1. HEALTH CARE FINANCING under
NHM
13th Common Review Mission

2. 2
Increase Govt. Health Expenditure as % of GDP from
existing 1.15% to 2.5% by 2025
Increase State sector health spending to >8% of their
budget by 2020
National Health Policy 2017
Increase in State Health Budget by 10%
every year

3. Year-wise health expenditure to achieve
2.5% of GDP
(Rs. in Lakh Crore)
Year
Expenditure
on Health as a
% of GDP
GDP ( assuming
growth@7.5% at current
prices over baseline of
2017-18)
GDP with Rate of
Inflation @4%only
Expenditure on
Health
35% of
Expend. for
Centre
65% of
Expend. for
State
1 2 3 4 5=4*2 7 8
2018-19* 1.40% 178.75 185.90 2.60 0.91 1.69
2019-20* 1.40% 199.83 207.84 2.91 1.02 1.89
2020-21 1.58% 223.42 232.36 3.67 1.28 2.39
2021-22 1.76% 249.79 259.78 4.57 1.60 2.97
2022-23 1.98% 279.26 290.43 5.75 2.01 3.74
2023-24 2.22% 312.22 324.70 7.21 2.52 4.68
2024-25 2.50% 349.06 363.02 9.07 3.17 5.90
* Assuming that Govt. health expenditure is 1.4% of GDP, in 2017-18, as per Economic Survey, 2017-18

4. Budget document of State Government
Category
No. of
State/UTs
States/UTs
More than 4% 5
Bihar (4.5), Jharkhand (4.2), Madhya Pradesh (4.4), Uttarakhand
(4.4), Andhra Pradesh (4.3),
More than 5% 8
Odisha (5.1), Nagaland (5.1), Manipur (5.2), TamilNadu (5.1),
Gujarat (5.4), Uttar Pradesh (5.3), Rajasthan (5.1), Chhatisgarh
(5.9),
More than 6% 1 Mizoram (6)
More than 7% 2 Delhi (11.6) and Meghalaya (7.2)
State Health Expenditure

5. 5
Category
No. of
State/UTs
States/UTs
State increased by 10%
and above over last yr.
6
Andhra Pradesh (35%), Delhi (18%), Nagaland (77%), Tamil Nadu
(11%), Uttarakhand (24%) and Gujarat (11%)
State increased less
than 10%
1 Odisha (3%)
State Health Budget
decreased from last
year
1 Mizoram (-14%)
SHB not reported for
the FY 2019-20 over
last yr.
8
Bihar, Chhattisgarh, Jharkhand, Meghalaya, Madhya Pradesh,
Manipur, Rajasthan, and Uttar Pradesh
State Health Budget Status for FY 2019-20

6. B.E.
(2018-19)
R.E
(2018-19)
BE
(2019-20)
NHM 25,154.61 26,118.05 27,989.00
(11 % increase over last year)
Total
(DoHFW- NHM +
Health)
52,800.00 54,302.60 62,659.12
(19% Increase over last year)
Rs. in Crore
Budgetary Allocations under NHM and DoHFW

7. Department B.E. (Gross) %
Health 23,108.12 37%
NHM 27,989.00 45%
Strengthening of State Drug
Regulatory System
206.00
0%
RSBY 156.00 0%
PMJAY 6,400.00 10%
Human Resources for Health
& Medical Education
4,250.00
7%
Tertiary Care Programme 550.00 1%
Annual Budget 62,659.12 100%
Rs. in Crore
Department-wise Budget Estimate (Gross) 2019-20

8. NATIONAL HEALTH MISSION
Flexible Pools under NHM

9. National Health Mission
(NHM)
NCD Pool Infrastructure
Maintenance
NRHM –Flexible pool-
(I) RCH Pool, RI, PPI,
NIDDCP
(II) Health System
Strengthening
Pool
(a) Other Health System
Strengthening
(b) AB –HWC
(c) ASHA Benefit
Packages
NRHM
`
Health System Strengthening- includes components -- NPCD, NOHP, Burns &
Trauma, NPCF and other New Initiatives under NCD
NUHM
Communicab
le Disease
Pool
2 Sub-Missions
Health System
Strengthening
Ayushman
Bharat -
Health and
Wellness
Centres

