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).

Importance of understanding the specific health situation of each state

Understanding the health and disease trends in groups of states at a similar level of development or epidemiological transition is an important intermediate step in teasing apart the heterogeneity of disease and risk factor epidemiology in India. However, effective action to improve health must finally be based on the specific health situation of each state. This point is elucidated by significant variations in the burden from leading diseases and risk factors in 2016 between the following pairs of states that have physical proximity and are at similar levels of development and epidemiological transition.

The major EAG states of Madhya Pradesh and Uttar Pradesh both have a relatively lower level of development indicators and are at a similar less advanced epidemiological transition stage. However, Uttar Pradesh had 50% higher disease burden per person from chronic obstructive pulmonary disease, 54% higher burden from tuberculosis, and 30% higher burden from diarrheal diseases, whereas Madhya Pradesh had 76% higher disease burden per person from stroke.

The cardiovascular risks were generally higher in Madhya Pradesh, and the unsafe water and sanitation risk was relatively higher in Uttar Pradesh. The two North-East India states of Manipur and Tripura are both at a lower-middle stage of epidemiological transition but have quite different disease burden rates from specific leading diseases.

Tripura had 49% higher per person burden from ischaemic heart disease, 52% higher from stroke, 64% higher from chronic obstructive pulmonary disease, 159% higher from iron-deficiency anaemia, 59% higher from lower respiratory infections, and 56% higher from neonatal disorders.

Manipur, on the other hand, had 88% higher per person burden from tuberculosis and 38% higher from road injuries. Regarding the level of risks, child and maternal malnutrition, air pollution, and several of the cardiovascular risks were higher in Tripura.

The two adjoining north Indian states of Himachal Pradesh and Punjab both have a relatively higher level of development indicators and are at a similar more advanced epidemiological transition stage. However, there were striking differences between them in the level of burden from specific leading diseases.

Punjab had 157% higher per person burden from diabetes, 134% higher burden from ischaemic heart disease, 49% higher burden from stroke, and 56% higher burden from road injuries.

On the other hand, Himachal Pradesh had 63% higher per person burden from chronic obstructive pulmonary disease. Consistent with these findings, Punjab had substantially higher levels of cardiovascular risks than Himachal Pradesh.

The Executive summary says these examples highlight why it is necessary to understand the specific disease burden trends in each state, over and above the useful broad insights provided by trends common for groups of states at similar levels of epidemiological transition, if health action has to be planned for the specific context of each state.

The chances of achieving the overall health targets set by India would be much higher if the biggest health problems and risks in each state are tackled on priority than with a more generic approach that does not take into account the specific disease burden trends in each state.

Application of the state-level disease burden findings and future work. The findings in this report of the India State-level Disease Burden Initiative can be used for planning of state health budgets, prioritisation of interventions relevant to each state, informing the government’s Health Assurance Mission in each state, monitoring of health-related Sustainable Development Goals targets in each state, assessing impact of large-scale interventions based on time trends of disease burden, and forecasting population health under various scenarios in each state.

Future plans of the India State-level Disease Burden Initiative include annual updates of the estimates based on newly available data, and more disaggregated findings such as the rural-urban estimates planned for next year and sub-state level estimates subsequently when adequate data become available.