Niti Aayog releases Health Index: Understand the report card
New Delhi: The federal think tank NITI Aayog's fourth Health Index report has been released showing progress on health systems performance and outcomes while developing healthy competition and encouraging cross-learning among states and Union territories.
In 2017, the Niti Aayog in collaboration with the Ministry of Health and Family Welfare (MoHFW) and the World Bank initiated an annual health index for tracking overall performance and incremental performance across all states and UTs.
Health Index is a weighted composite score incorporating 24 indicators covering key aspects of health performance comprising of select indicators in three domains: Health Outcomes; Governance and Information; and Key Inputs and Processes. The indicators are selected on the basis of their importance and availability of reasonably reliable data at least annually from existing data sources such as the Sample Registration System (SRS), Civil Registration System (CRS) and Health Management Information Systems (HMIS).
Indicators
The report said it is expected that the exercise will help drive the efforts of the state and UTs towards the achievement of health-related sustainable development goals (SDGs) including those related to universal health coverage (UHC) and other health outcomes.
The period 2019-20 (reference year) was taken into account in the fourth Health Index by the agency.
The states are ranked on parameters including Neonatal Mortality Rate (NMR), the Under-five Mortality Rate (U5MR) and full-immunisation coverage. The learnings from the previous three rounds of the Health Index were taken into account to develop the Health Index Round IV 2019-20. Previous indicators were reviewed and three new ones were added for larger states. These are Maternal Mortality Ratio (MMR), the proportion of pregnant women who received four or more antenatal care checkups (ANC) and the level of registration of deaths.
The indicators are selected on the basis of their importance and availability of reasonably reliable data at least annually from existing data sources such as the Sample Registration System, Civil Registration System and Health Management Information Systems.
Salient features of NITI Aayog's fourth Health Index report:
"The Covid-19 pandemic has reinforced the importance of the health sector and the need for doubling up health systems strengthening efforts. Though this round of the health index (Round IV) 2019-20 does not capture the impact of Covid-19 on health outcomes or any of the other indicators, as the index performance relates to the base year (2018-19) and reference year (2019-20), largely the pre-Covid period, it will provide good guidance on areas of improvement to states and UTs," Niti Aayog member Vinod Paul said in his comment on the report.
The report pointed out that for the fourth consecutive round Kerala emerged as the best performer in terms of overall performance.
The gap in the Overall Performance between the best and the worst performing Larger State and UTs narrowed in the current round of the Health Index, while it increased for the Smaller States. Among the Larger States, Kerala was at the top with the Index Score of 82.20 and Uttar Pradesh at the bottom with the Index Score of 30.57, in the Reference Year (2019-20).
Overall Performance
In Reference Year (2019-20), Kerala and Tamil Nadu occupied the first and second ranks, with Overall Performance Scores of 82.20 and 72.42 respectively. Kerala has been the top ranking Larger State in all the four rounds of the Health Index. Among the Larger States, only four states improved their Base Year (2018-19) rank in the Reference Year (2019-20).
Ten states including Kerala, Tamil Nadu, Maharashtra, Chhattisgarh, Haryana, Jharkhand, Rajasthan, Madhya Pradesh, Bihar and Uttar Pradesh retained their rank , while four states improved their rankings from Base Year (2018-19) to Reference Year (2019-20).
Telangana improved its position from fourth to third, Gujarat from seventh to sixth, and Punjab from ninth to eighth.
The most significant progress was observed in Assam as it improved its ranking by three positions, from fifteenth to twelfth.
On the contrary, five states observed a decline in their ranking from Base Year (2018-19) to Reference Year (2019-20).
Odisha had the steepest decline of two positions, while the ranking of Andhra Pradesh, Himachal Pradesh, Karnataka and Uttarakhand declined by one position each.
The Health Index Score for the Reference Year (2019-20) revealed wide disparities in Overall Performance across the Larger States. Among the 19 Larger States, the Overall Performance Score of the best-performing state was about 2.7 times of the least-performing state. Kerala continued to champion the Larger States with an Overall Performance Score of 82.20, while Uttar Pradesh was the least performing state with an Overall Performance Score of 30.57. Compared to the Base Year (2018-19), the gap between the best performing Larger State and the least performing Larger State has narrowed down in the Reference Year (2019-20).
Despite good performance, even the best performing states have significant room for improvement as the highest observed Overall Index Score was 82.20 for Kerala which is some distance from the frontier (maximum potential score is 100). The lowest Index Score is 30.57 for Uttar Pradesh preceded by Bihar (31.00), Madhya Pradesh (36.72) and Rajasthan (41.33).
Performance report:
Among UTs, D&N Haveli & Daman & Diu, along with Chandigarh made it to the top of the overall health index while Delhi and Jammu & Kashmir ranked among the bottom UTs in terms of Overall Performance but emerged as the leading performer in terms of Incremental Performance.
