Analysis of NITI AAYOG (National Institution For Transforming India) Health Index Report on the Ranking of States and Union Territories: Round 2 (2015-2016/ 2017-2018)-V2

Background/Rationale

By adopting the Sustainable Development Goals (SDGs), India is committed for Goal 3 of SDGs which is for ensuring healthy lives and promoting well-being for all. NITI Aayog in India has established the annual State Health Index tool for ranking the States/UTs on health outcomes, Governance and Information, and Key Inputs/Processes. The outcome is complemented with the MoHFW’s (Ministry of Health and Family Welfare) Government of India to link a part of NHM funds to the States on this Index [1, 2]. I am presenting the second version of review of Round-2 of the Health Index, discussing the status of States and the UTs during the period 2015-16 (Base Year) and 2017-18 (Reference Year), i.e., a two-year period [3, 4]. The report on Health Index highlights the areas to focus by states and UTs for improvement in overall health outcomes. NITI Aayog measures the annual performance and rank States and UTs on the basis of incremental change. Health Index Scores and rankings are generated to assess Incremental Performance (year-to- year progress) and Overall Performance of state/UT for achievement of health-related Sustainable Development Goals (SDGs) as well as Universal Health Coverage (UHC).

Objectives

Aim of NITI Aayog of India is to promote a co-operative positive competition amongst the States and UTs of India for transformative action in achieving better health outcomes. The key Objective is to calculate and release a composite annual state/UTs Health Index by utilizing key health outcomes, health systems and service delivery indicators for generating Health Index scores and rankings of the States and UTs based on incremental performance and overall performance. Other objectives are to calculate positive/ negative development on health, to encourage healthy competition and mutual learning among states and UTs, to ensure States’ participation and ownership, transparency by using an independent validation of data by an independent agency.

Study Design

This was a cross-sectional retrospective observational quantitative and qualitative study. The Health Index consists of indicators in the domains of Health Outcomes, Governance and Information, and Key Inputs/Processes. Health Outcomes are assigned the highest weight, indicators were selected on the basis of their importance and availability of reliable data at least annually from pre- existing data sources such as the Sample Registration System (SRS), Civil Registration System (CRS) and Health Management Information Systems (HMIS). Data on indicators is included for Index calculations only after validation by the IVA. A composite Index is calculated as a weighted average of various indicators, for a base year (BY) and a reference year (RY). The change in the Index score of each State from the base year to a reference year is the annual incremental progress of each State. States and UTs were grouped in 3 categories to ensure comparison among similar entities, namely 21 Larger States, 8 Smaller States, and 7 UTs [3, 4]. The same 23 indicators were used for the Health Index-2018 as in the first round. Taking into account importance and availability of reliable data 23 indicators were included in the Health Index. OOPE (out of pocket expenditure) used in first round was not available [3, 4]. Setting For calculation of Index values and ranks, data was submitted online and validated by an Independent Validation Agency (IVA). The States were previously sensitized about the process for data submission through workshops and key stakeholders (Table 1). Data was submitted by participants States and UTs through online portal hosted by NITI Aayog and data from pre-existing sources in the public domain was pre-entered. After validation of data by an IVA it was used

This novel study was conducted over a period of eight months in 2018-19 see table-5. The States and UTs participated for finalization of the indicators/variables, workshops for sharing the methodology, process of data submission.

Participants

All states and UTs of India were participants. Multiple

stakeholders as discussed above contributed to the Index development: The various Index was developed by NITI Aayog with help of World Bank, States and UTs, the Ministry of Health and Family Welfare (MoHFW), domestic and international sector experts and other development partners Categorization of States and UTs for ranking were based on the size, and administration [3, 4]. The States were ranked in three categories, namely Larger States, Smaller States and UTs [1] (Table 2).

This categorization was done due to the following reasons:

• The SRS data on health outcomes (NMR, U5MR, TFR and SRB) were not available for 8 Smaller States and 7 UTs,
• Reliable estimates for these outcome indicators/variables based on raw data obtained from SRS for the Smaller States and UTs could not be derived due to statistically small sample size and insufficient number of events.

