A staggering divide exists between India’s best and worst states in public health.

Healthcare in the southern state of Kerala is more than twice as good as it is in the northern state of Uttar Pradesh, according to a new report by the government think tank NITI Aayog.

The difference is stark when it comes to infant deaths, five times as likely in Uttar Pradesh than in Kerala.

The report also points to the reasons that contribute to this divide.

Almost half of all childbirths in Uttar Pradesh in financial year 2016 did not take place at a health institution, while nearly all babies in Kerala were delivered under the care of professionals. Additionally, far more number of expecting mothers in Kerala enrol for early pregnancy care during their first trimester.

Out-of-pocket expenses during infant delivery at a public health facility are also more than three times as much in Kerala than in Uttar Pradesh. This correlates with a similar difference in the two states’ per capita income.

Health-related data from multiple official sources in Uttar Pradesh suffers from a large discrepancy of 36.6%, while in Kerala the deviation is only 3%, the report adds.

On most other health parameters, too, Kerala outperforms Uttar Pradesh.

Parameter Kerala Uttar Pradesh Deaths of children under the age of 5 for every 1000 live births 13 51 Girls born for every 1000 boys born 967 879 Average out-of-pocket expenses in infant delivery at a public health facility Rs6,901 Rs1,956 Vaccine coverage among infants 94.6% 84.8% Birth registrations 100% 68.3% Share of people living with HIV who have been enrolled in antiretroviral therapy 66.7% 57.8% Overall health score out of 100 76.55 33.69

However, Uttar Pradesh fares significantly better than Kerala when it comes to the tenure of key state-level bureaucrats—principal secretary to government, director of national health mission, director of health services—and the top district-level public health official.

State governments have the power to transfer these officials from one role or station to another. “A stable tenure for key administrative positions is very critical for effective implementation of the programs,” the report says.