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The 15th Lok Sabha is close to the end of its tenure. A key legislation that proposes major reforms in food security was listed for discussion in Parliament. The National Food Security Bill, 2011 has been scrutinised by a Standing Committee. In January, we compared the Standing Committee's recommendations with the provisions of the Bill. Since then, amendments to the Bill have been introduced in Parliament. Debates on the Bill have revolved around the method of delivering food security, the identification of beneficiaries and the financial implications of the Bill. Method of delivery The Bill aims to make the right to food a statutory right. It proposes to use the existing Public Distribution System (PDS) to deliver foodgrain to 75% of the rural and 50% of the urban population. However, the Bill also allows for cash transfers and food coupons in lieu of grains as mechanisms to deliver food security. While the PDS is known to suffer from leakages as high as 40%, cash transfers and food coupons are known to expose recipients to volatility and price inflation. Each method of delivery would have its own implications, financial and otherwise. The table below compares these methods of delivery.[i] [table id=7 /]
Identification The Bill does not universalise food entitlements. It classifies the population into two categories of beneficiaries, who shall be identified by the centre and states. Mechanisms that aim to target benefits to certain sections of the population have been prone to large inclusion and exclusion errors. A 2009 expert group study headed by N.C. Saxena that evaluated PDS, estimated that about 61% of the eligible population was excluded from the BPL list while 25% of APL households were included in the BPL list. Beneficiaries under the Food Security Bill will be identified through a similar process. It is unclear how these errors in identification of beneficiaries under the PDS will be addressed by the Bill. Financial implications - cost sharing between the centre and states A Bill that aims to deliver food security to a large section of the country would have significant financial implications. Costs shall be shared between the centre and states. Costs imposed on states (partial or full) include: nutritional support to pregnant women and lactating mothers, mid-day meals, anganwadi infrastructure, meals for children suffering from malnutrition, transport and delivery of foodgrains, creating and maintaining storage facilities, and costs associated with District Grievance Redressal Officers and State Food Commissions. Although the centre shall provide some assistance, states will have to bear a significant financial burden on account of implementation. It is unclear whether Parliament can require states to allocate funds without encroaching on the powers of state legislative assemblies. If a state chooses not to allocate the necessary funds or does not possess the funds to do so, implementation of the Bill could be seriously affected. The Standing Committee examining the Bill had recommended that an independent body, such as the Finance Commission, should be consulted regarding additional funds to be borne by states. The Right to Education Act with similar centre-state sharing of funds provides for such a consultation with the Finance Commission. Cost of implementation of the Bill Another contentious issue is the cost of implementing the Bill. The Bill estimates the cost at Rs 95,000 crore. However, experts have made varying estimates on the costs ranging from Rs 2 lakh crore to Rs 3.5 lakh crore. Ashok Gulati, Chairman of the Commission for Agricultural Costs and Prices, estimated the cost at 2 lakh crore per year whereas the Minister of Food, K.V. Thomas was reported to have estimated the cost at Rs 3.5 lakh crore. The passage of the food security Bill in Parliament will depend on the ability of the government to build consensus on these issues. It remains to be seen how the Bill is debated next Parliament session.
[i] Kapur D., Mukhopadhyay P., and A. Subramanian. “The Case for Direct Cash Transfers to the Poor.” Economic and Political Weekly. Vol 43, No 15 (Apr 12-18, 2008). Khera, R. “Revival of the Public Distribution System: Evidence and Explanations.” Economic and Political Weekly. Vol XLVI, Nos 44 & 45 (Nov 5, 2011). Shah, M. “Direct Cash Transfers: No Magic Bullet.” Economic and Political Weekly. Vol 43, No 34, pp. 77-79 (Aug 23-29, 2008).
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.
