New Delhi: Bihar, still reeling from over 100 child deaths caused by a suspected encephalitis outbreak its healthcare infrastructure failed to check, is perhaps the least surprising name among the worst performers listed in Niti Aayog’s second annual health index, released this week.
According to the index, Bihar registered a deterioration in most health indicators such as total fertility rate, low birth weight, sex ratio at birth, institutional deliveries, TB treatment success rate, and delayed transfer of fund under the National Health Mission.
Only one out of 21 larger states fared worse than Bihar — Uttar Pradesh.
The health index, which made its debut last year, is a composite score of states’ healthcare infrastructure that takes into account 23 indicators. It analysed states’ performance and incremental improvement on these parameters between 2015-16 (base year) and 2017-18 (reference year).
“The decline in the overall health index score for five empowered action group (EAG) states including Bihar, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Odisha between the base year and reference year is attributed to the deterioration of performance in several indicators,” the index noted.
The worst performer of the index, Uttar Pradesh, was ranked among the bottom three last year, though it was also among the three states that registered the most improvement.
Identification this year as the worst marks a fall in two ranks for Uttar Pradesh, whose ailing healthcare system often lands it in gruesome headlines.
Last year, more than 70 children died at a government-run hospital in Bahraich amid an alleged lack of facilities to tackle the patient influx, while over 31 children died in 48 hours in 2017 at a state hospital in Gorakhpur after its oxygen supply allegedly ran out.
In November 2017, the same hospital in Gorakhpur again recorded 30 child deaths within 48 hours.
The index identifies a host of factors responsible for UP’s crumbling healthcare situation: Absence of medical officers, revolving-door appointments for crucial posts, failure of institutionalised deliveries, falling success rates of tuberculosis treatment, and no functioning rooms at government facilities to treat cardiac arrest.
Uttar Pradesh: State of ailing healthcare
According to the health index, the deterioration in Uttar Pradesh’s performance is evident in several indicators.
Despite a boost in funding for TB treatment under the Modi government, which seeks to eliminate the disease in India by 2025, UP recorded a fall in the success rate. According to the index, between 2015 and 2016, the success rate for TB treatment in UP declined by more than 15 percentage points.
The report also points out that incumbents in key administrative positions overseeing public health programmes in the state don’t have stable tenures, with many of the posts also vacant.
“Based on the data from states in 2015-18, the average occupancy of principal secretary, mission director (National Health Mission), and director (health services) or equivalent positions in a period of three years was low in UP,” the report states.
The average occupancy for the post of district chief medical officer (CMO) was recorded at less than 12 months, further hindering the effective implementation of key public health programmes in the state, the report adds.
The state also recorded a high total fertility rate (TFR), which is described by the WHO as the “total number of children born or likely to be born to a woman in her life time if she were subject to the prevailing rate of age-specific fertility in the population”.
It indicates poverty, low maternal education, gender inequality, low female labour participation rates, and a similar performance on other measures of social and economic development, the report notes.
Despite the high TFR, the state boasts of “low levels of institutional deliveries”, another key indicator of a robust healthcare system. “Only about half of the total deliveries in UP, Nagaland, and Daman and Diu were conducted in health facilities,” the index states.
The report also points out how UP is one of the states where district hospitals don’t have a functional cardiac care unit (CCU), which provides life-saving procedures and interventions during emergencies.
The low level of human resources make the situation more bleak for UP: According to Rural Health Statistics 2018, a separate annual report prepared by the Ministry of Health, against a requirement of 3,288 specialists for the state’s government health facilities, just 192 positions were filled.
“For doctors at primary health centres, out of 3,621 required, over 3,000 posts lie vacant,” said Avani Kapur, a fellow at the Centre for Policy Research (CPR), a New Delhi-based thinktank.
Kerala has recorded a stellar performance on several indicators, meeting targets set by the United Nations under the 2030 sustainable development goals (SDG) programme, a collection of 17 aims to end poverty and protect the planet.
For example, the state has achieved a neonatal mortality rate (NMR) of less than 12 per 1,000 live births and an under-five mortality rate (U5MR) of under 25 per 1,000 live births.
Kerala also leads other larger states in sex ratio at birth (SRB), a measure for the number of girls born for every 1,000 boys. Out of the 21 ‘larger states’, Kerala was only one of two — the other being Chhattisgarh — with an SRB of more than 950, which means less gender discrimination and fewer sex-selective abortions.
However, it’s SRB of 959 in the second health index marks a drop from the first one, which estimated that 967 girls were born in Kerala for every 1,000 boys.
Another worrying point is that the proportion of community health centres and primary health centres with quality accreditation certificates has declined in the state.
Kerala versus Uttar Pradesh
Importantly, Kerala has built enough hospitals to treat its population while Uttar Pradesh lags behind.
“Kerala has a well-established health infrastructure. While the entire country is struggling with a shortage of hospitals, the state with a population of 35 million has more than 135 hospitals that have over 100 beds,” said Dr Girdhar J. Gyani, director general of the Association of Healthcare Providers, India (AHPI), which represents 2,500 specialty and 8,000 smaller hospitals across India.
“It has 50 hospitals with over 300 beds. Hence, the basic infrastructure is almost in place,” Gyani added. “On the contrary, Uttar Pradesh has a population of 200 million but only has 90 hospitals with over 100 beds.”
‘A worrying picture’
Among the top 10 performers, seven registered an improved performance over the 2018 index: Andhra Pradesh, Maharashtra, Gujarat, Himachal Pradesh, Jammu & Kashmir, Karnataka, and Telangana.
Apart from Bihar, Uttar Pradesh shares healthcare notoriety with Odisha, Madhya Pradesh, and Uttarakhand.
Experts say the new health index paints a worrying picture because even the best performer among larger states, Kerala, which is also last year’s topper, has recorded a lower score on some parameters.
“The recently-released index is worrying, especially since, not just Uttar Pradesh, but many other states saw a decline in performance,” said Kapur of CPR.
“Only about half the states and union territories showed an improvement in the overall score between 2015-16 and 2017-18,” she added, “Even Kerala hasn’t performed well on many of the indicators. This aspect needs to be investigated, whether it’s due to an anomaly in the base year or a more systemic issue.”