India is lagging behind in many critical health indicators compared with countries having similar levels of economic development, according to Health Index 2019 published by NITI Aayog, India’s policy think tank.
In the last decade, India achieved tremendous progress in various facets of growth. Millions of people were uplifted from poverty. Health system and health outcomes have also significantly improved. Despite the remarkable progress, health remains a critical area that needs improvement, notes the second edition of annual Health Index document which was bought out in collaboration with the Ministry of Health & Family Welfare (MoHFW) and with technical assistance from the World Bank.
The Health Index, which aims to measure the performance of states and union territories (UTs), also shows huge disparities across the states within the country. The health outcomes of some states are comparable to that of some upper middle-income countries and high-income countries, while some others have health outcomes similar to that in the poorest countries in the world.
The neonatal mortality rate (NMR) in the southern state of Kerala, for example, is similar to that of Brazil or Argentina where NMR in Odisha is close to that of Sierra Leone.
The overall health index score of the best-performing state is more than two and a half times that of the least-performers.
Kerala topped with an overall score of 74.01, while its larger counterpart Uttar Pradesh, a northern state, was the least performing with a score of 28.61.
The scores of the smaller states in north-eastern region also varied highly. Nagaland scored poor with 38.51 while it went up to 74.97 for Mizoram.
Among the UTs, the scores varied between 41.66 in Daman and Diu to 63.62 in Chandigarh.
There is room for improvement in all states, even among the best-performing ones, the report says. Among the least performing states and UTs, particularly, there is an urgent need to accelerate efforts to narrow the performance gap.
Falling short of SDG goals
States vary in progress towards achieving Sustainable Development Goals (SDG) as well. Kerala and Tamil Nadu have already reached the 2030 SDG target for NMR, which is 12 neonatal deaths per 1,000 live births. Maharashtra and Punjab are also close to achieving the target.
When it comes to Under-Five Mortality Rate (U5MR), Maharashtra and Punjab have already achieved the SDG target, which is 25 deaths per 1,000 live births. Other states and UTs still need significant improvements to meet SDG targets.
Incremental vs overall performance
The changes in health index scores from 2015-16 to 2017-18 varied significantly across states and UTs, implying different levels of momentum to improve performance. Only about half of them had an improvement in the overall score during the period.
The degree of change in incremental performance scores differed across the three categories of states. The magnitude of change was bigger in UTs compared to larger and smaller states.
Among the larger states, Haryana, Rajasthan and Jharkhand are the top three in terms of incremental performance, while Kerala, Andhra Pradesh, and Maharashtra are the top three in terms of overall performance.
In terms of incremental performance, the top three ranked states in the group of larger states are Haryana (up 6.55 points), Rajasthan (up 6.30 points) and Jharkhand (up 5.99 points). However, in terms of overall performance, these states are among the bottom two-thirds of the range of index scores, with Kerala (74.01), Andhra Pradesh (65.13) and Maharashtra (63.99) showing the highest scores.
Andhra Pradesh and Maharashtra are the only two states that are among the top one-third on both overall performance as well as incremental performance.
Andhra Pradesh has the highest proportion of indicators (63 percent) among the larger states which fall in the category of “Most Improved” or “Improved”.
Among the larger states, seven of the top ten states on overall performance also continued to improve on their health index scores from the base year (2015-16) to the reference year (2017-18), while several of the least-performing states further deteriorated, leading to a wider performance gap across larger states.
Among the top ten performers, Andhra Pradesh, Maharashtra, Gujarat, Himachal Pradesh, Jammu & Kashmir, Karnataka and Telangana had made further improvements in overall performance scores. However, among the six least performing states (Uttar Pradesh, Bihar, Odisha, Madhya Pradesh, Uttarakhand, and Rajasthan), five had declined in the overall performance scores, with the exception of Rajasthan which improved the score by 6.30 points.
The decline in the overall health index score for Bihar, Uttar Pradesh, Uttarakhand, Madhya Pradesh and Odisha can be attributed to the deterioration of their performance in several indicators. For instance, in Bihar, the performance related to total fertility rate, low birth weight, the sex ratio at birth, TB treatment success rate, quality accreditation of public health facilities and time-taken for National Health Mission (NHM) fund transfer showed deterioration. In the case of Uttar Pradesh, the performance related to low birth weight, TB treatment success rate, the average tenure of key positions at state and district level and level of birth registration accounted for the deterioration.
Similarly, Uttarakhand had a decrease in the health index score mainly because of the deterioration in NMR, U5MR, stability of tenure of key administrative positions at the district level, the functionality of First Referral Units (FRU), and NHM fund transfer. Odisha’s health index score reduction was mostly due to worsening of the full immunization rate and TB treatment success rate and Madhya Pradesh had a reduction in the level of birth registration and TB treatment success rate, leading to lower Health Index score.