Scoring on health
States, now with greater resources at their command, must upgrade primary health care
Why in news?
- NITI Aayog released the Second Edition of “Healthy States, Progressive India”.
About the report
- Incremental change: The report ranks states and Union territories innovatively on their year-on-year incremental change in health outcomes, as well as, their overall performance.
- Period: The Round II report focuses on measuring and highlighting the overall performance and incremental improvement over a two year period (2016-17 and 2017-18) in the States and UTs
- Performance tool: The report is an annual systematic performance tool to measure the performance of the States and UTs.
- It ranks states and union territories on their year on year incremental change in health outcomes, as well as, their overall performance with respect to each other.
- The ranking is categorized as Larger States, Smaller States and Union Territories (UTs), to ensure comparison among similar entities.
- Composite Index: The Health Index is a weighted composite Index based on 23 indicators grouped into the domains of Health Outcomes, Governance and Information, and Key Inputs/Processes. .
- Each domain has been assigned weights based on its importance and has been equally distributed among indicators.
- The States are categorized on the basis of reference year Index score range:
- Front-runners: top one-third,
- Achievers: middle one-third,
- Aspirants: lowest one-third.
- The States are categorized into four groups based on incremental performance:
- not improved (<=0 incremental change);
- least improved (0.01 to 2 points increase);
- moderately improved (2.01 to 4 points), and
- most improved (>4 points increase).
- Larger States: Kerala, Andhra Pradesh & Maharashtra ranked on top in terms of overall performance, while Haryana, Rajasthan and Jharkhand are the top three ranking States in terms of annual incremental performance.
- Haryana, Rajasthan and Jharkhand showed 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), Proportion Low Birth Weight among New-borns, Proportion of districts with functional Cardiac Care Units (CCUs), Proportion of ANCs registered within first trimester, Proportion of CHCs/PHCs with Quality Accreditation Certificates, full immunization coverage, institutional deliveries, Proportion of Specialist positions vacant at District Hospitals and Proportion of total staff (regular and contractual) with e-pay slip generated in the IT enabled Human Resources Management Information System.
- Smaller States: Mizoram ranked first followed by Manipur on overall performance, while Tripura followed by Manipur were the top ranked States in terms of annual incremental performance.
- Manipur registered maximum incremental progress on indicators such as full immunization coverage, institutional deliveries, total Case Notification Rate of Tuberculosis, Average Occupancy of a District Chief Medical Officer for last three years and Completeness of IDSP reporting of P and L forms.
- UTs: Chandigarh and Dadra and Nagar Haveli were ranked on top in terms of overall performance (Chandigarh-1 and Dadra and Nagar Haveli-2) as well as annual incremental performance (Dadra and Nagar Haveli-1 and Chandigarh-2).
- These two UTs showed the highest improvement in indicators such as total Case Notification Rate of Tuberculosis, Average Occupancy of an officer (in months) for 3 Key State posts for last 3 years, Proportion of ANMs positions vacant at Sub Centres, Proportion of Staff Nurses positions vacant at PHCs and CHCs, Proportion of MO positions vacant at PHCs, Proportion of total staff (regular and contractual) with e-pay slip generated in the IT enabled Human Resources Management Information System, Proportion of facilities functional as FRUs, Proportion of districts with functional Cardiac Care Units (CCUs), Proportion of ANCs registered within first trimester, Completeness of IDSP reporting of P and L forms, and transfer of National Health Mission (NHM) funds from State Treasury to implementation agency.
- The Health Index 2019 makes the important point that some States and Union Territories are doing better on health and well-being even with a lower economic output, while others are not improving upon high standards. Some are actually slipping in their performance.
- In the assessment during 2017-18, a few large States present a dismal picture, reflecting the low priority their governments have accorded to health and human development since the Aayog produced its first ranking for 2015-16. The disparities are stark.
- Populous and politically important Uttar Pradesh brings up the rear on the overall Health Index with a low score of 28.61, while the national leader, Kerala, has scored 74.01.
- Andhra Pradesh and Maharashtra join Kerala as the other top performers, with the additional distinction of making incremental progress from the base year.
- The NITI Aayog Index is a composite based on 23 indicators, covering such aspects as neonatal and infant mortality rates, fertility rate, low birth weight, immunisation coverage and progress in treating tuberculosis and HIV. States are also assessed on improvements to administrative capability and public health infrastructure.
- For a leading State like Tamil Nadu, the order of merit in the report should serve as a sobering reminder to stop resting on its oars:
- it has slipped from third to ninth rank on parameters such as low birth weight, functioning public health centres and community health centre grading.
Primary health care
- For the Health Index concept to spur States into action, public health must become part of mainstream politics.
- While the Centre has devoted greater attention to tertiary care and reduction of out-of-pocket expenses through financial risk protection initiatives such as Ayushman Bharat, several States remain laggards when it comes to creating a primary health care system with well-equipped PHCs as the unit. This was first recommended in 1946 by the Bhore Committee.
- The neglect of such a reliable primary care approach even after so many decades affects States such as Bihar, where much work needs to be done to reduce infant and neonatal mortality and low birth weight, and create specialist departments at district hospitals.
- Special attention is needed to shore up standards of primary care in Odisha, Madhya Pradesh, Uttarakhand, Rajasthan, Assam and Jharkhand, which are at the bottom of the scale, as per the NITI Aayog assessment.
- The Health Index does not capture other related dimensions, such as non-communicable diseases, infectious diseases and mental health. It also does not get uniformly reliable data, especially from the growing private sector.
- What is clear is that State governments now have greater resources at their command under the new scheme of financial devolution, and, in partnership with the Centre, they must use the funds to transform primary health care.
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