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How Fares India in Healthcare? a Sub-National Analysis

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How Fares India in Healthcare? a Sub-National Analysis FEBRUARY 2020 How Fares India in Healthcare? A Sub-National Analysis KRITI KAPUR How Fares India in Healthcare? A Sub-National Analysis KRITI KAPUR ABOUT THE AUTHOR Kriti Kapur is a Junior Fellow with ORF’s Health Initiative. ISBN: 978-93-89622-65-2 © 2020 Observer Research Foundation. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without permission in writing from ORF. How Fares India in Healthcare? A Sub-National Analysis ABSTRACT India’s geographical landscape is vast, cultural differences can be sharp, and income disparities are stark in certain regions. Access to healthcare, therefore, is varied and the on-ground gaps and challenges are complex. The NITI Aayog Health Index is an attempt by the current government to formulate a mechanism to monitor at the sub-national level the country’s performance in improving healthcare. This paper uses the findings of the Health Index to analyse the key trends in the most essential health outcomes across States and Union Territories. Using multiple data points from the health index reports, this paper explores the shortcomings of the health systems and processes with the aim of findings ways to address the problems. Attribution: Kriti Kapur, “How Fares India in Healthcare? A Sub-National Analysis,” ORF Occasional Paper No. 237, February 2020, Observer Research Foundation. ORF OCCASIONAL PAPER # 237 FEBRUARY 2020 1 HOW FARES INDIA IN HEALTHCARE? A SUB-NATIONAL ANALYSIS I. INTRODUCTION India has seen immense progress across different socio-economic indicators over the past 70 years since independence. This development, however, has been highly uneven: while some sectors have shown remarkable progress, others are experiencing marginal development. Today, India is the world’s largest democracy, with a population of over 1.37 billion people1 in 2019. Given current trends, India is expected to overtake China’s population by 2027.2 The country’s literacy rates have risen to 69.1 percent, with male literacy at 75.7 percent and that for females, 62 percent.3 At the same time, India continues to face stubborn challenges in many social and development sectors. The country’s burden of disease, for one, specifically non-communicable diseases, has risen in recent years.4 Yet, India’s expenditure on health remains stagnant at approximately 2.25 percent5 of total central budgetary expenditure. This figure comes to just over one percent6 of Gross Domestic Product (GDP), well below the 2.5- percent goal set by the National Health Policy of 2017.7 (See Map 1 for a visual representation of the proportion of GDP allocated to healthcare across the globe.) Indeed, the country’s contribution to the global healthcare infrastructure is highly inadequate, despite the highest-ever budgetary allocation of INR 690 billion8 to health for 2020-21, a six- percent rise from 2019-20.9 2 ORF OCCASIONAL PAPER # 237 FEBRUARY 2020 HOW FARES INDIA IN HEALTHCARE? A SUB-NATIONAL ANALYSIS Map 1. Health expenditure as percentage of Total GDP, 2009-13 Source: Francis S. Collins, World Economic Forum, ‘Growing importance of health in the economy’, https://widgets.weforum.org/outlook15/10.html NITI Aayog Report: ‘Healthy States, Progressive India’ The NITI Aayog report, ‘Healthy States, Progressive India’ outlines India’s performance in health and highlights the varied complexities and challenges therein, as well as the scope for improvement. The report aims to catalyse reforms at the sub-national level and help fulfill the country’s goals towards cooperative and competitive federalism.10 To begin with, healthcare access across the country is varied, owing to different factors like the vast geographical landscape, deep cultural peculiarities, and wide income disparities. Recognising the complexities in understanding the problems of healthcare access at the federal level, the NITI Aayog uses a Health Index as a pillar for tracking health goals. The report, ‘Healthy States, Progressive India’, tracks the progress made by states and UTs in the index, highlighting the areas that each State should focus on to facilitate improvement in their overall health system. ORF OCCASIONAL PAPER # 237 FEBRUARY 2020 3 HOW FARES INDIA IN HEALTHCARE? A SUB-NATIONAL ANALYSIS The Health Index The NITI Aayog Health Index consists of a set of relevant indicators (See Appendix 