Variables

The main criteria for inclusion of indicators/variables were the availability of reliable data with at least an annual frequency. The output Index is a weighted composite Index based on indicators/variables in 3 fields: (1) Health Outcomes; (2) Governance and Information; and (3) Key Inputs/Processes. Each domain was assigned a weight based on its importance. The indicator values are scaled from 0 to 100 for generating composite Index scores and performance rankings for 2015-16 (Base Year) to 2017-18 (Reference Year), i.e., a two-year period. The annual incremental progress made from BY to RY is used to generate incremental ranks. Table 3 shows the number of indicators/variables in each domain and sub-domain along with weights, while Table 4 provides the detailed Health Index with indicators/ variables, their definitions, data sources, and specifics of base and reference years.

Table 3: Health Index: Summary. Source – NITI Aayog-India. Here it is important to mention that for round-2 larger states have 23 indicators unlike 24 of round 1and total weight 1080 instead of 1130; smaller states 19 instead of 20 of round 1 and weight 680 instead of 730; UTs 18 indicators instead of 19 of round 1 and weight 630 instead of 680 for round1. * The data for indicator no. 1.2.6 related to out of pocket expenditure was available only for 2015-16 and hence was used to calculate independently the RY Index and rank of round1.

Data sources/Measurement

The Health Index consists of 23 indicators/variables related to Health Outcomes, Governance and Information, and Key Inputs/Processes (Table 4 provides Health Index- indicator details and data sources).

Bias

Grouping and ranking the states according to size is a biased view. The researcher feels that population density/ per capita income/ literacy rate/ health workforce/ corruption-scam index etc. should be considered for ranking states. Summarizing the complexities and condensing it in an Index has limitations. Health Outcomes are assigned the highest weight knowing the fact that it is entirely dependent on input and governance. The governance in states such as Bihar is always controversial such as lack of Directorate, corruption, posting scams etc [5]. Hence the researcher feels that governance and input indicators are more important and it is a total biased view to provide health outcome highest weight which is totally dependent on other two.

Study Size

All states and UTs of India were participants. Table 5 shows study period (This second edition of this exercise was conducted over a period of eight months in 2018-19.) The States were informed about the Health Index-2018 on July 14, 2018 through video conference chaired by the Chief Executive Officer (CEO), NITI Aayog. During the discussions an agreement was reached that the Base Year would be 2015- 16, while the Reference Year would be 2017-18 for round 2.

Methodological Details of Constructing The Index-Computation of Index Scores and Ranks

After validation of data by the IVA, data was used for the Health Index score calculations. Indicator value was scaled, based on the nature of the indicator, for positive indicators, where higher the value, better the performance, the scaled value (Si) for the indicator, with data value as Xi , was calculated as follows:

Scaled value (Si) for positive indicator = (Xi – Minimum value) x 100/ (Maximum value – Minimum value) For negative indicators where lower the value, better the performance (e.g. NMR, U5MR,) scaled value was calculated as follows:

Scaled value (Si) for negative indicator = (Maximum value – Xi) x 100/ (Maximum value – Minimum value) The Minimum and Maximum Values of Each Indicator Were Ascertained Based on the Values for That Indicator across States within the Grouping of States (Larger States, Smaller States, and Uts) For that Year: Indicator value lies between the ranges of 0 to 100; e.g. the State with the lowest institutional deliveries will get a scaled value of 0, while the State with the highest institutional deliveries will get a scaled value of 100. For a negative indicator such as NMR, the State with the highest NMR will get a scaled value of 0, while the one with the lowest NMR will get a scaled value of 100. Accordingly, the scaled value of other States will lie between 0 and 100 in both cases. Based on these scaled values (Si), a composite Index score was calculated for the base year and reference year by application of the weights using the formula:

Composite Index = (∑ Wi *Si)/ (∑ Wi) --Where Wi is the weight for I th indicator The composite Index score has been used for generating overall performance ranks. The difference between the composite Index score of reference and base years was the annual incremental performance. The ranking is primarily based on the incremental progress, however, rankings based on Index scores for the base year and the reference year performance calculated to provide the overall performance of the States and UTs.