10. ALLOCATION FOR 2019-20 UNDER DIFFERENT POOLS OF NHM
Sl. No. Name of the Flexible Pools
Allocation
(Rs.in crore)
% of
Allocation
A NRHM-RCH Flexible Pool 17,585.74 62.8
1
RCH Flexible pool including Routine Immunization, Pulse Polio
Immunization, National Iodine Deficiency Disorders Control Programme
etc.
5,703.52 20.4
2 Health System Strengthening under NRHM 11,882.22 42.5
B National Urban Health Mission-Flexible Pool 950.00 3.4
C. Flexible Pool for Communicable Diseases 2,178.00
7.8
D. Flexible Pool for Non-Communicable Diseases, Injury & Trauma 717.00
2.6
E. Infrastructure Maintenance 6,343.41
22.7
F.
Misc. Programme
(Forward Linkage Scheme, Pilot projects, SDRS, PMDP etc.)
214.86 0.7
Grand Total
27,989.01 100

11. 11
FINANCIAL PROGRESS AND AREAS OF FINANCIAL
REVIEW

12. PLAN WISE ALLOCATION & RELEASE UNDER NHM
Sr. No. Financial Year B.E. R.E.
Central
Expenditure
% Expenditure
against R.E.
1 10th FYP (2 years) 15,424 13,951 13,771 99
2 11th FYP 70,030 68,064 66,131 97
3 2012-13 20,542 17,000 16,763 99
4 2013-14 20,999 18,100 18,215 101
5 2014-15 21,912 17,628 18,037 102
6 2015-16 18,295 18,295 18,282 100
7 2016-17 19,000 20,000 18,887 99
8 2017-18 21,941 26,110 25,975 99
9 2018-19 25,154 26,118 26,027 100
10 2019-20* 27,989 - 16,673** 60
Total (NHM) 2,61,286 2,25,266 2,38,761
(Rs. in crore)
•R.E. (2019-20) is not available. Therefore, utilization is compared with BE.
** Release is updated up to 30.09.2019

13. Absorption capacity of States (Release including State Share)
Rs.in crore
6285
7487
11604
12589
14925
16446
19288
22009
23136 23130
26177
28261
38633 38565
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2017-18 2018-19

14.  Delay in Transfer of Central Grants from State Treasury to
State Health Society (SHS) account, varies with a minimum
delay of 18 days to maximum delay of 313 days against the
stipulated 15 days.
 States Expenditure on Health ranging from 4.2% to 11.6% of
State budget.
 Delays in contribuation of State share – State of Nagaland
and Delhi have not received first instalment due to shortage of
state share.
 The Performance Based Financing gives opportunity to sates
to earn incentive up to 20% of allocation.
14
ISSUES

15. Parameters for CRM Review
• Finance & Administration - Status on Human Resources, delegation of
financial power etc.
• Funds Flow - E-transfer of funds, Frequency of funds transfer, Implementation
of PFMS
• Financial Management - Maintenance of Records /Books of Accounts,
Monitoring & Reporting.
• Accountability- Internal control mechanisms, Audits (Statutory /Concurrent/
AG Audit).
• Cost of Care – User Charges, Health Services coverage, Out-of-pocket
expenditure etc.
• Other financial management matters including best practices if any.

16. Finance & Administration- At state level
• Human Resources (HR) – Status on in-position and vacancy in Finance,
Trainings on Financial Management at State & Districts and its impact in
improving financial management, Delegation of Financial &
Administrative Powers, Integration of Finance Staff of all programmes
under NHM.
• Dissemination of District ROPs. If not, the reasons thereof.
• Delay in transfer of funds for programme implementation and reasons
thereof.

17. Finance & Administration
• Allocation of funds to HPDs : Higher allocation of 1.3 times for
HPDs in comparison to other districts.
• Mechanism for responsive funding/ differential funding of Untied
Funds.
• Status Registration of Societies and Meetings of GB, Ex. Bodies
etc.
• Instances of diversion of NHM funds to other State Specific
Programmes and its impact on NHM activities.

18. Fund Flow
 Transfer of funds from Treasury (e-transfer/Chq./DD/PLA to
SHS.
 Mode of transfer of funds from SHS to DHS and Peripheries.
 Status of Implementation of DBT and REAT module of
PFMS.
 Release of funds to districts and peripheries (pool wise or
activity wise).
 Problems encountered by the facilities while receiving and
utilizing NHM funds.
 User Charges under RKS (provision of digital collection)

19. Financial Management- Facility level
• Verify the maintenance of records and books of accounts and
timeliness.
• Authentication of books of accounts by DDO.
• Timeliness of payment made to JSY beneficiaries, ASHA,
salary of staff, compensation under family planning schemes and
their modalities (DBT or any other mode).
• Frequency of bank reconciliation including peripheries.
• Maintenance of advance registers and age wise analysis of
advances.
• Maintenance of Fixed Assets registers.

