The NITI Aayog’s health index, which ranks states across the three broad categories—health outcomes, governance and information, and key inputs/processes—is an useful tool to identify areas of concern in health and public healthcare. There is, of course, scope to make the index more comprehensive; The Wire quotes experts to highlight that the report doesn’t assess states on mental health and non-communicable diseases, both of which should be top concerns for policymakers. Moreover, the grouping of states with disparate demographic and endemic epidemiological realities has been flagged as a major problem in the comparison.
That said, there are key takeaways from the index, especially in terms of government spending on health and bolstering health workforce. While Kerala coming in at the top is no surprise, poll-bound Uttar Pradesh, which is at the bottom of the list, has registered the biggest incremental improvement over 2018-19, albeit over a low base. To illustrate how the base influences the ranks, Bihar recorded the highest fall in neonatal morality rate (NMR), from 28 to 25, in the reference period over the base period; Kerala, where the NMR remained unchanged at 0, ranks 13th in this list.Given the index covers the year before the Covid-19 pandemic broke out, a caveat about changed realities, because of how the pandemic has spurred governments to beef up healthcare, is necessary. Nevertheless, the index should reflect the momentum on which each state would have mounted further efforts.
A key metric is efficiency on health spending. The NITI indicator of the average number of days taken for transfer of National Health Mission funds from state treasury to the implementing agency can be seen as a proxy for this. Eight of the larger states had managed to reduce delays between the base period and the reference period while for the remaining the time taken to transfer had increased; Punjab clocked the sharpest reduction in the time to transfer, from 342 days to 134 days, while Himachal Pradesh, at the bottom, recorded a worsening from 34 days to 186 days.
A long gestation for central funds to translate into meaningful on-ground spending is important in the context of the Centre’s recent concern over states having collectively used a mere 17% of the Rs 23,000 crore available to them under the Emergency Covid Response Package II.Also concerning is the fact that 15 of the 19 large states, including Kerala, had deficiencies in the strength of healthcare providers in public healthcare that, as a proportion of the requirement, ran into double-digits. In the case of a Bihar, this was as high as 41.27 the year before the pandemic, although down from 48% the year earlier.
The pandemic, of course, brought this significant deficiency to the fore at the national level. However, given how such large deficiencies will also make it difficult to push up desired outcomes for non-Covid diseases, the states need to address the gaps on a war footing. The Centre, as this newspaper has pointed out earlier citing experts such as Dr K Srinath Reddy of PHFI and Dr Devi Shetty of Narayana Hrudayalaya, also has a role to play, in terms of relooking policies that constrain meaningful addition to the healthcare workforce, taking a cue from jurisidictions globally that have managed to meet and better the WHO-recommended standards.
The index also gives us a picture of how far most of our states are from the desired levels of health and healthcare. Nine large states are below the mid-point mark, with only the southern states (except Karnatka) above or close to the 70-point mark. The pandemic is likely to have gotten administrations to shed inertia, even so, getting healthcare to perform optimally remains an uphill task.