As of April 23, Delhi has 2,248 cases of COVID-19. After Maharashtra and Gujarat, Delhi has the highest number of cases in the country. On March 22, when the number of cases rose to 29, the Delhi government announced lockdown in the state until March 31, to contain the spread of COVID-19. This has been followed by a nation-wide lockdown by the central government between March 25 and May 3. In this blog, we summarise some of the key measures taken by the state government in response to COVID-19 so far.
Before the lockdown
On March 8, with three cases of COVID-19 in the state, the Department of Health and Family Welfare decided to carry out an awareness drive at various crowded places during Holi. Along with it, the government also took several other steps for mitigating the spread of COVID-19 in the state. Some of these measures are summarised below.
Health Measures
Disinfecting the vehicles: On March 11 and 12, the government ordered to disinfect minibuses, school buses and school cabs daily.
The Delhi Epidemic Diseases, COVID-19 Regulations, 2020: On March 12, with six cases of COVID-19, the Delhi government notified The Delhi Epidemic Diseases, COVID-19 Regulations, 2020. These regulations are valid for a year. Key provisions include:
(i) All government and private hospitals should have dedicated flu corners.
(ii) home quarantine for people who have travelled through the affected areas, and
(iii) Certain persons authorised under the Regulations, with the approval of the State Task Force, 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.
Movement Restrictions
Educational institutions: On March 12, the government ordered the closure of all educational institutions up to March 31. The students writing examinations were allowed to attend them along with the staff. However, on March 19, the government ordered the postponement of exams until March 31.
Public gatherings:
Restaurants and private establishments: On March 19, all restaurants were ordered to discontinue sitting arrangements until March 31. Private establishments were ordered to allow their employees to work from home till March 31.
Delhi-Kathmandu bus service: On March 20, the government suspended the Delhi-Kathmandu bus service, officially known as the Maitri Bus Sewa.
During the lockdown
On March 22, when the number of cases rose to 29, the Delhi government announced the lockdown in the state until March 31. The lockdown involved: (i) suspending the public transport services, (ii) sealing borders with Haryana and Uttar Pradesh, (iii) suspending all domestic and international flights arriving in Delhi, and (iv) banning the congregation of more than five persons at any public place. This was followed by a nation-wide lockdown enforced by the central government between March 25 and April 14, now extended till May 3.
Starting from April 20, the central government allowed certain activities in less-affected districts of the country. However, the Delhi government, on April 19, announced that there will not be any relaxation in the lockdown in Delhi, until another comprehensive assessment which will be made on April 27.
Welfare Measures
The Delhi government announced several welfare measures to address the difficulties being faced by people during the lockdown. Key measures include:
Night shelters: The Delhi Urban Shelter Improvement Board is providing free meals to the homeless people staying in the night shelters. On March 25, a hunger helpline was set up which directs the needy people to the nearest night shelter for food.
Hunger Relief Centers: On March 26, the government directed the District Magistrates to set up at least two hunger relief centres in every municipal ward for providing 500 meals twice (lunch and dinner) every day at each centre.
Financial assistance: The government is providing one-time financial assistance of Rs 5,000 to drivers of vehicles such as autos, taxis, and e-rickshaws.
Compensation to family members: The Delhi government will be giving compensation of one crore rupees to the family members of the employees who may die due to COVID-19.
Health Measures
Additional manpower: On March 24, the government ordered the hospitals and institutions under the Department of Health and Family Welfare to engage up to 25% additional manpower in outsourced services such as sanitation, security, and nursing assistants.
Wearing masks made compulsory: On April 8, the government made it compulsory for all people to wear masks in public places, offices, gatherings, meetings, and personal vehicles.
Identification of paid quarantine facilities: On April 13, the government ordered all district magistrates to identify paid quarantine facilities in their respective districts for housing the people who would like to use private facilities on payment basis.
Creation of a multi-sectoral dedicated team: On April 13, the government ordered for the creation of the Corona Foot Warriors and Containment Team at every booth. The government aims to enhance ground level intervention through them.
Setting up Helpline: On April 17, the Department of Health and Family Welfare set up a dedicated 24x7 Whatsapp number for receiving complaints and requests from the people related to COVID-19.
Measures related to Media
The government took the following steps to control the spread of fake news related to COVID-19:
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.
