In Depth – India’s Health Index

• 04 Jul 2019

In 2017, NITI Aayog, in collaboration with the World Bank and the Ministry of Health and Family Welfare, developed the first comprehensive State Health Index in India. The first edition of “Healthy States, Progressive India - Report on the Ranks of States and Union Territories”, was released in February, 2018. It was the first attempt to establish an annual systematic tool to measure the heterogeneity of the nation’s performance in the health sector. The index was launched with the hope to promote a cooperative and competitive spirit among the states and UTs.

The second edition, released on June 25, 2019, focuses on measuring the overall performance and incremental improvement over a two year period (2016-17 and 2017-18) in all states and union territories. The base year taken is 2015-16. For the second time in a row, Kerala has emerged as the top ranking state in overall health performance, while Uttar Pradesh was the worst-performing state.

NITI Aayog Health Index 2018

• The indicators, methodology and categorisation of states and union territories in the health index 2018 were broadly consistent with the year 2017 edition with a total of 23 indicators grouped into the domains of health outcomes, governance and information and key inputs and processes.
• There were many indicators like birthweight of the child at the time of birth, sex ratio, accredition of healthcare facilities, infectious diseases like tuberculosis being controlled as per the government norms etc.
• The states were ranked in two ways: on the overall or historical performance and on the incremental performance.

How is it different?

• The Health Index is an attempt by NITI Aayog to bring the focus on outcomes such as lower mortality and fertility rates. Generally, the practice is to look at the quantum of budget and the amount that has been spent and also some kinds of infrastructure like clinics, Primary Healthcare Centres (PHCs), district hospitals etc.
• It is also a tool for assessing India’s readiness on achieving the SDG goals
• It also sets up incentives for the states that if they perform well on the health system measurements, more funds will be allocated to them. The Index has been linked to incentives under the National Health Mission.

2018 Rankings

• States and union territories, on the basis of population, have been ranked in three categories: Larger states, Smaller states and Union territories, to ensure comparison among similar entities.

Larger States

• Among the larger states, Kerala, Andhra Pradesh and Maharashtra are ranked on top in overall performance.
• Gujarat, Punjab and Himachal Pradesh are fourth, fifth and sixth respectively.
• Uttar Pradesh, Bihar and Odisha were among the worst performing states.
• In terms of annual incremental performance, Haryana, Rajasthan and Jharkhand are the top three states.
  • These states also show the maximum gains in improvement of health outcomes from base to reference year in indicators such as neonatal mortality rate (NMR), under-five mortality rate (U5MR), the proportion of low birth weight among newborns, proportion of community health centres and public health centres with quality accreditation certificates, full immunization coverage, institutional deliveries, and proportion of specialist positions vacant at district hospitals.

Smaller States

• Among the smaller states, Mizoram ranked first followed by Manipur on overall performance. Tripura followed by Manipur were the top two states in terms of annual incremental performance.
  • Manipur registered maximum incremental progress on indicators such as full immunization coverage, institutional deliveries and total case notification rate of tuberculosis.
• Sikkim and Arunchal Pradesh had the biggest decrease in overall health index scores among the smaller states.

Union Territories

• Among the UTs, Chandigarh followed by Dadra and Nagar Haveli occupied the top two positions in terms of overall performance as well as annual incremental performance.

Other Findings

• The report highlighted a decline in the overall health index score of the five empowered action group (EAG) states of Bihar, Uttar Pradesh, Uttarakhand, Madhya Pradesh, and Odisha because of deterioration in various parameters.
• The report points out that there was a general positive correlation between the heath index scores and the economic development levels of states and union territories as measured by per capita net state domestic product.
• The report also notes that overall there is a room for improvement in all states even among the best.
• Many states have also made good progress towards achieving the Sustainable Development Goals included in the index.

