Assessing Private Health Insurance in India: Impact and Regulatory Issues

This paper examines two issues:
• What is the likely impact of the entry of private health insurance companies in India, on the costs of health care, equity in the financing of care, and the quality and cost-effectiveness of such care?
• In light of the above, what are the main regulatory gaps in the health sector that need addressing? The entry of private health insurance firms could have adverse implications for some of above goals of health policy, particularly for equity. However, an informed consumer and well-defined and implemented insurance regulation regime will ameliorate some of the bad outcomes. Regulation relating to benefit-packages, restrictions on risk selection and consumer protection would be clearly useful. Also required are improved enforcement of regulatory regimes, creating large insurance buyer groups, and better coordination between IRDA and other regulatory bodies. New legislation in improving standards in health care provision may also be needed.

Most rural population now not solely in agriculture: NCAER survey

As part of India Human Development Survey the team covered 42000 households across the country

Employment in agriculture has fallen sharply over the last seven years and a combination of farm-oriented and non-farm work is now the most common form of rural employment according to the findings of a nationwide representative sample survey conducted by the National Council for Applied Economic Research (NCAER).The Hindu is reporting exclusively from the findings of the NCAER’s 2011-12 round of the India Human Development Survey.

The NCAER team covered 42000 households across the country 83 per cent of which were surveyed for the last round of the IHDS in 2004-05. The IHDS is the largest independent household sample survey in the country.

The IHDS’s findings on employment show that the fall in agricultural employment — documented in the 2011 Census as well — is much larger than what was previously believed. In 2004-05 half of all rural men and 83 per cent of rural women worked only on farms making it the most common type of rural employment. However exclusive farm-oriented work is still the most prevalent form of employment among rural women engaging 66 per cent. The IHDS findings contradict the latest data of the government’s National Sample Survey Organisation (NSSO) which shows purely farm-based work as the biggest employer in the country.

“It is a fact that the NSSO has not been able to adequately capture the combinations of different types of economic activities that people engage in” said Preet Rustagi a labour economist professor and joint director at the New Delhi–based Institute for Human Development (IHD).

According to the IHDS findings non-farm work is now a bigger employer for rural men in Punjab Haryana Assam north-eastern States Kerala and Tamil Nadu. The same is true for rural women as well in the two southern States.

The IHDS confirms an alarming trend — the NSSO found so too — of a fall in the participation of women in the workforce — from 47 per cent women aged 15-59 in 2004-05 to 43.7 per cent in 2011-12. The participation rate which considers all those employed or looking for work for men is 78.9 per cent and 77.2 per cent in 2004-05 and 2011-12 respectively.

While the fall in male participation is primarily explained by rising higher education enrolment the work participation rate for women have fallen even for those in their 20s and 30s.

The IHDS also confirms that wages have grown exponentially over the last decade. The daily agricultural labour wage has nearly tripled for men in the last seven years while the non-agricultural wage has more than doubled. The wages of women workers though still much less that male workers have grown similarly.

(Part 2 of a five-part series)

Keywords: Agricultural employment non-farm work NCAER survey

Sonalde Desai, Omkar Joshi and Reeve Vanneman: Employer of the last resort?

The Centre’s rural employment guarantee scheme can be substantially improved but it has undeniably helped Dalits Adivasis and women find work

In an era of growing globalisation and rising inequality the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) stands out as a unique attempt to provide a social safety net via a massive public works programme. The government as an employer of the last resort is an idea that has existed in policy discourse around the world for much of the 20th century gaining most currency during the Great Depression in the United States. However MGNREGA takes this policy to a new realm because of its massive reach universal nature and its initiation during a period of rapid economic growth.

It is a good time to explore the reach and impact of MGNREGA. India Human Development Surveys of 2004-05 and 2011-12 organised by the National Council of Applied Economic Research (NCAER) and the University of Maryland surveyed about 27000 rural households in 2004-05 before the Act was passed and in 2011-12 when the programme was implemented in all districts. Hence it provides a unique opportunity to examine household well-being before and after the implementation of the Act.

