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Intergovernmental Fiscal Transfers for Health

In many large federal or decentralized countries, the majority of public spending on health is executed by state and district governments (see graph below). Improving health in these countries—and globally—depends on improving the sufficiency, efficiency, and effectiveness of health spending at the subnational level. The Intergovernmental Fiscal Transfers for Health Working Group, a partnership of CGD and the Accountability Initiative in India, is tasked with identifying practices that improve health and increase the efficiency of subnational allocations.

Health status, access, and care vary greatly across subnational entities, and the decentralization of health systems and spending has mixed and complex results. To understand this complexity better, CGD and researchers at the Accountability Initiative (AI) in India have examined national-to-subnational fiscal transfers in India to identify practices that have global implications. The goal is to identify lessons for domestic reforms and implications for countries and donors facing similar challenges. We have also examined worldwide experience in allocating budgets according to health needs, leveraging greater subnational spending on health, and boosting subnational performance on health outcomes and delivery.

Key questions for the working group

  • What are better practices in intergovernmental fiscal transfers for health worldwide that can also help improve health outcomes in India?
  • How can the central government create incentives for increased allocation to health by states, given low levels of current spending?
  • What should be done to increase synergies in health expenditure by the central government and states?
  • What role can intergovernmental fiscal transfers play in supporting state and district level innovations to improve health outcomes?
  • What role for external funders in this space? What is the policy research and data agenda going forward?

Working Group Members

Yamini Aiyar, Accountability Initiative, Center for Policy Research

Sambit Basu, IDFC Foundation

Pinaki Chakraborty, 14th Finance Commission

Samik Chaudhuri, Institute of Economic Growth

Mita Choudhury, National Institute of Public Finance and Policy

Ravi Duggal, International Budget Partnership

Victoria Fan, University of Hawaii at Manoa

Saurabh Garg, Ministry of Finance

Amanda Glassman, Center for Global Development

Indrani Gupta, Institute of Economic Growth

Nishant Jain, GIZ

Avani Kapur, Accountability Initiative, Center for Policy Research

Anit Mukherjee, Center for Global Development

Aparajita Ramakrishnan, Bill and Melinda Gates Foundation

Rajeev Sadanandan, Ministry of Labor and Employment

Deepak Sanan, Government of Himachal Pradesh

Shakthivel Selvaraj, Public Health Foundation of India

Tapas Sen, National Institute of Public Finance and Policy


Non-CGD Publications

Going Local by Victoria Fan and Amanda Glassman (Finance & Development - International Monetary Fund).