Lok Sabha Question No. 154 (STARRED), answered on 2022-02-11
Subject: Health Index Ranking of States
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Bache Gowda B.N., Bheemrao Baswanthrao Patil

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENT OF HEALTH AND FAMILY WELFARE

## LOK SABHA STARRED QUESTION NO.154 TO BE ANSWERED ON THE 11 TH  FEBRUARY, 2022

## HEALTH INDEX RANKING OF STATES

## *154. SHRI B.N. BACHE GOWDA: SHRI B.B. PATIL::

Will  the  Minister  of  HEALTH  AND  FAMILY  WELFARE  be  pleased  to state:

- (a) whether the Government has recently published a comprehensive State Health Index, jointly developed with NITI Aayog and World Bank;
- (b)  if  so,  the  details  thereof  along  with  the  indicators  used/criteria  fixed  in  this regard and the major findings therein;
- (c)  whether  the  said  report  indicates  that  health  status  has  stagnated  and  health services have deteriorated in most States;
- (d) if so, the details thereof along with the list of progressive and worst performing States/UTs;
- (e) whether based on the said report, the Government proposes to extend financial support  to  low  performing  States  such  as  Uttar  Pradesh  and  Bihar  to  strengthen their health infrastructure and if so, the details thereof;
- (f) the details and present status of major health indicators including institutional deliveries,  maternal  mortality  rate,  birth  rate  and  death  registration  in  various States including Uttar Pradesh, Bihar and Madhya Pradesh; and
- (g)  whether  the  Government  has  any  action plan to improve the  rankings  of the States/UTs and if so the details of the status of Health Index of States/UTs since 2014 along with the year on year incremental changes in the health outcomes/performance thereof?

## ANSWER THE MINISTER OF HEALTH AND FAMILY WELFARE (DR MANSUKH MANDAVIYA)

- (a) to (g) A Statement is laid on the Table of the House.

## STATEMENT REFERRED TO IN REPLY TO LOK SABHA STARRED QUESTION NO. 154* FOR 11 TH  FEBRUARY, 2022

(a)  &  (b)  NITI  Aayog,  in  collaboration  with  the  Ministry  of  Health  &  Family Welfare  (MoHFW)  and  the  World  Bank  has  published  Health  Index  Round  IV 2019-20  (Healthy  States,  Progressive  India  -  Report  on  the  Ranks  of  States and UTs).

The  Health  Index  is  a  useful  tool  to  measure  and  compare  the  overall performance and incremental performance across States/UTs over a period of time and is an important instrument in understanding the variations in performance on 24  indicators  across  three  domains:  (i)  Health  Outcomes;  (ii)  Governance  and Information; and (iii) Key Inputs and Processes. Each domain is assigned weights, based on its importance, with the Health Outcomes carrying the highest weightage across  different  categories  of  States/UTs.  Within  a  domain  or  sub-domain,  the weight is equally distributed among the indicators in that domain or sub-domain. A Composite Index is calculated to measure the state of health in each State/UT for a Base Year (2018-19) and a Reference Year (2019-20). The Composite Score of Reference Year (2019-20) provides the Overall Performance while the change in the Index Score of each State/UT from the Base Year (2018-19) to the Reference Year (2019-20) measures the Incremental Performance of each State/UT. States/UTs are grouped in three categories to ensure comparability among similar entities,  namely  19  Larger  States,  8  Smaller  States,  and  7  UTs (West  Bengal (Larger State) did not participate in the Health Index exercise. UT of Ladakh not included  due  to  non-availability  of  data). The  details  of  indicators  are  given  in Annexure-I .

## Major Findings

Amongst the Larger States, Kerala, Tamil Nadu and Telangana emerged as the best three performers in terms of Overall Performance. Uttar Pradesh ranked at the top in terms of Incremental Performance by registering the highest incremental change  from  the  Base  Year  (2018-19)  to  Reference  Year  (2019-20).  Telangana performed  well  both  in  terms  Overall  Performance  as  well  as  Incremental Performance  and  secured  the  third  position  in  both  instances.  For  the  fourth consecutive  round,  Kerala  emerged  as  the  best  performer  in  terms  of  Overall Performance.

