The success of decentralization as a mechanism for the greater autonomy and accountability at lower levels of the system, especially in the health sector, depends on a large extent on the vision driving the initiative from the top and the perception of the effectiveness of decentralization by administrative and political personnel at the lower levels. At the policy level, ideas on decentralization are translated into action through various health programs and policies that are established and orders that are issued. However, in the finally it is the perception of the elected representatives and the administrative functionaries at different PRI tiers which will be instrumental in operationalzing decentralization. Unfortunately after the Thirteen years (2005) of implementation of NRHM there has been no empirical research done to examine how much decentralization has taken place and whether there is any correlation between this increase in autonomy (decision space) and health outcomes. The absence of a suitable analytical framework of role of Panchayats to implement NRHM is also one of the reason for this. Therefore, this book attempts to bridge the existing research gap by examining the possible impact of decentralization and increase in decision space on the rural health outcomes in the state of Karnataka with special references to NRHM.