Healthy States, Progressive India by World Bank India

Ministry of Health & Family Welfare

Healthy States, Progressive India R e p o r t o n t h e R a n k s o f S t a t e s a n d U n i o n Te r r i t o r i e s

Visit http://social.niti.gov.in/ to download this report, state-wise data and other content

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

Department of Health & Family Welfare; Mr. Manoj Jhalani, Additional Secretary and Mission Director, National Health Mission, as well as the Joint Secretaries and their teams from the programme divisions provided their complete support to the initiative and worked in close co-ordination with NITI Aayog during its entire course. Technical Assistance to NITI Aayog was provided through the entire duration by The World Bank, along with authorship of this report. We are grateful to Mr. Junaid Kamal Ahmad, Country Director and the technical team led by Ms. Sheena Chhabra, Senior Health Specialist along with Dr. Rattan Chand, Senior Consultant; Dr. Nikhil Utture, Consultant; and Dr. Iryna Postolovska, Young Professional with support from Ms. Manveen Kohli, Consultant. Peer review of the final report by Dr. Rekha Menon, Practice Manager; Dr. Ajay Tandon, Lead Economist; Dr. Mickey Chopra, Global Lead on Service Delivery; and Dr. Owen K. Smith, Senior Economist is gratefully acknowledged. Inputs from statistical, economics and sector experts including Prof. Pulak Ghosh, IIM-Bangalore; Prof. Karthik Muralidharan, University of California, San Diego; Prof. Ladu Singh, International Institute of Population Sciences; Prof. Arvind Pandey, ICMR; Prof. Mudit Kapoor, Indian Statistical Institute; Dr. Shamika Ravi, Brookings India (and currently a Member of the Economic Advisory Council to the Prime Minister), were obtained at various stages of the project. Support provided by the Registrar General and Census Commissioner of India and the officials from the Office of Registrar General and Census Commissioner, India is gratefully acknowledged. Inputs received from Technical Organizations including UNICEF and DFID are also acknowledged. NITI Aayog is most grateful to senior officials of the Health departments, nodal officers and their teams in all the States and UTs for their extensive co-operation throughout the project, including providing inputs and feedback during the development of the index, participation in regional sensitization workshops, submission of data on the online portal and provision of required supporting documentation/evidence for validation of data. The mentor organizations, USAID (led by Mr. Xerxes Sidhwa and Mr. Gautam Chakraborty, and the team led by Ms. Alia Kauser and Dr. Rashmi Kukreja), Regional Resource Centre for the North Eastern States, branch of National Health Systems Resource Centre, MoHFW (led by Dr. Bamin Tada and Mr. Bhaswat Das), Centre for Innovations in Public Systems (led by Dr. Nivedita Haran) and TERI (led by Ms. Meena Sehgal) provided their valuable support to the States during the data submission phase of the project. Extended mentor support provided by Mr. Pankaj Gupta, USAID is also gratefully acknowledged. The data validation was conducted by the team at IPE Global led by Mr. Soumitro Ghosh and Ms. Daljeet Kaur. The online portal was developed by Silvertouch Technologies, led by Ms. Surbhi Singhal and Mr. Rushiraj Yadav. The project was designed and executed under the guidance of the senior leadership of NITI Aayog, Dr. Arvind Panagariya, former Vice Chairman, NITI Aayog; Dr. Rajiv Kumar, Vice Chairman, NITI Aayog; Dr. Bibek Debroy, Member and Dr. Vinod Paul, Member, NITI Aayog. The Health Division team led by Mr. Alok Kumar, Adviser; Mr. Sumant Narain, former Director; Dr. Dinesh Arora, Director, and Dr. Kheya Furtado, Research Assistant, with support from Ms. Jyoti Khattar, Senior Research Officer planned, implemented and co-ordinated the entire project.

Amitabh Kant Chief Executive Officer, NITI Aayog

Abbreviations AHPI ANC ANM ART BCG BY CCU CHC CIPS CMO CRS C-Section DH DPT EAG ENT GBD FLV FRU Hb HIV HMIS HRMIS IDSP IMR INR IVA ISO IT JSSK JSY LBW L Form MCTS MCTFC MIS MMR MO MoHFW NA NABH NACO NCDs NE NFHS NHM NHP NITI

Association of Healthcare Providers (India) Antenatal Care Auxiliary Nurse Midwife Antiretroviral Therapy Bacillus Calmette–Guérin Base Year Cardiac Care Unit Community Health Centre Centre for Innovation in Public Systems Chief Medical Officer Civil Registration System Caesarean Section District Hospital Diphtheria, Pertussis, and Tetanus Empowered Action Group Ear-Nose-Throat Global Burden of Disease First Level Verification First Referral Unit Hemoglobin Human Immunodeficiency Virus Health Management Information System Human Resources Management Information System Integrated Disease Surveillance Programme Infant Mortality Rate Indian Rupees Independent Validation Agency International Organization for Standardization Information Technology Janani Shishu Suraksha Karyakram Janani Suraksha Yojana Low Birth Weight IDSP Reporting Format for Laboratory Surveillance Mother and Child Tracking System Mother and Child Tracking Facilitation Centre Management Information System Maternal Mortality Ratio Medical Officer Ministry of Health and Family Welfare Not Applicable National Accreditation Board for Hospitals and Healthcare Providers National AIDS Control Organization Non-communicable Diseases North-Eastern National Family Health Survey National Health Mission National Health Policy National Institution for Transforming India iii

NMR NQAS OPV ORGI OOP PCPNDT P Form PHC PLHIV RRC-NE RNTCP RU RY SBR SC SDGs SDH SLV SRB SRS SN SNO TA TB TERI TFR U5MR USAID UTs

Neonatal Mortality Rate National Quality Assurance Standards Oral Polio Vaccine Office of the Registrar General and Census Commissioner, India Out-of-Pocket Pre-Conception and Pre-Natal Diagnostic Techniques IDSP Reporting Format for Presumptive Surveillance Primary Health Centre People Living with HIV Regional Resource Centre for North Eastern States Revised National Tuberculosis Control Programme Reporting Unit Reference Year Still Birth Rate Sub-Centre Sustainable Development Goals Sub-District Hospital Second Level Verification Sex Ratio at Birth Sample Registration System Staff Nurse State Nodal Officer Technical Assistance Tuberculosis The Energy Research Institute Total Fertility Rate Under-Five Mortality Rate United States Agency for International Development Union Territories

Contents FOREWORD

ABBREVIATIONS

iii

LIST OF TABLES

vii

LIST OF FIGURES

viii

EXECUTIVE SUMMARY

BACKGROUND

1. OVERVIEW – EVOLUTION AND RATIONALE

2. ABOUT THE INDEX – DEFINING AND MEASURING

2.1

Aim

2.2

Objectives

2.3

Salient Features

2.4

Methodology

2.4.1

Computation of Index scores and ranks

2.4.2

Categorization of States for ranking

2.4.3

The Health Index - List of indicators and weightage

2.5

Limitations of the Index

3. PROCESSES – FROM IDEA TO PRACTICE

15 17

3.1

Key stakeholders - Roles and responsibilities

3.2

Process flow

3.2.1

Development of Index

3.2.2

Regional workshops with States

3.2.3

Submission of data on the portal

3.2.4

Independent validation of data

3.2.5

Index and rank generation

RESULTS AND FINDINGS

4. UNVEILING PERFORMANCE – ENCOURAGING ACTIONS

4.1

4.2

4.3.

Performance of Larger States

4.1.1

Overall performance

4.1.2

Incremental performance

4.1.3

Domain-specific performance

4.1.4

Incremental performance on indicators

Performance of Smaller States

4.2.1

Overall performance

4.2.2

Incremental performance

4.2.3

Domain-specific performance

4.2.4

Incremental performance on indicators

Performance of Union Territories

4.3.1

Overall performance

4.3.2

Incremental performance

4.4

4.3.3

Domain-specific performance

4.3.4

Incremental performance on indicators

States and Union Territories: Performance on indicators

WAY FORWARD

5. INSTITUTIONALIZATION â&#x20AC;&#x201C; TAKING THE INDEX AHEAD

ANNEXURES

Annexure 1: Discrepancies in data and resolution

Annexure 2: Original Health Index

Annexure 3: Reference Year Index (with and without the indicator on out-of-pocket expenditure) 77 Annexure 4: Snapshot: State-wise performance on indicators

List of Tables Table E.1 -

Categorization of Larger States on incremental performance and overall performance

Table E.2 -

Categorization of Smaller States on incremental performance and overall performance

Table E.3 -

5 6

Categorization of Union Territories on incremental performance and overall performance

Table 2.1 -

Categorization of States and UTs

Table 2.2 -

Health Index: Summary

Table 2.3 -

Health Index: Indicators, definitions, data sources, base and reference years

Table 3.1 -

Key stakeholders: Roles and responsibilities

Table 3.2 -

Timeline for development of Health Index

Table 3.3 -

Health Index regional workshops

Table 3.4 -

List of mentor agencies

Table 4.1 -

Larger States: Overall performance in reference year - Categorization

Table 4.2 -

Larger States: Incremental performance from base to reference year - Categorization

Table 4.3 -

Smaller States: Overall performance in reference year - Categorization

Table 4.4 -

Smaller States: Incremental performance from base to reference year - Categorization

Table 4.5 -

Union Territories: Overall performance in reference year - Categorization

Table 4.6 -

Union Territories: Incremental performance from base to reference year - Categorization

Table A.2.1 - Original Health Index indicators: A snapshot

Table A.2.2 - Original Health Index: Indicators, definitions and data sources

Table A.4.1 - Larger States: Health Outcomes domain indicators, base and reference years

Table A.4.2 - Larger States: Governance and information domain indicators, base and reference years

Table A.4.3 - Larger States: Key Inputs/Processes domain indicators, base and reference years

Table A.4.4 - Smaller States: Health outcomes domain indicators, base and reference years

Table A.4.5 - Smaller States: Governance and information domain indicators, base and reference years

Table A.4.6 - Smaller States: Key Inputs/Processes domain indicators, base and reference years

Table A.4.7 - Union Territories: Health outcomes domain indicators, base and reference years

Table A.4.8 - Union Territories: Governance and information domain indicators, base and reference years

Table A.4.9 - Union Territories: Key Inputs/Processes domain indicators, base and reference years

vii

List of Figures Figure E.1 Figure E.2 Figure E.3 -

Larger States: Incremental scores and ranks, with overall performance from base year to reference year and ranks

Smaller States: Incremental scores and ranks, with overall performance from base year to reference year and ranks

Union Territories: Incremental scores and ranks, with overall performance from base year to reference year and ranks

Figure 3.1 -

Steps for validating data

Figure 4.1 -

Larger States: Overall performance - Composite Index score and rank, base and reference years

Larger States: Overall and incremental performance, base and reference years and incremental rank

Figure 4.3 -

Larger States: Overall and domain-specific performance, reference year

Figure 4.4 -

Larger States: Performance in the Health Outcomes domain, base and reference years

Larger States: Performance in the Key Inputs/Processes domain, base and reference years

Larger States: Number of indicators/sub-indicators, by category of incremental performance

Smaller States: Overall performance - Composite Index score and rank, base and reference years

Smaller States: Overall and incremental performance, base and reference years and incremental rank

Smaller States: Overall and domain-specific performance, reference year

Figure 4.2 -

Figure 4.5 Figure 4.6 Figure 4.7 Figure 4.8 Figure 4.9 -

Figure 4.10 - Smaller States: Performance in the Health Outcomes domain, base and reference years Figure 4.11 -

Smaller States: Performance in the Key Inputs/Processes domain, base and reference years

Smaller States: Number of indicators/sub-indicators, by category of incremental performance

Union Territories: Overall performance - Composite Index score and rank, base and reference years

Union Territories: Overall and incremental performance, base and reference years and incremental rank

Figure 4.15 -

Union Territories: Overall and domain-specific performance, reference year

Figure 4.16 -

Union Territories: Performance in the Health Outcomes domain, base and reference years

Union Territories: Performance in the Key Inputs/Processes domain, base and reference years

Union Territories: Number of indicators/sub-indicators, by category of incremental performance

Figure 4.19 -

Indicator 1.1.1: Neonatal Mortality Rate - Larger States

Figure 4.20 -

Indicator 1.1.2: Under-five Mortality Rate - Larger States

Figure 4.12 Figure 4.13 Figure 4.14 -

Figure 4.17 Figure 4.18 -

viii

Figure 4.21 -

Indicator 1.1.4: Proportion of Low Birth Weight among newborns - Larger States

Figure 4.22 -

Indicator 1.1.4: Proportion of Low Birth Weight among newborns Smaller States and UTs

Figure 4.23 -

Indicator 1.1.5: Sex Ratio at Birth - Larger States

Figure 4.24 -

Indicator 1.2.1: Full immunization coverage - Larger States

Figure 4.25 -

Indicator 1.2.1: Full immunization coverage - Smaller States and UTs

Figure 4.26 -

Indicator 1.2.2: Proportion of institutional deliveries - Larger States

Figure 4.27 -

Indicator 1.2.2: Proportion of institutional deliveries - Smaller States and UTs

Figure 4.28 -

Indicator 1.2.3: Total case notification rate of TB - Larger States

Figure 4.29 -

Indicator 1.2.3: Total case notification rate of TB - Smaller States and UTs

Figure 4.30 -

Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases - Larger States

Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases - Smaller States and UTs

Indicator 1.2.5: Proportion of people living with HIV on antiretroviral therapy - Larger States

Indicator 1.2.5: Proportion of people living with HIV on antiretroviral therapy - Smaller States

Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility (in INR) - Larger States

Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility (in INR) - Smaller States and UTs

Figure 4.36 -

Indicator 2.1.1: Data Integrity Measure - Institutional deliveries - Larger States

Figure 4.37 -

Indicator 2.1.1: Data Integrity Measure - ANC registered within first trimester - Larger States

Indicator 2.1.1: Data Integrity Measure - Institutional deliveries Smaller States and UTs

Indicator 2.1.1: Data Integrity Measure - ANC registered within first trimester Smaller States and UTs

Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level for last three years - Larger States

Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level for last three years - Smaller States and UTs

Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three years - CMOs or equivalent post - Larger States

Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three years - CMOs or equivalent post - Smaller States and UTs

Indicator 3.1.1a: Proportion of vacant healthcare provider positions ANMs at sub-centres - Larger States

Indicator 3.1.1a: Proportion of vacant healthcare provider positions ANMs at sub-centres - Smaller States

Indicator 3.1.1b: Proportion of vacant healthcare provider positions Staff nurses at PHCs and CHCs - Larger States

Figure 4.31 Figure 4.32 Figure 4.33 Figure 4.34 Figure 4.35 -

Figure 4.38 Figure 4.39 Figure 4.40 Figure 4.41 Figure 4.42 Figure 4.43 Figure 4.44 Figure 4.45 Figure 4.46 -

Figure 4.47 -

Indicator 3.1.1c: Proportion of vacant healthcare provider positions Medical officers at PHCs - Larger States

Indicator 3.1.1c: Proportion of vacant healthcare provider positions Medical officers at PHCs - Smaller States

Indicator 3.1.1.d: Proportion of vacant healthcare provider positions Specialists at district hospitals - Larger States

Indicator 3.1.1d: Proportion of vacant healthcare provider positions Specialists at district hospitals - Smaller States and UTs

Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units - Larger States

Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units - Smaller States

Figure 4.53 -

Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Larger States

Figure 4.54 -

Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Smaller States

Figure 4.55 -

Indicator 3.1.4: Proportion of districts with functional Cardiac Care Units Larger States

Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations - Larger States

Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations - Smaller States and UTs

Figure 4.58 -

Indicator 3.1.6: Level of registration of births - Larger States

Figure 4.59 -

Indicator 3.1.6: Level of registration of births - Smaller States and UTs

Figure 4.60 -

Indicator 3.1.7: Completeness of IDSP reporting of P form - Larger States

Figure 4.61 -

Indicator 3.1.7: Completeness of IDSP reporting of P and L forms - Smaller States

Figure 4.62 -

Indicator 3.1.8: Proportion of CHCs with grading above 3 points - Larger States

Figure 4.63 -

Indicator 3.1.10: Average number of days for transfer of Central National Health Mission fund from State Treasury to implementation agency (Department/Society) based on all tranches of the last financial year - Larger States

Indicator 3.1.10: Average number of days for transfer of Central NHM fund from State Treasury to implementation agency (Department/Society) based on all tranches of the last financial year - Smaller States and UTs

Figure 4.48 Figure 4.49 Figure 4.50 Figure 4.51 Figure 4.52 -

Figure 4.56 Figure 4.57 -

Figure 4.64 -

Figure A.3.1 - Larger States: Ranking for reference year (2015-16) with and without the OOP expenditure indicator

Figure A.3.2 - Smaller States: Ranking for reference year (2015-16) with and without OOP expenditure indicator

Figure A.3.3 - Union Territories: Ranking for reference year (2015-16) with and without OOP expenditure indicator

Executive Summary

Background and Methodology Key Results Conclusions and Way Forward 1

Background and Methodology 1. The National Institution for Transforming India (NITI) Aayog is spearheading the Health Index initiative to bring about transformational change in achieving desirable health outcomes: India has achieved significant economic growth over the past decades, but the progress in health has not been commensurate. Despite notable gains in improving life expectancy, reducing fertility, maternal and child mortality, and addressing other health priorities, the rates of improvement have been insufficient, falling short on several national and global targets. Furthermore, there are wide variations across States in their health outcomes and systems performance. In order to bring about transformational change in population health through a spirit of co-operative and competitive federalism, NITI Aayog has spearheaded the Health Index initiative, to measure the annual performance of States and Union Territories (UTs), and rank States on the basis of incremental change, while also providing an overall status of Statesâ&#x20AC;&#x2122; performance and helping identify specific areas of improvement. It is envisaged that this tool will propel States towards undertaking multi-pronged interventions that will bring about the much-desired optimal population health outcomes.