In case of Smaller States, Mizoram emerged as best performer and Arunachal Pradesh and Manipur as the worst performers, both in terms of Incremental and Overall Performance.
Karnataka, categorised among 19 large states, has slipped from 16th position in 2018-19 to 19th this year in the incremental index and has gone down from the 8th position to 9th in the overall index. Of all southern states, Karnataka has shown the sharpest decline. The state's overall score on various parameters slipped from 59.29 to 57.93.
Incremental Performance
The largest increase in Index Scores (5.52 points) was shown by Uttar Pradesh while the largest decline was observed by Karnataka (-1.37 points). Apart from Karnataka, all Southern States showed improvements in the Composite Index Scores between the Base Year (2018-19) and the Reference Year (2019-20). All the eight Empowered Action Group (EAG) States, except Chhattisgarh, were in the bottom half in terms of Overall Performance. However, in terms of Incremental Performance, the picture was mixed.
Uttar Pradesh, Jharkhand, Madhya Pradesh, Bihar, Uttarakhand and Odisha showed improvement in the Incremental Performance, while Chhattisgarh and Rajasthan showed marginal decline of less than half percentage point in Incremental Performance. Himachal Pradesh, Haryana and Karnataka, are among one-third of the Larger States in terms of Overall Performance indicating better health systems, but have negative Incremental Performance from Base Year (2018-19) to Reference Year (2019-20) Among the Larger States,
Telangana emerged as the strongest performer both in terms of Incremental Performance as well as Overall Performance.
Though Andhra Pradesh, Kerala, Tamil Nadu and Maharashtra were Front-runners in terms of Overall Performance, these states showed least or moderate improvement from Base Year (2018-19) to Reference Year (2019-20). On the other hand, Assam and Uttar Pradesh, bottom performers in terms of Overall Performance, fall in the category of Most Improved states in terms of Incremental Performance.
Rajasthan is the weakest performer both in the case of Incremental Performance and Overall Performance.
For a vast majority of the states and UTs, there has been a shift in the Overall Performance ranking from Base Year (2018-19) to Reference Year (2019-20). From the Base Year (2018-19) to the Reference Year (2019-20), Uttar Pradesh led in improving the performance of 33 out of 43 indicators/sub-indicators. On the other hand, Kerala showed improvement in only 19 indicators, and additionally had three indicators in the category of Fully Achieved.
Only five Larger States and two Smaller States showed good Overall Performance and continued to improve on their Health Index Score from the Base Year (2018-19) to Reference Year (2019-20). Mizoram and Telangana were the only two states that demonstrated strong Overall Performance and showed most improvements in the Incremental Performance between the Base Year (2018-19) and Reference Year (2019-20).
Categorisation of Larger States, Smaller States and UTs based on Overall Performance and Incremental Performance between Base Year (2018-19) and Reference Year (2019-20)
Observations
There is a general negative correlation between the Health Index Scores and the poverty levels of states and UTs as measured by the Multidimensional Poverty Index recently released by NITI Aayog. However, many states with the same level of poverty performed better in Health Index indicating that factors beyond income determine health sector performance.
In terms of institutional delivery, among larger states, the highest percentage of institutional deliveries was observed by Kerala in 2014-15 (96 per cent) and Telangana in 2019-20 (96.3 per cent). The list includes life-saving equipment and hygienic conditions, and UP was the worst performer in both 2014-15 (43.6%) and 2019-20 (60.8%) followed by Bihar and Madhya Pradesh as the second and third-worst performers.
As per the report, the larger states recorded a shortage in the required number of specialists in the district hospitals. The state with the highest increase in specialists is Bihar where they increased by 23 percent from base year (2018-19) to reference year (2019-20), whereas Uttarakhand had the biggest drop (-19 per cent).
The think tank has noted that there are wide disparities in the Health Outcomes Domain Index Scores across states and UTs. "In the Governance and Information domain, majority of states/UTs registered an increase in Index Scores from Base Year (2018-19) to the Reference Year (2019-20). There are wide disparities in the Key Inputs and Processes Domain Index Scores across states and UTs as well as among the Larger States, Telangana is the only state that demonstrated strong Overall Performance as well as Incremental Performance while Rajasthan reported weak performance on both counts", the report pointed out.
The Health Index is a useful tool to measure and compare the Overall Performance and Incremental Performance across states and UTs over time and nudging the states and UTs to shift the focus from inputs and outputs to outcomes. The Health Index has strengthened the culture of use of data at the state/UT level to monitor performance and is contributing to the agenda of improving availability, quality and timeliness of data.
"States are beginning to take cognizance of indices such as the State Health Index and use them in their policymaking and resource allocation. This report is an example of both competitive and cooperative federalism,'' said VC Dr Rajiv Kumar.
"Our objective through this index is to not just look at the states' historical performance but also their incremental performance. The index encourages healthy competition and cross-learning among States and UTs," CEO Amitabh Kant stressed the significance of the health index.
