Lok Sabha Question No. 3677 (UNSTARRED), answered on 2018-08-08
Subject: Comprehensive Health Index
Ministry: PLANNING
Asked by: C. MAHENDRAN, (ADV.) JOICE GEORGE

## GOVERNMENT  OF INDIA MINISTRY OF PLANNING

LOK SABHA TTNSTARRED QUESTION  NO. 3677 TO BE ANSWERED  ON 08.08.20I8

## COMPREHENSIVE  HEALTH INDEX

## 3677. SHRI C. MAHENDRAN: ADV. JOICE GERGE:

Willthe MINISTER OF PLANNING be pleased to state

- (a) whether the Government  has published recently the comprehensive Health Index report;
- (b) if so, the details thereof;
- (c) whether the report ranks States and Union Territories innovatively on their year-on-year incremental change in health  outcomes  as well as their overall  performance with respect to each other;
- (d) if so, the details thereof along with the list of performers and worst perforrners among States; and
- (e) whether the Government  has any action plan to improve State rankings  and if so, the details thereof?

## ANSWER

MINISTER OF STATE (INDEPENDENT  CHARGE) OF THE MINISTRY OF PLANNING AND MINISTER OF STATE IN THE MINISTRY OF CHEMICALS AND FERTILIZERS (RAO INDERJIT  SINGH)

- (a): Yes, Madam
- (b)  : "Healthy States, Progressive India-Report on the ranks of States and UTs" has been jointly released by NITI Aayog  and Ministry of Health and Family Welfare.  'The repofi is available on the officialwebsite of NITI for which the link is as under:

http://niti.eov.in/writereaddata/files/document  publication/Healthy-States-Proqressive-lndiaReport  0.pdf

- (c): Yes, Madam.
- (d): The key results  ofthe report are annexed  here to.
- (e): Ministry of Health & Family  Welfare has put in place a system of incentives/disincentives that is based on outcome  indicators  and health system initiatives to help accelerate  the progress  on achievement of the National Health Mission and Sustainable  Development  goals.  The incentives are provided to the States  on the basis of the performance  of the States which is assessed  based on conditionality  framework for the year. This framework of conditionality  includes  incentive/penalty based  on NITI Aayog ranking  of States  on 'Performance  on Health  outcomes'.

## KTY RESULTS

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5. Th.ere is a large gap in ooerull  ptformance befroeen  thc b6t and the least perforning  Sta.tes and UTs; besidcs, all Statcs and UTs luoe substantial soope  for  imprcaemmt:  In the reference year (2015-16) among l,arger States, the Index score for overall performance ranged widely between 33.69 in Uttar Pradesh to 76.55 in Kerala. Similarly,  among Smaller States, the Index score for overall performance  varied between 37.38 in Nagaland  to 73.70  in Mizoram,  and among UTs this varied between 3+.6+ in Dadra & Nagar Haveli to 65.79 in l,akshadweep. Among Larger States,  the variation between the best and least performing States and UTs was the widest around 43 points as compared with 36 points in Smaller  States and 3l points in UTs. Howeve4  based on the highest observed  overall Index scores in each category of States and UTs, dearly there is room for improvement  in all States and UTs.
6. Tlw Statos and Ws mnh differcnrly on oaemll  Pfiornonce  and. armual hwemqtal perfomanu: States and UTs that start at lower levels of the Health Index (lower  levels of development of their health systems) are generally  at an advantage in notching up incremental progress over States with high Health  Index score due to diminishing  marginal returns in outcomes for similar effort levels. It is a challenge for States at high levels of the Index score even to maintain  their performance levels. For example, Kerala ranls on top in terms of overall per{ormance  and at the bottom in terms of incremental progress mainly as it had already achieved  a low level of Neonatal  Monality Rate (NMR) and Under-{ive Mortality Rate (tlsMR) and replacement  level fertiliry leaving  limited space for any further  improvements.