Among  the  Smaller  States,  Mizoram  emerged  as  the  best  performer  in Overall Performance as well as Incremental Performance while among UTs, Delhi and Jammu & Kashmir emerged as the leading performer in terms of Incremental Performance.

(c)  &  (d)        No.  The  Health  Index  is  a  useful  tool  to  measure  and  compare  the Overall  Performance  and  Incremental  Performance  across  States/UTs  over  time, and  is  an  important  instrument  in  understanding  the  variations  in  performance across various parameters including health  outcomes,  governance and data integrity,  key  inputs  and  processes.  It  measures  the  annual  performance  of States/UTs  and  ranks  States/UTs  on  the  basis  of  incremental  change  or  the  data that  captures  annual  progress  within  the  overarching  context  of  the  overall performance of the States/UTs.

The  health  status  and  health  services  have  shown  a  positive  increment  in majority of States/ UTs in terms of indicators which are used in the report.  The performance of States/UTs is, however, assessed through State Health Index (SHI) report and Conditionality Framework so that the desired objectives are achieved. The  category  wise  list  of  States/UTs  in  terms  of  the  positive  and  negative incremental performance is as under:

| Category            | Positive Incremental Performance                                                                                                                                                                                                              | Negative Incremental Performance                                                                  |
|---------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------|
| Larger States (19)* | (5.52) Uttar Pradesh (4.34) Assam (4.22) Telangana (3.60) Maharashtra (3.38) Jharkhand (3.35) Madhya Pradesh (1.74) Punjab (1.62) Tamil Nadu (1.14) Gujarat (1.07) Andhra Pradesh (0.76) Bihar (0.60) Kerala (0.58) Uttarakhand (0.13) Odisha | (-1.37) Karnataka (-0.55) Haryana (-0.25) Rajasthan (-0.09) Chhattisgarh (-0.06) Himachal Pradesh |
| Smaller States (8)  | (18.45) Mizoram (17.70) Meghalaya (3.43) Nagaland (0.19) Tripura                                                                                                                                                                              | (-12.68) Goa (-5.73) Manipur (-1.54) Arunachal Pradesh (-0.72) Sikkim                             |
| UTs (7)             | (9.68) Delhi (9.55) Jammu &Kashmir (7.72) Lakshadweep (1.58) Puducherry (0.14) Andaman &Nicobar                                                                                                                                               | (-10.85) Chandigarh (-3.53)DH&DD                                                                  |

*Among the Larger States, West Bengal did not participate in this round and data for UT of Ladakh was not available

Note: Figure in parentheses indicate Incremental Performance Score, i.e., change between the Composite index Score of Base Year (2018-19) and Reference Year (2019-20)

(e) As Public Health and Hospitals is a State subject, the primary responsibility of  strengthening  public  healthcare  system  lies  with  the  respective  State/UT Governments. However, the Ministry of Health and Family Welfare provides the technical  and  financial  support  to  the  States/UTs  to  strengthen  their  public healthcare  system  based  on  the  requirements  posted  by  States/UTs  in  their Programme Implementation Plans (PIPs) and within the overall resource envelope.

Further,  the  annual  resource  envelope  of  a  State  is  decided  based  on  its population and a weight-age factor which depends on areas of the State, health lag/ socio economic backwardness.

Since FY 2012-13, 10% of the total allocation under RMNCH+A and Health System  Strengthening  Flexible  Pool  of  NHM  is  linked  to  performance  of  the States/UTs,  which  was  increased  to  20%  of  the  total  Government  of  India allocation in F.Y 2018-19.

Apart from the support  under  NHM, following financial support  has been extended to States/ UTs to strengthen their health infrastructure.

-  Under India COVID-19  Emergency  Response  and  Health System Preparedness  Package  (ECRP-I),  an  amount  of  Rs.  1113.21  crore  & Rs.  8147.28  crore  have  been  released  during  FY  2019-20  &  2020-21 respectively.
-  ECRP Phase-II  with  Rs.  23,123  crores  (with  Rs.  15,000  Cr  as  Central Component &Rs. 8,123 Cr as State component) has also been approved and allocated.
-  PM Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) with an  outlay  of  Rs.  64,180  crores  support  over  a  period  of  5  years  from 2021-22 to 2025-26 envisages increased investments in public health and other health reforms to safeguard against future resurgences of COVID19, if any, and future public health emergencies.
-  The  total  grants-in-aid  supported  of  Rs.  70,051  Cr  -  through  local governments spread over a period of  5 years from 2021-22 to 2025-26 have been approved under 15 th Finance Commission to the health sector over the award period.

