Kerala retained the top spot in terms of health performance among larger states, followed by Andhra Pradesh and Maharashtra, whereas Uttar Pradesh and Bihar remained at the bottom, according to the NITI Aayog’s second round of health index.

Gujarat, Punjab and Himachal Pradesh stood at fourth, fifth and sixth spots, according to the report, titled Healthy States, Progressive India: Report on Rank of States and UTs.

Among the smaller states, Mizoram ranked first in overall performance, while Tripura and Manipur were the top two states in terms of incremental performance. Among the Union Territories, Chandigarh ranked first in overall performance, while Dadra and Nagar Haveli improved the most.

Noting that overall, there is room for improvement in all states, even among the best, NITI Aayog said that “among the larger states, the overall health index score of the best-performing state is more than two-and-a-half times of the overall score of the least-performing state”.

The report said several states have made good progress towards achieving sustainable development goals (SDG) included in the index.

How is the health index prepared?

The report focuses on measuring and highlighting the overall performance and incremental improvement over a two-year period in the states and UTs, which are categorised as larger states, smaller states and UTs to ensure comparison among similar entities.

NITI Aayog in collaboration with the World Bank and the Ministry of Health and Family Welfare (MoHFW) embarked on a journey in 2017 to develop the first comprehensive State Health Index and published the first edition of Healthy States, Progressive India - Report on the Ranks of States and UTs. The second edition of this exercise was conducted over a period of eight months in 2018-19.

The second round of the health index took into account the period 2015-16 (base year) to 2017-18 (reference year).

The health index highlights the progress reached by the individual states and UTs and is an important instrument in understanding the variations and complexity of the nation’s performance in health. It highlights the areas each state should focus on to facilitate improvement in overall health outcomes.

The health index is a weighted composite index based on 23 indicators grouped into the domains of health outcomes, governance and information, and key inputs/processes.

Releasing the report, NITI Aayog vice-chairman Rajiv Kumar said the Aayog is committed to establishing the health index as an annual systematic tool to propel states towards undertaking multi-pronged interventions to bring better health outcomes.

NITI Aayog member Vinod Kumar Paul said the Union government should spend 2.5 per cent of gross domestic product on health. “State governments should increase their spending on health from an average of 4.7 per cent to 8 per cent of their budget (net state domestic product) on health,” Paul said.

Haryana tops in incremental performance

Among the larger states, Haryana, Rajasthan and Jharkhand are the top three states in terms of incremental performance. Kerala championed the larger states with an overall score of 74.01, while Uttar Pradesh was the least performing state with an overall score of 28.61.

Andhra Pradesh and Maharashtra are the only two states that are among the top one-third states on both overall performance as well as incremental performance. Andhra Pradesh has the highest proportion of indicators (63 per cent) among the larger states which fall in the category of “most improved” or “improved”.

What is the scenario in EAG states?

The Empowered Action Group (EAG) states include Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Rajasthan, Uttarakhand, Uttar Pradesh and Odisha.

Among the eight EAG states, only three - Rajasthan, Jharkhand and Chhattisgarh - showed improvement in the overall performance between 2015-16 and 2017-18. The report says, while it is important to identify the challenges faced by the EAG states that hinders improvement in performance, the impressive improvement in some EAG states provides learning opportunities for the rest to identify effective actions to improve their overall performance scores.

Mizoram best performer is smaller states

Among the smaller states, Mizoram ranked first in overall performance, while Tripura and Manipur were the top two states in terms of incremental performance. The overall performance score of four smaller states declined in 2017-18. Arunachal Pradesh registered the largest decline in the overall performance score from 49.51 to 46.07.

Chandigarh is the healthiest UT

Among the UTs, Chandigarh ranked first in overall performance, while Dadra and Nagar Haveli improved the most. Chandigarh and Dadra and Nagar Haveli ranked first and second in terms of overall performance ranking because of the impressive 11 and 22 point increase respectively in the overall performance. Three UTs - Lakshadweep, Andaman and Nicobar Islands and Delhi - registered a decline in their overall scores.

Analysis on some key indicators

Neonatal Mortality Rate (NMR)

The first month after the birth of a child (more specifically the first 28 days) is called the neonatal period. NMR is measured as the number of neonatal deaths per 1,000 live births. Death occurred during this period is of great concern because it reflects the availability and quality of the prenatal, intrapartum and neonatal care services.

In India, NMR remains a public health concern as more than two-thirds of infant deaths occur during the neonatal period. There is a huge disparity in NMR across India. Among the larger states, Odisha and Madhya Pradesh had the highest NMR, while Kerala had the lowest.

Among the 21 larger states, Kerala and Tamil Nadu have already reached the 2030 SDG target for NMR, which is 12 neonatal deaths per 1,000 live births.

Under-Five Mortality Rate (U5MR)

U5MR, the probability of dying before completing the age of five, is a critical indicator of child survival. It reflects a gamut of health and non-health factors that affect child survival, such as nutritional status of women and children, maternal education, availability of basic public health interventions (e.g. immunisation, oral rehydration therapy, water and sanitation) and socio-economic status.

Compared to countries with similar level of economic development, U5MR remains high (39 per 1,000 live births) in India with large variation across states. Madhya Pradesh had the highest U5MR among the larger states, while Kerala had the lowest.

Kerala, Tamil Nadu, Maharashtra and Punjab had already achieved the SDG target on U5MR, which is 25 deaths per 1,000 live births.

Sex Ratio at Birth (SRB)

SRB measures the number of girls born for every 1,000 boys born. It reflects the extent to which gender discrimination leads to sex-selective abortion. The low SRB in India relative to global average has received considerable attention.

Out of the 21 larger states, only two states (Chhattisgarh and Kerala) had an SRB of more than 950 girls for every 1,000 boys. Chhattisgarh had the highest SRB (963), whereas Haryana had the lowest (832).