State of Health in India

The Health Index report 2019, recently released by the Niti Ayog, demonstrates that health and well-being of citizens remains a concern area in several Indian states. The Health Index  is a composite measure of 23 critical health indicators like neonatal & infant mortality rates, fertility rate, sex ratio at birth, low birth weight, immunization coverage, progress in treatment of diseases like tuberculosis and AIDS and so on.

In the 2019 report, covering assessment year 2017-18, among 21 “big” states, Kerala continues to hold the top spot while Uttar Pradesh continues to languish at the bottom. Big gainers vis-à-vis base year 2015-16 have been Andhra Pradesh (8th to 2nd), Maharashtra (6th to 3rd) and Rajasthan (20th to 16th) while big losers are Punjab (2nd to 5th) and TN (3rd to 9th). One of the worrying facts is that 3 of India’s most populous states (UP, Bihar & MP) occupy places in the bottom 4 on the composite health index.  

The other concern is the wide range of index scores – Kerala at the top of the heap has an index of 74.01 while UP at the bottom most slot has an index of only 28.61, indicating of the wide disparity in quality of health services accessible to citizens.

Looking at some of the more critical indicators going into the index, the states with best and worst performances are as below (among 21 large states):

Neonatal Mortality Rate (no. of child deaths per 1000 in the first 28 days from birth):

Top 3 – Kerala (6), Tamil Nadu (12), Punjab (13)

Bottom 3 – Odisha / MP (32), UP/U’khand (30), Rajasthan (28)

  • On NMR, the wide disparity is observed between the states. Kerala’s NMR is comparable to upper-middle income countries while that of Odisha, MP, UP, U’khand is worse than low income countries. Kerala and TN have already reached the 2030 target for NMR (12 or less deaths per 1000).

Under-five mortality rate (no. of child deaths per 1000 before attaining age of 5 yrs.):

Top 3 – Kerala (11), Tamil Nadu (19), Maharashtra (21)

Bottom 3 – MP (55), Assam (52), Odisha (50)

  • As compared to countries with similar economic development, U5MR in India remains high (39/1000) with very wide variations. Kerala, TN, Maharashtra and Punjab have already achieved the 2030 target on U5MR (not more than 25 deaths per 1000)

Total Fertility Rate (no. of children likely to be born to a woman at current fertility rate between age of 15 & 49):

Top 3 – West Bengal (1.6), Tamil Nadu (1.6), Punjab (1.7)

Bottom 3 – Bihar (3.3), UP (3.1), MP (2.8)

  • In developing countries, high TFR is associated with poverty, low maternal education, gender inequality, low female employment participation rates etc. TFR remains high in India’s most populous states (Bihar, UP, MP, Rajasthan)

Proportion of Low Birth Weight (<2500 gms) among new borns:

Top 3: J&K (5.5), Andhra Pradesh (5.6), Jharkhand (7.1)

Bottom 3: Odisha (18.2), West Bengal (16.4), Tamil Nadu (15.5)

  • From base year (2015/16), the proportion of LBW has come down remarkably in Haryana (14.9 –> 8.5) and Rajasthan (25.5 –> 14.0). This has been achieved through measures like early registration of pregnancy and early detection and management of high risk pregnancies.

Sex ratio at birth (no. of girl child born per 1000 boys born):

Top 3: Chhattisgarh (963), Kerala (959), Odisha (948)

Bottom 3: Haryana (832), Gujarat (848), U’khand (850)

  • Sex ratio at birth (SRB) is an indicator of the extent to which gender discrimination leads to sex selective abortion. Worryingly, of the 21 “large” states, only 2 (Chhattisgarh and Kerala) had a SRB of 950+. UP, Maharashtra, Rajasthan and Gujarat all had a SRB below 900 with Haryana rock-bottom at 832 girls b0rn per 1000 boys. Moreover, compared to the base period (2013-15), the SRB has declined in 12 large states and improved in 9.

Full immunization coverage:

100.0%: J&K, Kerala, Jharkhand, Andhra Pradesh

Bottom 3: Odisha (59.8%), Tamil Nadu (76.1%), Madhya Pradesh (78.0%)

  • While 4 of the large states have achieved 100% immunization coverage, 10 large states remain below 90% on the same – including populous states like Bihar (89.7%), UP (84.7%), Rajasthan (81.6%) and MP (78.0%).

Proportion of institutional deliveries (babies born in health facilities):

Top 3: Telangana (91.7), Gujarat (91.6), Kerala (90.9)

Bottom 3: UP (50.6), Bihar (56.0), MP (62.3)

  • The top 3 are the only 3 large states with 90%+ proportion of pregnant women delivering in health facilities with 10 states below 80%. India’s 3 largest and most populous states alarmingly occupy the bottom 3 positions. Not surprising that these states also lag behind on neonatal mortality rates.

The composite health index is a welcome and necessary step in the improvement of health metrics in our country. As the stats show, there is a fair gap that exists in several Indian states on key health parameters from the desirable levels. Learnings from states that have been successful in delivery of key health measures needs to transmit to the laggard states to help them also move ahead on the index.

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