Benchmarking in the Healthcare System

The right to health has so far not been accorded the status of a Fundamental Right to the Indian citizens. It is not even a statutory right, unlike education.

Moreover, health is a subject which is assigned to State Governments as per our Constitution. This is reflected in the way we finance it, with about two-thirds of the total governmental expenditure on health coming from the State Governments and the balance one-third being provided by the Government of India. Despite this, it is also a reality that the Government of India has significant influence in the policy space with pathbreaking schemes such as the National Health Mission (NHM) and Ayushman Bharat, with its twin prongs of the Health and Wellness Centres to deliver comprehensive primary health care and Pradhan Mantri Jan Arogya Yojana (PMJAY).

India is also a signatory to the 2030 Agenda for Sustainable Development, whereby it has committed as a nation to “ensure healthy lives and promote well-being for all”. In the last decade, millions of Indians have escaped from extreme poverty because of the rapid economic growth. As would be expected of rapidly growing economy, the health system and population level health outcomes have also improved significantly albeit at a much more gradual pace. Despite notable gains in improving life expectancy, reducing maternal and child mortality, and addressing other health priorities, our health system needs a lot of improvement judged by the rather modest benchmark of countries with similar levels of economic development. Furthermore, there are huge variations across States in their health outcomes and health systems’ performance. It is unfortunate that by and large, health has not received the kind of political and administrative salience that this vital sector deserves. With the federal compact among the Central and the State Governments having been clearly defined in the Constitution, the key questions that motivated the team involved in the design of Health Index were as

follows:

a. Can we develop a tool to bring health into greater political focus to ensure that what gets measured gets done?

b. Can we benchmark the performance of the health system of various States which can be put forth in the public domain in a timely manner? Is it possible to capture the diversity and yet ensure that high performing states do not get complacent and the low performing States are not discouraged?

c. Can appropriate instrument or incentives be put in place that can nudge the States to try and radically improve their health system performance? Can this be done in a manner that respects the federal compact and allows autonomy to individual State Governments to make policy choices to achieve the specified benchmarks?

d. What are the parameters that could credibly capture the complex story of health system performance? Can those parameters capture outcomes at the system level rather than merely tracking inputs such as budget, number of facilities or outputs such as number of OPDs/IPDs? Is data relating to those parameters available from third party source? Is the data of reasonable quality and available at least annually? What is the emphasis (weights) to be provided on each of the individual parameters? The answer to these questions– admittedly imperfect-was to craft a Health Index – a journey which NITI Aayog embarked upon in 2017 in collaboration with the Ministry of Health and Family Welfare (MoHFW) and the World Bank. It is the firstever systematic exercise for tracking the progress on health outcomes and health systems’ performance across all the States and Union Territories (UTs) in India on an annual basis. The Health Index is a weighted-composite

Index based on select indicators in three domains:

(a) Health Outcomes;

(b) Governance and Information; and

(c) Key Inputs and Processes, with the health outcomes carrying the most weight across the different category of

States/UTs. For generation of ranks, the States are classified into three categories (Larger States, Smaller States and UTs) to ensure comparability among similar entities.

A range of indicators such as the neo-natal mortality rate (deaths occurring in the first 28 days of life), full immunisation coverage, treatment success rate of confirmed tuberculosiscases, stability of tenure of key administrators, vacancy of doctors and specialists in health facilities, and functionality of primary health centres, first referral units and cardiac care units, are included in the Index. In February 2018, the first round of the Health Index report on ranks and scores was released which measured the annual and incremental performance of the States and UTs over the period of 2014-15 (base year) to 2015-16 (reference year). This was followed by the second round of Health Index that tracked performance for the period 2015-16 (base year) and 2017-18 (reference year). The same set of indicators and weights were used for the first two rounds.

The Health Index is a useful tool to measure and compare the overall performance and incremental performance across States and UTs over time. It is an important instrument in understanding the variations and complexity of the nation’s performance in health. The critical factors that contributed to the success of the Health Index include: a) Timelines of the report so that it stimulates action and not merely academic discussions; b) Provision of financial incentives based on the annual incremental performance of states under the National Health Mission; and; c) Verification of self-reported data by states by a third party, independent verification agency to enhance credibility. However, there are limitations to the Index as no single index can purport to comprehensively capture the complex story of the evolution of the health system. Also, due to constraints of availability of quality data critical areas such as non-communicable diseases, mental health, and private sector service utilisation could not be captured. Thus, the Health Index is a work in progress and continuous refinements will be made as additional quality data becomes available and data systems improve.