2. Multiple stakeholders contributed to the Index development: The Index was developed by NITI

Aayog with technical assistance from the World Bank through an iterative process in consultation with the Ministry of Health and Family Welfare (MoHFW), States and UTs, domestic and international sector experts and other development partners (Table 2.3 provides Health Index-indicator details and data sources).

3. States and UTs have been ranked on a composite Health Index in three categories (Larger States, Smaller States and UTs) to ensure comparison among similar entities: With a focus on outcomes,

outputs and critical inputs, the main criteria for inclusion of indicators was the availability of reliable data for States and UTs, with at least an annual frequency. The Index is a weighted composite Index based on indicators in three domains: (a) Health Outcomes; (b) Governance and Information; and (c) Key Inputs/Processes, with each domain assigned a weight based on its importance. The indicator values are standardized (scaled 0 to 100) and used in generating composite Index scores and overall performance rankings for base year (2014-15) and reference year (2015-16). The annual incremental progress made by the States and UTs from base year to reference year is used to generate incremental ranks (Section 2 provides methodological details of constructing the Index). States and UTs have been ranked in three categories (Larger States, Smaller States and UTs) to ensure comparison among similar entities (Table 2.1 deals with categorization of States and UTs).

4. For generation of Index values and ranks, data was submitted online and validated by an Independent Validation Agency (IVA): The States were sensitized about the Health Index including

indicator definitions, data sources and process for data submission through a series of regional workshops and mentor support was provided to most States (Table 3.4). Data was submitted by States on the online portal hosted by NITI Aayog and data from sources in the public domain was pre-entered. This data was then validated by an IVA and was used as an input into automated generation of Index values and ranks on the portal (Sections 3.2.4 and 3.2.5).

Key Results 5. There is a large gap in overall performance between the best and the least performing States and UTs; besides, all States and UTs have substantial scope for improvement: In the reference year

(2015-16) among Larger States, the Index score for overall performance ranged widely between 33.69 in Uttar Pradesh to 76.55 in Kerala. Similarly, among Smaller States, the Index score for overall performance varied between 37.38 in Nagaland to 73.70 in Mizoram, and among UTs this varied between 34.64 in Dadra & Nagar Haveli to 65.79 in Lakshadweep. Among Larger States, the variation between the best and least performing States and UTs was the widest around 43 points as compared with 36 points in Smaller States and 31 points in UTs. However, based on the highest observed overall Index scores in each category of States and UTs, clearly there is room for improvement in all States and UTs.

6. The States and UTs rank differently on overall performance and annual incremental performance: States and UTs that start at lower levels of the Health Index (lower levels of development of their health systems) are generally at an advantage in notching up incremental progress over States with high Health Index score due to diminishing marginal returns in outcomes for similar effort levels. It is a challenge for States at high levels of the Index score even to maintain their performance levels. For example, Kerala ranks on top in terms of overall performance and at the bottom in terms of incremental progress mainly as it had already achieved a low level of Neonatal Mortality Rate (NMR) and Under-five Mortality Rate (U5MR) and replacement level fertility, leaving limited space for any further improvements. Figure E.1 - Larger States: Incremental scores and ranks, with overall performance from base year to reference year and ranks

80.00

76.55

Kerala

63.38

63.28

Tamil Nadu

Himachal Pradesh

61.20

Maharashtra

60.09

Karnataka

54.94 48.63

Chhattisgarh

Assam

Odisha Bihar Rajasthan

38.99 39.23

39.43

34.55

Uttar Pradesh 28.14

3.39 -2.90 6.87

45.32

40.09

34.70

0.45

55.39

-0.10

44.13

43.53

Madhya Pradesh

0.38

58.25

45.33 45.22

Uttarakhand

-1.03

59.73

49.87

38.46

Jharkhand

2.41

52.02

46.97

Haryana

6.83

60.16

57.87

Telangana

0.98

60.35

58.70

West Bengal

-0.92

61.07

57.75

Andhra Pradesh

-1.29

62.12

53.52

Jammu & Kashmir

0.10

63.28

61.99

Gujarat

3.19

65.21

62.02

Punjab

-3.45

0.60 1.10 0.20 3.76

38.46 36.79

2.24

33.69 30

5.55 50

Overall Performance Index Score Base Year (2014-15) Reference Year (2015-16)

-4

Incremental Change

Overall Reference Incremental Year Rank Rank

7. Among the Larger States, Jharkhand, Jammu & Kashmir, and Uttar Pradesh are the top three ranking States in terms of annual incremental performance, while Kerala, Punjab, and Tamil Nadu ranked on top in terms of overall performance: In terms of annual incremental performance in Index scores from the base to the reference year, the top three ranked States in the group of Larger States are Jharkhand (up 6.87 points), Jammu & Kashmir (up 6.83 points) and Uttar Pradesh (up 5.55 points). However, in terms of overall levels of performance, these States are in the bottom two-third of the range of Index scores, with Kerala (76.55), Punjab (65.21) and Tamil Nadu (63.38) showing the highest scores. Jharkhand, Jammu & Kashmir, and Uttar Pradesh showed the maximum gains in improvement of health outcomes from base to reference year in indicators such as NMR, U5MR, full immunization coverage, institutional deliveries, and people living with HIV (PLHIV) on antiretroviral therapy (ART).

8. Among Smaller States, Manipur ranked first in terms of annual incremental performance and second in terms of overall performance, while Goa ranked second in terms of annual incremental performance: Among Smaller States, Mizoram (73.70) followed by Manipur (57.78) are the best

overall performers. In annual incremental performance, Manipur (up 7.18 points) and Goa (up 6.67 points) ranked the highest. For Smaller States, among the top performers, the indicators that contributed to higher incremental performance varied. Manipur, ranked at the top and registered maximum incremental progress on indicators such as PLHIV on ART, first trimester antenatal care (ANC) registration, grading of Community Health Centres (CHCs) on quality parameters, average occupancy of three key State-level officers, and good reporting on the Integrated Disease Surveillance Programme (IDSP). Figure E.2 - Smaller States: Incremental scores and ranks, with overall performance from base year to reference year and ranks 71.27

Mizoram Manipur

57.78

50.60

Sikkim

43.51

Nagaland

Base Year (2014-15) Reference Year (2015-16)

-1.09

48.35

-4.84

45.26

37.38 30

6.67

50.60

49.51

Tripura

-0.19

53.13

46.46

Goa

5.43

53.39

53.20

Arunachal Pradesh

7.18

56.83

51.40

Meghalaya

2.43

73.70

-7.88 60

Overall Performance Index Score

-10

Incremental Change

Overall Reference Year Rank

Incremental Rank

9. Among UTs, Lakshadweep showed both the highest annual incremental performance as well as the best overall performance: In annual incremental performance, Lakshadweep ranked at the top (up 9.56 points) followed by Andaman & Nicobar Islands (up 3.82 points). In terms of overall performance, Lakshadweep (65.79) ranked at the top, followed by Chandigarh (52.27). Lakshadweep showed the highest improvement in indicators such as institutional deliveries, tuberculosis (TB) treatment success rate and transfer of Central National Health Mission (NHM) funds from State Treasury to implementation agency.

Figure E.3 - Union Territories: Incremental scores and ranks, with overall performance from base year to reference year and ranks Lakshadweep

56.23

48.05

Delhi Andaman & Nicobar Islands

46.18

Puducherry

46.54 36.10

Daman & Diu Dadra & Nagar Haveli

31.34 30

-5.22

57.49

52.27

Chandigarh

9.56

65.79

50.02

1.97

50.00

3.82

47.48

0.94

44.77

-8.67

34.64 40

3.30 50

Overall Performance Index Score

-10

-5

Incremental Change

Overall Reference Year Rank

Incremental Rank

Base Year (2014-15) Reference Year (2015-16)

10. The incremental measurement shows that about one-third of the States have registered a decline in their Health Indices in the reference year as compared to the base year: This is a matter of concern and should nudge the States into reviewing and revitalizing their programmatic efforts. Among the Larger States, six States, namely Uttarakhand, Himachal Pradesh, Karnataka, Gujarat, Haryana and Kerala have shown a decline in performance from base year to reference year, despite some of them being among the top ten in overall performance. Among the Smaller States, Sikkim, Arunachal Pradesh, Tripura and Nagaland have shown a decline; and among the UTs, Chandigarh and Daman & Diu have shown a decline. Tables E.1, E.2 and E.3 provide a categorization of States and UTs based on the level of annual incremental performance and the overall performance. Table E.1 - Categorization of Larger States on incremental performance and overall performance Incremental Performance

Not Improved

Least Improved

Moderately Improved Most Improved

Overall Performance Aspirants Uttarakhand Haryana

Achievers Himachal Pradesh Karnataka Gujarat

Front-runners Kerala

Madhya Pradesh Assam Odisha

Maharashtra Telangana West Bengal

Tamil Nadu

Bihar Rajasthan

Chhattisgarh Andhra Pradesh

Punjab

Jharkhand Uttar Pradesh

Jammu & Kashmir

Note: Overall Performance: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>62); Achievers: middle one-third (Index score between 48 and 62), Aspirants: lowest one-third (Index score<48). Incremental Performance: The States are categorized on the basis of incremental Index score range: ‘Not Improved’ (incremental Index score<=0), ‘Least Improved’ (incremental Index score between 0.01 and 2), ‘Moderately Improved’ (incremental Index score between 2.01 and 4), ‘Most Improved’ (incremental Index score>4.0).

Table E.2 - Categorization of Smaller States on incremental performance and overall performance Incremental Performance

Overall Performance Aspirants

Not Improved

Achievers

Front-runners -

Tripura

Sikkim

Nagaland

Arunachal Pradesh

Least Improved

Moderately Improved

Mizoram

Most Improved

Manipur Meghalaya Goa

Note: Overall Performance: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>61.60), Achievers: middle one-third (Index score between 49.49 and 61.60), Aspirants: lowest one-third (Index score <49.49). Incremental Performance: The States are categorized on the basis of incremental Index score range: ‘Not Improved’ (incremental Index score<=0), ‘Least Improved’ (incremental Index score between 0.01 and 2), ‘Moderately Improved’ (incremental Index score between 2.01 and 4), ‘Most Improved’ (incremental Index score>4.0). Table E.3 - Categorization of Union Territories based on incremental performance and overall performance Incremental Performance

Not Improved Least Improved

Moderately Improved Most Improved

Overall Performance Aspirants

Achievers

Front-runners

Daman & Diu

Chandigarh

Delhi

Dadra & Nagar Haveli -

Puducherry

Andaman & Nicobar Islands

Lakshadweep

Note: Overall Performance: The UTs are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>55), Achievers: middle one-third (Index score between 45 and 55), Aspirants: lowest one-third (Index score<45). For Incremental Performance: The UTs are categorized on the basis of incremental Index score range: ‘Not Improved’ (incremental Index score<=0), ‘Least Improved’ (incremental Index score between 0.01 and 2), ‘Moderately Improved’ (incremental Index score between 2.01 and 4), ‘Most Improved’ (incremental Index score>4.0).

In terms of numbers of indicators, Chhattisgarh, Goa and Delhi showed improvement in the highest number of parameters, within the three categories of States respectively (Figures 4.6, 4.12, 4.18). The specific indicators for which the States’ performance has dipped or improved and actual values for these are provided in Annexure 4. The indicators where most States and UTs need to focus include addressing vacancies in key staff, establishment of functional district Cardiac Care Units (CCUs), quality accreditation of public health facilities, and institutionalization of Human Resources Management Information System (HRMIS). Additionally, almost all Larger States need to focus on improving the Sex Ratio at Birth (SRB).

11. The overall performance of States is not always consistent with the domain-specific performance:

Some States fare significantly better in one domain than others, suggesting that there is scope to improve their performance in lagging domains with specific targeted interventions. For example, while most States showed a better performance in Health Outcomes, Tamil Nadu, West Bengal, Assam, Madhya Pradesh, Odisha, Rajasthan, Daman & Diu, and Dadra & Nagar Haveli performed better in terms of Key Inputs/Processes. Domain-wise incremental performance among the three categories of States showed the highest improvement in outcomes, respectively for Jammu & Kashmir, Uttar Pradesh and Jharkhand; Goa and Manipur; Andaman & Nicobar Islands and Lakshadweep.

Conclusions and Way Forward 12. The Health Index is a useful tool for systematic measurement of annual performance across States and UTs: Rich learnings have emerged that will guide improvement of both the methods and

the data to make the Index better. The Health Index is an important aid in understanding the heterogeneity and complexity of the nationâ&#x20AC;&#x2122;s performance in health. It is the first attempt at establishing an annual systematic tool for measurement of performance across States and UTs on a variety of health parameters within a composite measure. In its first year, it may not have achieved perfection; however, it does set the foundation for a systematic output and outcome based performance measurement. In linking this Index to incentives under the NHM, the MoHFW has underlined the importance of such an exercise. The results and analysis in this report provide an important insight into the areas in which States have improved, stagnated or declined and this will help in better targeting of interventions. Owing to the multiplicity of determinants that impact health outcomes, some of these actions may lie outside the ambit of health departments and, in fact, depend on the actions of the private sector and sectors other than health. The learnings that have emerged during the process of development of the Health Index, will guide in refining the Index for the coming year and also address some of the limitations. The exercise also calls for urgently improving the data systems in health, in terms of representativeness of the priority areas, periodic availability for all States and UTs, and completeness for private sector service delivery.