Flgun E.l  -  lrrgor  Sbtcc: lncramcnh!  scom  rnd  nnb,  ri$ ororall  pcrlormanca  hom bEss  yea]  to rclercnce year  and nnts

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| lmlr                                               | 75.55 --<E0.00                                     | -3.45I 1                                           | 21                                                 |
|----------------------------------------------------|----------------------------------------------------|----------------------------------------------------|----------------------------------------------------|
| ProFi 62.02 F 65.21                                | r3.ls                                              | 2                                                  | 6                                                  |
| TmllX.tr 63.28 o                                   | 63.3E 0.10                                         | 3                                                  | t5                                                 |
| cnFd 61.90 r                                       | 6it.2t .1.29I                                      | I                                                  | 19                                                 |
| lfim.cldPillrdr 61.20 .r                           | 62.12 .0.92t                                       | 5                                                  | 1t                                                 |
| I.ls.ltt! 60.093 01.07                             | t 0.98                                             | 6                                                  | 10                                                 |
| Jilnru&Idunl $.52 H m.35                           | I6.E3                                              | 7                                                  | 2                                                  |
| ftrmr Pr.aldt 57.75 o-.61t.10                      | -2.11                                              | 8                                                  | 7                                                  |
| lamhit 58.70 - 59.73                               | -1.tsr                                             | 9                                                  | 18                                                 |
| Wrdri{.| 57.E7 0 58.25                        | r0.38                                              | 10                                                 | 1t                                                 |
| Td.oe.rr 54.$ e 55.39                              | t0.15                                              | 11                                                 | 12                                                 |
| Oteat 18.[Xl >:' 52.92                             | tr3.30                                             | 12                                                 | 5                                                  |
| lllrFm 15.07 +r {9.87                              | .2.90I                                             | 13                                                 | 20                                                 |
| ilhttila 88.{6 o-a t5.3ll                          |                                                    | il                                                 | 1                                                  |
| lllrll5r.rld {5.22 c 45.32                         | -0.10                                              | 15                                                 | 16                                                 |
| hfir 49.58 G 4l.ls                                 | -6.87 t0.c0                                        | 16                                                 | 11                                                 |
| X.CttPndd $.gg rl0.ll9                             | 11.t0                                              | 17                                                 | g                                                  |
| fihlr 39.23 e 39.{3                                | 0.m                                                | 16                                                 | 1t                                                 |
| th 31.?0 o-+ 39.15                                 | r3.7f                                              | 19                                                 | I                                                  |
| R.ld.r &t.55 }. 36.79                              | 42.24                                              | m                                                  | 0                                                  |
| ttrrPrldr|[ 28.14 r-. 38.69                   | I5.55                                              | 7l                                                 | t                                                  |
| l2o-oo o 60 60 70                                  | oo -1 048                                          |                                                    |                                                    |
| I , ltmnll Prrlormancc lnder                       | Scon lncfslnont l Ctange                           | ovonll Bsloranct Yce, Ranl                         | lncrcmontal Rrnl                                   |
| I Eare Yorr (2014-15) ::t'i Rolemnco Ycr (2015-16) | I Eare Yorr (2014-15) ::t'i Rolemnco Ycr (2015-16) | I Eare Yorr (2014-15) ::t'i Rolemnco Ycr (2015-16) | I Eare Yorr (2014-15) ::t'i Rolemnco Ycr (2015-16) |

7. Among tlw l-argr Statcs,Jharhhand,Jammu  €l KashmiA  and Uttar Pmdcsh  are th.e top three rankmg Statcs in tstns of omrual inoemental perfurmarce, uhilc Krala, hmjab, and. Thmil Nad,u ranhcd on tap in tenns of oaaall perfoma,nce.'In terms of annual incremental performance in Index scores  from the base to the reference  yearJ the top three ranked States  in the group of Larger States areJharkhand  (up 6.87 points),Jammu & Kashmir  (up 6.83 points) and Uttar Pradesh (up 5.55 points). Howeve4 in terms of overall levels of performance,  these States are in the bottom two-third  of the range of Index scores, with Kerala (76.55), Punjab (65.21) and Tamil Nadu (63.38) showing  the highest scores.Jharkhand,Jamrnu  & Kashmiq  and Uttar Pradesh  showed the maximum gains in improvement  of health outcomes  from base to reference  year in indicators  such as NMR, U5MR, full immunization coverage,  institutional deliveries, and people living with HIV (PLHIV) on antiretroviral  therapy  (ART).
8. Among Smailcr State$, IUIanipur  ranhcd  first  in tenns of amual inosnental performane and. sewnd in terms of oaerall performance,  whi,Ie Goa runhcd seoond in tnms of draaul bwenental perfonnance:  Among Smaller States, Mizoram (73.70) followed by Manipur  (57.78) are the best overall  performers. In annual incremental  performance, Manipur (up 7.18 points) and Goa (up 6.67 points)  ranked the highest. For Smaller  States, among the top performers, the indicators  that contributed to higher incremental  performance  varied. Manipur,  ranked  at the top and registered maximum incremental progress on indicators  such as PLHIV on ARf, first trimester antenatal care (ANC) registration,  grading  of Community Health  Centres  (CHCs) on quality parameters,  average occupancy of three key StateJevel o{Ecers, and good reporting on the Integrated Disease Surveillance Programme  (IDSP).
9. Anwng UTs, Lahshaduee,p slwued both tlw higltest amunl brcremental pefomane as well as tlw best u.terall prformonce: In annual incremental performance, Lakshadweep  ranked at the top (up 9.56 points) followed by Andaman  & Nicobar Islands (up 3.82 points). In terms of overall performance, l,alshadweep  (65.79) ranked at the top, followed by Chandigarh  (52.27).I+kshadweep showed the highest  improvement in indicators such as institutional,  deliveries, tuberculosis (IB) treaunent  success rate and transfer  of Central National  Health Mission (I,[HI\{) funds from State Treasury  to implementation  agency.