1), divided into three key domains: Ÿ Health Outcomes – including mortality rates, sex ratios, and immunisation levels; Ÿ Governance and Information – the status of the governance structures and information systems within states; and Ÿ Key Inputs & Processes – areas such as healthcare quality and availability, staff shortages and birth registration level Each domain was assigned weights based on importance (See Appendix 2): the highest weightage was given to the Health Outcomes, primarily because they comprise most of the measures in SDG Goal 3. Within a domain, the weights have been equally distributed amongst each indicator. The data for the indicators under each domain was taken from existing annual and reliable data sources such as the Sample Registration Survey (SRS), Civil Registration Survey (CVS), and Health Management Information Systems (HMIS), along with online submissions by the states using the Web portal. The data was validated and analysed by an external agency. A composite index was calculated as a weighted average of the various indicators to measure the health performance of each state and UT in each period (2014-15, 2015-16, and 2017-18). It provides the overall performance, as well as across domains. This paper explores the key trends in the health indicators across States and Union Territories, highlighting the challenges they face in their health systems and processes. The paper identifies the domains and indicators where each state and UT is lacking. This analysis paves the way for further research across health domains, sub-domains, key indicators, and regions. 4 ORF OCCASIONAL PAPER # 237 FEBRUARY 2020 HOW FARES INDIA IN HEALTHCARE? A SUB-NATIONAL ANALYSIS II. OVERALL HEALTH INDEX ANALYSIS In the following analysis, each State and UT has been divided into four categories: Leader, Aspirant,a Risk, and Danger. ‘Leader’ signifies States or UTs that have seen an incremental rise in the health index in the first term (2014-15 to 2015-16) and second term (2015-16 to 2017-18). ‘Aspirants’ are those that experienced a decline in the health index in the first term but a rise in the health index in the second term. ‘Risk’ signifies States or UTs that climbed in the health index in the first term but dropped in the second term. ‘Danger’ signifies States or UTs that have seen a decline in the health index in both first term and second term. Aspirant Leader (displayed (displayed growth in the growth in both second term) terms) Danger Risk (displayed a (displayed decline in both growth in the terms) first term) Larger States In terms of absolute numbers, 38 percent of India’s larger states have seen a positive trend across both the reports (See Figure 1). For Jharkhand, Rajasthan, J&Kb, Chhattisgarh, Andhra Pradesh, Telangana, Maharashtra and Assam, the health index has improved for both the periods 2014-15 to 2015-16, and 2015-16 to 2017-2018. These states a Definition of ‘Aspirants’ States/UTs in the NITI Aayog health Index Report is different and is based on the incremental gain in the health index from 2015- 2016 to 2017-18, but this report utilizes a separate definition based on the incremental growth in both the terms of the report b Since Jammu & Kashmir was split into UTs in August 2019 and the NITI report was launched in July 2019, this paper considers Jammu & Kashmir a state in its analysis ORF OCCASIONAL PAPER # 237 FEBRUARY 2020 5 HOW FARES INDIA IN HEALTHCARE? A SUB-NATIONAL ANALYSIS are ‘Leaders’ (See Figure 2), even though the absolute index has remained on the lower side. Almost all states in this category saw an improvement in more than 50 percent of the indicators in the health index, with Andhra Pradesh and Jharkhand leading the group with an improvement in 19 and 18 indicators (out of 30), respectively. Figure 1: Health Index Score (Large States) 100 s 90 e t a 80 74.01 t s r 65.13 63.99 e 70 63.52 63.01 62.41 62.37 61.14 60.41 p 59 57.17 s 60 53.51 53.36 e 51.33 r 48.85 o c 50 43.1 s 40.2 38.39 x 35.97 e 40 32.11 d 28.61 n I 30 l l a r 20 e v O 10 0 r t l a a d b a d l a n d h h a h u a h m a a r r a s s l k h a a n a h n r n n n d r s t j a i h a s s e h a a g e a a a h a a i a i a s e h n t r g c t j e y d n d g h s m s h B d d s N a u s e r u a u d a a e i k n k a h A a l a a r n r K t O P r r a i s j r B G e a m t r m r l P P a r i a H a a P t a a m P e a m h h s K a H a R r h K T t J a r a a e y t a T h J h t h U C t M W d d U n a A 2014-15 2015-16 2017-18 M Source: Author’s own.
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