Background

Overview – evolution and rationale About the Index – defining and measuring Processes – from idea to practice 8

1. Overview – evolution and rationale India has achieved significant economic growth over the past decades, but the progress in health has not been commensurate. The inability to rapidly improve the human capital also places a binding constraint on economic growth. Between 1991 and 2015, India made major improvements, for instance, life expectancy at birth increased by approximately 10 years; Infant Mortality Rate (IMR) more than halved; Total Fertility Rate (TFR) dropped to near replacement level; and Maternal Mortality Ratio (MMR) declined by more than 60 percent1. At the same time, non-communicable diseases (NCDs) have emerged as the leading cause of morbidity and death for adults, contributing to 55 percent of all disease burden and more than 62 percent of deaths in the country2. When compared with India’s economic progress and achievements, the rates of improvement in health outcomes have remained slower than that of developing countries with comparable levels of spending on health3. Furthermore, there is large variation in terms of health outcomes and health systems across States. The National Development Agenda unanimously agreed to by all State Chief Ministers and Lieutenant Governors of Union Territories in 2015 had inter alia identified education, health, nutrition, women and children as priority sectors. To fulfil the National Development Agenda, it is imperative to make rapid improvement in these sectors. While the responsibility in this regard is shared between the Center and the States, given that health is a State subject, implementation is largely done by the States. The Center’s role is limited primarily to financing, setting policy principles and program guidelines. India, along with other countries, has committed itself to adopting the Sustainable Development Goals (SDGs) to end poverty, protect the planet, and ensure prosperity for all as part of a new global sustainable development agenda to be fulfilled by 2030. There is renewed commitment in India to accelerate the pace of achievement of the SDGs, including Goal 3 related to ensuring healthy lives and promoting the well-being for all. In order to bring about rapid transformative action in achieving the desired outcomes, a priority for NITI Aayog is to nudge the States towards improvement in outcomes in the coming years. The broader goal is to develop a spirit of co-operative and competitive federalism whereby the Center and States can jointly determine the route to progress and prosperity. It is in this context that NITI Aayog has spearheaded the Health Index initiative with the MoHFW, and has an explicit focus on the outcomes of health systems. Technical assistance for the Health Index initiative was provided by the World Bank. Various stakeholders, including the States, domestic and international sector experts and development partners, were consulted throughout the process and given the opportunity to provide feedback. An interactive web portal hosted by NITI Aayog, provided a pre-designed format for the States to submit data concerning identified indicators for the Health Index. The data was verified by IPE Global, an independent validation agency prior to computing the Index and ranks for all States and UTs. The Health Index consists of 24 indicators grouped in the domains of Health Outcomes, Governance and Information, and Key Inputs/Processes. The States and UTs have been ranked in three categories to ensure comparison among similar entities - Larger States, Smaller States, and UTs. The Health Index will be calculated and disseminated annually, with a focus on measuring and highlighting annual incremental improvement in the States and UTs. The composite Health Index and ranking of States and UTs will assist in monitoring the States’ performance, also serving as an input for performance-based incentives, leading ultimately to improvements in the state of health in each State.

1 2

World Bank. 2017. World Development Indicators 2017. Washington, DC. © World Bank. https://openknowledge.worldbank.org/handle/10986/26447 License: CC BY 3.0 IGO. Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation. India: Health of the Nation's States — The India State-Level Disease Burden Initiative. New Delhi, India: ICMR, PHFI, and IHME; 2017. Paper no I/2015, Working Paper Series I, Health Division, NITI Aayog.

2. About the Index – defining and measuring 2.1 AIM

To promote a co-operative and competitive spirit amongst the States and UTs to rapidly bring about transformative action in achieving the desired health outcomes. 2.2 OBJECTIVES

To develop a composite Health Index based on key health outcomes and other health systems and service delivery indicators.

To ensure States’ participation and ownership through Health Index data submission on a web-based portal with requested mentor support.

To build transparency through independent validation of data by an independent agency.

To generate Health Index scores and rankings for different categories of the States and UTs based on year-to-year progress (annual incremental performance) and overall performance.

2.3 SALIENT FEATURES

•

The Health Index consists of a limited set of relevant indicators categorized in the domains of Health Outcomes, Governance and Information, and Key Inputs/Processes.

•

Health Outcomes are assigned the highest weight, as these remain the focus of performance.

•

Indicators have been selected on the basis of their importance and availability of reliable data at least annually from existing data sources such as the Sample Registration System (SRS), Civil Registration System (CRS) and Health Management Information Systems (HMIS).

•

Data on indicators is included for Index calculations after validation by the IVA.

•

A composite Index is calculated as a weighted average of various indicators, focused on measuring the state of health in each State and UT for a base year (BY) and a reference year (RY).

•

The change in the Index score of each State from the base year to a reference year measures the annual incremental progress of each State.

•

States and UTs have been grouped in three categories to ensure comparison among similar entities, namely 21 Larger States, 8 Smaller States, and 7 UTs.

2.4 METHODOLOGY

2.4.1 Computation of Index scores and ranks After validation of data by the IVA, data submitted by the States and pre-entered from established sources was used for the Health Index score calculations. Each indicator value was scaled, based on the nature of the indicator. For positive indicators, where higher the value, better the performance (e.g. service coverage indicators), the scaled value (Si) for the ith indicator, with data value as Xi. was calculated as follows:

Scaled value (Si) for positive indicator =

(Xi – Minimum value) x 100 (Maximum value – Minimum value)

Similarly, for negative indicators where lower the value, better the performance (e.g. NMR, U5MR, human resource vacancies), the scaled value was calculated as follows: Scaled value (Si) for negative indicator =

(Maximum value – Xi)

x 100

(Maximum value – Minimum value)

The minimum and maximum values of each indicator were ascertained based on the values for that indicator across States within the grouping of States (Larger States, Smaller States, and UTs) for that year. The scaled value for each indicator lies between the range of 0 to 100. Thus, for a positive indicator such as institutional deliveries, the State with the lowest institutional deliveries will get a scaled value of 0, while the State with the highest institutional deliveries will get a scaled value of 100. Similarly, for a negative indicator such as NMR, the State with the highest NMR will get a scaled value of 0, while the one with the lowest NMR will get a scaled value of 100. Accordingly, the scaled value of other States will lie between 0 and 100 in both cases. Based on the above scaled values (Si), a composite Index score was then calculated for the base year and reference year after application of the weights using the following formula: Composite Index =

(∑ Wi*Si ) (∑ Wi)

where Wi is the weight for ith indicator. The composite Index score provides the overall performance and domain-wise performance for each State and UT, and has been used for generating overall performance ranks. The difference between the composite Index score of reference and base years was used to compute the annual incremental performance. Ranks were also generated to ascertain the relative position of the States in terms of annual incremental performance. The ranking is primarily based on the incremental progress made by the States and UTs from the base year to the reference year. However, rankings based on Index scores for the base year and the reference year performance have also been presented to provide the overall performance of the States and UTs. A comparison of the change in ranks between the base and reference years has also been undertaken. 2.4.2 Categorization of States for ranking Based on the availability of data and the fact that similar States should be compared, it was decided to rank the States in three categories, namely Larger States, Smaller States and UTs (Table 2.1).

Table 2.1 - Categorization of States and UTs

Category

Number of States and UTs

States and UTs

Larger States

Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, Jammu & Kashmir, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu,Telangana, Uttar Pradesh, Uttarakhand, West Bengal

Smaller States

Arunachal Pradesh, Goa, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura

Union Territories

Andaman & Nicobar, Chandigarh, Dadra & Nagar Haveli, Daman & Diu, Delhi, Lakshadweep, Puducherry

This categorization was adopted due to the following reasons: •

The SRS data on health outcomes (NMR, U5MR, TFR and SRB) are not available for 8 Smaller States and 7 UTs, and though options were explored by the Office of the Registrar General and Census Commissioner of India (ORGI) to generate these estimates, no reliable option was available.

•

Experts consulted4 by NITI Aayog also reported that reliable estimates for these outcome indicators based on raw data obtained from SRS for the Smaller States and UTs could not be derived due to small sample size and insufficient number of events.

2.4.3 The Health Index - List of indicators and weightage As the Index is a weighted composite Index based on indicators in three domains, each domain has been assigned weights based on its importance. Within a domain or sub–domain, the weight has been equally distributed among the indicators in that domain or sub-domain. Table 2.2 provides a snapshot of the number of indicators in each domain and sub-domain along with weights, while Table 2.3 provides the detailed Health Index with indicators, their definitions, data sources, and specifics of base and reference years. Table 2.2 - Health Index: Summary Larger States Domain

Sub-domain

Number of Indicators

Smaller States

Weight

Number of Indicators

Union Territories

Weight

Number of Indicators

Weight

Health

Key Outcomes

500

100

Outcomes

Intermediate Outcomes

300*

250*

Governance and Information

Health Monitoring and Data Integrity

Governance

Health Systems/Service

200

1130

730

680

Key Inputs/ Processes

Delivery TOTAL

* The data for indicator no. 1.2.6 related to out of pocket expenditure was available only for 2015-16 and hence was used to calculate independently the reference year Index and rank (as provided in Annexure 3). This was not included for analyzing improvements between the base and reference years/annual incremental performance as data between the two years needed to be comparable for that purpose.

Experts included Pulak Ghosh, Professor, Indian Institute of Management, Bangalore; Arvind Pandey, Advisor, Indian Council for Medical Research/ National Institute of Medical Statistics (ICMR-NIMS); Laishram Ladusingh, Director, International Institute of Population Studies; Mudit Kapoor, Associate Professor of Economics, the Indian Statistical Institute (ISI).

Table 2.3 - Health Index: Indicators, definitions, data sources, base and reference years S. No. Indicator

Definition

Data Source

Base Year (BY) Remarks & Reference Year (RY)

DOMAIN 1 – HEALTH OUTCOMES Sub-domain 1.1 - Key Outcomes (Weight: Larger States – 500, Smaller States & UTs – 100) 1.1.1

Neonatal Mortality Rate (NMR)

Number of infant deaths of less than 29 days per thousand live births during a specific year.

SRS [pre-entered]

BY: 2014 RY: 2015

1.1.2

Under-five Mortality Rate (U5MR)

Number of child deaths of less than 5 years per thousand live births during a specific year.

SRS [pre-entered]

BY: 2014 RY: 2015

1.1.3

Total Fertility Rate (TFR)

Average number of children that would be born to a woman if she experiences the current fertility pattern throughout her reproductive span (15-49 years), during a specific year.

SRS [pre-entered]

BY: 2014 RY: 2015

1.1.4

Proportion of Low Birth Weight (LBW) among newborns

Proportion of low birth weight (<=2.5 kg) newborns out of the total number of newborns weighed during a specific year born in a public health facility.

HMIS

BY: 2014-15 RY:2015-16

1.1.5

Sex Ratio at Birth (SRB)

The number of girls born for every 1,000 boys born during a specific year.

SRS [pre-entered]

BY: 2012-14 RY: 2013-15

Indicators 1.1.1, 1.1.2, 1.1.3, and 1.1.5 are not applicable for category of Smaller States and UTs

Sub-domain 1.2 - Intermediate Outcomes (Weight: Larger & Smaller States – 300, UTs – 250) 1.2.1

Full immunization coverage

Proportion of infants 9-11 months old who have received BCG, 3 doses of DPT, 3 doses of OPV and one dose of measles against estimated number of infants during a specific year.

HMIS

BY: 2014-15 RY: 2015-16

1.2.2

Proportion of institutional deliveries

Proportion of deliveries conducted in public and private health facilities against the number of estimated deliveries during a specific year.

HMIS

BY: 2014-15 RY: 2015-16

1.2.3

Total case notification rate of tuberculosis (TB)

Number of new and relapsed TB cases notified (public + private) per 100,000 population during a specific year.

Revised National Tuberculosis Control Programme (RNTCP) MIS, MoHFW [pre-entered]

BY: 2015 RY: 2016

1.2.4

Treatment success rate of new microbiologically confirmed TB cases

Proportion of new cured and their treatment completed against the total number of new microbiologically confirmed TB cases registered during a specific year.

RNTCP MIS, MoHFW [pre-entered]

BY: 2014 RY: 2015

1.2.5

Proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART)

Proportion of PLHIVs receiving ART treatment against the number of estimated PLHIVs who needed ART treatment for the specific year.

Central MoHFW Data [pre-entered]

BY: 2014-15 RY:2015-16

Indicator not applicable for category of UTs.

1.2.6

Average out-of-pocket expenditure per delivery in public health facility (in INR)

Average out-of-pocket expenditure per delivery in public health facility (in INR).

National Family Health Survey (NFHS)-4 [pre-entered]

RY: 2015-16

Indicator applicable only for reference year ranking. Not considered for generating incremental performance scores/ranks or drawing comparison between base and reference years scores/ranks.

S. No. Indicator

Definition

Data Source

Base Year (BY) Remarks & Reference Year (RY)

DOMAIN 2 – GOVERNANCE AND INFORMATION Sub-domain 2.1 – Health Monitoring and Data Integrity (Weight: 70) 2.1.1

Data Integrity Measure: a. Institutional deliveries

Percentage deviation of reported data from standard survey data to assess the quality/ integrity of reported data for a specific period.

HMIS and NFHS-4

b. ANC registered within first trimester

BY & RY: The NFHS data was 2015-16 (NFHS) available only for reference year and BY & RY: the data for this was 2011-12 to repeated for the 2015-16 base year and (HMIS) reference year.

Sub-domain 2.2 – Governance (Weight – 60) 2.2.1

2.2.2

Average occupancy of an officer (in months), combined for following three posts at State level for last three years 1. Principal Secretary 2. Mission Director (NHM) 3. Director (Health Services)

Average occupancy of an officer (in months), combined for following posts in last three years: 1. Principal Secretary 2. Mission Director (NHM) 3. Director (Health Services)

State Report

Average occupancy of a full-time officer (in months) for all the districts in last three years - District Chief Medical Officers (CMOs) or equivalent post (heading District Health Services)

Average occupancy of a CMO (in months) for all the districts in last three years.

State Report

BY: April 1, 2012-March 31, 2015 RY: April 1, 2013-March 31, 2016

BY: April 1, 2012- March 31, 2015 RY: April 1, 2013-March 31, 2016

DOMAIN 3 – KEY INPUTS/PROCESSES Sub-domain 3.1 – Health Systems/Service Delivery (Weight – 200) 3.1.1

3.1.2

3.1.3

Proportion of vacant healthcare provider positions (regular + contractual) in public health facilities

Vacant healthcare provider positions in public health facilities against total sanctioned healthcare provider positions for following cadres (separately for each cadre) during a specific year: a. Auxiliary Nurse Mid-wife (ANM) at sub-centers (SCs) b. Staff nurse (SN) at Primary Health Centers (PHCs) and Community Health Centers (CHCs) c. Medical officers (MOs) at PHCs d. Specialists at District Hospitals (Medicine, Surgery, Obstetrics and Gynaecology, Pediatrics, Anesthesia, Ophthalmology, Radiology, Pathology, Ear-Nose-Throat (ENT), Dental, Psychiatry)

State Report

BY: As on March 31, 2015

Proportion of total staff (regular + contractual) for whom an e-payslip can be generated in the IT-enabled Human Resources Management Information System (HRMIS).

Availability of a functional IT-enabled HRMIS measured by the proportion of staff (regular + contractual) for whom an e-payslip can be generated in the IT-enabled HRMIS against total number of staff (regular + contractual) during a specific year.

State Report

a. Proportion of specified type of facilities functioning as First Referral Units (FRUs)

Proportion of public sector facilities conducting specified number of C-sections* per year (FRUs) against the norm of one FRU per 500,000 population during a specific year.

State Report on number of functional FRUs, MoHFW data on required number of (FRUs

b. Proportion of functional 24x7 PHCs

Proportion of PHCs providing all stipulated healthcare services** round the clock against the norm of one 24x7 PHC per 100,000 population during a specific year.

State Report on number BY: 2014-15 of functional 24x7 PHCs, MoHFW data on RY: 2015-16 required number of PHCs

RY: As on March 31, 2016

BY: As on March 31, 2015 RY: As on March 31, 2016

BY: 2014-15 RY: 2015-16

Indicator definition modified

S. No. Indicator

Definition

Data Source

Base Year (BY) Remarks & Reference Year (RY)

3.1.4

Proportion of districts with functional Cardiac Care Units (CCUs)

Proportion of districts with functional CCUs [with desired equipment (ventilator, monitor, defibrillator, CCU beds, portable ECG machine, pulse oxymeter etc.), drugs, diagnostics and desired staff as per programme guidelines] against total number of districts.

State Report

BY: As on March 31, 2015

Proportion of ANC registered within first trimester against total registrations

Proportion of pregnant women registered for ANC within 12 weeks of pregnancy during a specific year.

HMIS

Level of registration of births

Proportion of births registered under Civil Registration System (CRS) against the estimated number of births during a specific year.

Civil Registration System (CRS) [pre-entered]

Completeness of IDSP reporting of P and L forms

Proportion of Reporting Units (RUs) reporting in stipulated time period against total RUs, for P and L forms during a specific year.

Central IDSP, MoHFW Data [pre-entered]

BY: 2014

Proportion of CHCs with grading above 3 points

Proportion of CHCs that are graded above 3 points against total number of CHCs during a specific year.

