Does the National Health Index Truly Measure the Health Status? | Chathukulam, Joseph & Buch

Abstract

This paper critically looks into the strengths and weakness of the NITI Aayog’s National Health Index. It also reflects on why India needs a Comprehensive Health Index in the post-pandemic world.

Introduction

India has made improvement in terms of life expectancy, in reducing fertility rate, maternal mortality rate (MMR), infant mortality rate (IMR), under five mortality rate (U5MR) over the years. However, taking into India’s commitment towards Sustainable Development Goals (SDGs), the country has miles and miles to go if it wants to achieved the required SDG targets by 2030. It is in this context, National Institution for Transforming India (NITI) Aayog, the premier policy think-tank of the Government of India and the nodal agency entrusted with the task of guiding India to fulfill the commitments under SDGs decided to formulate a mechanism for measuring outcomes in critical areas like health. With an aim to bring about transformational change in population health through a spirit of co-operative and competitive federalism, in 2017, the NITI Aayog, in collaboration with Ministry of Health and Family Welfare (MoHFW) and World Bank initiated a National Health Index. In February 2018, the first round of the Health Index (referred to as Health Index-2017) titled ‘Healthy States: Progressive India’ was released, which measured the annual and incremental performance of the States and UTs over the period of 2014-15 (Base Year) to 2015-16 (Reference Year). The second edition of the Health Index was released in June 2019. The Third edition of Index was released in December 2020, and the fourth Index in December 2021.

Table No. 1: Overall and Incremental Health Index Score & Rank* 

Source: Compiled by authors based on the four National Health Indexes by NITI Aayog

*Ranks shown in parentheses.
** Data for Jammu and Kashmir for the year 2019 - 2020 is listed under Union Territories. In October 2019, Jammu and Kashmir was bifurcated into two Union Territories- Jammu and Ladakh.
*** West Bengal did not participate in the Nation Health Index in 2018 -19 and 2019-2020.
****In 2019-20 Jammu & Kashmir was incorporated into Union Territory and on December 2019 Dadra & Nagar Haveli and Daman & Diu was made into one single Union Territory. The UT of Ladakh was not included citing lack of data in 2019. The UT of Ladakh was formed in 2019, so no separate health index data available for Ladakh alone as prior to 2019 it was part of the state of Jammu and Kashmir.

Among the larger states, Kerala has maintained the top spot in terms of overall performance in all the four rounds of National Health Index (See Table No.1). However, Kerala ranks twelfth in terms of incremental performance. Though Uttar Pradesh, which has one of the lowest Overall Reference Year Index Score and is always ranked at the bottom in all the four rounds of the Health Index, it ranked at the top in terms of incremental performance by registering the highest incremental change from the Base Year (2018-19) to Reference Year (2019-20).

Strengths of National Health Index

The National Health Index prepared by the NITI Aayog in the last four years is praiseworthy despite some serious flaws. The efforts, the research, the commitment and the hard work involved in constructing a National Health Index since 2017 is commendable. The Index has the potential to serve as an instrument in improving population health and understanding the variations in the complexity of the nation’s improvement in health.

1. A Systematic and Scientific Tool to Measure Performance on Healthcare Access and Quality

The National Health Index is developed in such a way that it can be used as an annual systematic tool to motivate states and UTs towards undertaking multi-pronged interventions that will bring better health outcomes. The Index is a scientific framework to measure and compare the overall performance and incremental on a variety of indicators — Health Outcomes, Governance and Information and Key Inputs and Processes. It has the potential to act as an instrument in capturing the strengths and drawbacks in healthcare sector in India. The data and findings from the Index can be used by policy makers and health experts and other stakeholders to formulate a number of comprehensive health strategies to address the shortcomings in health services offered in the country. The Index uses a scientific process and methodology to assess the health of its people and the overall health of the nation in general. The Index in a way has become an eye opener to many states and UTs and it has made them aware of the strength and weaknesses in their health systems.

2 Motivating States and UTs to build Better Health Systems and Improve Service Delivery

The National Health Index helps in understanding variations in different parameters across states and UTs and it identifies and points out indicators that each state/UT should focus on to facilitate improvement in overall outcomes in terms of health. Thus, the Index is serving as a good mentor or advisor to states and UTs by making them aware about the strengths and weakness, threats and opportunities in their healthcare systems and motivates them to build robust health systems and improve their service delivery. The Index is more or less like a SWOT analysis on health systems and practices in the country.

