Health is a State subject, yet Union schemes shape health financing outcomes. Analyse the federal dimension of India's progress towards UHC.

Health is in the State List of Schedule VII. Even so, Union-designed schemes have driven most of India's progress towards Universal Health Coverage (UHC). The National Health Accounts (NHA) 2023–24 show that households' out-of-pocket expenditure (OOPE) fell from 64.2% to 42.7% of total health expenditure between 2013-14 and 2023–24 [1]. This came about through cooperative fiscal federalism, though progress has been uneven.

Union levers shaping financing

• Risk-pooling: AB PM-JAY, together with State insurance schemes, raised the social-security share of health spending from 6% to 11% [1].
• Primary care: Ayushman Arogya Mandirs are delivered through State health systems. Government spending on primary care reached about ₹1.53 lakh crore in 2023–24 [1].
• Medicines: Janaushadhi, AMRIT pharmacies and NPPA price control target drugs, which are the largest OOPE item [1].
• Crisis support: Union-led COVID spending cut OOPE to 39.4% and lifted public health spending to 1.84% of GDP in 2021-22 [2].

Federal fault-lines

• Fiscal effort: When one-time COVID spending ended, public health spending fell to 1.43% of GDP in 2022-23 [3]. This is well below the National Health Policy 2017 target of 2.5% by 2025 [4]. PRS finds that budget allocations still fall short of policy targets [5].
• Post-COVID reversal: OOPE rose again, from 39.4% to 42.7% [2][1]. Short Union spending surges cannot replace steady State spending.
• Delivery depends on States: CAG Report No. 11 of 2023 found that 69% of PM-JAY patients in Meghalaya paid ₹12.34 crore at discharge from a "cashless" scheme. It also found few empanelled hospitals in Assam, Maharashtra, Rajasthan and UP, and State Grievance Redressal Committees that never met in five States/UTs [6].
• Leakage and unspent funds: The CAG found ₹57.53 crore in excess payments in four States [6]. The Parliamentary Standing Committee reported that poor planning of time and cost left health funds unspent [4].

Union schemes have set the direction of UHC financing. States decide whether that pooled money actually protects patients. Three steps would turn cooperative federalism into lasting progress:

• Link part of Union grants to States raising and spending their health budgets [4][5].
• Close the PM-JAY gaps in hospital empanelment and grievance redress [6].
• Publish the full yearly NHA series.

Together these would advance SDG 3.8 and the Article 47 duty to improve public health.