HMIS

BY: 2014-15

Proportion of public health facilities with accreditation certificates by a standard quality assurance program (NQAS/NABH/ISO/AHPI)

Proportion of specified type of public health facilities with accreditation certificates by a standard quality assurance program against the total number of following specified type of facilities during a specific year. 1. District hospital (DH)/Sub-district hospital (SDH) 2. CHC/Block PHC

State Report

Average number of days for transfer of Central NHM fund from State Treasury to implementation agency (Department/Society) based on all tranches of the last financial year

Average time taken (in number of days) by the State Treasury to transfer funds to implementation agencies during a specific year.

Centre NHM Finance Data# [pre-entered]

3.1.5

3.1.6

3.1.7

3.1.8

3.1.9

3.1.10

RY: As on March 31, 2016 BY:2014-15 RY: 2015-16 BY: 2013 RY: 2014

RY: 2015

RY: 2015-16 BY: As on March 31, 2015 RY: As on March 31, 2016

BY: 2014-15 RY: 2015-16

*Criteria for fully operational FRUs: SDHs/CHCs - conducting minimum 60 C-sections per year (36 C-sections per year for Hilly and North-Eastern States except for Assam); DHs - conducting minimum 120 C-sections per year (72 C-sections per year for Hilly and North-Eastern States except Assam). **Criteria for functional 24x7 PHCs: 10 deliveries per month (5 deliveries per month for Hilly and North-Eastern States except Assam) # Centre NHM Finance data includes the RCH flexi-pool and NHM-Health System Strengthening flexi-pool data (representing a substantial portion of the NHM funds) for calculating delay in transfer of funds.

2.5 LIMITATIONS OF THE INDEX

•

Some critical areas such as infectious diseases, NCDs, mental health, governance, and financial risk protection could not be fully captured in the Index due to non-availability of acceptable quality of data on an annual basis.

•

For several indicators, the data was limited to service delivery in public facilities due to the paucity and uneven availability of private sector data on health services in the HMIS.

•

As data was not available for various indicators at the time of Index development, analytical tools could not be used to derive indicator or domain-specific weights and expert opinion was thus used to assign weights. The data generated for this Index will be helpful in refining the Index and assigning weights in the future. This will also be helpful in fixing the minimum and maximum values of the scale for the next several years, instead of a year-to-year basis.

•

For SRS related key outcome indicators, data was available only for Larger States. Hence, the Health Index scores and ranks for Smaller States and UTs were calculated excluding these indicators. 15

•

Data for some indicators was available for formerly undivided States. In such instances, the decision was based on data triangulation. For example, data on the SRB was available only for the undivided State of Andhra Pradesh, and the same value was used for the States of Andhra Pradesh and Telangana as this was comparable with other data sources. However, in the case of MMR, it was observed that the estimates for separate States varied widely as compared with formerly undivided States and it was decided to drop the indicator from the Index.

•

For several indicators, HMIS data and program data was used without any field verification by the IVA due to the lack of feasibility of conducting independent field surveys.

•

Since the integrity of administrative data was to be measured in comparison with reliable independent data, National Family Health Survey (NFHS-4) was used, which overlapped the base and reference year period of the Index. Therefore, the same values of the indicator on data integrity measure were used for base and reference years.

•

In some instances, such as the TB case notification rate, the programmatically accepted definition was used, which is based on the denominator per 100,000 population. The more refined indicator of TB cases notified per 100,000 estimated number of TB cases would have been used if data was available.

•

In some cases, proxy indicators or proxy validation criteria were used. Thus, for the number of functional First Referral Units (FRUs) and 24x7 Primary Health Centers (PHCs), the annual number of C-sections and deliveries respectively were used as proxy criteria. The field validation of functionality based on available human resources and infrastructure was not viable.

•

Due to unavailability of detailed records at the State level for a few indicators, such as vacancies of human resources and districts with functional CCUs, the validation agency had to rely on certified statements provided by the State.

•

For a few indicators, such as vacancies of healthcare providers, the proportion of people living with HIV on ART and the average number of days for transfer of funds from the State Treasury; the State level and Central level program data was inconsistent. In such instances the data was reviewed and the most reliable source of data was considered by the IVA.

3. Processes â&#x20AC;&#x201C; from idea to practice 3.1 KEY STAKEHOLDERS - ROLES AND RESPONSIBILITIES

Multiple stakeholders were involved in the entire exercise and their roles and responsibilities are summarized in Table 3.1. Table 3.1 - Key stakeholders: Roles and responsibilities NITI Aayog

States

Technical Assistance (TA) Agency (The World Bank)

Mentor Agencies5

Independent Validation Agency (IPE Global)

Development and dissemination of the Health Index along with necessary guidance in close partnership with MoHFW

Adopt and share Health Index with various departments

TA to NITI Aayog in developing the Health Index, protocols and guidelines

Assist States in understanding the Health Index, data being sought, and mechanism for providing the responses

Validation and acceptance of the data submitted by the States for various indicators including comparison with other data sources as needed

Facilitate interaction between States and TA, mentor and independent validation agencies

Input data on the indicators as per identified sources on web portal and submit data in a timely manner

Support to NITI Aayog to disseminate the Health Index in Regional/State-level workshops

Participate in Regional and State-level workshops organized by NITI Aayog

Review of supporting documents and participation in data validation workshops with States

Host a web portal for States to input data, its validation and dissemination of State-wise rankings

Co-ordination with different districts, mentor and independent validation agencies

Technical oversight to the mentor agencies, portal agency and the independent validation agency

Provide guidance to the States for submission of data by visiting State Health Departments/Directorates

Submission of final validation report with State details to NITI Aayog

Provide technical support for generation of composite Index and report

Follow up with States for timely submission of data/ supporting documents on the web portal

Generation and validation of ranks and final certification of data on the portal

Overall coordination and management

3.2 PROCESS FLOW

The process of development of the Health Index involved various steps (Table 3.2). Table 3.2 - Timeline for development of Health Index Sr No. Step/Activity

2016 Jun-Nov

Development of the Index

Regional workshops with States

Mentorship to States and submission of data on portal

Validation of data and validation workshops with States

Refinement of the Index

Index and rank generation

Report and dissemination of ranks

2017-18 Dec

Jan

Feb

Mar-Apr May

Jun

Jul

Aug

Sep-Oct Nov-Jan

United States Agency for International Development (USAID), Regional Resource Centre for North Eastern States (RRC-NE), Centre for Innovation in Public Systems (CIPS), The Energy Research Institute (TERI).

3.2.1 Development of Index The initial idea of a Health Index to benchmark improvements in the Statesâ&#x20AC;&#x2122; performance on key health outcomes originated in March 2016. Development of the Index commenced in June 2016. The selection of indicators and the methodology for the composite Index were among the most challenging tasks. For the selection of indicators, a thorough review of data sources, management information systems and similar global indices was conducted. After detailed deliberations, an initial draft with over 100 indicators was developed and shared with several stakeholders including the States, MoHFW, domestic and international experts, and development partners for review and feedback. A pre-test was conducted in two States to identify state-level issues regarding availability of data, sources for data collection and data validation. Through an iterative process, taking into account importance availability (at least annually) of reliable data, 28 indicators were included in the Health Index (Annexure 2). Once data collection and initial validation was completed, the availability and quality of data for all States was reviewed in a meeting chaired by Member, NITI Aayog. Based on the observations shared by MoHFW, the World Bank, and IVA, as well as inputs from States and experts, 23 indicators were retained and five indicators were dropped for calculating the annual incremental performance and the overall performance in the base and reference years. However, Index scores and ranks for the reference year were also calculated independently, based on 24 indicators including an additional indicator on out-of-pocket expenditure, as the data for this was available only for 2015-16 (Annexure 3). 3.2.2 Regional workshops with States In order to guide the States on the Health Index and related processes, five regional workshops were held by a team comprising NITI Aayog, MoHFW, the World Bank, mentor agencies, and the portal agency covering all States and UTs (Table 3.3). Table 3.3 - Health Index regional workshops Region

Venue

Date

States/UTs

North

New Delhi

23.12.2016

Uttar Pradesh, Haryana, Punjab, Rajasthan, Uttarakhand, Jammu and Kashmir, Himachal Pradesh, Delhi, Chandigarh

West

Goa

13.01.2017

Gujarat, Maharashtra, Madhya Pradesh, Karnataka, Goa, Dadra & Nagar Haveli, Daman & Diu

East

New Delhi

27.01.2017

Bihar, Jharkhand, Odisha, Chhattisgarh, Andaman & Nicobar Islands

South

Vijayawada

03.02.2017

Andhra Pradesh, Telangana, Kerala, Tamil Nadu, Lakshadweep, Puducherry

North East

Shillong

10.02.2017

Meghalaya, Assam, Nagaland, Mizoram, Manipur, Arunachal Pradesh, Sikkim, Tripura, West Bengal

3.2.3 Submission of data on the portal Mentors were assigned to most States to facilitate data collection and submission on the portal. The Empowered Action Group (EAG) States and North-Eastern States were provided dedicated mentor support which other States received on request. The mentor agencies assigned to various States are listed in Table 3.4.

Table 3.4 - List of mentor agencies Agency

States

United States Agency for International

Uttar Pradesh, Uttarakhand, Odisha, Chhattisgarh, Punjab, Himachal Pradesh, Bihar,

Development (USAID)

Jharkhand, Rajasthan, Madhya Pradesh, Haryana, Chandigarh, West Bengal

Regional Resource Centre for North Eastern

Assam, Meghalaya, Arunachal Pradesh, Mizoram, Manipur, Nagaland, Sikkim, Tripura

States (RRC-NE) Centre for Innovation in Public Systems (CIPS)

Andhra Pradesh, Telangana

The Energy Research Institute (TERI)

Delhi

The dedicated interactive web portal, developed and hosted by NITI Aayog includes functions for submission of data and its validation and generates and displays state-wise Index scores and ranks. Data was entered in the portal by the States and UTs, except some designated indicators pre-entered on the basis of data source identified at the outset. For State-level data entry, options were provided to the States to either enter data at the State level or assign this to the districts. However, the final submissionof data on the portal was done by the designated State-level competent authority. The process of data entry and submission by the States began in February 2017 and ended in June 2017. 3.2.4 Independent validation of data An Independent Validation Agency (IVA), namely, IPE Global, was hired by NITI Aayog through a competitive selection process to review and validate the Health Index data and the State rankings. The data submitted on the portal was validated by the IVA from May-October 2017 as summarized in Figure 3.1. Figure 3.1 - Steps for validating data DESK REVIEW (FLV) • Review of data for completeness, accuracy, consistancy. Comparison with published sources like NFHS, SRS etc. as specified

Interaction with State Nodal Officers (FLV) • Discrepancies found during the desk review validated with State Nodal officers

Documenting Gaps and Inconsistencies • In case the nodal officer is unable to address the discrepancies, sample field visits undertaken

Field Visits to States & Districts (SLV) • Sample states and districts visited to validate results/figures provided by the state for specific indicators

FLV - First level verification, SLV - Second level verification

Field visits were conducted to carry physical validation of the data in Assam, Chhattisgarh, Rajasthan, Kerala, Himachal Pradesh, Bihar and Jharkhand6. A regional workshop was also held to cover the seven North-Eastern States. The detailed note on discrepancies in data submitted and their resolution is provided in Annexure 1. 3.2.5 Index and rank generation The data validated and finalized by the IVA after resolving issues with the States was used in Index generation and rankings. Once the data was accepted by the IVA, the ranks were automatically generated by the portal hosted by the NITI Aayog. In addition, to ensure accuracy the indices and ranks were manually calculated and cross-checked with the results from the portal and the final values were certified by the IVA. The activity of Index and rank generation was undertaken in September and October 2017. 6

Physical verification of the documents and meetings with State Nodal Officers were conducted by project offices of the IVA.

Results And Findings

Performance of Larger States Performance of Smaller States Performance of Union Territories States and UTs: Performance on indicators 20

4. Unveiling performance – encouraging actions This chapter presents the States’ overall and incremental performance on the Health Index. The results are presented for each group of States separately: Larger States, Smaller States, and UTs. Overall performance is measured using the composite Index scores for base and reference years, and incremental performance is calculated as the change in composite Index scores from base to reference year. 4.1 PERFORMANCE OF LARGER STATES

4.1.1 Overall performance In the base year (2014-15), the composite Health Index ranged from 28.14 in Uttar Pradesh to 80 in Kerala. On an average, modest improvement was observed between the base and reference year, with the difference between the worst and best performing States narrowing. In the reference year 2015-16, Uttar Pradesh at 33.69 remained the poorest performing State, and Kerala remained the best performing State despite a slight decline in the Health Index to 76.55. Figure 4.1 displays the composite Index scores for base and reference years for the Larger States and ranks the States based on their overall performance. The lines depict changes in the ranking: a blue line denotes a negative change in the State’s ranking from base to reference year, a green line indicates a positive change, and a grey line indicates no change in ranking. The top five performing States in the reference year based on the composite Index score are Kerala (76.55), Punjab (65.21), Tamil Nadu (63.38), Gujarat (61.99), and Himachal Pradesh (61.20). On the other end of the spectrum, Uttar Pradesh (33.69) scored the lowest and ranks at the bottom preceded by Rajasthan (36.79), Bihar (38.46), Odisha (39.43), and Madhya Pradesh (40.09). The EAG7 States (except Chhattisgarh) and Assam lie at the tail end of the distribution, ranking between 14th and 21st positions. Among the 21 Larger States, only five States improved their position from base to reference year. These States are Punjab, Andhra Pradesh, Jammu & Kashmir, Chhattisgarh and Jharkhand. The most significant progress was observed in Jharkhand and Jammu & Kashmir. Both States moved up by four positions in the ranking. Meanwhile, Punjab improved its performance in the ranking by three positions. Andhra Pradesh and Chhattisgarh have shown modest improvement – both up by one position. Despite increases in the composite Health Index scores, the rankings of Maharashtra, Madhya Pradesh, Bihar, Rajasthan, and Uttar Pradesh did not change between base and reference years. Kerala continued to be at the top position and the remaining States fell in ranking by 1-2 positions.

Eight states namely Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand, and are referred to as the Empowered Action Group (EAG) States.

Kerala

80.00

76.55

Kerala

Tamil Nadu

63.28

65.21

Punjab

Gujarat

63.28

63.38

Tamil Nadu

Himachal Pradesh

62.12

61.99

Gujarat

Punjab

62.02

61.20

Himachal Pradesh

Maharashtra

60.09

61.07

Maharashtra

Karnataka

59.73

60.35

Jammu & Kashmir

West Bengal

57.87

60.16

Andhra Pradesh

57.75

58.70

Karnataka

Telangana

54.94

58.25

West Bengal

Jammu & Kashmir

53.52

55.39

Telangana

Haryana

49.87

52.02

Chhattisgarh

48.63

46.97

Haryana

Uttarakhand

45.32

45.33

Jharkhand

Assam

43.53

45.22

Uttarakhand

Odisha

39.23

44.13

Assam

Madhya Pradesh

38.99

40.09

Madhya Pradesh

Jharkhand

38.46

39.43

Odisha

Bihar

34.70

38.46

Bihar

Rajasthan

34.55

36.79

Rajasthan

Uttar Pradesh

28.14

33.69

Uttar Pradesh

Base Year 2014-15

Reference Year Rank

Base Year Rank

Figure 4.1 - Larger States: Overall performance - Composite Index score and rank, base and reference years

Reference Year 2015-16

Note: Lines depict changes in composite Index score rank from base to reference year. The composite Index score is presented in the circle.

Based on the composite Index scores for the reference year (2015-16), the States are grouped into three categories: Aspirants, Achievers, and Front-runners (Table 4.1). Aspirants are the bottom one-third states with an Index score below 48. These States are largely the EAG States (except Chhattisgarh) and given the substantial scope for improvement, require concerted efforts. Achievers represent the middle one-third States with an Index score between 48 and 62. Overall, these States have made good progress and can move to the next group with sustained efforts. Front-runners, the top one-third States with an Index score above 62 are the best performing States. Despite relatively good performance, however, even the Front-runners could further benefit from improvements in certain indicators as the highest observed Index score of 76.55 is well below 100. Table 4.1 - Larger States: Overall performance in reference year - Categorization Aspirants

Achievers

Front-runners

Haryana Jharkhand Uttarakhand Assam Madhya Pradesh Odisha Bihar Rajasthan Uttar Pradesh

Gujarat Himachal Pradesh Maharashtra Jammu & Kashmir Andhra Pradesh Karnataka West Bengal Telangana Chhattisgarh

Kerala Punjab Tamil Nadu

Note: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>62), Achievers: middle one-third (Index score between 48 and 62), Aspirants: lowest one-third (Index score<48).