3 Strengthening Data Culture, Data Integrity and Opening the Doors for Big Data Analytics

One of the biggest contributions of the National Health Index, in the last four years, is that it has helped to strengthen the culture of use of data at the state/UT level to monitor their performance. The Index has proved to be instrumental in improving availability, quality, integrity and timeliness of data. In addition to that, many states and UTs have started to adopt this data culture to assess their performance in health and related sectors at the sub-national level and grassroots level. For instance, States like Andhra Pradesh, Assam, Chhattisgarh, Gujarat and Karnataka have replicated the Index and are regularly monitoring district performance using data tools and framework used in the Index. The Index has helped a great deal in furthering the data agenda in the health sector. In addition to that, the process of data validation and discussions among state and union level programme managers is helping reinforce good practices related to data scrutiny and validation of data in Health Management Information Systems (HMIS).

4 Emphasis on Performance Based Financing for Better Outcomes 

The decision of the MoHFW to link a share of incentives under the National Health Mission (NHM) funds to the progress achieved by states and UTs in the National Health index is a good practice. It shows the emphasis given to performance-based financing for better outcomes. Based on the interim findings of the fourth round of the Health Index (2019-20), the MoHFW provided 10 percent of the state/UTs’ total NHM funds as NHM incentive based on agreed conditionalities.

5 Helping India’s Efforts in health-related Sustainable Development Goals (SDGs)

The National Health Index tracks progress on health outcomes and health systems performance, among states and UTs. The Index scores and rankings for states and UTs are generated to assess Incremental Performance (year-to-year progress) and Overall Performance (current performance). The Index has the potential to help drive state/UT’s efforts towards achievement of health-related SDGs including those related to Universal Health Coverage (UHC) and other health outcomes. The SDG Targets covered in the Index include NMR, U5MR, MMR, institutional deliveries and total case notification of Tuberculosis. Goal 3 UHC tracer indicators covered in the Index include percentage of incident TB cases that are detected and successfully treated and percentage of people living with HIV currently receiving antiretroviral therapy. The Index also covers indicators related to child immunisation, pregnancy and delivery care, and health work-force.

6 The Covid 19 Pandemic and the Increasing Relevance of National Health Index in the Post Pandemic India

The Covid 19 pandemic has exposed that India is in desperate need of a strong public healthcare system and in the process to build such a system a Comprehensive National Health Index is a must. The pandemic has shown that India’s healthcare system is underfunded and under staffed. It is in this context, the 15th Union Finance Commission (UFC), in the wake of Covid 19 pandemic, decided to allocate health grants to local governments for strengthening grassroots health infrastructure including urban health and wellness centres (HWCs), ‘building-less’ sub centre, PHCs & CHCs, block level public health units, support for diagnostic infrastructure for the primary healthcare facilities for sub centres and PHCs & Urban PHCs and conversion of rural PHCs and sub-centres to health and wellness centres appears more significant (Chathukulam & Joseph, 2022). A National Health Index will be helpful in accomplishing these goals by instilling the healthy spirit of competitive federalism.

Weaknesses in the National Health Index 

While National Health Index have good aspects and facets, it also has some drawbacks. 

1 Promoting Unhealthy Competitive Federalism

Competitive federalism is a concept where union competes with states, and states compete with each other. It denotes a horizontal competition as well as a vertical competition between union and regional governments. It is intended to generate a healthy competition among the states through transparent-rankings. While NITI Aayog endeavours to promote competitive federalism by facilitating improved performance of States/UTs through various Indices including National Health Index, many states have failed to incorporate the true essence of competitive federalism. This has paved the way for deficit in federalism and in the name of competition there is political slugfest in the name of sub-nationality, religion and hate. The Index but not limited to Health Index, have become an instrument for naming and shaming each other. Though the recent war of words between Uttar Pradesh Chief Minister Yogi Adityanath and Kerala Chief Minister Pinarayi Vijayan was not on the basis of the rankings from the Health Index, both of them could have made use of the findings from the Health Index at least to appreciate each other’s merits and accept the drawbacks where they need to improve. While Kerala kept on bragging about the many top achievements it has made, CM Yogi could have countered the claims with the fact that India’s largest state Uttar Pradesh has emerged as the top performer in terms of incremental health performance among larger states in the latest National Health Index by NITI Aayog.

