Measuring the status of health of a state or a country is a complex process. Not only because it is something that is extremely difficult to model and needs reliable data from diverse areas, but also because states are so different from each other historically, geographically, economically and disease-burden wise. Possibly, because of the challenges in creating such a document, there was no grading document prior to 2014.
Notwithstanding such challenges, the government went ahead not only in making such a document but also linked a part of the central funding on healthcare to the index. Currently 10% of the government's health funding under the National Health Mission is linked to this index to reward the better performing states. Soon it will be raised to 20% and the World Bank, too, could factor the health index while deciding on health project funding to states.
Irrespective of its shortcomings, the NITI Aayog's just-released 2015-16 health index – titled Healthy States, Progressive India – can serve as an instrument to nudge the states and Union Territories to put greater focus on outcome-based measurement of their performance in health sector.
"It is driven by a good spirit and will spur healthy competition among states," said Vinod K Paul, a former professor at the All India Institute of Medical Sciences, Delhi, and a member of NITI Aayog.
To prepare the index, states were asked to submit data on 23 indicators belonging to three domains – key outcomes, governance and information, and key inputs or processes. An additional dataset on out-of-pocket expenditure was added later for the reference year (2015-16) though it was not there in the 2014-15 index.
On health outcomes, data on factors like still-birth rate, neonatal mortality, under-five mortality, maternal mortality, low birth weight, immunisation coverage, successful treatment of TB and the proportion of HIV positive people getting the anti-retroviral therapy were fed to the model.
The second subset of data have information on the manpower scenario at every level in the healthcare network whereas in the third category information was collected on things like functional cardiac care units, integrated disease surveillance programme, primary health care centres operating round the clock and public health facilities with quality certifications. The data was subsequently validated and fed into a statistical model to generate the index.
Large states – 21 of them according to the index – were compared on all the indicators. But the performance of smaller states (8) were examined on 19 of these indicators. For seven UTs, only 18 indicators were selected for the evaluation. States were ranked on the basis of their overall performance as well as on incremental advances or how much they improved from the last ranking.
Among the larger states, Kerala, Punjab and Tamil Nadu ranked on top in terms of overall performance while Jharkhand, Jammu and Kashmir and Uttar Pradesh are the best three on the scale of incremental performance. The latter three states showed the maximum gains in improvement of health outcomes from the 2014-15 report on neonatal mortality rate, under-five mortality rate, full immunisation coverage, institutional deliveries and HIV positive people getting the therapy.
Among smaller states, Mizoram ranked first, followed by Manipur, on overall performance whereas Manipur and Goa took the top slots on incremental performance. Among UTs, Lakshadweep won on both counts.
Karnataka found a place among those six states that showed a decline in their incremental health performance. The case is somewhat similar to Kerala, which ranked number one on overall performance but fared the worst in the incremental change index because having already achieved a low level of neonatal mortality, under-five mortality and replacement level fertility, there is limited space for further improvement.
The common challenge for such states is to fill up vacancies in staff positions, set up functional cardiac care units, quality accreditation of public health facilities and improving human resource management information system.
One sordid fact brought out by the index is most of the states' failure to improve the sex ratio at birth, suggesting continuation of illegal sex selection practice. Karnataka is one of the nine states that witnessed a drop of 10 points (950 girls in 2012-14 and 939 in 2013-15, against 1,000 boys) in the sex ratio at birth. Other guilty states are Chhattisgarh, Himachal Pradesh, Assam, Maharashtra, Rajasthan, Gujarat, Uttarakhand and Haryana. The only three states that recorded improvement are Bihar, Punjab and Uttar Pradesh.
Treatment of tuberculosis – India's biggest public health worry – is another problem area for Karnataka. The National Health Policy, 2017, establishes a target of more than 85% success in TB treatment. Karnataka and Maharashtra are the only two large states that failed to meet that target. Karnataka's case notification on TB is also one of the poorest among the states.
Another mark of success is to have functional cardiac care units (CCU) at the district level. Six large states – Assam, Bihar, Jharkhand, Telangana, UP and Uttarakhand – don't have a single functional unit; 3% of districts in Odisha (30 districts) and Chhattishgarh (27) have such a unit. Among the small states, Goa, Manipur, Meghalaya, Sikkim and Tripura don't have a single functional CCU at the district level.
Despite its limitations (such as its failure to capture the rapid rise of non-communicable diseases in India), the health index is an important document on the individual state's performance. But it should not be seen in isolation. The states' performance in healthcare should ideally be examined along with the state-level disease burden data that illustrates how wide the gap in disease burden among states (some cases almost twice) and how the burden due to the leading diseases ranges 5-10 times between the states.
Given such variations between states on disease burden and health performance, the big question is whether it is the right time to introduce the National Health Protection Scheme that seeks to offer health insurance for 10 crore Indian families?