4.1.2 Incremental performance Incremental performance measures the change in the Health Index score from base to reference year, which is masked by the year-specific rankings. It is important to identify the year-on-year pace of improvement made by States. States that start at lower levels of Health Index are generally at an advantage for higher incremental progress due to diminishing marginal returns for States that start at a high Index score. This measure is particularly important for identifying States with negative incremental progress. In Figure 4.2, the left side, presents the State-wise movement in Health Index from base to reference year along with their relative position and on the right side, actual increments are presented. Overall, the incremental performance does not appear to be associated with the overall Index score. Importantly, some of the better-performing Larger States have made negative incremental progress. Three of the top five Larger States (Kerala, Gujarat, and Himachal Pradesh) recorded negative changes in the overall performance Index score between base and reference years. Figure 4.2 - Larger States: Overall and incremental performance, base and reference years and incremental rank Jharkhand

38.46

45.33

Jammu & Kashmir Uttar Pradesh Bihar

53.52 28.14 34.70

38.46 48.63

62.02

Madhya Pradesh

38.99

40.09 60.09

Assam

43.53

Telangana

54.94

55.39

57.87 39.23

61.07

44.13

West Bengal

58.25

39.43

Tamil Nadu

63.28

Uttarakhand

45.22

62.12

58.70

Gujarat

59.73

61.99 46.97

63.28

49.87

Kerala

76.55 20 30

80.00 80

Overall Performance Index Score Base Year (2014-15)

3 4

3.39

3.19

6 7

2.24

1.10

0.98

0.60

0.45

0.38

0.20

0.10

15 16

-0.10

61.20

Haryana

63.38

45.32

Himachal Pradesh Karnataka

2.41

60.16

36.79

Maharashtra

Odisha

65.21

57.75 34.55

6.83

3.76 52.02

Punjab Andhra Pradesh

5.55

33.69

Chhattisgarh

Rajasthan

60.35

6.87

-0.92

-1.03

-1.29

-2.90

-3.45

-4

Incremental Change

8 Incremental Rank

Reference Year (2015-16)

Among the 21 Larger States, 15 States displayed a positive incremental change in the Index score. The remaining six States showed negative incremental change. Except for Uttarakhand that showed a slight negative incremental performance, the EAG States registered positive incremental progress. Jharkhand (ranked at top) followed by Jammu & Kashmir and Uttar Pradesh made significant incremental progress, with more than a five-point change in Index score from base to reference year. However, for Bihar, Chhattisgarh, Punjab, Andhra Pradesh and Rajasthan, the Index score increased by 2 to 4 points. Further, limited improvement was observed in Madhya Pradesh, Maharashtra, Assam, Telangana and West Bengal. Odisha, Tamil Nadu and Uttarakhand more or less maintained their respective Health 23

Index scores and made negligible incremental progress. Meanwhile, Himachal Pradesh, Karnataka, Gujarat, Haryana and Kerala showed declines in the reference year as compared to the base year, resulting in a negative incremental Index score. Fifteen states observed positive incremental change in Index scores from base to reference year, whereas only five States (Punjab, Andhra Pradesh, Jammu & Kashmir, Chhattisgarh, and Jharkhand) increased in their overall performance ranks from base year to reference year. This depicts that only these five States made significant incremental progress leading to improvement in the overall performance position. The remaining States with modest or negative incremental progress have retained their earlier position or have moved down in the ranking. Based on their incremental performance, States are categorized into four groups: ‘not improved’ (<= 0 incremental change), ‘least improved’ (0.01 to 2 point increase), ‘moderately improved’ (2.01 to 4 point increase), and ‘most improved’ (>4 point increase) (Table 4.2). Table 4.2 - Larger States: Incremental performance from base to reference year - Categorization Not improved

Least improved

Moderately improved

Most improved

Uttarakhand Himachal Pradesh Karnataka Gujarat Haryana Kerala

Madhya Pradesh Maharashtra Assam Telangana West Bengal Odisha Tamil Nadu

Bihar Chhattisgarh Punjab Andhra Pradesh Rajasthan

Jharkhand Jammu & Kashmir Uttar Pradesh

Note: The States are categorized on the basis of incremental Index score range into categories: ‘not improved’ (incremental Index score<=0), ‘least improved’ (incremental Index score between 0.01 and 2), ‘moderately improved’ (incremental Index score between 2.01 and 4), ‘most improved’ (incremental Index score>4.0).

Among the most improved States in terms of incremental progress, Jharkhand is the top most improved State and has showed maximum gains in improvement of health outcomes from base to reference year in indicators such as U5MR (44 to 39 per 1000 live births), TFR (2.8 to 2.7), full immunization (81 to 88 percent) and institutional deliveries (61 to 67 percent). Jammu & Kashmir, ranked at second, has shown good incremental progress on health outcomes of NMR (26 to 20 per 1000 live births), U5MR (35 to 28 per 1000 live births), full immunization coverage (90 to 100 percent) and PLHIV on ART (89 to 96 percent). Similarly, Uttar Pradesh, ranked third has attained significant incremental improvement on the parameters of U5MR (57 to 51 per 1000 live births), low birth weight (11.74 to 9.60 percent), institutional deliveries (44 to 52 percent), and PLHIV on ART (51 to 58 percent). Among the States which could not register positive incremental performance, Kerala is ranked at the bottom mainly as it had already achieved low level of NMR and U5MR and replacement level fertility, leaving very limited space for any further improvements. Additionally, Kerala also registered a decline in sex ratio at birth from base to reference year (974 to 967 females per 1000 males). Haryana with a negative incremental score performed poorly due to increase in U5MR (40 to 43 per 1000 live births) and decline in the Sex Ratio at Birth (866 to 831 females per 1000 males) from base to reference year. Gujarat registered a significant decline in sex ratio at birth (907 to 854 females per 1000 males) that dragged down its incremental progress. The indicators where most Larger States need to focus on include addressing the issue of sex ratio at birth, establishment of functional district Cardiac Care Units, ensuring quality accreditation of public health facilities, and institutionalization of Human Resources Management Information System.

4.1.3 Domain-specific performance Overall performance is an aggregate measure of a Stateâ&#x20AC;&#x2122;s performance and does not reveal specific areas requiring further attention. To identify such areas, the Index is disaggregated into the domains of Health Outcomes, Governance and Information, and Key Inputs/Processes. The domain of Governance and Information is not presented in this section as it has a limited number of indicators (three) due to data limitations and thus might not be fully representative of the domain. The overall performance of the States is not always consistent with the domain-specific performance (Figure 4.3). Some top performing States fare significantly better in one domain suggesting that there is scope to improve their performance in the lagging domain with specific targeted interventions. Most States showed a better performance on health outcomes; however, Tamil Nadu, West Bengal, Assam, Madhya Pradesh, Odisha and Rajasthan performed better in terms of Key Inputs/Processes. Figure 4.3 - Larger States: Overall and domain-specific performance, reference year

Reference Year (2015-16) Score

70 60 50 40 30 20 10

Health Outcomes

Key Inputs/Processes

Uttar Pradesh

Rajasthan

Bihar

Odisha

Madhya Pradesh

Assam

Uttarakhand

Jharkhand

Haryana

Chhattisgarh

Telangana

West Bengal

Karnataka

Andhra Pradesh

Jammu & Kashmir

Maharashtra

Himachal Pradesh

Gujarat

Tamil Nadu

Punjab

Kerala

Overall Performance

Figure 4.4 and Figure 4.5 present the overall performance of Larger States in the domains of Health Outcomes and Key Inputs/Processes for base and reference year. In these figures, from top to bottom, States are presented in descending order of Health Index scores for the reference year. For the Health Outcomes domain, Kerala is ranked at the top and Rajasthan is at the bottom, while for Key Inputs/Processes, Tamil Nadu earned the top position and Uttar Pradesh received the lowest ranking.

In the domain of Health Outcomes, 11 States (Kerala, Punjab, Jammu & Kashmir, Telangana, Andhra Pradesh, Chhattisgarh, Jharkhand, Assam, Bihar, Madhya Pradesh, and Uttar Pradesh) have improved their Index score from base to reference year. The Index score has declined from base to reference year for the other States. Jammu & Kashmir saw the largest positive incremental change (10.05) followed by Uttar Pradesh (7.13) and Jharkhand (6.89), while negative changes of more than 2 points were observed in West Bengal, Haryana, and Uttarakhand. Figure 4.4 - Larger States: Performance in the Health Outcomes domain, base and reference years Kerala

69.87

64.54

Jammu & Kashmir

56.49

Himachal Pradesh

61.53

Andhra Pradesh

62.30

Maharashtra

61.41

Gujarat

59.78

West Bengal

56.43

Chhattisgarh

52.67 44.93

Haryana

46.05

48.13

Uttarakhand

45.56

47.91

42.02

Bihar

34.01

Madhya Pradesh

33.86 26.09

Rajasthan

-1.48

64.04

-0.48

62.78

-1.19

62.60

-0.52

60.30 59.14

-2.71 1.23 6.89 -2.08 -2.35 0.73

42.75

4.82 1.08

37.00 34.29

-0.43 7.13

33.22 30.37

29.58 20

3.27 2.12

38.83

35.92

Odisha

-1.88

53.90 51.82

Jharkhand

Assam

67.77

62.57

62.56

Karnataka

10.05

64.80

60.45

Tamil Nadu

5.33

66.54 65.89

Telangana

Uttar Pradesh

-0.79 40

Health Outcomes Index Score BaseYear (2014-15) Reference Year (2015-16)

Note: States ranked based on their reference year score in the Health Outcomes domain.

0.56

82.33 82.89

Punjab

-4

-2

Incremental Change

In the Key Inputs/Processes domain, the Index score has improved from base to reference year in 15 of the 21 States. The Key Inputs/Processes score declined in Kerala, Karnataka, Punjab, Haryana, Telangana and Uttar Pradesh. Large incremental increases of more than 10 points were observed in Rajasthan, Chhattisgarh, Jammu & Kashmir, Bihar, and Jharkhand. Negative incremental change of more than 2 points was observed in Kerala, Haryana, Telangana and UP. Figure 4.5 - Larger States: Performance in the Key Inputs/Processes domain, base and reference years Tamil Nadu

74.20 69.62

Kerala West Bengal

52.78

Andhra Pradesh

56.78

57.30

Karnataka

55.96

56.69

54.76 47.57

Punjab

9.21 8.66 0.52 -0.73 0.40

55.16 53.17

5.60

52.13 51.90

Rajasthan

32.59

-0.23

49.80

Himachal Pradesh

43.20

Haryana

17.21

49.80

6.60 -2.45

46.41 48.86 45.02 45.23

Assam Chhattisgarh

29.81

Jammu & Kashmir

32.37

1.64

40.49

8.42 12.34

32.54

Telangana

31.92

Jharkhand 15.30

25.02 10

10.24

41.30

32.07 20.20

Uttar Pradesh

14.48

42.61 39.66

Uttarakhand

0.21

44.29

Madhya Pradesh Bihar

-4.55

58.69

Gujarat Odisha

74.17

61.99

50.03

Maharashtra

3.86

78.06

-7.34

39.26 29.41 29.28

14.11 -4.26 40

-10

Key Inputs/Processes Index Score

-5

Incremental Change

Base Year (2014-15) Reference Year (2015-16)

Note: States ranked based on their reference year score in the Key Inputs/Processes domain.

4.1.4 Incremental performance on indicators Figure 4.6 captures the incremental performance on indicators and sub-indicators and provides the number of indicators and sub-indicators in each category, i.e, ‘most improved’, ‘improved’, ‘no change’,‘deteriorated’ and ‘most detriorated’. Chattisgarh has the highest proportion of indicators among Larger States (70 percent), which fall in the category of ‘most improved’ and ‘improved’. On the other hand, Haryana has the highest proportion (43 percent) of indicators which fall in the category of ‘deteriorated’ and ‘most deteriorated’. Detailed indicator-specific performance snapshot of States is presented in Annexure 4, which provides the direction as well as the magnitude of the incremental change of indicators from base year to reference year.

Figure 4.6 - Larger States: Number of indicators/sub-indicators, by category of incremental performance Number of Indicators/Sub-indicators 0

Chhattisgarh

30 2

Assam

Jharkhand

Rajasthan

Gujarat

Bihar West Bengal

Uttar Pradesh Karnataka Andhra Pradesh

Maharashtra

Himachal Pradesh

Odisha

Tamil Nadu

Madhya Pradesh Punjab Uttarakhand Telangana Kerala Haryana

Most Improved

Improved

No Change

Deteriorated

2 4

6 10

Most Deteriorated

2 4

8 6

0 11

Jammu Kashmir

States

3 3

Not Applicable

Note: For a State, the incremental performance on an indicator is classified as not applicable (NA) in instances such as: (i) If State has achieved TFR <= 2.1 in both base and reference years; (ii) Data Integrity Measure indicator wherein the same data has been used for base year and reference year due to overlapping periods of NFHS-4; (iii) Service coverage indicators with 100 percent values in both base and reference years; (iv) The data value for a particular indicator is NA in base year or reference year or both.

4.2 PERFORMANCE OF SMALLER STATES

4.2.1 Overall performance In the base year (2014-15), the overall performance among the Smaller States ranged from 45.26 in Nagaland to 71.27 in Mizoram (Figure 4.7). Both states retained their respective rankings in the reference year. Mizoram exhibited a small improvement since base year, with the Health Index score rising to 73.70 in the reference year (2015-16). Meanwhile, Nagalandâ&#x20AC;&#x2122;s performance worsened substantially - the Stateâ&#x20AC;&#x2122;s Health Index fell from 45.26 in the base year to 37.38 in the reference year. Tripura received a score of 43.51 and is the second-to-last State among this group. Notably, while Manipur, Meghalaya, Sikkim, Goa and Arunachal Pradesh are among the better performing Smaller States, these States scored only between 50 and 58 points on the Health Index in the reference year. This suggests that there is substantial scope for improvement even for these relatively better-performing states.

Mizoram

71.27

73.70

Mizoram

Sikkim

53.39

57.78

Manipur

Meghalaya

51.40

56.83

Meghalaya

Manipur

50.60

53.20

Sikkim

Arunachal Pradesh

50.60

53.13

Goa

Tripura

48.35

49.51

Arunachal Pradesh

Goa

46.46

43.51

Tripura

Nagaland

45.26

37.38

Nagaland

Base Year 2014-15

Reference Year 2015-16

Reference Year Rank

Base Year Rank

Figure 4.7 - Smaller States: Overall performance - Composite Index score and rank, base and reference years

Note: Lines depict changes in composite Index score rank from base to reference year. The composite Index score is presented in the circle.

Only two States, namely Manipur and Goa, improved their position from base year to reference year each up by two positions. Mizoram, Meghalaya, and Nagaland retained their first, third, and eighth positions, respectively. The position of Sikkim worsened by two ranks (from second to fourth) and that of Arunachal Pradesh and Tripura worsened by one position from fifth to sixth and sixth to seventh, respectively. Based on the composite Index score range for reference year (2015-16), Tripura and Nagaland (Table 4.3) are categorized as Aspirants, and have substantial scope for improvements, while Manipur, Meghalaya, Sikkim, Goa and Arunachal Pradesh are Achievers, and though have demonstrated better performance, still need to improve. Mizoram is categorized as a Front-runner - with the highest observed performance among the Smaller States. Despite relatively good performance, even Mizoram could further benefit from improvements.

Table 4.3 - Smaller States: Overall performance in reference year - Categorization Aspirants

Achievers

Front-runners

Tripura Nagaland

Manipur Meghalaya Sikkim Goa Arunachal Pradesh

Mizoram

Note: The States are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>61.60), Achievers: mid one-third (Index score between 49.49 and 61.60), Aspirants: lowest one-third (Index score<49.49).