Descriptive Data

Independent Validation of Data: IVA namely, Sambodhi Research and Communications Private Limited was hired by NITI Aayog to review and validate the data, Index scores and rankings of States and UTs. The data submitted on the portal was validated by the IVA from September to December 2018.

Outcome data Most Improved Improved No Change Deteriorated Most Deteriorated Not Applicable

See Table-6, 7, 8, 9, 10, 11, 12, 13, and 14 for outcome data,

Main Results: see Figure 4.1/ E.1/E.2/ E.3 and table- 15/16/17/E.3

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Figure E.1: Larger States: Overall and incremental performance, Base and Reference Years and incremental rank. Source-NITI Aayog-India Note: As West Bengal did not submit data on the portal, the overall and incremental performance scores were generated based on pre-filled indicator data for 12 indicators and for the remaining 11 indicators the data from the Base Year were repeated for the Reference Year. Base (2015-16) Year Reference Year (2017-18)

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Figure E.2: Smaller States: Incremental scores and ranks, with overall performance from base year to reference year and ranks. Source-NITI Aayog-India

Table 17: Categorization of Smaller States on incremental performance and overall performance. Source-NITI Aayog-India. Note: The States are categorized on the basis of Reference Year Index score range: Front-runners: top one-third (Index score >62.82), Achievers: middle one-third (Index score between 50.67 and 62.82), Aspirants: lowest one-third (Index score <50.67). The States are categorized into four groups based on incremental performance: ‘Not Improved’ (<=0 incremental changes), ‘Least Improved’ (0.01 to 2.0 points increase), ‘Moderately Improved’ (2.01 to 4.0 points increase), and ‘Most Improved’ (>4 points increase).

Figure E.3: Union Territories: Incremental scores and ranks, with overall performance from base year to reference year and ranks and table E.3.

Table E.3: Categorization of UTs on incremental performance and overall performance. Source-NITI Aayog-India.

Other Analyses: see figure E.4 and E.5: It was found that the Health Index scores and the economic development levels of States and UTs as measured by per capita Net State Domestic Product (NSDP) are directly related to performance of States / UTs see-Figure E.4., except a few States with low level of economic development performed well in the Health Index, such as Jammu and Kashmir, Manipur, Mizoram, Andhra Pradesh, and Punjab.

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Lesson learned

Jammu and Kashmir, Manipur, Mizoram, Andhra Pradesh, and Punjab may provide some insights on how to improve Health Index scores in States with similarly low level of economic development such as Bihar. Exceptions on the other end are States and UTs with high level of economic development but not performing well in Health Index score, e.g. Goa, Delhi and Sikkim.

There is narrowing gap in performance from Base Year to Reference Year among UTs (Figure E.5). There was a convergence in Health Index scores from Base Year to Reference Year across UTs, that is, UTs with higher Health Index scores in the Base Year tended to deteriorate whereas least performing UTs in the Base Year tended to improve their performance in the Reference Year. Among the Larger and Smaller States, there was neither divergence nor convergence in Health Index scores over time [1, 2].

Key results

The Health Index revealed large disparities in overall performance across States and UTs. Among the Larger States, the overall Health Index score of the best-performing State is greater than 2.5 times of the least-performing State. Kerala was at top with overall score of 74.01, while Uttar Pradesh was at bottom with overall score of 28.61 (Figure E.1). For the Smaller States, scores varied between least 38.51 in Nagaland and top 74.97 in Mizoram (Figure E.2). Among the UTs, the scores were between 41.66 in Daman and Diu to 63.62 in Chandigarh (Figure E.3). Among the least performing States/ UTs such as Bihar and Uttar Pradesh, there is an urgent need to increase efforts to increase performance.