2 Covid 19 Pandemic Missing in the Fourth National Health Index Released in 2021

The NITI Aayog makes it clear that fourth round of the National Health Index (2019-20) does not capture the impact of Covid 19 pandemic on health outcomes or any of other indicators, as the Index Performance relates to 2018-19 and 2019 -20, largely the pre -Covid period ( the fourth Index though it deals with the data in 2019-2020, it was released in 2021). The Health Index, further adds that though data belongs to pre — pandemic era. It will still serve as a good guidance on areas of improvement to states and UTs. However, none of these can be categorized as a valid excuse as NITI Aayog could have easily prepared a National Health Index in the time of Covid 19 pandemic, though not on an extensive scale given the social distancing norms and challenges posed by the pandemic. Meanwhile, in November 2020, NITI Aayog has released a report on Mitigation and Management of COVID-19: Practices from India’s States & Union Territories and it was released in the midst of the pandemic. In such a scenario, the premier policy think-tank of India could have easily prepared a National Health Index in 2020 and 2021 to evaluate how health systems across India responded to the Covid 19 pandemic and the challenges and setbacks. However, it didn’t dare to do so as it was pretty much evident that the health infrastructure in the country collapsed and a National Health Index in the wake of Covid 19 pandemic would become a liability to India. On the other hand, the 15th Union Finance Commission of India (UFC), in the wake of Covid 19 pandemic, allocated Health Grants to local governments amounting to Rs.70,051 crore for strengthening grassroots health care infrastructure (XV Finance Commission Report for 2021-26). The Health Grants were among the core recommendations of the 15th UFC titled Finance Commission in the Time of Covid 19. The NITI Aayog could have taken a leaf out of it to prepare a Comprehensive Health Index on how states and grassroots health care institutions handled the Covid 19 pandemic.

3 Non-Communicable Diseases and Mental Health Not Included in Health Index

The indicators used to calculate the National Health Index are grouped into three domains:

• Health outcomes
• Key inputs and processes (health infrastructure and human resources)
• Governance and information (quality of data collected and healthcare sector efficiency)

Most indicators in the ‘health outcomes’ domain was concerned with states’ performance on maternal and child health, and to some extent about tuberculosis and AIDS. But the domain didn’t capture states’ performance against non-communicable diseases (NCDs) in all the four rounds of National Health Index. NITI Aayog itself admit that “Some critical areas such as infectious diseases, non-communicable diseases (NCDs), mental health, governance, and financial risk protection could not be captured in the Index due to non-availability of acceptable quality data on an annual basis”. However, such an excuse doesn’t sound reasonable to exclude NCDs and mental health as lot of secondary data is readily available. For instance, according to the National Health Portal, 5.8 million people die of heart and lung diseases, stroke, cancer and diabetes — all NCDs — every year in India (Nethan et al., 2017). Given the high prevalence of NCDs, the fact that the Health Index failed to capture this worrying trend is disappointing. The mental health is another crucial area where the Index is silent. A study by the India State-Level Disease Burden Initiative showed that the disease burden in India due to mental disorders increased from 2.5% in 1990 to 4.7% in 2017 in terms of disability-adjusted life years, and was the leading contributor to years lived with disability (YLDs) contributing to 14.5% of all YLDs in the country (Sagar et al., 2019). In the 2019, the data from National Crime Records Bureau (NCRB) revealed that Kerala recorded the fifth highest suicide rate in the country. Then in 2020, the NCRB data showed that a total of 153,052 suicides - an average of 418 daily - in 2020. Majority of suicides, 19,909 in total, were reported in Maharashtra followed by 16,883 in Tamil Nadu, 14,578 in Madhya Pradesh, 13,103 in West Bengal, and 12,259 in Karnataka accounting for 13 per cent, 11 per cent, 9.5 per cent, 8.6 per cent and 8 per cent of the total suicides (NCRB, 2020). All these data suggest a worrying trend in deterioration of mental health and most importantly there is a rich data base on it and NITI Aayog could have easily incorporated it into the Index.

4 Failed to Understand the Socio-Economic, Demographic and Epidemiological Realities While Classifying States

The National Health Index groups the states into two categories as “larger” and “smaller states”. The Union Territories are not grouped into special category. States including Uttar Pradesh, Andhra Pradesh, Assam Telangana, Tamil Nadu, Kerala, Himachal Pradesh, Bihar, Maharashtra, Jharkhand, Madhya Pradesh, Rajasthan, Chhattisgarh, Haryana, Punjab, Jharkhand, Uttarakhand fall under the “larger states” category. States including Arunachal Pradesh, Goa, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura under the “smaller states” category. One of the major problem is that the classification doesn’t do justice to the demographic and epidemiological realities of the larger and smaller states. For instance, take the case of two larger states — Kerala and Uttar Pradesh. The demographic epidemiological realities and even the progress and challenges in the socio-economic realities of both the states are vastly different. Meanwhile, NITI Aayog’s classification of states based on their performance into - Aspirants, Achievers, and Front — Runners is a good move.

