by Pavithra Manivannan, Aakriti Narang, and Susan Thomas.
Introduction
A robust public financial management (PFM) system ensures that resources allocated in the budget are deployed as planned. One way to test this is the spending gap: the difference between what a state budgets for an item and what it actually spends. This gap offers a useful measure of a state's fiscal marksmanship. When looked further, a large spending gap may indicate that the state has either misestimated demand or struggled to manage suppliers, including ensuring timely delivery and payment. Both are critical to effective public procurement. The spending gap, therefore, offers one measure of a state's capability to procure well.
We apply this test to drug procurement. Tamil Nadu is widely regarded as the gold standard for drug procurement in India, and many researchers attribute this to the institutional design of its procurement agency, the Tamil Nadu Medical Services Corporation (TNMSC). Following TN's lead, many states have since set up similar bodies. In this article, we compare Tamil Nadu's spending gap in drug procurement with Karnataka, a state of comparable budget size, and population, that set up its own corporation in 2019. We ask - has Tamil Nadu's institutional development of its public healthcare system translated into capability in budgeting efficiency, for drug procurement?
Data and Methodology
We use the Detailed Demand for Grants (DDG) released by each state, to get the annual budgeted and actual expenditure numbers. "Drugs" include medicines, medical supplies and medical equipment1. Hence, to identify expenditure on drugs we extract each of these specific line-items from the Department of Health and Family Welfare's budget of both the states.
This is not a straightforward exercise. State budgets are published only as PDFs running into hundreds of pages, and the data in them is, therefore, not research ready. Without structured data, there is no practical way to trace a budget line item across years and states. We overcome this with the India Public Finance Lab Portal, developed by XKDR Forum, which uses LLM pipelines to convert these budget PDFs into granular, research-ready data. Every line item sits in neatly labelled columns, so the data can be sliced, filtered and manipulated as needed. This lets us isolate and aggregate the different heads for both states and follow them year by year.
The portal covers data of ten years for Tamil Nadu and nine for Karnataka. To keep the comparison robust, we start in 2018-19, the first year with data for both states. Additionally, the actual expenditure for a year appears in the budget documents with a two-year lag, so actuals for 2025-26 and 2026-27 are not yet available. Therefore, we stop our analysis at 2024-25.
For each state and year, we calculate the spending gap from 2018-19 to 2024-25 (Study Period) as:
Spending gapyear = 100 × (Actual Expenditureyear − Budgeted Expenditureyear) / Budgeted Expenditureyear
A positive gap means the state's actual spending is more than its Budgeted Estimates (BE), and a negative gap means it spent less. We then compute the average and the standard deviation of the annual gap for each state. This helps us test our hypothesis; if Tamil Nadu has greater state capability for drug procurement, its average spending gap and variability of spending gap must be lower than Karnataka's.
Finding 1: Tamil Nadu has a higher budget for drugs
In absolute figures, we find that Tamil Nadu budgets a higher amount for drugs than Karnataka in every year of the Study Period, and by more than twice as much in most years. In Figure 1, we report the per capita drug expenditure of both the states. We find that, over the Study Period, Tamil Nadu's per capita drug expenditure averaged to Rs. 114 per person, about 2.2 times that of Karnataka's average of Rs. 53.4 per person.
Figure 1: Per capita drug expenditure for Tamil Nadu and Karnataka
Finding 2: Tamil Nadu's spending stays closer to its budget
Tamil Nadu's actual spending on drugs tracks its budget far more closely than Karnataka's, with a spending gap that stays within a much narrower band around zero. Over 2018-19 to 2024-25, Karnataka's average spending gap is more than three times Tamil Nadu's. The variability differs even more. The standard deviation of the gap for Karnataka is about nine times higher than for Tamil Nadu. Karnataka's gap peaked at over 400% in 2020-21, while Tamil Nadu's highest gap was 48%, in 2018-19.
Figure 2: Spending gap for Tamil Nadu and Karnataka, BE v. Actuals
| Average spending gap | Standard deviation | |
|---|---|---|
| Karnataka | 56.1% | 184.7% |
| Tamil Nadu | 17.3% | 21.2% |
Finding 3: The difference is not just COVID
Plausibly, much of this volatility in spending may just be driven by the unanticipated shock of COVID-19. We therefore recalculate the summary statistics after excluding 2020-21 for both states.
Without the year 2020-21
| Average spending gap | Standard deviation | |
|---|---|---|
| Karnataka | -7.8% | 81.7% |
| Tamil Nadu | 13.4% | 20.2% |
Without 2020-21, Karnataka underspends on average, and its standard deviation falls by more than half. Although, it still remains about four times Tamil Nadu's. Tamil Nadu does not see as drastic a difference as Karnataka's. Figure 1 also shows that the two states responded differently to COVID. Tamil Nadu roughly doubled its drugs budget in 2020-21, while Karnataka raised its budget only gradually over the following years. This early increase may explain why the COVID year hit Tamil Nadu's spending gap far less: its budget absorbed the surge, whereas Karnataka's did not.
Finding 4: Karnataka corrects itself
We also know that the states publish revised estimates (RE), which update the budget estimate with more realistic figures. After looking at these numbers along with the budget and actuals, we see that Karnataka's revised estimates track its actual spending far more closely than its original budgets do.
Figure 3: Karnataka: BE vs RE vs Actuals
We also repeat the calculation against the RE:
(Revised) Spending gapyear = 100 × (Actual Expenditureyear − Revised Expenditureyear) / Revised Expenditureyear
| Average spending gap (vs RE) | Standard deviation (vs RE) | |
|---|---|---|
| Karnataka | -18% | 24.4% |
| Tamil Nadu | 0.38% | 15.9% |
Against its revised estimates, Karnataka's gap falls. It spends about 18% less than its revised estimate on average, and its standard deviation falls from 184.7% to 24.4%. However, Tamil Nadu still seems to do better. Its actual spending lands almost exactly on its revised estimates, with a lower deviation as well.
