospitals should have separate corners for the screening of COVID patients. Further, they should record the travel history of such persons during screening,
No hospital can refuse the treatment of suspected/ confirmed COVID-19 cases,
People travelled through affected areas must voluntarily report to the authorities, and
District administration can take necessary measures to contain the spread of COVID-19, such as (i) sealing a geographical area, (ii) restricting the movement of vehicles and people, and (iii) initiating active and passive surveillance of COVID-19 cases.
The Assam COVID-19 Containment Regulations, 2020: On March 21, the government issued the Assam COVID-19 Containment Regulations, 2020. These regulations detail the measures to be taken in case of community transmission within a geographical area. These include enhanced active surveillance, testing of all suspected cases, isolation of cases and home quarantine of contacts, among others.
Guidelines to Airports: On March 18, the government issued instructions regarding procedures to be followed at the airports for the screening of passengers. The guidelines allocate responsibilities such as thermal screening of passengers, counselling, transportation of passengers among others to various teams at the airports.
Medical colleges and Hospitals: On March 23, the Department of Health and Family Welfare directed all medical colleges and district hospitals to set up isolation wards. On March 27, the Department of Health and Family Welfare released measures to be followed in medical colleges and hospitals. These include: (i) seven days of training on critical care to all doctors, nurses, final year students of bachelor programs and Postgraduate students, (ii) Principals should set up a core team in every college for managing COVID-19 patients, among others.
Welfare measures
Food distribution: On March 28, the government decided to provide gratuitous relief such as rice, pulses among others to all wage earners, slum dwellers, rickshaw pullers, homeless, and migrant labourers living in municipal towns for seven days.
Minor Forest Produce (MFP): For enhancing the income of tribal farmers, the government revised rates of 10 MFPs such as honey, hill broom and added 26 new MFPs for Minimum support price in the state.
One-time financial assistance for persons stranded outside India: On March 22, the government announced one-time financial assistance of $2,000 to residents of Assam stranded in foreign countries. People who went abroad 30 days before the stoppage of international flights (on March 22) and are unable to return will receive this financial assistance.
Administrative measures
On March 21, the government constituted the task force at the State level and District level for implementation of various measures for containment of COVID-19 in the state.
On April 2, the government constituted a committee for monitoring and checking of fake news across all forms of media.
On April 29, the Department of Finance announced certain austerity measures in the context of the fiscal situation that arose due to COVID-19. These include suspension of MLA area development funds from April to July 2020, reduction in establishment expenditure, and a ban on the purchase of vehicles by the government (except ambulances and for policy duty).
For more information on the spread of COVID-19, and the central and state government response to the pandemic, please see here.
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.