Our scorecard on MGNREGA focusses on three issues: (i) The reach and targeting of the programme; (ii) Experience of the households that participated in MGNREGA; and (iii) Broader changes in the rural labour markets between 2005 and 2012.

The MGNREGA website claims that 500 lakh households — about 36 per cent of rural households — obtained employment from MGNREGA in 2011-12. Our household survey finds only about 25 per cent of the rural households participating in MGNREGA. Another independent household survey the National Sample Survey of 2009-10 also finds about 25 per cent of households participating in MGNREGA.

Well-targeted scheme

Regardless of the discrepancy between administrative statistics and actual usage the programme is remarkably well-targeted. This targeting operates at three levels. At the village level the uptake in villages with low levels of infrastructure is higher (28 per cent) than in villages with better infrastructure (21 per cent). It is more difficult to organise new programmes in more backward areas so MGNREGA’s success in achieving this goal is quite remarkable.

At the household level households from the marginalised communities — Dalits and Adivasis — are far more likely to participate in MGNREGA (36 per cent and 30 per cent respectively) than other households (20 per cent). At the individual level older workers are disproportionately more likely to participate in MGNREGA than in the general labour force. Women too have higher participation rates; although only 29 per cent of all non-agricultural wage workers are women 44 per cent of all MGNREGA workers are women.

However even for those households doing MGNREGA work the number of MGNREGA work-days is not very large. About 50 per cent of participating households work 40 or fewer days. MGNREGA administrative data shows that less than 10 per cent of the households complete their full 100 days; the India Human Development Survey (IHDS) data record about 15 per cent of the participating households completing 100 days. In the run-up to the election the government has raised the limits for Schedule Tribes (ST) households living in forest areas to 150 days from 100. But 85 per cent of the participating ST households and 95 per cent of all ST households have not exhausted their current limit of 100 days. When asked by IHDS interviewers why they had not completed the full 100 days 75 per cent of the MGNREGA participants cited “No Work” as the primary reason. It would seem more important to focus on ensuring the full 100 days of work for everyone than to increase entitlement to 150 days.

For those households that participate in MGNREGA the income from MGNREGA forms about 14 per cent of their total income. While the Act mandates payment in cash for people who are not offered work we found few respondents knew about this provision and even fewer availed of it.

It is not clear whether MGNREGA is providing alternative sources of work or attracting people who were formerly underemployed or disguisedly employed. The IHDS data document an increase of just five days of work for men over a 12- month period in rural areas and four days for women. This is not a massive increase suggesting that some of the MGNREGA work may have replaced rather than added to former work.

The IHDS also documents other changes in rural labour markets. Among workers non-farm work has grown substantially while an exclusive agriculture focus has declined. The proportion of individuals who focus solely on agricultural activities— cultivation agricultural labour and animal care— has gone down from 51 per cent of men aged 15-59 to 35 per cent; for women the drop is from 84 per cent to 66 per cent. Much of this drop comes from changes in agricultural wage work and caring for animals; own-account cultivation is unchanged. While we do not know that MGNREGA caused these changes the alternative non-farm employment is certainly part and parcel of broader changes in rural labour markets.

Increase in daily wage

This declining agricultural employment has accompanied wage growth for daily wage workers particularly agricultural labour. For male agricultural workers daily wages in constant terms grew from Rs. 90 a day to Rs. 134; for male non-agricultural workers they grew from Rs.126 a day to Rs. 155. The growth for women agricultural workers was from Rs. 62 to Rs. 91 and for non-agricultural workers from Rs. 77 to Rs. 111.