5 Decentralization of Health and Relevance of Rural and Urban Local Governments in Public Health Completely Ignored

The Covid-19 pandemic has taught us an important lesson — decentralisation is key to successful prevention, detection and management of diseases in rural and urban areas. The Eleventh Schedule added to the Constitution by the Seventy-third Amendment lists 29 functions to be devolved by states to Panchayati Raj Institutions (PRIs). Among the 29 listed items related to public health includes, (i) Health and sanitation including hospitals, primary health centres and dispensaries, (ii) family welfare, (iii) women and child development, (iv) drinking water, (v) social welfare, including welfare of the handicapped and mentally retarded. Public health is also one of the functions listed for devolution to municipalities under the Twelfth Schedule to the Constitution. Public health sanitation, conservancy and solid waste management, safeguarding the interests of the weaker sections of society, including the physically handicapped and mentally unsound, water supply for domestic purposes are the prominent among them. Despite public health being a state subject, the union government is the key actor in designing health policies and programmes. This has largely been due to greater spending ability and availability of better technical resources. A centralised public health research institution’s functioning has consequences on the last mile delivery system of a country’s health services. It becomes challenging to address state-specific public health crises through a top-down approach. Then there is Mission Antyodaya Survey which effectively captures the various aspects related public health and sanitation and has rich data on the availability of public health facilities including Primary Health Centres, Community Health Centres, Jan Oushadi Kendras, Sub Centres, anganwadis centres and even data on village wise reports on nutrition health. In such a context NITI Aayog should have set an example by incorporating the role of Panchayats and urban local governments in public health and their performance in the National Health Index.

6 Nutrition Status Missing in Health Index

Though there may be limitations and constraints to include each and every aspect while preparing a National Health Index, the nutritional status is an inevitable factor. The NITI Aayog has conducted studies to assess the nutritional status of the state and UTs in India and it could have either linked the findings from their previous studies on nutrition in the Index, it would have been more reasonable. For instance, on September 30, 2021, the NITI Aayog and the International Food Policy Research Institute, the Indian Institute of Population Sciences, UNICEF and Institute of Economic Growth launched a report titled ‘State Nutrition Profiles’ for 19 of India’s states and UTs. It provides useful information on the prevalence of various nutrition outcomes, like wasting, stunting, anaemia, etc., based on data from National Family Health Survey (NFHS 4 in 2015 -16) and NFHS 5 (2019-2020). Prior to this report, the MoHFW released the Comprehensive National Nutrition Survey (CNNS) in 2020, which contains relevant data not only about the nutritional status but also about the prevalence of NCDs among children (Chathukulam et al., 2021). The NITI Aayog, MoHFW should have made use of the findings from these reports and studies to create a Nutrition Index within the Health Index.

7 In the age of Make in India and Atmanirbhar Bharat Mission why depend on World Bank for Technical Assistance in preparing a National Health Index?

Atmanirbhar Bharat Mission aims to revive all aspects of the Indian economy right from demand, supply to manufacturing. On the other hand, the Make in India initiative endeavours to develop the manufacturing sector of the country. In this context, it’s high time we develop and equip ourselves with much needed technology and human resources to prepare Indices and reports on our own. The NITI Aayog could have easily collaborated with reputed public health research institutions like Indian Council of Medical Research (ICMR) as well as and academic institutions for technical assistance rather than completely relying on World Bank. Then there is Indian Institute of Population Sciences which has the capability and resources to deeply engage in such resources. It could have also sought the assistance of the vast social science research institutions in the country which have ample experience in handling research and data driven studies on a large-scale basis. Then there is Public Health Foundation of India and Indian Institute of Public Health (IIPH), which aims to strengthen training, research and policy development in the area of public health. India has IIPHs in Gujarat, Delhi, Odisha, Hyderabad and Telangana. Aren’t these institutions sufficient enough to provide technical and non-technical assistance in preparing a National Health Index. If NITI Aayog was hoping for a collaboration on international standards, it could have tried to rope in John Hopkins University, Stanford University, Harvard University, Oxford and Cambridge as they have made significant researches and contributions in the field of public and community health.

