Healthy States, Progressive India

Foreword NITI Aayog has been mandated with transforming India by exercising thought leadership and by invoking the instruments of co-operative and competitive federalism, focussing the attention of the State Governments and Union Ministries on achieving outcomes. As the nodal agency responsible for charting India’s quest for attaining the commitments under the Sustainable Development Goals (SDGs), it was necessary to devise a mechanism for measuring outcomes particularly in the critical social sectors – such as Health and Education, where India’s record has been less than stellar. This was intended to provide feedback to all stakeholders as to whether we are on course to what we have set out to achieve, and deviations, if any, to be pointed out in time to ensure necessary mid-course correction.

It is important to realize that implementation of social sector programs is squarely in the domain of the State Governments and India’s achievement of SDGs is therefore critically dependent on the action in the States. Nudging States towards improving their social outcomes therefore requires developing indices that would capture annual increments in performance through an independent third party process and publish these. It is true that summarizing the complexities of a given sector and condensing it in an Index has its own limitations. However, in an environment where the focus is on budget spends and outputs with limited attention on outcomes, there is a need to increase competition among States to encourage them to strive evermore for increasing the pace of change.

The Health of its population is central to a nation’s well-being and productivity. While India has made some significant gains in improving life expectancy and reducing infant and maternal mortality, our rates of improvement have been inadequate as a nation.

Further, there are large variations in health system performance and outcomes achieved across States. The “Performance in Health Outcomes” Index seeks to capture the annual progress of States and Union Territories (UTs) on a variety of indicators – Outcomes, Governance and Processes. While we have also reported the overall levels of performance of States, the focus of the NITI Index is to propel change, highlighting those States that have shown most improvement. The exercise has been spearheaded by NITI Aayog in collaboration with the Ministry of Health and Family Welfare, with technical assistance from the World Bank, the authors of this report on the ranks and their interpretation.

The exercise, which is the first of its kind attempted by the Union Government was conducted over a period of eighteen months. In addition to the technical expertise of the World Bank, experts in public health, economics, statistics and health systems were consulted in the development of the Index. It involved extensive engagement with the States for finalization of the indicators, sensitization workshops for sharing the methodology, process of data submission and addressing concerns; mentoring of States for the data submission process on an online portal and independent data validation.

The process of Index development and implementation highlighted the large gaps in data availability on health outcomes.The need for making outcome data available for smaller states, more frequent and updated outcomes for non-communicable diseases and financial protection, and the need for robust programmatic data that can be used for continuous monitoring, were important issues that despite our efforts, could not be addressed optimally in this first round. Despite these challenges and limitations, it was decided to launch the Index in the first year as a model to measuring performance and ranking States on change. We thereby hope to spur action on several fronts in bringing about national level transformation. We will strive to address the lessons learned in this first round and refine the Index in the successive years of its implementation. The linking of the Health Index with incentives under the National Health Mission by the Ministry of Health and Family Welfare underlines the importance of such an exercise. It re-emphasizes the move towards performance based financing for better outcomes.

I would like to acknowledge here the large number of individuals who contributed to the initiative being brought to completion of its first round. The Ministry of Health and Family Welfare under the guidance of Mr. C.K. Mishra, former Secretary, Department of Health & Family Welfare; Ms. Preeti Sudan, Secretary, i