(f) The  details  on  performance  of  indicators  of  each  State/UT  are  placed  at Annexure F (pg. 112-181) of the said Report. The report is available at the website of  NITI  Aayog  i.e.  https://www.niti.gov.in  at  the  Uniform  Resource  Locator (URL)as under:

https://www.niti.gov.in/sites/default/files/2021-12/NITI-WB\_Health\_Index\_Report\_24-12-21.pdf

(g) The compilation and publication of the said report has started since 2017. These Health Index Report aims to nudge the States/ UTs towards building robust health systems and improving service delivery. The importance of this annual tool is re-emphasized to link this Health Index to incentives under NHM and this has been instrumental in shifting the focus from budget spending, inputs, and outputs to outcomes.

States/UTs are incentivized/dis-incentivized based on the score on conditionalities. 20% of the resource envelope of NHM for the States/UTs is given based  on  State's/UT's  performance  on  agreed  conditionalities.  The  States/UTs could lose or gain up to 20% of funding under NHM based on the conditionality score. The State Health Index (SHI) score has a weightage of 40% in conditionality framework scoring.

Details of status of health index of States/ UTs since 2014 along with year on year incremental changes in the health outcomes/ performance may be seen at Annexure-II .

## Details of indicators

| Sr. No. Domain                                                                           | Indicators By Domain And Sub-Domain                                                                                                                                                                                                                             |
|------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 1: Health Outcomes Sub-domain 1.1 Key Outcomes                                           | 1: Health Outcomes Sub-domain 1.1 Key Outcomes                                                                                                                                                                                                                  |
| 1.1.1                                                                                    | Neonatal Mortality Rate (NMR) *@                                                                                                                                                                                                                                |
| 1.1.2                                                                                    | Under-five Mortality Rate (U5MR)*@                                                                                                                                                                                                                              |
| 1.1.3                                                                                    | Sex Ratio at Birth (SRB)*                                                                                                                                                                                                                                       |
| 1.1.4                                                                                    | Maternal Mortality Ratio (MMR)*@                                                                                                                                                                                                                                |
| Domain 1: Health Outcomes Sub-domain 1.2 Intermediate Outcomes                           | Domain 1: Health Outcomes Sub-domain 1.2 Intermediate Outcomes                                                                                                                                                                                                  |
| 1.2.1                                                                                    | Modern Contraceptive Prevalence Rate (MCPR)+                                                                                                                                                                                                                    |
| 1.2.2                                                                                    | Full immunisation coverage (percent)                                                                                                                                                                                                                            |
| 1.2.3                                                                                    | a. Proportion of Antenatal care (ANC) registered within first trimester against total registrations                                                                                                                                                             |
|                                                                                          | b. Proportion of pregnant women who received 4 or more ANCs                                                                                                                                                                                                     |
| 1.2.4                                                                                    | Proportion of institutional deliveries                                                                                                                                                                                                                          |
| 1.2.5                                                                                    | Total Case Notification of TB (percent)                                                                                                                                                                                                                         |
| 1.2.6                                                                                    | TB Treatment Success Rate                                                                                                                                                                                                                                       |
| 1.2.7                                                                                    | Proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART)+                                                                                                                                                                                   |
| Domain 2: Governance and Information Sub-domain 2.1 Health Monitoring and Data Integrity | Domain 2: Governance and Information Sub-domain 2.1 Health Monitoring and Data Integrity                                                                                                                                                                        |
| 2.1.1                                                                                    | Data Integrity Measure*: Institutional deliveries                                                                                                                                                                                                               |
| 2.2.1                                                                                    | Average occupancy of an officer (in months), combined for following three posts at State level for last three years. (Principal Secretary/Secretary where PS not applicable; Mission Director (NHM); Director (Health Services)/ DGHS where DHS not applicable) |
| 2.2.2                                                                                    | Average occupancy of a full-time CMO(in months) in last three years for all districts                                                                                                                                                                           |
| 2.2.3                                                                                    | Number of days for transfer of Central NHM fund from State treasury to implementation agency (Department/Society) based on the largest tranche of the last financial year+@                                                                                     |
| Domain 3: Key Inputs and Processes Sub-domain 3.1 Health Systems/Service Delivery        | Domain 3: Key Inputs and Processes Sub-domain 3.1 Health Systems/Service Delivery                                                                                                                                                                               |
| 3.1.1                                                                                    | Proportion of shortfall of health care providers (regular + contractual) against required number of health care providers in public health facilities@                                                                                                          |
| 3.1.2                                                                                    | Proportion of total staff (regular + contractual) covered under a functional IT enabled integrated Human Resources Management Information System (HRMIS)                                                                                                        |
| 3.1.3                                                                                    | a. Proportion of specified type of facilities functioning as First Referral Units (FRUs)                                                                                                                                                                        |
|                                                                                          | b. Proportion of public health facilities with Kayakalp score of >70% against total number of public health facilities                                                                                                                                          |
| 3.1.4                                                                                    | Proportion of functional Health and Wellness Centres                                                                                                                                                                                                            |
| 3.1.5                                                                                    | Proportion of district hospitals with functional Cardiac Care Units (CCUs)                                                                                                                                                                                      |
| 3.1.6                                                                                    | a. Level of registration of births (percent)                                                                                                                                                                                                                    |
|                                                                                          | b. Level of registration of deaths (percent)                                                                                                                                                                                                                    |
| 3.1.7                                                                                    | Completeness of IDSP reporting of P and L Form (percent)                                                                                                                                                                                                        |
| 3.1.8                                                                                    | a. Proportion of public health facilities with accreditation certificates by a standard quality assurance programme (NQAS/NABH)                                                                                                                                 |
|                                                                                          | b. Proportion of district hospitals and CHCs certified under LaQshya (separately for labour room and maternity OT)                                                                                                                                              |
| 3.1.9                                                                                    | Proportion of State Government health expenditure to total state expenditure*                                                                                                                                                                                   |

