We wrote an FAQ on the Lok Pal Bill for Rediff. See http://www.rediff.com/news/slide-show/slide-show-1-all-you-wanted-to-know-about-the-lokpal-bill/20110808.htm The full text is reproduced below. What is the purpose of the Lok Pal Bill? The Bill seeks to establish an institution that will inquire into allegations of corruption against certain public functionaries. It establishes the office of the Lok Pal for this purpose. What is the composition of the Lok Pal? The Lok Pal shall consist of a Chairperson and up to eight members. The Chairperson, and at least half of the members have to be current or former judges of the Supreme Court or Chief Justices of High Courts. The other members will have at least 25 years experience in matters related to anti-corruption policy, vigilance, public administration, finance, law and management. Who selects the Lok Pal? The Selection Committee consists of the Prime Minister, Lok Sabha Speaker, the Leader of Opposition in each House of Parliament, a Union Cabinet Minister, a sitting Supreme Court Judge, a sitting High Court Chief Justice, an eminent jurist, a person of eminence in public life. The two judges on this Committee will be nominated by the Chief Justice of India. Who comes under the jurisdiction of the Lok Pal? There are seven categories of persons under the Lok Pal: (a) Prime Minister after demitting office; (b) current and former Ministers; (c) current and former MPs (d) all Group A officers of the central government; (e) all Group A equivalent officers or PSUs and other government bodies; (f) directors and officers of NGOs which receive government financing; (g) directors and officers of NGOs which receive funds from the public, and have annual income above a level to be notified by the government. The speech and vote of MPs in Parliament are exempt from the purview of the Lok Pal. What are the major powers of the Lok Pal? The Lok Pal has two major wings: investigation wing and prosecution wing. The Lok Pal can ask the investigation wing to conduct preliminary investigation of any offence alleged to be committed under the Prevention of Corruption Act, 1988. It can then conduct an inquiry. If the inquiry concludes that an offence was committed, the Lok Pal can recommend disciplinary action. It can also file a case in the Special Court. Does the Lok Pal need any prior sanction to initiate any action? No. The Bill states that the Lok Pal does not need prior sanction to inquire into an offence, or to initiate prosecution in the special court. What are special courts under this Bill? The central government is required to constitute special courts to hear and decide cases under this Bill. The Lok Pal shall recommend the number of such courts. What are the various time limits for conducting inquiry and trial? All preliminary investigation or inquiry must be completed within 30 days of the complaints (and can be extended for a further three months, with written reasons). The inquiry is to be completed within six months (extendable by six months). The trial is to be completed within one year of filing the case. This time may be extended by three months (and in further periods of three months each time) with written reasons, but the total time should not exceed two years. How can the Lok Pal be removed from office? The President may make a reference to the Supreme Court, (a) either on his own, or (b) if 100 MPs sign a petition, or (c) if a citizen makes a petition and the President is satisfied that it should be referred. If the Supreme Court, after an inquiry, finds the charge of misbehaviour was valid against the Chairperson or a Member and recommends removal, he shall be removed by the President. What are the provisions for the expenses of the Lok Pal? The Bill provides that all expenses will be charged, i.e., the amount will be provided without requiring a vote in Parliament. The Bill estimates recurring expenditure of Rs 100 crore per annum, and a non-recurring expenditure of Rs 50 crore. It also estimates a further Rs 400 crore for a building. What are the major differences from the Jan Lok Pal Bill drafted by Team-Anna? There are several differences. The composition of the Lok Pal and the selection process are different; the Jan Lok Pal draft included a search committee with civil society members to shortlist the eligible members of the Lok Pal. The Lok Pal had jurisdiction over the PM, the judiciary and all public servants (only Group A officers in the government Bill); it included the speech and vote of MPs in Parliament; it did not include NGOs. The Jan Lok Pal Bill provided that the investigation and prosecution wings of the CBI shall report to the Lok Pal for corruption cases. It also had penalties ranging from six months to life imprisonment (under the government Bill, the maximum imprisonment is derived from the Prevention of Corruption Act, 1988, and is 7 years).
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.