4.2.2 Incremental performance Figure 4.8 presents the incremental progress made by the States along with their relative position to each other as well as the respective increments and ranks. Figure 4.8 - Smaller States: Overall and incremental performance, base and reference years and incremental rank 50.60

Manipur

57.78

46.46

Goa Meghalaya

53.13

53.20

Sikkim Arunachal Pradesh

43.51

Tripura Nagaland

37.38 30

53.39

-1.09

48.35 50

-0.19 -4.84

45.26 40

2.43

73.70

50.60

49.51

5.43

71.27

Mizoram

6.67

56.83

51.40

7.18

7 8

-7.88 60

Overall Performance Index Score

-10

0 Incremental Change

Incremental Rank

Base Year (2014-15) Reference Year (2015-16)

From base to reference year, four States (Manipur, Goa, Meghalaya and Mizoram) showed positive incremental progress, while the remaining four States (Sikkim, Arunachal Pradesh, Tripura and Nagaland) registered negative incremental performance (Figure 4.8). The States of Manipur (ranked at the top), Goa and Meghalaya made significant incremental progress – recording increases in the Health Index score of 5 points or more between the base and reference years. Mizoram also made some incremental progress with a 2.43 point change in Index scores from base to reference year. Sikkim has observed almost no change in its Health Index score between the two periods. The Index score in Arunachal Pradesh and Tripura declined by 1.09 and 4.84 points, respectively. Nagaland observed the highest negative incremental change of -7.88 points between base and reference years. Mizoram has shown incremental progress from base to reference year and has retained the top rank. Although, three States (Manipur, Goa, and Meghalaya) have observed positive incremental change in Index scores from base to reference year, only Manipur and Goa have been able to improve their overall performance ranks from base year to reference year. The remaining States with modest or negative incremental progress retained their base year position or have moved down in the ranking. Based on their incremental performance from base to reference year, States are grouped into four categories: ‘not improved’, ‘least improved’, ‘moderately improved’, and ‘most improved’ (Table 4.4). Manipur, Goa, and Meghalaya are among the most improved states with an incremental Index score of more than 4 points. Meanwhile, Sikkim, Arunachal Pradesh, Tripura, and Nagaland have not improved and have in fact seen their overall Index scores decline between base and reference years.

Table 4.4 - Smaller States: Incremental performance from base to reference year - Categorization Not improved

Least improved

Sikkim Arunachal Pradesh Tripura Nagaland

Moderately improved

Most improved

Mizoram

Manipur Goa Meghalaya

Among the most improved States, Manipur registered maximum incremental progress from base to reference year due to good progress on indicators such as PLHIVs on ART (54 to 64 percent), average occupancy of 3 key state level officers (13 to 21 months), first trimester ANC registration (59 to 63 percent), IDSP reporting format for presumptive surveillance (P form) submission (35 to 63 percent), and CHC grading (0 to 29 percent). Further, Goa, ranked second and progress from base to reference year was notable on indicators such as low birth weight (17 to 16 percent), full immunization coverage (91 to 95 percent), average occupancy of three key State-level officers (15 to 22 months), CHC grading (25 to 75 percent), vacancy of medical officers at PHCs (31 to 14 percent) and specialists at district hospitals (43 to 40 percent). Among the States which have not shown any improvement from base year to reference year, Nagaland, ranked at the bottom, and performed poorly on indicators such as TB treatment success rate (91 to 72 percent), average occupancy of three key State-level officers (12 to 7 months), first trimester ANC registration (47 to 36 percent) and time taken to transfer Central NHM funds from State Treasury to implementation agency (101 to 213 days). Tripura, ranked second from the bottom, and fared poorly on indicators such as full immunization coverage (87 to 84 percent), TB case notification rate (195 to 61), PLHIVs on ART (23 to 6 percent), vacancies of Auxiliary Nurse Midwives (ANMs) at sub-centres (15 to 39 percent), and level of birth registration (91 to 82 percent). The indicators where almost all Smaller States need to focus include filling vacancies of ANMs at sub-centres, establishment of functional district Cardiac Care Units, quality accreditation of public health facilities, and institutionalization of Human Resources Management Information System. 4.2.3 Domain-specific performance The overall performance of the States is not always consistent with the domain-specific performance (Figure 4.9). All Smaller States showed a better performance on Health Outcomes as compared to Key Inputs/Processes.

Figure 4.9 - Smaller States: Overall and domain-specific performance, reference year 100 90 80

Reference Year (2015-16) Score

70 60 50 40 30 20 10 0

Mizoram

Manipur

Health Outcomes

Meghalaya

Sikkim

Key Inputs/Processes

Goa

Arunachal Pradesh

Tripura

Nagaland

Overall Performance

In the domain of Health Outcomes, five States (Mizoram, Manipur, Meghalaya, Goa and Sikkim) improved their performance from base year to reference year and the performance of the remaining three States (Arunachal Pradesh, Nagaland and Tripura) has worsened (Figure 4.10). Mizoram achieved the highest score of 92.97 in the Health Outcomes domain. However, the range of scores was wide. Manipur received a second highest score of 66.07, while the poorest performing State of Tripura scored only 39.56 points. Figure 4.10 - Smaller States: Performance in the Health Outcomes domain, base and reference years 88.77

Mizoram Manipur

60.71

Meghalaya

60.63 45.62

Goa

48.97

Sikkim Arunachal Pradesh

45.98

Nagaland

44.80

5.36

63.40

2.77

52.79

7.17

50.17

1.20

46.02

-0.04 -15.75

60.55

-15.29 80

Health Outcomes Index Score Base Year (2014-15) Reference Year (2015-16)

Note: States ranked based on their reference year score in the Health Outcomes domain.

4.20

66.07

54.85

39.56

Tripura

92.97

100

-20

-10

Incremental Change

In the Key Inputs/Processes domain, all Smaller States performed quite poorly and the range of scores was significantly smaller. Goa received the highest score of only 44.65, while Manipur scored 32.18 points. Four States (Goa, Meghalaya, Tripura and Manipur) improved their performance; whereas the performance of the remaining four States of Mizoram, Sikkim, Arunachal Pradesh and Nagaland worsened (Figure 4.11). Figure 4.11 - Smaller States: Performance in the Key Inputs/Processes domain, base and reference years

44.64

Mizoram Sikkim

41.31

Arunachal Pradesh

41.03

Meghalaya

55.56

27.09

Tripura

28.86 20

-2.24

42.00

-0.97 -4.44

44.63 38.38

33.96

Manipur

-10.92

43.55

40.19

Nagaland

2.15

44.65

42.50

Goa

11.29 2.42

36.38 32.18

3.32 40

Key Inputs/Processes Index Score

-15

-10

-5

Incremental Change

Base Year (2014-15) Reference Year (2015-16)

Note: States ranked based on their reference year score in the Key Inputs/Processes domain.

4.2.4 Incremental performance on indicators Figure 4.12 captures the incremental performance on indicators and sub-indicators and provides the number of indicators and sub-indicators in each category, i.e, ‘most improved’, ‘improved’, ‘no change’, ‘deteriorated’and ‘most detriorated’. Among the Smaller States, even though Goa has the highest number of indicators that have shown improvement, there are still nearly 30 percent of indicators that have either remained stagnant or deteriorated. Apart from Goa, other Smaller States did not record any improvements even in 40 percent of the indicators. Detailed indicator-specific performance snapshot of States is presented in the Annexure 4, which provides the direction as well as the magnitude of the incremental change of indicators from base year to reference year.

Figure 4.12 - Smaller States: Number of indicators/sub-indicators, by category of incremental performance Number of Indicators/Sub-indicators 0

Goa

Manipur

Nagaland

Mizoram

States

Most Improved

Improved

8 7

No Change

Deteriorated

Most Deteriorated

Arunachal Pradesh

Sikkim

15 9

Meghalaya

Tripura

Not Applicable

Note: For a State, the incremental performance on an indicator is classified as not applicable (NA) in instances such as: (i) Data Integrity Measure indicator wherein the same data has been used for base and reference years due to overlapping periods of NFHS-4; (ii) Service coverage indicators with 100 percent values in both base year and reference year; (iii) The data value for a particular indicator is NA in the base year or reference year or both.

4.3. PERFORMANCE OF UNION TERRITORIES

4.3.1 Overall performance The overall performance based on the Health Index score of UTs for the base year ranged from 31.34 points for Dadra & Nagar Haveli to 57.49 points for Chandigarh.

Chandigarh

57.49

65.79

Lakshadweep

56.23

52.27

Chandigarh

Delhi

48.05

50.02

Delhi

Puducherry

46.54

50.00

Andaman & Nicobar Islands

46.18

47.48

Puducherry

Daman & Diu

44.77

36.10

Daman & Diu

Dadra & Nagar Haveli

31.34

34.64

Dadra & Nagar Haveli

Base Year 2014-15

Reference Year Rank

Base Year Rank

Figure 4.13 - Union Territories: Overall performance - Composite Index score and rank, base and reference years

Reference Year 2015-16

Note: Lines depict changes in composite Index score rank from base to reference year. The composite Index score is presented in the circle.

Some improvements were observed in the reference year, but the best and worst scores still differed by more than 30 points. Despite a modest improvement, Dadra & Nagar Haveli received the lowest score of 34.64 points, while Lakshadweep moved to first place with a score of 65.79 points (Figure 4.13). Only two UTs, namely Lakshadweep and Andaman & Nicobar Islands, improved their position from base year to reference year - Lakshadweep from second to first and Andaman & Nicobar Islands from fifth to fourth position. Delhi has retained its third position during the period. Similarly, Daman & Diu and Dadra & Nagar Haveli did not change ranks and were ranked sixth and seventh, respectively. Puducherry and Chandigarh both fell by one position in the rankings (Puducherry from fourth to fifth, and Chandigarh from first to second). Based on the composite Index score range for reference year (2015-16), the UTs are categorized into three categories: Aspirants, Achievers, and Front-runners. Daman & Diu and Dadra & Nagar Haveli are categorized as Aspirants, and are among the bottom one-third UTs, and have substantial scope for improvement. Chandigarh, Delhi, Andaman & Nicobar Islands and Puducherry are grouped as Achievers and also have significant room for improvement. Lakshadweep with the highest overall performance is categorized as Front-runner, and could also benefit from improvements with an Index score of 65.79, which is well below 100.

Table 4.5 - Union Territories: Overall performance in reference year - Categorization Aspirants

Achievers

Front-runners

Daman & Diu

Chandigarh

Lakshadweep

Dadra & Nagar Haveli

Delhi Andaman & Nicobar Islands Puducherry

Note: The UTs are categorized on the basis of reference year Index score range: Front-runners: top one-third (Index score>55), Achievers: mid one-third (Index score between 45 and 55), Aspirants: lowest one-third (Index score<45).

4.3.2 Incremental performance Figure 4.14 shows that from base to reference year, five UTs (Lakshadweep, Andaman & Nicobar, Dadra & Nagar Haveli, Delhi and Puducherry) registered positive incremental progress and the remaining two UTs (Chandigarh and Daman & Diu) registered negative incremental change. From base year to reference year, Lakshadweep (ranked at the top) observed the highest incremental performance of 9.56 points. Andaman & Nicobar, Dadra & Nagar Haveli and Delhi saw an increase in the Health Index score of between 2 to 4 points from base year to reference year. Puducherry achieved approximately a one point incremental increase. Daman & Diu and Chandigarh reported negative changes in the Health Index score, with the Health Index score declining by 8.67 and 5.22 points, respectively, over the time period. Figure 4.14 - Union Territories: Overall and incremental performance, base and reference years and incremental rank Lakshadweep

56.23

Andaman & Nicobar Islands

46.18

Dadra & Nagar Haveli 31.34

9.56 3.82

50.00

34.64

Delhi

46.54

Chandigarh

5 6

-5.22

57.49

44.77 40

0.94

47.48

52.27 36.10

1.97

50.02

-8.67 60

Overall Performance Index Score

-10

1 2

3.30

48.05

Puducherry

Daman & Diu

65.79

-5

Incremental Change

Incremental Rank

Base Year (2014-15) Reference Year (2015-16)

Furthermore, five UTs (Lakshadweep, Andaman & Nicobar, Dadra & Nagar Haveli, Delhi and Puducherry) observed positive incremental performance in the Index scores from base to reference year, but only two UTs (Lakshadweep and Andaman & Nicobar) could move up in the overall performance ranks from base year to reference year. This suggests that only these two UTs made significant incremental progress leading to improvement in its overall performance position. The remaining UTs with modest or negative incremental progress retained their earlier position or have moved down in the rankings.

The categorization of States based on incremental performance is shown in Table 4.6. Table 4.6 - Union Territories: Incremental performance from base to reference year - Categorization Not improved

Least improved

Moderately improved

Most improved

Chandigarh

Delhi

Andaman and Nicobar Islands

Lakshadweep

Daman and Diu

Puducherry

Dadra and Nagar Haveli

Note: The UTs are categorized on the basis of incremental Index score range into categories: ‘not improved’ (incremental Index score<=0), ‘least improved’ (incremental Index score between 0.01 and 2), ‘moderately improved’ (incremental Index score between 2.01 and 4), ‘most improved’ (incremental Index score>4).

Lakshadweep is the most improved UT and ranked at the top with good incremental progress registered from base to reference years for indicators such as institutional deliveries (76 to 85 percent), TB treatment success rate (87 to 91 percent) and transfer of Central NHM funds from State Treasury to implementation agency (143 to 0 days). Among the UTs which did not register any incremental progress between the base and reference years, Daman & Diu fared poorly on indicators such as low birth weight (17 to 24 percent), full immunization (85 to 80 percent), institutional deliveries (75 to 72 percent), vacancy of specialists at district hospitals (38 to 47 percent), level of registration of births (98 to 76 percent), IDSP reporting format for presumptive surveillance (P-form) submission (100 to 75 percent) and IDSP reporting format for laboratory surveillance (L-form) submission (86 to 75 percent). Similarly, Chandigarh performed very poorly on first trimester ANC registration that fell from 50 percent in the base year to 37 percent in the reference year. The indicators where almost all UTs need to focus include filling vacancies of medical officers at PHCs and specialists at district hospitals, establishment of functional First Referral Units, 24X7 PHCs, and district Cardiac Care Units, CHC grading, quality accreditation of public health facilities, and institutionalization of Human Resources Management Information System. 4.3.3 Domain-specific performance The overall performance of the UTs differs with the domain-specific performance and suggests some opportunities to improve the performance in the lagging domain(s) (Figure 4.15). While most UTs showed a better performance on most Health Outcomes, Daman & Diu and Dadra & Nagar Haveli performed better in terms of Key Inputs/Processes.

Figure 4.15 - Union Territories: Overall and domain-specific performance, reference year 80 70

Reference Year (2015-16) Score

60 50 40 30 20 10 0 Lakshadweep

Chandigarh

Health Outcomes

Delhi

Andaman & Nicobar Islands

Key Inputs/Processes

Puducherry

Daman & Diu

Dadra & Nagar Haveli

Overall Performance

Note: For Chandigarh and Daman and Diu, the Key Input/Processes domain score is the same as the overall performance score.

In the domain of Health Outcomes, all UTs except Chandigarh and Daman & Diu have improved their performance from base year to reference year (Figure 4.16). For the Health Outcomes domain in the reference year, the range of Index scores is very wide and Lakshadweep scored highest with 74.37 points compared to Daman & Diuâ&#x20AC;&#x2122;s lowest score of 15.89. Figure 4.16 - Union Territories: Performance in the Health Outcomes domain, base and reference years 60.15

Lakshadweep Chandigarh

63.58

Andaman & Nicobar Islands

40.24 53.82 50.90

Puducherry

19.82

20.61 3.01

56.83

2.68

53.58

3.82

23.64

Daman & Diu 15.89

14.22 -9.56

73.14 60.85

Delhi

Dadra & Nagar Haveli

74.37

32.10 20

-16.21 50

Health Outcomes Index Score

-20

-10

Incremental Change

Base Year (2014-15) Reference Year (2015-16)

Note: States ranked based on their reference year score in the Health Outcomes domain.

In the case of the Key Inputs/Processes domain, three UTs (Delhi, Dadra & Nagar Haveli and Lakshadweep) improved their performance; whereas the performance of the remaining four UTs (Puducherry, Chandigarh, Daman & Diu and Andaman & Nicobar) has fallen. The range is smaller for the Key Inputs/Processes domain. In this domain, Puducherry scored highest with 52.99 points, while Andaman & Nicobar scored the lowest with 26.75 points. Overall, the range of scores is quite low and indicates that all UTs need to focus on this domain.