For Smaller States: Indicators 1.1.1, 1.1.2, 1.1.3, 1.1.4, 2.1.1 and 3.1.9 are not applicable.

## Overall Health Index and incremental changes

## Annexure-II

| States                   | 2014 2015     | 2014 2015           | 2014 2015     | 2017                | 2017          | 2017                | 2018          | 2018                |
|--------------------------|---------------|---------------------|---------------|---------------------|---------------|---------------------|---------------|---------------------|
|                          | Overall index | Incremental changes | Overall index | Incremental changes | Overall index | Incremental changes | Overall index | Incremental changes |
| Larger States            |               |                     |               |                     |               |                     |               |                     |
| Andhra Pradesh           | 60.16         | 2.41                | 65.13         | 4.97                | 67.84         | 3.67                | 69.95         | 1.07                |
| Assam                    | 44.13         | 0.6                 | 48.85         | 4.72                | 52.49         | 1.58                | 47.74         | 4.34                |
| Bihar                    | 38.46         | 3.76                | 32.11         | -6.35               | 36.39         | 1.89                | 31.00         | 0.76                |
| Chhattisgarh             | 52.02         | 3.39                | 53.36         | 1.34                | 53.15         | -2.94               | 50.70         | -0.09               |
| Gujarat                  | 61.99         | -1.29               | 63.52         | 1.53                | 63.15         | -1.65               | 63.59         | 1.14                |
| Haryana                  | 46.97         | -2.9                | 53.51         | 6.55                | 46.4          | 0.21                | 49.26         | -0.55               |
| Himachal Pradesh         | 61.2          | -0.92               | 62.41         | 1.21                | 65.45         | -3.01               | 63.17         | -0.06               |
| Jharkhand                | 45.33         | 6.87                | 51.33         | 5.99                | 40.19         | -6.94               | 47.55         | 3.38                |
| Karnataka                | 58.7          | -1.03               | 61.14         | 2.44                | 58.05         | -2.32               | 57.93         | -1.37               |
| Kerala                   | 76.55         | -3.45               | 74.01         | -2.55               | 79.44         | 3.06                | 82.20         | 0.6                 |
| Madhya Pradesh           | 40.09         | 1.1                 | 38.39         | -1.7                | 37.17         | -1.98               | 36.72         | 3.35                |
| Maharashtra              | 61.07         | 0.98                | 63.99         | 2.92                | 64.53         | -4.08               | 69.14         | 3.6                 |
| Odisha                   | 39.43         | 0.2                 | 35.97         | -3.46               | 46.18         | 3.67                | 44.31         | 0.13                |
| Punjab                   | 65.21         | 3.19                | 63.01         | -2.2                | 59.81         | 0.49                | 58.08         | 1.74                |
| Rajasthan                | 36.79         | 2.24                | 43.1          | 6.3                 | 47.71         | -0.49               | 41.33         | -0.25               |
| Tamil Nadu               | 63.38         | 0.1                 | 60.41         | -2.97               | 67.4          | 4.07                | 72.42         | 1.62                |
| Telangana                | 55.39         | 0.45                | 59            | 3.61                | 58.31         | 3.87                | 69.96         | 4.22                |