Flgun 8.2  -  Smallar Strtes: lncromontl  rcorar and nnks,  vltr oyerall  parlormance  lmm  lasc  yorr t0 ruhrrnce  ,srr  rnd nnls

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| ilizonfi                                           | 71-n >. 73.10                               | I2.13                     | 1                         | I              |
|----------------------------------------------------|---------------------------------------------|---------------------------|---------------------------|----------------|
| tillp0r                                            | fl!.fl! r__; 57.78                          | I7.18                     | 2                         | 1              |
| fofttfn                                            | 51.{0 o-.= 55.33                            | I5.48                     | 3                         | 3              |
| ffiir                                              | i9.20 . 53.39                               | -0.19                     | {                         | 5              |
| GB                                                 | f6.{6 }_+ 63.tg                             | I6.67                     | 5                         | 2              |
| lnndttl Pndqfr                                     | 49.51 I 80.60                               | -1.0s I                   | 6                         | 6              |
| Irtun                                              | l3.et *-+ 18.35                             | .t.84I                    | 7                         | 7              |
| lffihid                                            | 37.38 +-----r 15.26                         | -7.88I                    | 8                         | I              |
| 30 I Base Yerr (2O14-t5) # Boleronm Ysar (2015-16) | a0 50 00 70 m 0vcnll Pcrlomrnce lnder Score | -10 0 10 lmrsmenbl Ghrolo | 0tnrall Rderqro Ycar Ba:* | lncnmnbl Rflrf |

{

t

a

Figure  E.3  -  Union Terrltorbs:  lncremental  scores and ranl6,  wilh  ouerall  pedormance  from base  year  to relerence  year  and ranks

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10. TLc hwwurtol mp(Nuwtnsnt  shmus  thd about otto-thbd of thc Statcs harue rcgistoed a declbtc in ilwir Healtlt Indicw in tlw ,efervne  yeor  qs  ontpoed ta thp base year: This is a matter  of concern and should nudge the Stares into reviewing  and revitalizing their programmatic efforts. Among the Larger  States, six States, namely Uttarakhand,  Himachal Pradesh, Karnataka,  Gujarat, Haryana and Kerala have shown a decline in performance  from base year to reference yeaq despite some  of them being among the top ten in overall performance.  Among  the Smaller States, Sikkim, Arunachal Pradesh,  Tripura  and Nagaland have shown a decline; and among  the UTs, Chandigarh and Daman & Diu have shown a decline. Tables E.1, E.2 and E.3 provide  a categorization  of States  and UTs based on the level of annual  incremental  performance and the overall performance.

Iablo  E.l  -  C.tcgorlallon  ol laryil  Stltct  on lncremcntrl  perlomance  and ovrnll  peilormance

| lmffitcnlal Parhmance   |                            |                                   |             |
|-------------------------|----------------------------|-----------------------------------|-------------|
| tlo[ &rntomd            | tltbnltand llaryana        | Hlmactal Pndeslr f,arnahkr Gulanl | l(Gnlt      |
| l.t.rt lmproued         | llad!rya Pndesh A$am 0dbia | lla[enshtra Tclaqrna Wad Bcngal   | Tamll lladu |
| llodcnioly lmptoYed     | Bihar Ralrdhen             | GhhailsOarlr Andhra Pndedr        | Punlab      |
| roa mproucl             | Jhrilrand tlthr Pndosh     | Jammu & lhshmlr                   |             |

ilote:  0verall Performance:  Ihe  Shtos  are cabgcized  on the basls ol r8lofence  year  lndex score  range: kont-runners:  bp one-fiird  ondox  score>62);  Afilevers: mlddle me-hid  (lndex  scorc  beturcen 48 and 62), Aspiranb: lowest  one-$ird  (lndex scorc<18), lncremental  Fertonnance:  Ihe Stabs  ue cabgraized  on the basls ol incromenbf  lndex sore mnge: 'Not lmproved'  (ncremenhl  lndex scorecd)), 'least lmpro,ed' (ncremenhl  lndex score bstrren 0,01  and 2),'Modorably  lmprved'  (incremenbl  lndex score between  2.01  and 4),'tihst  tmpro\rsd'(incrsmenhl  lndex score>4.O).