Figure 4.17 - Union Territories: Performance in the Key Inputs/Processes domain, base and reference years Puducherry

52.99

Chandigarh

52.10 42.18

Delhi

37.09

Dadra & Nagar Haveli

26.75

Andaman & Nicobar

56.27

-4.17 3.78

45.96

3.88 8.78

38.33 36.11

Daman & Diu

-1.29

40.97

29.55

Lakshadweep

54.28

40.05

-3.94

30.13

-3.38 40

-4

Key Inputs/Processes Index Score

Incremental Change

Base Year (2014-15) Reference Year (2015-16)

Note: States ranked based on their reference year score in the Key Inputs/Processes domain.

4.3.4 Incremental performance on indicators Figure 4.18 captures the incremental performance on indicators and sub-indicators and provides the number of indicators and sub-indicators in each category, i.e, ‘most improved’, ‘improved’, ‘no change’, ‘deteriorated’ and ‘most deteriorated’. Though Delhi had the highest number of indicators where performance has improved between the reference and base years, it has half the indicators where the performance had remained stagnant or deteriorated. This shows that there is substantial scope of improvement for all UTs to improve their performance on various indicators. Detailed indicator-specific performance snapshot of UTs is presented in Annexure 4, which provides direction as well as the magnitude of the incremental change of indicators from base year to reference year. Figure 4.18 - Union Territories: Number of indicators/sub-indicators, by category of incremental performance Number of Indicators/Sub-indicators 0

5 3

Union Territories

Delhi

Puducherry

Chandigarh

Daman & Diu

20 4

No Change

Deteriorated

25 3

Andaman & Nicobar Islands

Improved

Most Improved

Dadra & Nagar Haveli

Lakshadweep

Most Deteriorated

Not Applicable

Note: For a UT, the incremental performance on an indicators is classified as not applicable (NA) in instances such as: (i) Data Integrity Measure indicator wherein the same data has been used for base year and reference year due to overlapping periods of NFHS-4; (ii) Service coverage indicators with 100 percent values in both base and reference years; (iii) The data value for a particular indicator is NA in base year or reference year or both.

4.4 STATES AND UNION TERRITORIES: PERFORMANCE ON INDICATORS

This section presents the findings related to State-wise performance by each indicator included in the Health Index. It also draws comparisons between the base year and reference year performance by each indicator. DOMAIN 1: HEALTH OUTCOMES SUB-DOMAIN 1.1: KEY OUTCOMES

Indicator 1.1.1: Neonatal Mortality Rate (NMR) Figure 4.19 - Indicator 1.1.1: Neonatal Mortality Rate - Larger States

40 35

35 32

32 30

Neonatal deaths per 1000 live births

28 26

25 20

1414

24 20 19

25 23

26 23

36 34

28 26

16 15

10 5

6 6

Base Year (2014)

Reference Year (2015)

Bi ha Ut r ta ra kh an d Ra ja sth Ut an ta rP ra M de ad sh hy aP ra de sh Od ish a

As sa Ch m ha tti sg ar h

Ke ra la Pu nj ab Ta m il Na M du ah ar as ht W ra es tB Hi m en ac ga ha l lP ra de sh Ka Ja rn m a m u & taka Ka sh m ir Gu ja ra t Jh ar kh an d Te la ng An an dh a ra Pr ad es h Ha ry an a

Source: SRS

The NMR or the number of neonatal deaths (occurring in the first 28 days of life) per 1000 live births during a specific year reflects the quality of prenatal, intrapartum, and neonatal care services. This is an important indicator as approximately 68 percent of infant deaths in India occur during the neonatal period8. The NMR is available for the Larger States and is the highest in Odisha and the lowest in Kerala for both the base year (2014) and reference year (2015). All States reported a decline in the NMR from the base year (2014) to reference year (2015) except for Haryana, Bihar and Uttarakhand where it increased marginally, remaining static in Kerala and Tamil Nadu. The most progressive decline in the NMR was observed in Himachal Pradesh and Jammu & Kashmir where the decline was approximately 23 to 24 percent. Despite reductions, the NMR remains high in many States and concerted efforts need to be made to reach the NMR national policy goal of 16 deaths per 1000 live births by 20259and 12 deaths per 1000 live births by 2030 (the SDGs). Kerala, Punjab, Tamil Nadu and Maharashtra have already attained the National Health Policy (NHP) 2017 NMR goal for 2025, while Kerala also has the notable distinction of surpassing the SDG 2030 target.

8 9

Office of the Registrar General and Census Commissioner (India). India SRS Statistical Report 2015. New Delhi, India. Ministry of Health and Family Welfare, Government of India. National Health Policy â&#x20AC;&#x201C; 2017. New Delhi: MoHFW; 2017.

Indicator 1.1.2: Under-five Mortality Rate (U5MR) The U5MR reflects the probability of dying before attaining the age of 5. The U5MR or the number of deaths under the age of 5 per 1000 live births during a specific year reflects a combination of several factors, such as the nutritional status of children, health knowledge of mothers, level of immunization and oral rehydration therapy, access to maternal and child health services, income of the family, and availability of safe drinking water and basic sanitation services. The U5MR is available only for the Larger States; a comparison between the base year and reference year shows that U5MR declined in 14 States, remained stagnant in four (Kerala, Punjab, West Bengal, and Karnataka) and increased in three States (Maharashtra, Uttarakhand and Haryana). Jammu & Kashmir, Jharkhand, Bihar, and Uttar Pradesh recorded significant decline (between 9 to 20 percent) in U5MR between the base year (2014) and the reference year (2015). Kerala and Tamil Nadu have already achieved the National Health Policy 2017 U5MR target for 2025 of 23 deaths per 1000 live births. However, 12 States, namely Uttarakhand, Andhra Pradesh, Gujarat, Jharkhand, Haryana, Bihar, Chhattisgarh, Rajasthan, Uttar Pradesh, Odisha, Assam and Madhya Pradesh, with U5MR above 35 deaths per 1000 live births will require concerted effort to ensure that this target is achieved. Figure 4.20 - Indicator 1.1.2: Under-five Mortality Rate - Larger States

50 40 21

30 20

20 23

28 30

40 39

41 39

40 43

57 50

60 51

66 56

65 62

Reference Year (2015)

As M sa ad m hy aP ra de sh

Ja Pu m nj m ab u& Ka sh m ir W es tB en ga l Ka rn Hi at m ak ac a ha lP ra de sh Te la ng an a Ut ta ra k An ha nd dh ra Pr ad es h Gu ja ra t Jh ar kh an d Ha ry an a

Base Year (2014)

Bi ha Ch r ha tti sg ar h Ra ja sth Ut an ta rP ra de sh Od ish a

0 Ke ra la Ta m il Na du M ah ar as ht ra

per 1000 live births

Under-five child deaths

Source: SRS

Indicator 1.1.3: Total Fertility Rate (TFR) The TFR represents the average number of children that would be born to a woman if she experiences the current age-specific fertility rate throughout her reproductive years (15-49 years). A high level of fertility is associated with extreme poverty, gender inequality, maternal mortality, and other dimensions of sustainable development. The TFR indicator is available only for the Larger States. In 2015, 12 of the 21 Larger States (Andhra Pradesh, Himachal Pradesh, Jammu & Kashmir, Karnataka, Kerala, Maharashtra, Odisha, Punjab, Tamil Nadu, Telangana, Uttarakhand and West Bengal) have achieved the replacement level fertility (TFR â&#x2030;¤ 2.1). The fertility rate remains at 2.7 or above in Bihar, Jharkhand, Madhya Pradesh, Rajasthan and Uttar Pradesh. The remaining three States (Assam, Gujarat, and Haryana) are close to achieving the replacement level of fertility with TFR levels between 2.2 and 2.3. A comparison between the base year (2014) and reference year (2015) indicates that six States (Chhattisgarh, Gujarat, Haryana, Jharkhand, Rajasthan and Uttar Pradesh) have showed a decline of 0.1 in TFR.

Indicator 1.1.4: Proportion of Low Birth Weight (LBW) among newborns The LBW (â&#x2030;¤2.5 kg) among newborns is an important predictor of newborn health and survival. There are several risk factors related to the mother that may contribute to low birth weight, such as child bearing at a young age, multiple pregnancies, poor nutrition, heart disease or hypertension, untreated coeliac disease, and insufficient prenatal care. Reduction in the proportion of babies born with LBW therefore requires the convergence of interventions across several determinants of health. The HMIS MoHFW data for base year (2014-15) and reference year (2015-16) show that the proportion of LBW among newborns is high in many States and UTs. Among all States and UTs, Dadra & Nagar Haveli report the highest percentage of LBW (35 percent in the base year and 29 percent in the reference year). Other States with a high (â&#x2030;Ľ15 percent) proportion of LBW newborns include Haryana, West Bengal, Assam, Odisha, Rajasthan, Goa and all UTs except Lakshadweep. Across all States and UTs there has been little progress in reducing the proportion of LBW newborns between the base year and the reference year and, in fact, this has increased in several States. Hence, almost all States and UTs need to focus on strategies and interventions to address this issue and break the inter-generational cycle of malnutrition.

27.4 25.5

Figure 4.21 - Indicator 1.1.4: Proportion of Low Birth Weight among newborns - Larger States

20.1 19.2

18.2 16.7

15.5 16.5

14.6 14.9

14.2 14.1

10.5 13.0

8.7

12.6

11.6 12.2

10.8 11.7

10.8 11.5

9.6

7.8 7.4

7.8 7.3

6.7 7.2

6.0 6.9

5.6 6.7

6.3 5.9

6.1 5.7

10.0

11.7

15.0

10.6 10.5

20.0

14.6 13.7

25.0

5.0

Base Year (2014-15)

Ra ja sth an

As sa m Od ish a

Ke ra Ch la ha Hi t t isg m ac ar ha h lP ra de sh Ta m il Na du M ah ar as M ad ht ra hy aP ra de sh Ha ry an W a es tB en ga l

Bi ha Ut r ta ra kh an d Jh ar kh Ut an ta d rP ra de sh Gu ja ra t Ka rn at ak a

0.0 Te Ja la m ng m u & ana Ka sh An m dh ir ra Pr ad es h Pu nj ab

Low birth weight among newborns (%)

30.0

Reference Year (2015-16)

Source: HMIS

Figure 4.22 - Indicator 1.1.4: Proportion of Low Birth Weight among newborns - Smaller States and UTs

Source: HMIS

10.0 5.0

34.7 16.9

20.9 21.4

22.5 20.8

24.4

29.4

15.0

16.1 17.2

20.0

0.0

Base Year (2014-15)

Da m Da an dr & a& Di u Na ga rH av el i

Go a

Tr ip ur a

Reference Year (2015-16)

25.0

18.5 15.5

6.8 7.8

Si kk im

0.0

30.0

De lh i

4.7 4.7

2.0

35.0

4.9 5.6

4.0

4.1 3.9

6.0

3.9 3.5

8.0

5.8 6.6

10.0

8.2 7.7

12.0

40.0

La ks ha dw ee p Pu du An c h da er m ry an & Ni co ba r Ch an di ga rh

10.6 11.1

14.0

Low birth weight among newborns (%)

16.7 15.6

16.0

Base Year (2014-15)

Union Territories

18.0

M an ip ur Na ga la nd M izo Ar un ra ac m ha lP ra de sh M eg ha la ya

Low birth weight among newborns (%)

Smaller States

Reference Year (2015-16) Source: HMIS

Indicator 1.1.5: Sex Ratio at Birth (SRB) Sex Ratio at Birth or the number of girls born for every 1000 boys born during a specific year is an important indicator and reflects the extent to which there is reduction in the number of girl children born by sex-selective abortions. This indicator was only available for the category of Larger States. The SRB is substantially lower in almost all Larger States - 17 out of 21 States have SRB of less than 950 females per 1000 males. Further, in most States, SRB has declined between the base year (2012-14) and reference year (2013-15), except for Bihar, Punjab and Uttar Pradesh where improvements in SRB were noted, and Jammu & Kashmir where it stagnated. Chhattisgarh, Karnataka, Himachal Pradesh, Assam, Maharashtra, Rajasthan, Gujarat, Uttarakhand and Haryana recorded substantial drops (10 or more points) in this indicator. There is a clear need for States to effectively implement the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 and take appropriate measures to promote the value of the girl child. Figure 4.23 - Indicator 1.1.5: Sex Ratio at Birth - Larger States

871 854

861

866

893

878

831

844

850

869

870

879

889

896

899 899

907

918 900

921 910 902

900

911

916 907

919 918

927 919

919 918

Number of girls born for every 1000 boys born

924

938

950 939

953 950

973 952 951

950

961

974 967

1000

800

Base Year (2012-14)

Ja As m sa m u& m Ka sh m ir Pu nj Ut ab ta rP ra de M sh ah ar as ht ra Ra ja sth an Gu ja ra Ut t ta ra kh an d Ha ry an a

Bi ha Ta r m il Na du Jh ar kh an d

Ke ra la Ch ha tti sg ar W h es tB en ga l Od ish a Ka Hi rn at m ak ac a ha lP ra M de ad s hy aP h ra de An sh dh ra Pr ad es h Te la ng an a

750

Reference Year (2013-15) Source: SRS

SUB-DOMAIN 1.2: INTERMEDIATE OUTCOMES

Indicator 1.2.1: Full immunization coverage This indicator reflects upon the success of the immunization programme and captures the proportion of infants between the ages of 9-11 months who have received one dose of BCG, 3 doses of DPT, 3 doses of OPV, and one dose of measles vaccine. Reference year data shows that 19 States and UTs have full immunization coverage of at least 90 percent, the 2025 target specified in the National Health Policy 2017. Jammu & Kashmir, Mizoram, Andaman & Nicobar Islands and Lakshadweep have 100 percentcoverage during the reference year (2015-16). Madhya Pradesh (75 percent), Nagaland 43

(64 percent) and Dadra & Nagar Haveli (77 percent) have the lowest coverage among the Larger States, Smaller States and UTs respectively. From base to reference year, Maharashtra, West Bengal, Kerala, Andhra Pradesh, Telangana, Odisha, Tamil Nadu, Rajasthan, Meghalaya, Tripura and Daman & Diu reported a decline in immunization coverage. It is evident that several States need to implement specific strategies to attain the goals set out in National Health Policy 2017, which targets more than 90 percent full immunization coverage by 2025. Telangana, Jharkhand, Assam, Odisha, Uttar Pradesh, Haryana, Tamil Nadu, Rajasthan, Madhya Pradesh, Tripura, Sikkim, Arunachal Pradesh, Nagaland, Daman & Diu, Puducherry and Dadra & Nagar Haveli fall short of the target of 90 percent coverage. Importantly, while the average full immunization coverage among the Larger States is 90 percent, it is significantly lower for Smaller States at 84 percent. Figure 4.24 - Indicator 1.2.1: Full immunization coverage - Larger States

74.3 74.8

79.0 78.1

80.0

85.5 82.7

82.5 83.5

82.9 84.8

88.0 85.3

84.1 88.0

80.8 88.1

100.0 89.1

82.1 89.7

85.8 90.5

90.3 90.6

97.6 91.6

95.5 94.6

94.9 95.2

100.0 95.9

92.3 96.2

98.6 98.2

91.8 99.3

100.0

96.1 99.6

100.0

89.8

between ages of 9-11 months (%)

Full immunization coverage among infants

120.0

60.0 40.0 20.0

Base Year (2014-15)

Od ish Ut a ta rP ra de sh Ha ry an a Ta m il Na du Ra ja M s th ad an hy aP ra de sh

As sa m

Bi ha r Te la ng an a Jh ar kh an d

Gu ja ra Ch t ha tti sg ar h

Ja m m u&

Ka sh m ir Pu nj ab Ut ta ra kh an M d ah ar as ht ra Ka rn at ak W a es tB Hi m en ac ga ha l lP ra de sh K er An al dh a ra Pr ad es h

0.0

Reference Year (2015-16) Source: HMIS

Figure 4.25 - Indicator 1.2.1: Full immunization coverage - Smaller States and UTs

Reference Year (2015-16)

75.5 77.1

73.9 77.6

85.0 79.7

92.3 93.6

90.9 96.2

100.0 100.0

100.0 84.6

80.0 60.0 40.0 20.0

Base Year (2014-15)

De lh i

Ch an di ga rh Da m an & Di u Pu du Da ch dr er a& ry Na ga rH av el i

0.0 La ks ha dw ee p

Ar Si un kk ac im ha lP ra de sh Na ga la nd

Go a M eg ha la ya Tr ip ur a

M izo ra m M an ip ur

0.0

100.0

Ni co ba r

20.0

120.0

An da m an &

40.0

Full immunization coverage among infants between 9-11months (%)

61.9 63.9

60.6 65.0

60.0

74.1 74.4

Union Territories

87.4 84.3

96.4 93.3

80.0

Base Year (2014-15)

91.3 95.2

94.4 96.3

100.0

100.0 100.0

120.0

between 9-11 months (%)

Full immuinization coverage among infants

Smaller States

Reference Year (2015-16) Source: HMIS

Indicator 1.2.2: Proportion of institutional deliveries Institutional deliveries (public and private) can play a substantial role in addressing maternal and infant mortality and morbidity. In the reference year (2015-16), only six States and UTs achieved more than 90 percent coverage - Gujarat and Kerala among Larger States; Mizoram and Goa among Smaller States; and Chandigarh and Puducherry among UTs. Other States need to make substantial efforts to improve the coverage of institutional deliveries, particularly Madhya Pradesh, Chhattisgarh, Uttarakhand, Bihar, Uttar Pradesh, Meghalaya, Nagaland and Arunachal Pradesh, where less than two-thirds of deliveries currently take place at health facilities. In terms of incremental progress, approximately 40 percent of the States and UTs made modest or no progress in institutional deliveries coverage. Andhra Pradesh (64 percent) and Telangana (44 percent) made the most notable progress and the coverage increased by more than 40 percent between base year (2014-15) and reference year (2015-16).

