Picture of health

Health index needs a rejig

The NITI Aayog’s fourth Health Index report for the year 2019-20, published in collaboration with the Ministry of Health and Family Welfare, ranking states on a weighted composite score based on 24 indicators, offers a useful granular picture of the state of Indian health care. Based on three broad domains —health outcomes, governance and information, and key inputs and processes —the index is reasonably comprehensive, covering not just standard health indicators such as child mortality but also factors such as modern contraceptive prevalence, the TB treatment success rate, and the average occupancy of a chief medical officer in districts for the last three years. Information for this exhaustive list comprises a combination of data from the Ministry of Health and Family Welfare’s database as well as other state government reports. The fact that the rankings are largely on expected lines, with the southern and wealthier western states doing far better than the economically more backward ones, attests to the veracity of the data. But some tweaks in emphasis could serve to make this ranking a more useful and meaningful tool for health policy and resource allocation within states rather than a source of competitive federalism.

The ranking shows how states stand in relation to each other. But here, too, the information is limited by the fact that the states are ranked within three categories — 19 larger states, eight smaller states, and seven Union Territories —which can be misleading in itself. For instance, Kerala and Tamil Nadu were the top two states in terms of overall performance, whereas Uttar Pradesh came in last. Yet, when it came to incremental performance, UP ranked first, and Kerala and Tamil Nadu ranked 12th and eighth, respectively, among the larger states. There are several problems here, not least because there is a danger of interpreting the data to suggest UP would soon become a model of health care delivery — a fact tragically contradicted by the year gone by (which is outside the period of this index). Since UP starts from a very low base, any improvement will show up in terms of a disproportionate bump in the incremental score. Further, the artificial division of states by size also skews the picture. Several smaller states and Union Territories registered far higher changes in incremental scores than UP — Mizoram, Meghalaya, Delhi, Jammu & Kashmir, and Puducherry, for instance.
 

Any ranking of human development indicators also offers a static picture and can be exploited for partisan ends unless they are measured against a standard. As far as the health index is concerned, the more pertinent measure is the “distance to frontier” — or the differential between the maximum score (100) and each state’s individual score. This has been given far less attention, yet it shows much more clearly that India is not in the pink of health. Nearly half the states and Union Territories did not pass the halfway mark in the composite overall index score (the “frontier” in this case) and even the top four states showed quite a distance to frontier. Kerala, which has been feted by Nobel laureate Amartya Sen for its health care system, registered an overall index score of 82.2, for instance. This suggests there is considerable room for improvement even in India’s best state. By that yardstick, UP has a very long journey to make —its overall reference year index score being just 30.57. The Covid-19 year indices may offer a more realistic picture.