The 2010 Commonwealth Games may have ended on October 14th, but the controversy surrounding the organising of the games is far from over. In Parliament, the Opposition has called for a Joint-Parliamentary Committee (JPC) to be formed to investigate suspected financial irregularities in the organising of the Games[1]. In a statement in Parliament on Tuesday, Minister for Youth Affairs & Sports M.S. Gill commented that “All irregularities will be examined and the guilty will not be spared”[2]. In July 2010, the Central Vigilance Commission (CVC) found irregularities in 14 Games related construction projects[3]. It has been reported that officials from the CVC now believe total misappropriation of Games Funds could be between Rs 5000 crore and Rs 8000 crore [4]. So what is being done about it? Currently, six different government organisations are conducting independent inquiries into financial irregularities, corruption, and mismanagement of the Games: the High Level (Shunglu) Commission, CVC, CAG, CBI, Income Tax Department, and Enforcement Directorate (ED). With so many government organisations involved, it can be difficult to decipher the big picture. Here is a breakdown of what each organisation is doing: High Level Commission (Shunglu Commission): The Commission was appointed by the Prime Minister on October 15th[5]. It is chaired by V.K. Shunglu, former Comptroller and Auditor General of India, who has been given the status equivalent to a Supreme Court Judge[6]. The Commission has a broad mandate to investigate all matters regarding the Games, specifically:[7]
A report from the Commission detailing its findings is expected by mid January. Central Vigilance Commission (CVC): The CVC first found financial irregularities in 14 Games projects in July 2010. Subsequently, it asked the CBI to register a corruption case against MCD officials in connection with a tender issued for a Games project[8]. In total, the CVC has found irregularities in 38 games related projects, under the following departments and agencies:[9]
The CVC has directed the above agencies to respond to queries regarding the irregularities and has directed the CBI to begin a Preliminary Inquiry into them [10]. The CVC will report its findings to the Shunglu Commission. Income Tax Department: The I-T Department is investigating tenders and awards of contracts for Games related works, as well as tax evasion [11]. It has conducted raids in offices of over 30 business firms and individuals [12]. Enforcement Directorate (ED): The ED is proceeding against Organising Committee officials for violations of the Foreign Exchange Management Act (FEMA) for projects involving venue development and overlays contracts awarded by the Organising Committee. Central Bureau of Investigation (CBI): It has been reported that the CBI had received over 300 complaints of corruption in Games projects by August 2010[13]. It is verifying these claims and investigating matters highlighted by the CVC. Comptroller and Auditor General (CAG): In August 2009, the CAG published a report entitled Preparedness for the XIX Commonwealth Games highlighting the lack of preparedness for the Games and its escalating cost. The CAG is conducting a detailed audit of the Games that is expected to be published in March 2011[14]. Given that CAG reports are tabled in Parliament, the March 2011 report will be critical to the Parliamentary debate on the Games. Two members of the Organising Committee, the Joint Director and the Deputy Director General, were arrested by the CBI this past Monday. However, Given that the report of the Shunglu Commssion is due in January 2011, the CAG audit will follow two months later, and the current Opposition demand for a JPC remains unresolved, it may be some time before significant details are made public.
[1] http://economictimes.indiatimes.com/news/politics/nation/BJP-to-press-for-JPC-probe-into-spectrum-Adarsh-CWG-scams/articleshow/6934697.cms [2] http://www.thehindu.com/news/article890174.ece [3] ttp://economictimes.indiatimes.com/news/news-by-industry/et-cetera/CVC-finds-irregularities-in-several-CWG-projects/articleshow/6229429.cms [4] http://www.deccanherald.com/content/105830/cwg-fraud-may-touch-rs.html [5] http://www.business-standard.com/india/news/games-over-pm-orders-probe-into-pre-event-mess/411739/ [6] http://economictimes.indiatimes.com/news/politics/nation/CWG-probe-Shunglu-given-status-of-SC-judge/articleshow/6818404.cms [7] http://pib.nic.in/newsite/PrintRelease.aspx?relid=66561 [8] http://timesofindia.indiatimes.com/city/delhi/CWG-construction-CVC-asks-CBI-to-register-corruption-case/articleshow/6237714.cms [9] http://www.hindustantimes.com/specials/sports/cwg-2010/22-more-CWG-works-under-CVC-scanner/CWG2010-TopStories/SP-Article10-614446.aspx [10] http://www.indianexpress.com/news/Claiming-fraud---favour-in-Games-rentals--CVC-to-CBI--begin-probe/700998/ [11]http://www.indianexpress.com/news/it-dept-collects-cwg-works-related-documents/698683/ [12] http://www.thehindu.com/news/national/article837892.ece [13] http://www.indianexpress.com/news/cbi-has-over-300-complaints-regarding-games-works/655692/ [14] http://economictimes.indiatimes.com/news/politics/nation/CAG-starts-Commonwealth-Games-audit-report-by-March-2011/articleshow/6252852.cms
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.