20.  PFMS has been implemented in all 36
states/UTs under NHM to capture exp
expenditure and fund flow on real time
basis.
 NHM Scheme has been chosen as
pilot project for implementation of
REAT module by the office of CGA.
 REAT module to be implemented
beyond block level.
PFMS
43%
69%
80%
87% 89% 89.05%
301210
487652
560836
612099 622889 623217
2013-14 2014-15 2015-16 2016-17 2017-18 2018-19

21. Financial Management -PFMS
• Whether all accounts are registered with PFMS application.
• Status of Agency Registration and in case of shortfall (if any) the reasons
thereof.
• Whether all payments are made through PFMS.
• No. of districts/Blocks have started filing expenditure (DBT & Non-DBT) on
PFMS and whether FMR is generated through PFMS.
• Status of all the bank accounts under NHM to be mapped in PFMS portal at
all levels (State, District and Sub-District level.
• Status of Internet connectivity and power supply.
• Implementation of REAT module beyond block level under NHM.
• Whether training under PFMS is adequate or further training is required.
• Comment on Problem areas under PFMS and resolution required.

22. Accountability
• Adequacy of Internal control mechanism in the State to
unearth any error or mis-appropriation of funds.
• Adherence of accepted modalities for procurement of articles.
Ensure competitive bidding.
• Joint signatories for all banking operations and one of
which must be a regular employee.
• Maintenance of duly approved documents and records.
• Expenditure is incurred in the approved activities of ROP.
• Timely submission of UCs by the State.
• In case of poor utilization of funds – Ask the reasons.

23. Accountability
• Implementation on findings of CAG’s Performance audit
and Action taken thereon by the State.
• Status on submission of Statutory Audit for 2018-19.
• Compliance of last year Statutory audit findings.
• Laying of Statutory Audit Report in the meeting of GB for
approval.
• Status of Concurrent Audit- Effectiveness and facilitate in
improving the Financial management. Quarterly reports
and its adherence by the Audit Committee.

24. Accountability
• Instances of parking of funds and its impact on
Programme implementation.
• Compliance with respect to i) Income tax, ii) action on
audit observations.
• Status of In-operative/Idle bank accounts.
• Mapping of all Bank accounts into PFMS.
• Monthly BRS for all NHM bank accounts at all levels.
• Utilization on State specific programmes not to be
included under NHM.

25. Cost of Care
 Out of pocket expenditure (OOPE) for outpatient
and inpatient care at facility level from OPD patients
and IPD patients at each facility.
 Measures taken by the public facility to reduce
OOPE.

26. Other matters
 Ascertain the constraints faced by the facilities in utilisation of
funds.
 Whether the facilities use any output or outcome indicators.
 Measures taken for capacity building i.e. Trainings held and its
impact in improving the capacity of finance staff.
 E-Governance measures under Financial management.
 Expenditure incurred on ASHA Benefit Package and NVHCP.
 Interest on delayed transfer of funds as per the rate of Interest
provided by the Ministry of Finance.

27. Common Findings
• Non preparation of Bank Reconciliation Statement (BRS)
by Block units.
• Non-maintenance of Fixed Assets Registers/Stock
Registers.
• Splitting of Invoices to avoid competitive bidding –
Procurement Processes.
• Booking of expenditure over PIP approvals.
• Books of accounts not closed at year end.
• Delay in deposit of TDS, delay in filing of TDS returns.

28. THANK YOU
&
WISH YOU ALL
A
VERY HAPPY & SAFE
JOURNEY

29. s.n. States State Share Audited Report
Average Delay
in Treasuary
Transfer (No of
Days)
SHB (Average)
State Health
Expenditure (% )
Incentive/penalty
1 Bihar 8% NR 99 Not Reported 4.5 -12
2 Chhattisgarh √ NR 32 Not Reported 5.9 6
3 Jharkhand 8% √ 121 Not Reported 4.2 5
4 Madhya Pradesh 8% √ 20 Not Reported 4.4 -7
5 Orissa 2% NR 18 3%(9%) 5.1 3
6 Rajasthan 6% NR 96 Not Reported 5.6 0
7 Uttar Pradesh Not Eligible NR 126 Not Reported 5.3 2
8 Uttarakhand 3% NR 46 24%(28) 4.4 -8
9 Andhra Pradesh 4% √ 25 35% (23%) 4.3 7
10 Gujarat 4% √ 24 11% 5.4 5
11 Tamil Nadu 5% √ 36 11%(115) 5.1 4
12 Delhi Not Eligible NR 45 18%(18%) 11.6 -5
13 Manipur √ NR 313 Not Reported 5.2 4
14 Meghalaya 2% NR 37 Not Reported 7.2 -20
15 Mizoram 2% NR 70 ,-14%, (16%) 6.0 -4
16 Nagaland Not Eligible NR 128 77%(36%) 5.1 -20
Status for FY 2019-20