These wage increases for women are particularly interesting. Historically the lack of non-agricultural work has constrained women’s wages. If MGNREGA is in any way associated with the growth in women’s wages this is a positive outcome. But these observations may also point to a real concern for farmers — a possible lack of availability of agricultural workers and high wages during harvest time. Rising agricultural wages for both men and women and simultaneously declining agricultural wage work suggest that it would be a sensible precaution to ensure that MGNREGA work is not timed for the peak agricultural periods.

The above discussion has noted several concerns with MGNREGA particularly the discrepancy between official data and household reports on usage as well as the potential wage impact. But we have also noted that the programme has been particularly successful in providing employment to Dalits Adivasis and women thereby serving as an attractive employer of the last resort to the most disadvantaged workers.

(Sonalde Desai Omkar Joshi and Reeve Vanneman are with the National Council of Applied Economic Research and the University of Maryland. This is Part 2 of a five-part series on the NCAER’s new household survey. The views expressed are personal.)

Keywords: rural employment MGNREGA Act Mahatma Gandhi National Rural Employment Guarantee Act potential wage impact Dalits Advasis NCAER new household survey

A Grim Statistical Picture of Married Indian Women

Two in five Indian women didn’t choose their spouse and about one in two was married before the legal age of 18 according to a new study that paints a grim statistical picture of married women across the country.

The National Council for Applied Economic Research a New Delhi-based think tank based their findings on interviews with more than 30000 married Indian women in 2011 and 2012. Women surveyed were between ages 16 and 49 living in over 1500 Indian villages and 971 urban neighborhoods.

Researchers spoke with women about their experience of domestic violence and the situations in which they thought they would be subject to a beating. Just over half — 54% — said women in their community would be beaten up for going out of the house without permission. Some 35% said that not cooking properly would leave them likely to be physically abused and 36% said that inadequate dowry payments would likely lead to a beating. Separately 46% believed that neglecting household duties would result in domestic violence.

“Some steps have been taken to empower women” Sonalde Desai a senior fellow at NCAER who headed the study said. “But this report shows just how grim their situation still is.”

An alarming large chunk of those surveyed – 48%  – said they were married before turning 18 the legal age for women to marry in India. States where women reported the highest underage marriages were Bihar and Rajasthan. About 73% women surveyed in Bihar where three quarters of the population lives in rural areas said they had married underage. In Rajasthan another largely-rural state the figure stood at 70%.

Punjab and Kerala among the richest states in the country have the lowest child marriage rates. In Punjab the figure stood at 13% and in Kerala 14% had married before the legal age.

NCAER also found that even though the dowry system was outlawed in 1961 the practice of giving a groom’s family items such as cash and heavy appliances among other things is still widespread in India. Indian women on average pay more than 30000 rupees or $491 as cash in dowry. The survey also said that about 40% reported their families purchased items such as a television motorbike or car for dowry. India does not maintain official statistics of dowry payments.

Declining sex ratios seen in gender scorecard

Sonalde Desai

On International Women’s Day the Election Commission of India held a special campaign to bring women voters to the polls. Although men and women vote at a more or less similar rate in State elections women are 6-8 percentage points behind in the Lok Sabha elections where national issues dominate. These disparities prompt us to take a deeper stock of gender inequalities in Indian society.

India Human Development Survey (IHDS) a nationally representative survey of about 42000 households conducted by researchers from the National Council of Applied Economic Research (NCAER) and the University of Maryland provides interesting insights for developing a gender scorecard covering the years of rapid economic growth between 2004-2005 and 2011-2012. NCAER is the oldest think tank in India and the only one outside the government which carries out large independent household surveys on social and economic issues. The IHDS is carried out under oversight from an advisory panel comprising eminent academicians representatives of civil society and those of a variety of statistical agencies. It is the only national panel survey covering the same households.

When it comes to changes in the nature of gender relations in India IHDS records a story of both progress and disappointments. The scorecard on gender reflects a broad stagnation in social mores where some achievements are cancelled out by backsliding in other areas; broader economic impacts on gendered outcomes are by and large negative; and some remarkably successful policy initiatives have been overlooked in an era of overall disenchantment with public policies.