Table E.2  -  Categotizalion  ol Smaller Slates  on inmemenlal  perrormance  and oyerall  perlormance

| lncremental Perlormrnee   |                   |                          |          |
|---------------------------|-------------------|--------------------------|----------|
| l{ot lmproved             | Trlpura llagaland | Slktlm Arunachal Pradesh |          |
| Least lmproved            |                   |                          |          |
| llodentely lmproved       |                   |                          | llizoram |
| t ilost hpruved           |                   | tanlpur Itleghalaya Goa  |          |

Note:  Overall Performance: Tlre  Statos arc cabgorized  on be basis of reference  year Index score  range: ftont-runners:  bp one-Uird  (lndex  score>61  .60), Achhvers: middle  one-hird  0ndex  score between 49.49  and 61 .@1,1spi1s,'rts: Iowest  one-trird  (lrdex score  <49.49).

(incremerltal  lndex score between  0.01  and 2),  'Moderately  lmproved'  (incremerhl lndex scors  betieen  2.01  af, 4),  'M6t lmproved'  (incremenbi  lndex score>4.G).

TaDle  E.3  -  Categoriatlon  ol Unlon Tenltorles  Dased  on incttmentil  pcrtormenco  rnd overrll  Dorlormance

| Itenmcnhl htlomencr   |                      |                            |             |
|-----------------------|----------------------|----------------------------|-------------|
| I rmrmprowt           | Oaman & Dlu          | Chandigarh                 |             |
| Lcdhp,[ffi            |                      | 0elhl Puduclnny            |             |
| tlfiLrably lmDrovod   | Dadn & llrgar lhveli | Andaman & llicoiar lslands |             |
| Y mou tmprorca        |                      |                            | Lakshadwcep |

t&te:  0€rall  Pedrmancg:Ihe  UIs are catsguized  m the be$s  of rcierence  y€ar  lrdor  score range: Front-runrnr:  bp one-$lrd  (lndex  score>S5), Achievers: middle onethird  @x  scce between  45 and 55), Asdnants:  lorvest on€-filrd  (lndex  scorc<4s).

Fff lncfemental  Performance:Ihe lIIs ue categulzed  m fte basb d tnc{emeflhl  lnd6x scole  range: 'l.ld lmproved'  (incrernenhl lndex so0re<=0),  'kast  lmproved' 0rrrementi  lndex score  betfeen 0.01  and 2), 'lroderately  lmgwed' (lrrremenbi  lndex scor bett een 2.01  ard 4), 'lrost lmproved'  (lncremefbl lndex score>r|.0).

In terms  of numbers  of indicators, Chhattisgarh, Goa and Delhi showed  improvement in the highest number of parameters, within the three categories  of States respectively  @igures  4.6,+.12, 4.18).  The specific  indicators  for which the States'performance has dipped  or improved  and actual values for these are provided in Annexure 4. The indicators where most States and Ll"Is need to focus include addressing  vacancies in key staf[, establishment  of functiona] district  Cardiac Care Units (CCUs), quality accreditation  of public health facilities, and institutionalization  of Human  Resources Management Information  System (HRMIS).  Additionally, almost all t arger States need to focus on improving  the Sex Ratio at Birth (SRB).

- [[.The oaero,ilperformance of Staresisttotalways  wttsistenturiththe  donai*specifrcperfomanu: Some States fare significantly  better in one domain than others, suggesting that there is scope to improve their performance in lagging domains with specific  targeted interventions.  For example, while most States showed  a better performance  in Health Outcomes, Thmil Nadu, West Bengal, Assam, Madhya Pradesh,  Odisha,  Rajasthan,  Daman & Diu, and Dadra & Nagar Haveli performed  better in terms of Key Inputs/Processes. Domain-wise incremental performance among the three categories  of States  showed the highest  improvement  in outcomes,  respectively  forJammu  & Kashmir, Uttar Pradesh andJharkhand;  Goa and Manipur; Andaman & Nicobar Islands and [,alshadweep.