With the spread of COVID-19, along with the central government, the state governments have also announced several policy decisions to contain and prevent the spread of the virus. In this blog post, we summarise some of the key measures taken by the Uttarakhand Government in this regard as of April 16, 2020.
As of April 15, 2020, 2,413 samples have been sent for testing in Uttarakhand. Of these, 37 have been found COVID-19 positive and the results of 354 samples are awaited. Of the 37 confirmed cases, 9 patients have been cured/discharged.[1]
Movement Restrictions
To contain the spread of COVID-19 in the state, the Government of Uttarakhand took the following measures for restricting the movement of people in the state.
On March 20, the Department of Health restricted the entry of all tourists (domestic and foreign) into the state.[2] The Department further issued orders for the closure of all educational institutions, gyms, swimming pools, museums, cultural and social centres, and theatres until March 31.[3]
On March 22, the state announced a complete lockdown till March 31.[4] Restrictions during the lockdown included: (i) prohibiting the gathering of more than five people at any public place, (ii) suspending all public transport including taxis and auto-rickshaws, and (iii) closure of all shops, commercial establishments, offices and factories. Establishments providing essential goods and services were excluded from the lockdown restrictions. These include: police, medical and health, print and electronic media, food, groceries, and their transportation, among others.4
On March 25, the central government announced on a 21-day country-wide lockdown till April 14.[5] On April 14, the lockdown was further extended till May 3, 2020.[6]
On April 15, the Ministry of Home Affairs issued guidelines on the measures to be taken by state governments until May 3.[7] As per these guidelines, select activities will be permitted from April 20 onwards, to mitigate hardship to the public due. These activities include health services, agriculture and related activities, certain financial sector activities, operation of Anganwadis, MNREGA works, and cargo movement, among others. Further, subject to certain conditions, commercial and private establishments, industrial establishments, government offices, and construction activities will also be permitted.7
Health Measures
Uttarakhand Epidemic Disease COVID-19 Regulations 2020
On March 15, 2020, the government notified the Uttarakhand Epidemic Disease COVID-19 Regulations, 2020 for the containment of COVID-19 in the state.[8] Key features of the regulations include the following:
All hospitals (government and private) must have dedicated flu corners for the screening of suspected COVID-19 cases.
The spread of any misinformation must be avoided. No person or organisation can use any print or electronic media for information regarding COVID-19 without prior permission of the state health department.
Guidelines for citizens, healthcare facilities and government departments
The state issued several guidelines and advisories on various subjects related to the containment of the virus.[9] These guidelines have been targeted towards citizens, healthcare facilities, as well as government departments. Some of these guidelines are given below:
For citizens: These include guidelines on the use of masks by the public, guidelines for home quarantine, and advisory to not consume tobacco to prevent the virus.8
For healthcare facilities: Guidelines for health care facilities include: sample collection, packaging and transport guidelines, infection prevention control for suspected cases, clinical management of COVID – 19, and discharge policy for COVID-19 patients, among others.8
For government: Guidelines for government departments include: guidelines for cluster containment, strategy, advisory on the use of hydroxychloroquine for high-risk population, and guidelines for quarantine facilities for COVID-19.8
Administrative Measures
On March 21, the state government cancelled all leaves for employees from the Department of Medical, Health and Family Welfare and ordered all the employees on leave to report back.[10] Further, on March 19, the state government announced that the administrative control of all properties and accommodations under the tourism department and other government enterprises will be given to the respective District Magistrates, temporarily.[11]
Education
On March 21, the state government postponed the correction of all state board examination booklets, which were to be corrected from April 1 to April 15, 2020.[12] The government also postponed exams for the Forest Research Institute, which were supposed to be conducted in March.[13]
For more information on the spread of COVID-19 and the central and state government response to the pandemic, please see here.
[1] Dehradun Health Bulletin on Corona Virus Disease (COVID-19), Status as on April 15, 2020 Time: 05:30 PM, Uttarakhand State Control Room COVID -19, Health and Family Welfare, Uttarakhand, http://health.uk.gov.in/files/Corrected-15-04-2020-Health-Bulletin.pdf.
[2] Order No. 48/PS-Secy(H)/2020, Department of Medical, Health and Family Welfare, March 20, 2020, https://prsindia.org/files/covid19/notifications/427.UK_Advisory_for_Tourists_20_Mar.pdf.
[3] Advisory on social distancing measure in view of spread of COVID-19 disease, Government of Uttarakhand, https://prsindia.org/files/covid19/notifications/1835.UK_Social_Distancing_Advisory_Uttarakhand.pdf.
[4] Order No. UKHFWS/PS-MDNHM/2019-20/217, Department of Medical, Health and Family Welfare and Medical Education, March 22, 2020, https://prsindia.org/files/covid19/notifications/432.UK_Order_Lockdown_Mar_22.pdf.
[5] Order No. 1-29/2020-PP, National Disaster Management Authority, March 24, 2020, https://mha.gov.in/sites/default/files/ndma%20order%20copy.pdf.
[6] “PM addresses the nation for 4th time in 4 Weeks in India’s fight against COVID-19” Press Release, Prime Minister’s office, April 14, 2020, https://pib.gov.in/PressReleseDetail.aspx?PRID=1614255.
[7] Order No.40-3/2020-DM-I(A), Ministry of Home Affairs, April 15, 2020, https://www.mha.gov.in/sites/default/files/MHA%20order%20dt%2015.04.2020%2C%20with%20Revised%20Consolidated%20Guidelines_compressed%20%283%29.pdf.
[8] Notification No. 370/XXVIII(1)/2020-01(06)/2020, Department of Medical Health and Medical Education, March 15, 2020, http://health.uk.gov.in/files/The_Uttarakhand__Epidemic__Disease__COVID-19_Regulation_2020.pdf.
[9] Website of Department of Medical, Health and Family Welfare, Corona (COVID19) updates, Government of Uttarakhand, last visited on March 16, http://health.uk.gov.in/pages/display/140-novel-corona-virus-guidelines-and-advisory-.
[10] Order No. 1P/Ra0pu0/miscellaneous/1/2018, Department of Medical, Health and Family Welfare, March 19, 2020, https://prsindia.org/files/covid19/notifications/430.UK_DG-Order-Cancellalation_of_Leave_Health_Workers_21_Mar.pdf.
[11] Order No. 42/Secy Health/2020, Department of Medical, Health and Family Welfare, March 19, 2020, https://prsindia.org/files/covid19/notifications/1826.UK_Advisory_for_KMVN_and_GMVN_Mar19.pdf
[12] Advisory No. 123/XXIV-B-5/2020/03(01)/2020, Secretary Uttarakhand Government, March 21, 2020, https://prsindia.org/files/covid19/notifications/429.UK_Advisory_for_Board_Student_of_Uttarakhand_21_Mar.pdf.
[13] Advisory No. 122/XXIV-B-5/2020/03(01)/2020, Secretary Uttarakhand Government, March 21, 2020, https://prsindia.org/files/covid19/notifications/1828.UK_Advisory_for_Board_Student_of_FRI_Uttarakhand_Mar21.pdf.
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.
