india

Updated: Jun 26, 2019 00:01 IST

Some of India’s worst states in terms of health care have slipped further, according to a comprehensive assessment by the Union government released on Tuesday which quantifies the wide gap between the best and the worst regions of the country – a contrast that was captured in how Kerala contained the Nipah outbreak while Bihar grappled with acute encephalitis syndrome deaths.

Kerala emerged at the top of the Niti Aayog’s second Healthy States, Progressive India report, while Bihar figured in the bottom three – second only to Uttar Pradesh, which earned scores significantly lower than others.

The assessment takes into account several indicators over a two-year period beginning 2015-16 (defined as base year) and compared with changes in 2017-18 (reference year). The report shows the bottom five – Uttar Pradesh, Bihar, Odisha, Madhya Pradesh and Uttarakhand, scored lower than they had in the first round of assessments.

“The decline in the overall health index score for five empowered action group (EAG) states including Bihar, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Odisha between the base year and reference year is attributed to the deterioration of performance in several indicators,” the report noted.

The ranking was done under three categories -- larger states, smaller states and Union territories (UTs) -- to ensure comparison among similar entities.

The report comes in the middle of a health crisis in Bihar, where at least 150 children have died due to a disease that leads to a fever affecting the brain since the beginning of the month, with some accounts putting the death toll higher.

The episode spotlighted the state’s crumbling state of infrastructure, which compelled authorities to turn a prison ward into an Intensive Care Unit (ICU).

Officials and experts said a big part of the problem is in the lack of spending on health. “The central government should spend 2.5% of the country’s GDP [gross domestic product] on health, and state governments need to increase their spending on health from an average of 4.7% to 8% of their total budget,” said Niti Aayog member VK Paul.

India spends about 1.15% of its GDP on health programmes and schemes at present.

“We are not putting enough money, public health outlay is not anywhere close to 2.5% of the GDP we have been talking about for the past 15 years. What’s more, no path has been chalked or milestones set to increase expenditure, it’s child’s play to calculate how much we need to invest for optimal public health gains,” said Dr Dileep Mavlankar, director, Indian Institute of Public Health Gandhinagar.

But, Mavlankar added, “throwing money at a problem doesn’t solve them. We also need strong management systems and the right managers to consistently deliver quality care and measure outcomes for course-correction”.

Another expert said the rankings reflected a reality that was exemplified in how Kerala and Bihar handled recent public health emergencies.

The rate of new deaths in Bihar sustained at a constant rate till early last week – more than a fortnight since the first AES death was reported – while Kerala mobilised thousands of health workers to stop the spread of highly infectious Nipah virus after it was detected in a patient in Ernakulam on June 4.

“A swift and strong response to the Nipah outbreak displayed the prowess of a well organised health system that coupled fast reflexes, technical competence and effective risk communication to stub the menace. Bihar, unfortunately, provided a stark contrast in these areas, with malnutrition, poor health literacy and sluggish health system response contributing to high child mortality,” said Dr K Srinath Reddy, president, Public Health Foundation of India.

Uttar Pradesh, which was last in both the assessments carried out till now, had in 2017 also grappled with an AES outbreak, which led to the deaths of at least 600 children that year at a state-run hospital in Gorakhpur.

In Bihar, the deterioration between base year and reference year was primarily due to the performance related to total fertility rate, low birth weight, sex ratio at birth, TB treatment success rate, quality accreditation of public health facilities, and time-taken for National Health Mission fund transfer. “In the case of Uttar Pradesh the performance related to low birth weight, TB treatment success rate, average tenure of key positions at state and district level and level of birth registration accounted for the deterioration,” the report said.

Only about half the States and UTs had an improvement in the overall score between 2015-16 and 2017-18. Andhra Pradesh and Maharashtra are the only two that are among the top one-third states on both overall performance as well as incremental performance.

The report also cited a lack of manpower in public health facilities as one of main reasons of health care underutilisation. “A stable tenure for key administrative positions is critical to ensure the effectiveness and sustainability of public health programs,” it said.