Health Index 2019: Kerala's dilemma and Bihar's tragedy

Linking funding under National Health Mission (NHM) to incremental performance of states puts good performing states in a fix

The Health Index 2019 released by the Niti Aayog puts southern states like Kerala and Tamil Nadu in a fix. Kerala has again come up trumps in the index. But its performance has deteriorated in 2017-18 as compared to 2015-16, which ranks it 16 out of 21 states in terms of incremental performance. So Kerala has been classified as a “not improved” state despite topping the charts. 

Now India’s Ministry of Health has decided to link funding under India’s Rs 31,745 crore National Health Mission (NHM) to performance of states in this index. States like Kerala and Tamil Nadu make little progress in this index because they have already reached the status of developed nations in healthcare delivery. Kerala achieved the United Nations 2030 Sustainable Development Goals (SDG) on infant mortality rate (12 per 1,000 live births) in 2000 – about 30 years ahead of schedule. According to the Niti Aayog, Kerala has also achieved the SDG 2030 target of under–five mortality rate of 25 per 1,000 live births. These two parameters are crucial components of the health outcome parameters used by the Niti Aayog to rank states on its health index. Health outcomes in the index carry half the weight while computing the states performances. So in effect, a territory like Kerala which has already achieved SDG targets decades in advance finds itself as showing the least improvement among states in India. By the Government of India’s logic of linking funding to the health index, a high performing state like Kerala or for that matter Tamil Nadu would get the least share of India’s health funding.

On the other hand is the case of poorer states such as Bihar and Uttar Pradesh. In the 2019 health index, these two states are at the bottom of the pile not just in terms of their performance in 2017-18 but are also shown to have deteriorated the most. According to government statistics, in Bihar, 38 out of every 1,000 newborn babies die at birth as compared to 10 in Kerala. In Uttar Pradesh, 43 out of every 1,000 newborns do not live to see another day as compared to 17 in Tamil Nadu. The sex ratio of Bihar deteriorated between 2001 and 2011 while Kerala’s improved. India’s infant mortality rate stands at 34 for every 1,000 live births. In the 2019 health index, Bihar, like Kerala is shown as a “not improved” state.

Kerala’s dilemma is that its performance on certain parameters such as infant mortality leave little scope for further rapid improvement. Bihar’s tragedy is that despite decades of central funding the state continues to be the worst performer on improving the survival chances of newborns, health of its women and other parameters which go into shaping the Niti Aaayog’s yearly health index. With funding now linked to the Niti Aayog’s index, India’s tragedy would be that Kerala and Bihar end up getting clubbed as “non-improvers” and receive less money from the National Health Mission’s Rs 34,000 crore allocation.