Kerala and Tamil Nadu have reached the 2030 SDG target for NMR, which are 12 neonatal deaths per 1,000 live births. Tamil Nadu, Maharashtra and Punjab have achieved the SDG target related to Under-Five Mortality Rate (U5MR), which are 25 deaths per 1,000 live births. Among the eight EAG States, only three of the States Rajasthan, Jharkhand and Chhattisgarh showed improvement Among the eight EAG States, only three of the States Rajasthan, Jharkhand and Chhattisgarh showed improvement ,least-performing States (mostly EAG1 States) further deteriorated, leading to a wider performance gap across Larger States (Table 15/16). The top ten performers were Andhra Pradesh, Maharashtra, Gujarat, Himachal Pradesh, Jammu & Kashmir, Karnataka and Telangana. The six least performing States were Uttar Pradesh, Bihar, Odisha, Madhya Pradesh, Uttarakhand, and Rajasthan, five had decline in the overall performance scores, with the exception of Rajasthan which improved the score by

6.30 points.

Note: 1. EAG States - Empowered Action Group States includes Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan, Uttarakhand, Uttar Pradesh, and Odisha.

In Bihar, the deterioration was primarily due to the performance related to total fertility rate, low birth weight, Sex Ratio at Birth, TB treatment success rate, quality accreditation of public health facilities, and time-taken for NHM fund transfer, while in the case of Uttar Pradesh the performance related to low birth weight, TB treatment success rate, average tenure of key positions at state and district level and level of birth registration accounted for the deterioration. Kerala maintained its ranking as the top performing Larger State.

Smaller States- Mizoram ranked first while Tripura and Manipur were top two States in terms of incremental performance (Figure E.2 and Table 17). Sikkim and Arunachal Pradesh had bigger decrease in overall Health Index scores due to poor performance of several indicators such as institutional deliveries, TB case notification rate, TB treatment success rate, 1st trimester ANCs, level of birth registration, and IDSP reporting of L-form.

UTs- Chandigarh ranked first in while Dadra and Nagar Haveli improved the most (Figure E.3 and Table E.3)., ranked second in terms of overall performance ranking. Decline in the overall Health Index scores of Lakshadweep and Andaman & Nicobar Islands is due to deterioration of health outcome indicators, 3 indicators deteriorated in Lakshadweep (low birth weight, full immunization, institutional delivery), and 4 indicators in Andaman & Nicobar (full immunization, institutional deliveries, TB case notification, and TB treatment success rate).

The indicators/variables where most States and UTs need to focus:

• Vacancies in key staff,
• Establishment of functional district Cardiac Care Units (CCUs),
• Quality accreditation of public health facilities, and
• Institutionalization of Human Resources Management Information System (HRMIS),
• Larger States need to focus on improving the Sex Ratio at Birth (SRB).

Limitations of the Index

• Infectious diseases, non-communicable diseases (NCDs), mental health, governance, and financial risk protection could not be fully captured in the Index due to non- availability of acceptable quality data on an annual basis.
• For several indicators, the data are limited to public facilities due to the paucity and uneven availability of private sector data on health services in the HMIS.
• For several key outcome indicators, data were available only for Larger States.
• Non-availability of acceptable quality of data on an annual basis.
• Assignment of highest weight to health outcomes is biased and not appropriate. Everyone knows that it is totally dependent on input and governance and these two are given low weight is amazing. Actually these two should be given more weight, it is evident from states like Bihar that there are failure/ignorance/ corruption /scams in these areas then how the state will improve without input and transparent good governance [5]. This may be an attempt to put everything on doctors and health staff and at the same time protect policy makers and administration from getting exposed.

Interpretation

The Health Index score ranking is an annual systematic tool for measurement of performance across States and UTs of health parameters. The results provide an important insight into the areas in which States have improved, stagnated or declined which will help in better targeting of interventions.