Health outcomes index: nudging India to progress
The index will encourage states to improve their health sector outcomes in the spirit of cooperative and competitive federalism
India is committed to the United Nations Sustainable Development Goal (UN-SDG) to ensure “good health and well-being” of all its citizens. The release of “Healthy States, Progressive India” report has spurred a vibrant debate on the status and future of India’s health sector. Understandably, the focus has been on the performance and annual progress of states and Union territories on a myriad of health indicators. This index will help nudge states towards improving their health sector outcomes in the spirit of cooperative and competitive federalism.
Kerala is the leader among large states, closely followed by Punjab and Tamil Nadu. Uttar Pradesh, Rajasthan and Bihar are the least-performing states. Mizoram is the best-performing small state, followed by Manipur, while Nagaland and Tripura take the final two spots. Lakshadweep secured the top spot among Union territories, and Dadra and Nagar Haveli is at the end of the rankings.
The goal of the index is not just to rank the states based on their historical performance, but also on their incremental performance. The attempt is to capture the change made during the course of the year. Jharkhand, Jammu and Kashmir, and Uttar Pradesh are ranked first, second and third in their incremental performance ranking. However, the ranking alone doesn’t tell us the whole story.
The “Performance On Health Outcomes” index is made up of 24 indicators in three different domains—health outcomes, governance and information, and key inputs and processes. The “health outcomes” account for 70% of the weight, and the other two domains weighs 12% and 18%, respectively. The “health outcomes” domain has indicators such as total fertility rate (TFR), neonatal mortality rate (NMR), sex-ratio at birth (SRB), etc. The governance and information domain measures the quality of data (data integrity indicator) and the average occupancy in important health-related posts such as principal secretary (health), chief medical officer, etc. Key inputs and processes measure the current status of healthcare professional vacancies, infrastructure at district hospitals, and the speed of financial governance in the states.
Kerala topped the overall index with a score of 76.55 in the reference year (2015-16). The state’s performance is even more stellar if we consider just the health outcomes domain, where it has improved its performance year-on-year to 82.89, a 13.02 point lead over Punjab. Incremental progress will be tougher as it has already achieved or exceeded several of the goals and targets in the National Health Policy and the UN-SDGs. However, a closer look at the indicators reveals major concerns. Sex ratio at birth has fallen to 967, while the proportion of infants with low birth-weight has gone up to 11.7%. The proportion of fully immunized children has also gone down. At the same time, it has fallen short in the “key inputs and processes” domain, falling to 69.62 in 2015-16, a 4.55 points’ drop.
What are the key results that emerge from the health index? First, there are large gaps between states. The gap between the best-performing states and the least-performing states is worrisome—Kerala and Uttar Pradesh are separated by 42.86 points, Mizoram and Nagaland by 36.32, and Lakshadweep, and Dadra and Nagar Haveli by 31.15 (see Table 1). Two-thirds of our citizens live in states with an overall score less than 60.
Second, incremental performance reveals that there has been a decline in performance on some states: While most states have registered an increase in their health index in 2015-16 relative to 2014-15, six states’ scores have declined—Kerala, Haryana, Gujarat, Karnataka, Himachal Pradesh, and Uttarakhand. These states need to work on health index’s parameters for continuous improvement.
Third, India has made significant strides in achieving the goals set out under the UN-SDG and our own National Health Policy. Some of our states have already met or exceeded the goals a decade ahead of 2030 (see Table 2).
What are the lessons that emerge from the health outcomes index? First, an exercise of this kind requires data on health outcomes, which is periodic, reliable and comparable across different states and Union territories. The effort did show us significant gaps in the availability of such data, especially for the smaller states. We need robust programmatic data than can be used for continuous monitoring.
Second, incentives need to be linked to performance. The two separate rankings, on absolute performance and year-on-year progress are designed to encourage states to work on their health sector and bring about meaningful transformation. The linking of the health index with incentives under the National Health Mission will further push states to improve outcomes.
NITI Aayog is creating a framework to track the performance of government hospitals based on outcome metrics. Together with the upgrading and setting up of health and wellness centres under the Ayushman Bharat Scheme and the National Health Protection Scheme, these measures will help us realize the goal of “good health and well-being” for all citizens.
Amitabh Kant is chief executive officer at NITI Aayog. Views expressed are personal.
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