There are indications that the Lok Pal Bill, 2011 is likely to be taken up for consideration and passing during the current Winter session of Parliament. The Bill was introduced on Aug 4, 2011 in the Lok Sabha after a prolonged agitation led by Anna Hazare (see PRS analysis of the Bill). It was referred to the Parliamentary Standing Committee on Personnel, Public Grievances, Law and Justice (see PRS note on Committee Systems). The Committee submitted its report on December 9, 2011. The report includes 10 dissent notes from 17 MPs. (a) Kirti Azad, Bal Apte, D.B. Chandre Gowda, Harin Pathak, Arjun Ram Meghwal, and Madhusudan Yadav. (b) Ram Jethmalani (c) Ram Vilas Paswan (d) Shailendra Kumar (e) Prasanta Kumar Majumdar (f) Pinaki Misra (g) A. Sampath (h) S. Semmalai (i) Meenakshi Natrajan, P.T. Thomas, and Deepa Dasmunshi (j) Vijay Bahadur Singh Presently, the government and the Opposition are in the process of formulating their stands on various key issues such as inclusion of the Prime Minister, the lower bureaucracy and the role of the Central Investigation Bureau. We provide a broad overview of the views of the members of the Committee on various key issues. Unanimity on issues On some issues, there was unanimity among the Committee members:
Dissent on issues Certain members of the Committee dissented on specific issues. In Table 1, we list the issues and the reason for the dissent. Table 1: Recommendation of Standing Committee and dissent by individual MPs
| Issues | Standing Committee recommendations | Points of dissent | Dissenting MPs |
| Inclusion of Prime Minister | Committee left the decision to Parliament stating that there are pros and cons to each view. | - PM should be included. - PM should be brought under the Lok Pal with some exceptions for national security, foreign policy, atomic energy etc. - The decision to investigate or prosecute the PM should be taken by the Lok Pal with 3/4th majority. | - Prasanta Kumar Majumdar, A. Sampath. - Kirti Azad etc, Shailendra Kumar, Pinaki Misra. |
| Grievance redressal mechanism | Enact separate law for a grievance redressal mechanism. | Include in the Lok Pal Bill. | Kirti Azad etc, Ram Jethmalani, Shailendra Kumar. |
| Inclusion of bureaucracy | Include Group B officers in addition to Group A. | - Include all groups of govt employees. - Include Group ‘C’. - Do not include bureaucrats. | - Kirti Azad etc, A. Sampath. - Meenakshi Natrajan etc, Shailendra Kumar, Prasanta Kumar. Majumdar, Pinaki Misra, Vijay Bahadur Singh. - Ram Vilas Paswan. |
| Lokayukta | Single, central law to deal with Lok Pal and state Lokayuktas to ensure uniformity in prosecution of public servants. | States should retain power to constitute Lokayuktas. | - S. Semmalai. |
| Private NGOs, media and corporate | Include all entities with specified level of govt control or which receive specified amount of public donations or foreign donations above Rs 10 lakh. | No private organsiations should be included. | - Kirti Azad etc., Ram Vilas Paswan. |
| Composition of search and selection committees | Selection Committee: In addition to PM and Speaker, it should include the Chief Justice of India, an eminent Indian unanimously nominated by the CAG, CEC and UPSC chairman and only Leader of Opposition of Lok Sabha. Search Committee: Mandatory to constitute. Minimum 7 members with 50% members from SC/ST, OBC, minorities and women. | Selection Committee: PM, Minister, LoPs of both Houses, two judges and CVC. Search Committee: CJI, CAG, CEC, Cabinet Secretary, judges of Supreme Court and High Courts. Selection Committee: PM, LoP in the Lok Sabha, one judge of SC and one Chief Justice of a HC, CVC, CEC and CAG. Search Committee: 10 members out of which 5 should be from civil society and 5 should be retired Chief Justice, CVC, CAG and CEC. Half the members to be from SC/STs, OBCs, minorities or women. | - Kirti Azad etc. - Shailendra Kumar. |
| Removal of Lok Pal | In addition to petitioning the President, a citizen should be allowed to approach the Supreme Court directly with a complaint. If admitted, it would be heard by a 5 judge bench. If President does not refer a citizen’s petition, he should give reasons. | Investigation should be conducted by an independent complaint authority. Heavy fines should be imposed in case of a false or frivolous complaint. Instead of the President, the Supreme Court should have power to suspend a member pending inquiry. | - Shailendra Kumar. |
| Role of CVC and CBI | CVC should investigate Group C and D employees. Instead of Lok Pal’s investigation wing, the CBI should investigate cases after inquiry by the Lok Pal. CBI to have autonomy over its investigation. Lok Pal shall exercise general supervision over CBI. | CBI should be under the control of the Lok Pal. The CBI Director should be appointed by the Lok Pal’s selection committee. The CVC should be under Lok Pal and the SVCs under the state Lokayuktas. | - Ram Jethmalani, Shailendra Kumar. - A. Sampath. - Meenakshi Natrajan etc. |
| False and frivolous complaints | Term of imprisonment should be maximum six months. Amount of fine should not exceed Rs 25,000. Specifically provide for complaints made in good faith in line with the Indian Penal Code. | The term of imprisonment should not exceed 30 days. | - Kirti Azad etc. |
| Article 311 | Article 311 of the Constitution should be amended or replaced with a statute. | The procedure adopted by the disciplinary authority should conform to Article 311. | - Kirti Azad etc, Meenakshi Natrajan etc. |
| Finance | Lok Pal Bill states that all expenses of the Lok Pal shall be charged to the Consolidated Fund of India (no need for Lok Sabha clearance). The Committee did not make any recommendation with regard to finances of the Lok Pal. | Lok Pal’s expenses should be cleared by the Parliament. Lok Pal should present its budget directly to Parliament rather than through a ministry. | - Kirti Azad etc. - Shailendra Kumar. |
| Sources: The Lok Pal Bill, 2011; the Department Related Standing Committee Report on the Lok Pal Bill, 2011 and PRS. | |||
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.
