Jharkhand, Jammu & Kashmir, and Uttar Pradesh showed the maximum gains in an improvement of health outcomes from base to reference year in indicators such as Neonatal Mortality Rate (NMR), Under-five Mortality Rate (U5MR), full immunization coverage, institutional deliveries, and People Living with HIV (PLHIV) on Anti-Retroviral Therapy (ART).

NITI Aayog recently unveiled the comprehensive Health Index report titled, “Healthy States, Progressive India”. 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.

Health Index has been developed as a tool to leverage co-operative and competitive federalism to accelerate the pace of achieving health outcomes. It would also serve as an instrument for “nudging” States & Union Territories (UTs) and the Central Ministries to a much greater focus on output and outcome-based measurement of annual performance than is currently the practice. With the annual publication of the Index and its availability on public domain on a dynamic basis, it is expected to keep every stakeholder alert to the achievement of Sustainable Development Goals (SDGs) Goal number 3.

States and UTs have been ranked in three categories namely, Larger States, Smaller States, and Union Territories (UTs). They ranked to ensure comparison among similar entities. The Health Index is a weighted composite Index, which for the larger States. It is based on indicators in three domains: (a) Health Outcomes (70%); (b) Governance and Information (12%); and (c) Key Inputs and Processes (18%), with each domain assigned a weight based on its importance.

Among the Smaller States, Mizoram ranked first followed by Manipur on overall performance. While Manipur followed by Goa was the top-ranked States in terms of annual incremental performance. Manipur registered maximum incremental progress on indicators. Such as PLHIV on ART, first-trimester antenatal care (ANC) registration, grading quality parameters of Community Health Centres (CHCs). The average occupancy of key State level officers and good reporting on the Integrated Disease Surveillance Programme (IDSP).

Among UTs, Lakshadweep showed both the best overall performance as well as the highest annual incremental performance. Lakshadweep showed the highest improvement in indicators such as institutional deliveries, tuberculosis (TB) treatment success rate, and transfer of National Health Mission (NHM) funds from State Treasury to implementation agency.

The Health Index report notes that while States and UTs that start at lower levels of development. That is generally at an advantage in notching up incremental progress over States with high Health Index scores. It is a challenge for States with high Index scores to even maintain their performance levels. For example, Kerala ranks on top in terms of overall performance. But sees the least incremental change as it had already achieved a low level of Neonatal Mortality Rate (NMR). And Under-five Mortality Rate (U5MR) and replacement level fertility, leaving limited space for any further improvements.

However, the incremental measurement reveals that about one-third of the States have registered a decline in their performance in 2016 as compared to 2015, stressing the need to pursue domain-specific, targeted interventions. Common challenges for most States and UTs include the need to focus on addressing vacancies in key staff, establishment of functional district Cardiac Care Units (CCUs), quality accreditation of public health facilities and institutionalization of Human Resources Management Information System (HRMIS). Additionally, almost all Larger States need to focus on improving the Sex Ratio at Birth (SRB).

The contribution of most of the major non-communicable disease groups to the total disease burden has increased all over India since 1990, including cardiovascular diseases, diabetes, chronic respiratory diseases, mental health and neurological disorders, cancers, musculoskeletal disorders and chronic kidney disease.

On the other hand, the DALY rates of stroke varied across the states without any consistent pattern in relation to the stage of epidemiological transition. This variety of trends of the different major non-communicable diseases indicates that policy and health system interventions to tackle their increasing burden have to be informed by the specific trends in each state. Increasing but variable burden of injuries among states.

The contribution of injuries to the total disease burden has increased in most states since 1990. The highest proportion of disease burden due to injuries is in young adults. Road injuries and self-harm, which includes suicides and non-fatal outcomes of self-harm, are the leading contributors to the injury burden in India. The range of disease burden or DALY rate varied 3 fold for road injuries and 6 fold for self-harm among the states of India in 2016. There was no consistent relationship between the DALY rates of road injuries or self-harm versus the stage of epidemiological transition of the states. The burden due to road injuries was much higher in males than in females. The DALY rate for self-harm for India as a whole was 1.8 times higher than the average globally for other geographies at a similar level of development in 2016.

The report says the disease burden due to child and maternal malnutrition has dropped in India substantially since 1990; this is still the single largest risk factor, responsible for 15% of the total disease burden in India in 2016.

This burden is highest in the major EAG states and Assam, and is higher in females than in males. Child and maternal malnutrition contributes to disease burden mainly through increasing the risk of neonatal disorders, nutritional deficiencies, diarrhoeal diseases, lower respiratory infections, and other common infections. As a stark contrast, the disease burden due to child and maternal malnutrition in India was 12 times higher per person than in China in 2016.

Kerala had the lowest burden due to this risk among the Indian states, but even this was 2.7 times higher per person than in China.

This situation after decades of nutritional interventions in the country must be rectified as one of the highest priorities for health improvement in India. Unsafe water and sanitation improving, but not enough yet Unsafe water and sanitation was the second leading risk responsible for disease burden in India in 1990, but dropped to the seventh leading risk in 2016, contributing 5% of the total disease burden, mainly through diarrheal diseases and other infections. The burden due to this risk is also highest in several EAG states and Assam, and higher in females than in males.

The improvement in exposure to this risk from 1990 to 2016 was least in the EAG states, indicating that higher focus is needed in these states for more rapid improvements.

Remarkably, the per person disease burden due to unsafe water and sanitation was 40 times higher in India than in China in 2016. The massive effort of the ongoing Swachh Bharat Abhiyan has the potential to improve this situation. Improvement was notice in household air pollution. Outdoor pollution worsened air pollution and remained high in India between 1990 and 2016, with levels of exposure among the highest in the world.

It causes burden through a mix of non-communicable and infectious diseases, mainly cardiovascular diseases, chronic respiratory diseases, and lower respiratory infections.

The burden of household air pollution decreased during this period due to decreasing use of solid fuels for cooking, and that of outdoor air pollution increased due to a variety of pollutants from power production, industry, vehicles, construction, and waste burning. Household air pollution was responsible for 5% of the total disease burden in India in 2016, and outdoor air pollution for 6%. The burden due to household air pollution is highest in the EAG states, where its improvement since 1990 has also been the slowest.

On the other hand, the burden due to outdoor air pollution is highest in a mix of northern states, including Haryana, Uttar Pradesh, Punjab, Rajasthan, Bihar, and West Bengal. Control of air pollution has to be ramped up through inter-sectoral collaborations based on the specific situation of each state.

India: Health of the Nation’s States from 9% to 12%

Infectious and associated diseases made up the majority of disease burden in most of the states in 1990, but this was less than half in all states in 2016.

However, the year when infectious and associated diseases transitioned to less than half of the total disease burden ranged from 1986 to 2010 for the various state groups in different stages of this transition.