India And The Niti Aayog Health Index: Beyond Absolute Numbers – Analysis


The Health Index released by the NITI Aayog provides a comprehensive state-wise assessment of the health situation in the country. But, it is imperative for India to look beyond absolute numbers to achieve its long term health goals.

By Kriti Kapur

The Niti Aayog recently released the second edition of the State Health Index “Healthy States and Progressive India” in collaboration with the World Bank and the Ministry of Health and Family Welfare.

This report, established to measure and understand the heterogeneity and complexity of the nation’s performance in the health sector, ranks each state on the basis of the Health Index.

The index is a weighted composite index based on 23 indicators, broadly categorized into 3 domains: Health outcomes (focusing on measures such as Mortality rates, sex ratio, and immunization), Governance and Information (focusing on the status of the governance structures and information systems within states), and Key inputs & processes (focusing on areas such as healthcare quality and availability, staff shortages and birth registration level).

The figures below show the increment growth of the overall health index across the states. Figure 1.1 & 1.2 show state wise growth from 2014-15 to 2015-16 and 2015-16 to 2017-18, respectively. Figure 1.3 shows increment growth from 2014-15 to 2017-18*:

For the second time, the Niti Aayog Health Index ranked Kerala as the best performing state while Uttar Pradesh was the lowermost.

While Kerala has been ranked the ‘topper’ with an index score of 74.01, which is 8.68 points higher than the second highest performing state (Andhra Pradesh at 65.13), what needs to be carefully looked at is the deteriorating performance of the state. The Index, decreasing from 80 in 2014-15 to 74.01 in 2017-18, indicates that the state has been defaulting in several aspects.

Kerala, despite attaining the 2030 UN Sustainable Development goals of 12 neonatal deaths per 1000 live births, has exhibited deterioration in 18 out of 23 indicators as compared to the 2018 report largely driven down by the performance in key inputs and processes indicators. While staff shortage was not a cause of concern, the low proportion of functional first referral units and uncertain quality accreditation of cardiac care units and primary health care units lead to a crunch in the healthcare system.

Other Health outcome indicators in Kerala such as the sex ratio at birth (no. of girls born per 1000 boys in a specific year) and Tuberculosis (TB) notification rate also showed a negative trend, seeming to be a cause of concern for the state. This comes as a surprise since the 2018 Health Index captures the Kerala sex ratio at birth at 974 (2014-15), whereas, the Health Index 2019 captures the same at 959 (2017-18), a fall of 2% in 3 years, primarily attributed to sex selection aided by improved technology, explored at length in ‘Disappearing Daughters: The Tragedy of Female Feticide’ by Gita Aravamudan.

The figures 2.1 & 2.2 show a clearer picture of the trends in Index Scores of Kerala & Haryana:

Index Score Trend in Kerala & Haryana

On the other hand, Uttar Pradesh, while being rated the lowest twice in a row showed one of the highest incremental growth in the 2018 Niti Aayog Health Index report. This year, however, the index score for UP at 28.61 declined by almost the same amount it had increased in the previous report.

The considerable decline is largely due to the stunted TB treatment success rate, low birth weight, and birth registration level. The governance and information domain in UP seems to be lagging, thereby pulling the overall index lower, even though key outcomes like Neonatal Mortality rate, Under 5 Mortality rate, Sex ratio and TB notification rate have shown a positive trend.

Even though health remains a critical area requiring significant improvement, there has been remarkable progress in some states like Haryana, Rajasthan, and Jharkhand, showing a positive improvement in the Health sector, according to the report.

While the state of Haryana may have reported a sinking index according to the 2018 Health Index report, the state seems to have redoubled its efforts with the highest incremental growth this year. Not only has Haryana seen a positive trend in mortality rate, low birth weight, and sex ratio, but also in the overall quality of key processes and inputs with a higher number of nurses and medical officers available in primary health care and cardiac care units.

The TB notification rate as well as the TB treatment success rate in Haryana maintains a stagnating trend. Furthermore, inadequate specialist positions in hospitals and lower number of functional primary health care units per 1,00,000 population remains a persistent issue. Also, variation in the timing of funds released by the Centre to the state has further led to insufficient service delivery.

Amidst the herd also lies the case of the underdog, Jharkhand. Where most states have seen a mixed trend over the years, Jharkhand has maintained a strong growth trend with an increase of 33% in the health index from 2014-15 to 2017-18.

Jharkhand has seen a progressive trend in 9 out of the 10 primary health outcomes along with a strong system of qualified health care professionals. Being a part of the Empowered Action Group (EAG), it has a long way to go in terms of absolute values, but the robust growth rate holds promises.

Figure 3.1 shows the trend in the health index of EAG states from 2014-15 to 2017-18:

While it is important to identify the challenges faced by the EAG States (with only 3 out of 8 showing an upward trend) that hinder improvement in performance, the impressive improvement in some EAG States (namely Jharkhand, Rajasthan and Chhattisgarh) provides learning opportunities for the rest to identify effective actions to improve their overall performance scores.

In the last decade, there has been significant alleviation in India’s poverty, which has contributed to improved outcomes. While the progress is reckonable, the health system still demands more focus and resources. Overall, there is substantial room for improvement, even among the best-performing states. The Health Index provides a good overview of the performance and is an important instrument in understanding the variations and complexity of the nation’s performance in health. The report highlights the areas where each state or union territory should focus on, to facilitate improvement in overall health outcomes.

The author is a research intern at ORF New Delhi.

Observer Research Foundation

ORF was established on 5 September 1990 as a private, not for profit, ’think tank’ to influence public policy formulation. The Foundation brought together, for the first time, leading Indian economists and policymakers to present An Agenda for Economic Reforms in India. The idea was to help develop a consensus in favour of economic reforms.

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