Social stagnation

On social issues IHDS paints a picture of overall stagnation except for a few bright spots. The declining gap in school enrolment between boys and girls is the shining story of the past decade. In 2005 among children aged between 6-14 88 per cent of girls and 92 per cent of boys entered school. By 2012 the percentage for both sexes rose to 96 per cent.

However if we read this improvement in women’s literacy to indicate an overall improvement in their status we are in for a disappointment. Women remain bound by strict patriarchal norms that govern where they go (18 per cent don’t even go to a Kirana shop) whether they can venture outside the home alone (50 per cent do not travel alone by bus/train even for a short distance) how much input they are allowed in household decisions vital to themselves and their children (only 25 per cent have the final authority on what to do when they are sick) and even whether they have any input in who they marry (only 25 per cent actually met their husbands before marriage). Rising incomes do little to improve women’s status since richer households appear to be more determined to control their movements and autonomy than poor households.

Perhaps the greatest area of concern lies in steadily declining sex ratios. Census 2001 recorded only 927 girls between the ages 0-6 compared to 1000 boys. This ratio dropped to 919 in 2011. It is a paradox that although today’s parents are even more likely to prefer boys to girls than those of the last decade often resorting to illegal sex-selection practices to ensure the desired sex composition the discrimination against daughters in education is steadily declining.

While this stagnation in women’s ability to control their own fate is disappointing some of the other gender indicators are downright alarming. During years of rapid economic growth women’s employment has steadily declined. In spite of the attempts the IHDS survey made to capture diverse sources of women’s work women’s work participation rates for those between the ages 15-59 dropped from 58 to 54 per cent for rural women and from 23 to 20 per cent for urban women between 2005 and 2012. While rising household incomes may explain some of these declines the consequences for women’s empowerment are worrisome.

Moreover women remain concentrated in the agricultural sector. In 2005 73 per cent of the rural men did any agricultural work; by 2012 this number fell to 65 per cent. In contrast the decline for women has been smaller from 91 per cent to 86 per cent. Women’s participation in non-farm work would have been even lesser without the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS). With the slow but steady migration of men out of agriculture into non-farm economy agricultural work is slowly becoming feminised leaving women concentrated in an increasingly smaller portion of the economy.

Public policy successes

What role do government policies play in shaping gendered outcomes? Here there are a number of positive signs. Programmes like Janani Suraksha Yojana (JSY) have had a tremendous impact. Hospital delivery rates soared between 2005 and 2012. In 2005 before the implementation of JSY which provides cash benefits of up to Rs.1400 for a hospital delivery only 50 per cent of the deliveries took place in a hospital; by 2012 this had risen to nearly 70 per cent. Implementation of the no-frills bank account has increased women’s financial inclusion.

The proportion of women with their name on a bank account has risen from 18 per cent to a whopping 38 per cent in these seven years. Efforts aimed at ensuring women’s participation in MGNREGS have also borne fruit. The scheme mandates that at least a third of beneficiaries should be women. IHDS records that 44 per cent of the beneficiaries are women.

While these major programmes have had an impact on women’s lives many other schemes have proven to be remarkably ineffectual.

Only about one per cent of households have registered their daughters for the much trumpeted girl-child schemes that provide cash incentives for the survival and education of girls. Moreover even large schemes often suffer from operational difficulties; the demand for hospital-based deliveries has fast outpaced the ability of government hospitals to deliver reasonable quality care.

So how will the women voters react in the 2014 election? Would these policy achievements outweigh the social stagnation and economic concerns? I suspect not.

(Sonalde Desai is senior fellow at the National Council of Applied Economic Research and professor of sociology at the University of Maryland. This is the first in a series of five opinion pieces based on the findings of the new IHDS. The views expressed are personal.)

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