Resource flow and fund management at district level in Odisha: Evidence for improving district health systems in developing countries

Planning, budgeting and utilisation of resources at the district level are critical issues for strengthening district health systems. The objectives of this study are to examine budget making, budget execution and budget monitoring processes at the district level; analyse the trend and pattern of public health expenditure at district level. Two districts based on district development index were selected. A mixed‐method study design, both quantitative and qualitative, was used. Quantitative data on resource allocations and utilisation by the government for health were collected and analysed. Qualitative interviews were conducted with government officials to examine budget making, execution and monitoring processes. Resources are transferred through treasury and state health society (SHS) to public health institutions at the district level. Bottom‐up planning process is mainly followed for money routed through SHS constituting 36%–40% of total district spending. It takes around 21 days to transfer funds from the treasury to the SHS and the district gets a major proportion of total funds within 10–15 days. Overall, utilisation of resources is around 80%–85% under treasury and 71%–85% under National Health Mission. However, utilisation for specific programmes, non‐communicable diseases, is extremely low. Multiple bank accounts, number of rules and regulations at each layer of administration make the system complex. There is a lack of integration of different programmes at the district and below. This study suggests to get rid of input‐based budgeting gradually and introduce outcome‐based budgeting to increase efficiency.