HAQ Index

• When it comes to world rankings, India was ranked 145^th among 195 countries on Healthcare Access and Quality (HAQ) index in 2016.
  • The index is based on 32 causes of death considered preventable with effective medical care.
  • It assigns a 0-100 score to each of the 195 countries and territories assessed.
• The comprehensive index released by Global Burden of Disease, funded by the Bill and Melinda Gates Foundation says that despite such low rankings, India has seen improvement in HAQ since the year 1990. India’s HAQ score 41.2 has improved from 24.7 score in the year 1990.
• Despite the16.5-point improvement in 26 years, India’s score is well below the global average of 54.4.
• India lags way behind its BRICS peers Brazil, Russia, China and South Africa on the HAQ index.
• India, however, matches China in the disparity in healthcare access and quality between states.
  • Within India, the best performers Kerala and Goa scored more than 60 points on the HAQ index in the year 2016.
  • Other top performers in order of rank are Delhi (56.2), Himachal Pradesh (51.7) and the union territories other than Delhi (56.2).
  • The worst performers were Chhattisgarh and Jharkhand, Bihar (37), Odisha (36.3), Uttar Pradesh (34.9) and Assam (34).
  • This gap between the highest and lowest scores increased from a 23.4 point difference in the year 1990 to a 30.8 difference in the year 2016.
  • The study said that these regional differences in India could be due to multiple reasons such as large variations in physical access to health facilities, the state of health infrastructure, the level and scale-up of medical technologies, and the provision of effective services across the spectrum of care.
• According to the index, India ranks worse than Bangladesh, Sri Lanka and Bhutan among its neighbours but better than Pakistan, Afghanistan and Nepal.
• India’s rank is also worse than that of many poorer countries in Sub-Saharan Africa such as Sudan (136), Equatorial Guinea (129), Botswana (122) and Namibia (137).
• The study found that, generally, countries that spend more on health per capita and had better health systems scored higher on the HAQ index. According to a report by the Journal IndiaSpend, India spends just 1.4% of its GDP on health. The World Health Organization (WHO) recommends that countries should spend 4-5% of their GDP on health to achieve universal healthcare.

India’s Healthcare System

• The healthcare delivery system is categorised into two major components: public and private.
• The public healthcare system is made up of secondary and tertiary care institutions in key cities and provides basic healthcare facilities in the form of Primary Healthcare Centres in rural areas.
• The private sector provides the majority of secondary, tertiary, quaternary care institutions with a major concentration in metros, Tier-1 and Tier-2 cities.
• India’s healthcare industry is one of the fastest growing sectors and is expected to reach 280 billion by the year 2020.
• India is also one of the leading destinations for high end diagnostics services with tremendous capital investment for advanced diagnostic facilities.

Indian Healthcare Initiatives

• India is on course to attain sustainable development goal targets for maternal and child health, much ahead of the agreed date of 2030.
• In 2014, the central government launched the Pradhan Mantri Surakshit Matritva Abhiyan as part of which doctors pledged a day of service per month to the campaign and 16 million ante-natal care check-ups were performed.
• In August 2018, the Government approved Ayushman Bharat-National Health Protection Mission contributed by both the center and the state government at a ratio of 60:40 for all States, 90:10 for hilly North Eastern States and 60:40 for Union Territories with legislature. It provides healthcare facilities to over 10 crore urban and rural poor families.
• On September 23, 2018, the government launched the Pradhan Mantri Jan Arogya Yojana (PMJAY), a cashless health insurance cover of up to Rs. 5 lakh per family per year covering 500 million poor citizens.
• The mission Indradhanush covers immunization. Under this, the government reached 32.8 million children and 8.4 million pregnant women in the last three years. The number of vaccines has been increased from 7 to 12.
• To address malnutrition among children, the government launched POSHAN Abhiyan and is also implementing Rashtriya Bal Swasthya Karyakram that has provided 800 million health check-ups and free referral treatment to 20 million children in the last 4 years.
• The Pradhan Mantri Matru Vandana Yojana is expected to benefit 50 million pregnant women and lactating mothers. The scheme enables direct benefit transfer to their bank accounts to compensate for wage loss, enable better nutrition and adequate rest before and after delivery.