| Uttar Pradesh            | 33.69         | 5.55                | 28.61         | -5.08               | 24.43         | 1.15                | 30.57         | 5.52                |
| Uttarakhand              | 45.22         | -0.1                | 40.2          | -5.02               | 43.86         | 2.94                | 44.21         | 0.58                |
| West Bengal              | 58.25         | 0.38                | 57.17         | -1.08               |               |                     |               |                     |
| Smaller States           |               |                     |               |                     |               |                     |               |                     |
| Arunachal Pradesh        | 49.51         | -1.09               | 46.07         | -3.44               | 40.59         | -2.7                | 33.91         | -1.54               |
| Goa                      | 53.13         | 6.67                | 51.9          | -1.23               | 69.09         | 6.22                | 53.68         | -12.68              |
| Manipur                  | 57.78         | 7.18                | 60.59         | 2.81                | 45.64         | -6.03               | 34.26         | -5.73               |
| Meghalaya                | 56.83         | 5.43                | 55.95         | -0.88               | 45.31         | -7.89               | 43.05         | 17.7                |
| Mizoram                  | 73.7          | 2.43                | 74.98         | 1.28                | 64.01         | -6.62               | 75.77         | 18.45               |
| Nagaland                 | 37.38         | -7.88               | 38.51         | 0.92                | 24.7          | 1.17                | 27.00         | 3.43                |
| Sikkim                   | 53.2          | -0.19               | 50.5          | -2.7                | 56.21         | -7.1                | 55.53         | -0.72               |
| Tripura                  | 43.51         | -4.84               | 46.38         | 2.87                | 65.12         | 2.87                | 70.16         | 0.19                |
| UTs                      |               |                     |               |                     |               |                     |               |                     |
| Andaman & Nicobar        | 50            | 3.82                | 49.89         | -5.85               | 52.75         | -6.96               | 44.74         | 0.14                |
| Chandigarh               | 52.27         | -5.22               | 67.08         | 8.73                | 64.88         | -2.65               | 62.53         | -10.85              |
| Dadar&                   | 34.64         | 3.3                 | 60.73         | 15.32               | 82.82         | 1.81                | 66.19         | -3.53               |
| Nagar Haveli & Daman Diu | 36.10         | -8.67               | 51.04         | 2.72                | 44.16         | -3.90               |               |                     |
| Delhi                    | 50.02         | 1.97                | 52.22         | -7.62               | 41.43         | -9.22               | 49.85         | 9.68                |
| Jammu& Kashmir           | 60.35         | 6.83                | 62.37         | 2.02                | 57.51         | 0.13                | 47.00         | 9.55                |
| Lakshadweep              | 65.79         | 9.56                | 50.22         | -4.36               | 47.87         | -6.99               | 51.88         | 7.72                |
| Puducherry               | 47.48         | 0.94                | 31.87         | -3.64               | 36.2          | -14.5               | 50.83         | 1.58                |