Results and Cross-Cutting Issues
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schemes suggests fiscal commitment of additional resources for health, or some conversion of supply- to demand-side subsidies.40 Table 3.7 compares government spending on GSHISs with expenditures on the public delivery system for government of India (GOI), AP and KA in 2008–09.41 Due to the maturity of the scheme and political commitment, AP contributed significantly more to health insurance than other states and the GOI in that year. However, the state expenditures shown in column (6) of table 3.7 for AP and KA are only for states’ own resources and do not include GOI transfers. GOI transfers account for a major share of primary care spending in the states. Therefore, the insurance spending as a percent of total government spending is overestimated to the extent that the central share of health spending in the state is not accounted for in the denominator. GSHISs account for 24, 41, and 6 percent of government spending by the GOI, AP, and KA, respectively in 2008–09. The level of spending in KA is for ESIS and Yeshasvini only, and does not account for Vajpayee Arogyashri which had yet to appear on the scene in 2008–09. These contributions represent additional spending to supply-side subsidies and account for an increasing share of total state spending on health. This is evidence of the political support and corresponding budgetary commitment these schemes enjoy. To date, there is no evidence that spending on GSHISs is substituting for public spending on public delivery. However, as discussed in a later section, some state authorities complain that their budgets would have grown more in the absence of GSHISs in their states. The extent to which these state schemes are approaching a fiscal limit is difficult to ascertain from available data. Anecdotal evidence suggests that AP probably cannot afford to significantly increase outlays for Aarogyasri to expand population coverage or deepen the benefits package. However, only in-depth revenue and expenditure analysis can confirm these claims. Converting supply-side to demand-side is an option under consideration, but its feasibility needs to be weighed in an environment in which any reduction in supply-side expenditures may not be easy. In the current Indian context, conversion itself would be the subject of a polarized and probably bitter debate with considerable political and bureaucratic positioning.
Spending on Medical Services Table 3.8 displays spending per beneficiary and per hospitalization derived from claims data. Noteworthy is the high per beneficiary spending by