Trends in rural fiscal decentralisation in India’s Karnataka state: A focus on public health

Commonwealth Journal of Local Governance, (25), 56-78.

For decades, health policy advocates have seen decentralisation reforms as a powerful instrument to improve health sector performance in developing countries. In India, the 73rd Constitutional Amendment introduced in 1992 called for strengthening rural local governments’ fiscal autonomy and service delivery capacity. This paper explores how decentralised governance influences public health sector resource allocation, equity and efficiency in rural Karnataka. For this, the authors analysed administrative data published by the Karnataka state government to create tailored standardised performance measures that capture the degree of local governments’ fiscal discretion in implementing public health programmes from 2011–18 at the district level. The findings highlight sector-specific differences in fiscal autonomy, ranging from high local discretion over funds in the nutrition sector to minimal discretion in the medical and public health sector. They also show that decentralised public health funding is not well-targeted to areas of greatest need in Karnataka.