Discussion
The main finding of this article is that Tamil Nadu's average spending gap (17.3%) remains substantially lower than Karnataka's (56.1%). The difference becomes even more pronounced during a crisis, when procurement systems are tested hardest. In 2020-21, Karnataka's spending gap rose above 400%, while Tamil Nadu's remained below 50%. The ability to estimate expenditure requirements accurately and spend broadly in line with budget allocations, even amid unexpected shocks, is an important marker of state capability and procurement efficiency. The pandemic emerged in December 2019, while the budgets for 2020-21 were presented in February 2020. It is plausible that Tamil Nadu anticipated the increased demand for medicines and budgeted accordingly. Although the spending gap alone cannot establish whether this was the case, Tamil Nadu's performance during this period suggests a greater capacity to maintain alignment between budgeted and actual expenditure under uncertain conditions.
We conjecture that this capability rests on two complementary sets of institutional capabilities: the budgeting capability of the TN Department of Finance and the procurement capability developed within TNMSC. The former ensures that resources are budgeted and released in line with requirements, and the latter enables the state to estimate demand accurately and manage the supply of medicines effectively.
First, the Department of Finance must have the capability to budget and spend as planned. Even when a procurement agency estimates demand accurately, the treasury must translate those estimates into realistic budget allocations and ensure that funds are available for expenditure as and when they are needed. Tamil Nadu's consistently narrow spending gap suggests that its Finance Department's broader budgeting framework is effective at aligning planned expenditure with actual spending. The inverse is also true. That is, procurement efficiency depends not only on the capabilities of the agency procuring medicines but also on the state's ability to finance and execute its plans. The spending gap is therefore an outcome of both procurement and budgeting capabilities.
Second, TNMSC appears to have developed three institutional capabilities that support more accurate demand estimation and effective supply management:
- First, is a rigorous approach to planning demand. Karnataka bases its demand on the requests raised by public healthcare institutions. TNMSC uses these requests too, but it also draws on a wider set of variables such as past consumption patterns, the changing demographics of the population served, the frequency of outbreaks and the disease profile of the population, and a 10% contingency stock on top of the estimated requirement.
- Second, these practices are not left to the discretion of individual officials. They are written into TNMSC's manuals and policies, so the forecasting method survives changes in personnel. Karnataka, by contrast, does not have a drug procurement manual.
- Third, Tamil Nadu's approach is also supported by technology. TNMSC uses a customised management information system, the Drug Distribution Management System (DDMS), which tracks stock and consumption at each warehouse and facility, and feeds it back directly into its demand estimates. Karnataka uses e-Aushadhi software, a standard platform used mainly for indenting and inventory management rather than for forecasting.
Tamil Nadu's experience suggests that procurement capability cannot be created through agencification alone. Establishing a dedicated procurement corporation modelled on TNMSC is an important first step, but it does not automatically confer the capabilities required to make the model work. These capabilities are built over time through experience, institutionalised procedures, and systems that enable decisions to be informed by reliable data. TNMSC, incorporated in 1994, has had considerably longer to develop these capabilities than Karnataka's Karnataka State Medical Supplies Corporation Limited (KSMSCL), established in 2019. This difference in institutional experience may help explain the gap in their performance, although it does not, by itself, establish causation.
This article compares two states, and the comparison could be extended in several directions. One, the same test could be applied to more states with different procurement models (such as long standing corporations vis-a-vis states that procure through their health departments) and varying information management systems. This would show whether the gap between Tamil Nadu and Karnataka reflects a broader pattern linked to institutional design, procurement planning and technology or experience and expertise. Second, states differ in how their health spending is funded. Where a larger share of drug spending depends on external funding, such as central schemes like the National Health Mission, the timing and size of fund releases are partly outside the state's control. The spending gap in these states may then reflect delays in funding as much as the state's own capability, and separating the two would sharpen the measure. Third, TNMSC procures only drugs, so a further question is whether Tamil Nadu's capability extends beyond them. How does Tamil Nadu perform on public healthcare procurement as a whole, and separately for goods, services and works?
Notes
1 Section 3(b) of the Drugs and Cosmetics Act, 1940, read with the Drugs and Cosmetics Rules, 1945 and the Medical Devices Rules, 2017. ↩
References
Aggarwal et al (2025), Information Extraction from Fiscal Documents using LLMs, XKDR Forum.
Chitgupi, Gorsi and Thomas (2022), Learning by Doing, The Leap Blog, November 2022.
Hart, T., et al (2025), Rewiring public finance for the health sector, ODI Global Report, London: ODI Global.
Manivannan, Mehta and Thomas (2024), Improving supply chain management of medicines for public healthcare in India, XKDR Forum.
Manivannan (2026), Designing procurement information systems for improved access to public healthcare, Public Finance in the Digital Era: Emerging Themes 2026, ODI Global Report.
Parthasarathi, R. and Sinha, S. (2016), Towards a Better Health Care Delivery System: The Tamil Nadu model, National Library of Medicine.
Pavithra Manivannan, Aakriti Narang, and Susan Thomas are researchers at XKDR Forum. We thank Jay Kulkarni, Amrita Aggarwal, Ajay Shah and all the participants of the Roundtable on {X}ray of State Finances in India at XKDR Forum for their valuable suggestions and comments on this work.