8 The Curious Case of Non —Cooperation of West Bengal in NITI Aayog Health Index

Apart from the first and second round of Health Index, the state of West Bengal doesn’t figure in the other two rounds of the Index. NITI Aayog in its second round of the Index cited that “As West Bengal did not submit the approved data on the portal, the overall and incremental performance scores were generated by using the pre-filled indicator data for 12 indicators and for the remaining 11 indicators the data were repeated for the Reference Year”. In the third and fourth Indexes, NITI Aayog has cited that “all the states and UTs participated except West Bengal.” But what exactly may be the reasons for the non-cooperation from the part of West Bengal? Given the political tension between West Bengal Chief Minister Mamata Banerjee and the Union Government and the worsening Centre — State Relations may be one among the primary reasons. Secondly, Mamata Banerjee’s open disdain for NITI Aayog could have also contributed it. But despite West Bengal’s reluctance to share data, NITI Aayog could have still collected the relevant data at least from secondary sources instead of relying on the simple excuse like West Bengal didn’t give data. Like Mamata Banerjee, CMs of states like Telangana and Punjab have also expressed their disdain for NITI Aayog by skipping the meeting chaired by the premier policy think tank. However, unlike West Bengal CM, other CMs have not stayed away from the Index. Meanwhile, one cannot rule out the possibility that some states can resort to the non-cooperation policy towards NITI Aayog Health Index, a practice started by the TMC government in West Bengal. The NITI Aayog should closely watch out against such tendencies and should try their best to take states and UTs into confidence rather than creating an exclusion on the lines of political differences and ideology of those in power.

9 Poor Outreach of the Health Index 

The NITI Aayog Health Index, all the four rounds are a good attempt despite its flaws. But what is most disappointing is that the academic and the public health experts in the country are not discussing and debating the Health Index in the same fervour as they discuss matters that they really care about. Even the media only discusses about the Index when it is released each year and the discussions are limited to which state topped and which state poorly performed other than that intellectual or academic discussions in the public domain are very limited. There are no policy briefs related to the Index and it is deeply disappointing. The citations received for the Index are also not very impressive. The NITI Aayog and MoHFW should facilitate more discussions among the academic community and general public to familiarize themselves with these reports. The citizens should be aware of the strengths and weakness of their health systems as it is their healthy well-being that can contribute towards building a healthy nation.

Conclusion

The Health Indexes, all the four rounds are extensive and in-depth studies backed with reliable data and it needs to be appreciated. However, there are some serious flaws too but those can be rectified in the upcoming National Health Indexes in the coming years. The NITI Aayog should aim at developing a Comprehensive National Health Index by incorporating the latest health challenges facing the country including the high prevalence of non-communicable diseases, abysmal level of nutrition status among children and adults etc. NITI Aayog should also come up with a Nation Health Index in the Time of Covid 19 Pandemic to find out the truth behind how states and UTs managed and mitigated the pandemic. Such an Index can also be used to address challenges in the post-pandemic India in terms of health. The upcoming Health Indexes should be prepared on the lines of Internationally Comparable Health Indices so that the international community and the health experts will also be aware where India as a nation stands in terms of health. The NITI Aayog should also focus on becoming self-reliant while preparing a National Index, though not limited to Health and it should design and discuss the finding from the Index and other studies to inculcate a sportsperson sprit and a healthy competitive federalism among the states. The policy think tank should promote healthy discussions and debates in the form of policy briefs, or academic and non-academic writings based on each Health Index only then the general public and the youth of the country will become aware of the areas and sectors that needs improvement and how as vigilant citizens they can contribute in addressing the deficits in our health systems.

Authors: Jos Chathukulam is former Professor, Ramakrishna Hegde Chair on Decentralisation and Development, Institute for Social and Economic Change, Bengaluru and currently the Director of Centre for Rural Management (CRM), Kottayam, Kerala. Email address: joschathukulam[at]gmail.com ; Manasi Joseph is a Researcher at Centre for Rural Management (CRM), Kottayam, Kerala, email: manasijoseph[at]gmail.com ; Krishnakant Buch is an Adjunct Professor at Centre for Rural Management (CRM) and Board Member of Essex Faculty of Royal College of General Practitioners (RCGP), London, UK. Email address: kbuch96[at]gmail.com

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