52.4 43.6

50.0

53.0 57.1

64.3 62.6

59.6 64.5

67.4

63.1 64.8

60.5

59.2 53.1

60.0

40.0 30.0 20.0 10.0

Base Year (2014-15)

Reference Year (2015-16)

Bi ha Ut r ta rP ra de sh

Ke An ra dh la ra Pr ad es h Te la ng a na M ah ar as ht ra Pu nj ab Ta m il Na du W es tB Ja m e ng m u& al Ka sh m ir Ha ry an a Ka rn at ak a As sa m Ra ja sth an Od Hi m ish ac a ha lP ra de sh Jh a rk M ha ad nd hy aP ra de sh Ch ha tti sg ar Ut h ta ra kh an d

0.0 Gu ja ra t

Institutional Deliveries (%)

70.0

67.5 67.5

74.8 73.5

74.7 73.9

72.7 74.3

77.1 78.8

80.8 80.3

81.5 80.5

86.0 81.8

83.2 82.3

79.9 81.3

80.0

89.2 85.3

85.4

90.0

87.1

97.8 90.8

100.0

96.0 92.6

Figure 4.26 - Indicator 1.2.2: Proportion of institutional deliveries - Larger States

Source: HMIS

Figure 4.27 - Indicator 1.2.2: Proportion of institutional deliveries - Smaller States and UTs

20.0

Base Year (2014-15)

75.3 72.0

76.2 80.2

79.4 80.6

76.4 85.4

100.0 100.0

60.0 40.0 20.0 0.0 Ch an di ga rh P Da ud uc dr a& he rry Na ga rH av el i La ks ha dw ee p

Si kk im M eg ha la ya Na ga Ar la un nd ac ha lP ra de sh

Tr ip ur a M an ip ur

Go a

0.0

80.0

Reference Year (2015-16) Source: HMIS

Base Year (2014-15)

An De da lh m i an & Ni co ba Da r m an & Di u

40.0

88.2 87.1

Institutional Deliveries (%)

56.0 56.5

57.0 58.1

60.0

59.6 62.1

72.0 70.2

100.0 74.9 73.5

78.5 79.4

91.3 92.5

120.0

80.0

M izo ra m

Institutional Deliveries (%)

100.0

100.0 96.3

120.0

100.0 100.0

Union Territories

Smaller States

Reference Year (2015-16) Source: HMIS

Indicator 1.2.3: Total case notification rate of tuberculosis (TB) Total case notification rate is the number of new and relapsed TB cases notified, in both public and private facilities per 100,000 population during a specific year. It is an important indicator reflecting diagnosis and reporting of TB cases in the National Surveillance System and is an essential element for effective implementation of the End TB Strategy. The total case notification varied between 72 per 100,000 population in Jammu & Kashmir to 207 per 100,000 population in Himachal Pradesh. The total case notification rate increased by 10 cases per 100,000 population or more in Gujarat, Madhya Pradesh, Kerala, Chhattisgarh, Uttar Pradesh, Tamil Nadu, Telangana, Bihar, Tamil Nadu, Uttar Pradesh, Chhattisgarh, Kerala, Madhya Pradesh, Gujarat, Sikkim, Delhi and Daman & Diu and has decreased by 10 cases per 100,000 population or more in Nagaland, Meghalaya, Tripura, Andaman & Nicobar and Lakshadweep.

74 72

84 72

93 93

106 99

100 105

100 108

113 123

122 123

113 125

137 136

123 137

145 138

128 138

139

139 143

164

165 172

155 164

136 145

100

143

150

50 0

Hi m ac ha lP ra de sh Gu ja ra Ha t M ad ry a hy a P na ra de M sh ah a ra An s dh ht ra ra Pr ad e Ra sh ja sth an Ke ra Ch ha la tti sg ar Ut h ta ra k ha Ut n ta rP d ra de sh Pu nj ab Ta m il Na du As s Te am la ng an a Jh ar kh a Ka nd rn at ak a Od i s W ha es tB en ga Ja l m Bi m u & ha Ka r sh m ir

Total case notification rate of TB per 100,000 population

170

200

193

210 207

Figure 4.28 - Indicator 1.2.3: Total case notification rate of TB - Larger States

Base Year (2015)

Reference Year (2016)

Source: RNTCP MIS, MoHFW

Figure 4.29 - Indicator 1.2.3: Total case notification rate of TB - Smaller States and UTs Union Territories

61 35

95 103

157 139

146 166

300 305

Ch an di ga rh Da m a n& An da Di m u an & Da Ni co dr ba a& r Na ga rH av el i Pu du ch er ry La ks ha dw ee p

De lh i

Reference Year (2016)

Base Year (2015)

138 133

400 350 300 250 200 150 100 50 0

337 348

Total case notification rate of TB per 100,000 population

195 61

Go a M an ip ur Tr ip ur a

82 81

127 131

170 137

173 139

186 183

183 186

222 241

300 250 200 150 100 50 0

Si kk im M izo Ar un ra ac m ha lP ra de sh Na ga la nd M eg ha la ya

Total case notification rate of TB per 100,000 population

Smaller States

Base Year (2015)

Reference Year (2016)

Source: RNTCP MIS, MoHFW

Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases Treatment success rate of TB cases is the proportion of new cases cured and their treatment completed against the total number of new microbiologically confirmed TB cases registered during a specific year. It is an important indicator that reflects the performance of the Revised National Tuberculosis Control Programme. The National Health Policy 2017 establishes a target of â&#x2030;Ľ85 percent for treatment success rate of TB cases, which was achieved by most States and UTs except Karnataka, Maharashtra, Manipur, Sikkim, Nagaland (dropped from base year) and Daman & Diu.

85.4

84.7

83.9 84.2

83.3

82.3

85.5 86.0

86.4 86.5

86.9 87.2

88.2 87.5

87.5

84.0

85.4 86.2

86.0

87.6 88.3

88.5

88.9

90.4

88.0

87.4

88.5 88.9

88.2 89.1

90.0 89.6

89.7 89.6

89.0 89.7

90.4 90.3

89.7 90.3

90.0

82.0 80.0

Ke ra Ut la ta rP ra de sh Pu nj ab W es tB en ga l As sa m Ut ta ra kh an d Ta m il Na du Ka rn at ak M a ah ar as ht ra

78.0 Jh ar M kh ad an hy d aP ra de sh Ra ja sth an Hi m Bi ac ha ha r lP ra de sh Te la ng an Ch a ha tti sg ar h Gu ja ra t O di An sh dh a ra Ja Pr ad m m u & esh Ka sh m ir Ha ry an a

Treatment success rate of new microbiologically confirmed TB cases (%)

92.0

89.8 90.9

Figure 4.30 - Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases - Larger States

Base Year (2014)

Reference Year (2015)

Source: RNTCP MIS, MoHFW

Figure 4.31 - Indicator 1.2.4: Treatment success rate of new microbiologically confirmed TB cases - Smaller States and UTs

Base Year (2014)

Reference Year (2015)

83.1 79.5

89.5 85.6

85.2 86.3

86.2 86.7

De lh i Na ga rH av el i Ch an di ga rh Da m an & Di u Da dr a&

86.7 91.3

85.5 91.5

La ks ha dw ee p Pu du ch er ry

Ni co ba r

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

An da m an &

Treatment success rate of new microbiologically confirmed TB cases (%)

90.7 71.9

78.8 77.2

85.0 82.6

Si kk im Na ga la nd

82.3 85.8

88.0 86.4

86.4 87.3

88.6 88.5

Ar un Go ac ha a lP ra de sh M eg ha la ya M an ip ur

86.5 90.6

M izo ra m Tr ip ur a

Treatment success rate of new mircobiolgically confirmed TB cases (%)

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

88.5 89.2

Union Territories

Smaller States

Reference Year (2015) Source: RNTCP MIS, MoHFW

Source: RNTCP MIS, MoHFW

Indicator 1.2.5: Proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART) This indicator tracks progress in access to treatment for PLHIV for the category of Larger and Smaller States, but not for UTs (data not available for some UTs). The National Health Policy 2017 sets a specific goal corresponding to achieving the global target of 2020, namely to ensure that 90 percent of all people tested positive for HIV receive sustained ART. Out of 29 States, three (Jammu & Kashmir, Meghalaya and Mizoram) have achieved this target while five have 80 to 90 percent of PLHIV on ART in the reference year (2015-16). Eight states have less than 50 percent of the PLHIV on ART (reference year 2015-16), namely Rajasthan, Jharkhand, Bihar, West Bengal, Odisha, Sikkim, Arunachal Pradesh and Tripura. Apart from Tripura, the other 28 states have shown some incremental progress in this indicator. However, significant improvements are needed to achieve 90 percent coverage.

28.3 33.0

31.0 35.9

30.7 37.2

42.4 46.4

52.3 51.5

36.1 39.4

40.0

50.2 52.4

47.2 53.1

51.3 57.8

53.0 61.0

62.7 65.3

58.9 64.6

60.0

61.8 66.7

72.4 76.1

79.2 79.9

77.2 84.6

80.0

81.9 87.1

PLHIV on ART (%)

100.0

83.5 87.7

88.7 96.4

120.0

83.3 88.7

Figure 4.32 - Indicator 1.2.5: Proportion of people living with HIV on antiretroviral therapy - Larger States

20.0

Base Year (2014-15)

Bi ha W r es tB en ga l Od ish a

As M sa ad m hy aP ra de Ut sh ta rP ra de sh Ch ha tti sg ar h Gu ja ra t Ha ry an a Ra ja sth an Jh ar kh an d

Ke ra la Ut ta ra kh an d

Ja m m u&

Ka sh m ir Ka rn at ak M a ah ar as ht ra Ta m il Na du Pu Hi m nj ac ab ha lP ra An de dh sh ra Pr ad es h Te la ng an a

0.0

Reference Year (2015-16) Source: Central MoHFW Data

Figure 4.33 - Indicator 1.2.5: Proportion of people living with HIV on antiretroviral therapy - Smaller States

23.1

18.7

40.0

28.2

32.5

60.0

33.5

54.0

63.9

72.8

70.9

73.8

100.0

96.7

80.0 63.8

PLHIV on ART (%)

100.0

98.7

120.0

5.8

20.0 0.0 Meghalaya

Mizoram

Nagaland

Goa

Base Year (2014-15)

Manipur

Sikkim

Arunachal Pradesh

Reference Year (2015-16)

Tripura

Source: Central MoHFW Data

Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility The National Family Health Survey (NFHS)-4 data on average out-of-pocket (OOP) expenditure per delivery in public health facility is considered here as a proxy indicator for overall OOP expenditure. This data is available only for 2015-16 and hence the indicator is reported only for the reference year. There is significant variation in the average OOP expenditure across the States. The expenditures range from as low as INR 471 in Dadra & Nagar Haveli to as high as INR 10,076 in Manipur. The top five States and UTs with average expenditure above INR 6,000 per delivery in a public facility are Manipur (INR 10,076), Delhi (INR 8,719), West Bengal (INR 7,782), Kerala (INR 6,901), and Arunachal Pradesh (INR 6,474). The average OOP expenditure per delivery in public health facility for Larger States is INR 3,080, for Smaller States it is INR 5,170, and for UTs it is INR 2,995. Given the number of NHM interventions targeting pregnant women, such as Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), and Referral Transport to ensure free delivery at public health facilities, the States should aim to reduce the OOP expenditure.

6901

8000 7000

7782

9000

4225

4192

4020

3893

3329

3210

3052

2399

2138

2136

1956

1890

1724

1503

1480

2000

1387

3000

1476

4000

2496

5000

3487

6000

1000

Ke ra W la es tB en ga l

Bi ha r Pu n Ut ja ta b rP ra de sh Gu An ja dh ra ra t Pr ad es h Ut ta ra kh an Ta d m il Na Ra du ja sth an Hi As m sa ac m ha lP ra de M sh ah ar as ht ra Ka rn at ak a Te la Ja n m ga m na u& Ka sh m ir Od ish a

0 M ad hy aP ra de sh Jh ar kh an Ch d ha tti sg ar h Ha ry an a

Average OOP expenditure per delivery in public health facility (in INR)

Figure 4.34 - Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility (in INR) - Larger States

Source: NFHS-4 (2015-16)

8719

8000

1581

1258

2000

1999

4000

2357

4580

6000

Da dr a&

De lh i

0 Na ga rH An av da el m i an & Ni co ba Da r m an & Di u Pu du ch er ry Ch an di ga rh La ks ha dw ee p

Go a Na Ar g un al an ac d ha lP ra de sh M an ip ur

Si kk im M eg ha la ya M izo ra m Tr ip ur a

10000

471

6474

5834

2000

Union Territories

(in INR)

4000

4412

2509

2892

6000

4327

8000

4836

10000

Average OOP expenditure

12000

per delivery in public health facility

10076

Smaller States

(in INR)

Average OOP expenditure

per delivery in public health facility

Figure 4.35 - Indicator 1.2.6: Average out-of-pocket expenditure per delivery in public health facility (in INR) - Smaller States and UTs

Source: NFHS-4 (2015-16)

DOMAIN 2: GOVERNANCE AND INFORMATION SUB-DOMAIN 2.1: HEALTH MONITORING AND DATA INTEGRITY

Indicator 2.1.1: Data Integrity Measure: Institutional deliveries and ANC registered within first trimester This indicator captures the percentage deviation of HMIS reported data from the NFHS-4 data in order to assess the quality and integrity of reported data. Specifically, data from HMIS for last 5 years (2011-12 to 2015-16) on the proportion of institutional deliveries and ANC registered within the first trimester is compared with NFHS-4 conducted during 2015-16. Figure 4.36 - Indicator 2.1.1: Data Integrity Measure - Institutional deliveries - Larger States

36.6

35.0

3.7

2.1

1.2

0.7

13.8

12.7

12.4

23.5

23.1

22.3

21.2

18.2

4.6

Bi ha r Te la ng an a Ka rn at ak Ch a ha t t i M s g ad ar hy h aP r ad An es dh h ra Pr ad es Ut h ta rP ra de sh

0.0

0.3

5.0

8.0

10.0

12.4

10.9

15.0

12.4

20.0

14.9

25.0

21.1

30.0

As sa m Gu ja ra M t ah ar as ht W ra es tB en ga l Ke ra la Ha ry an a Jh ar kh an d Ta m il Na du Ja P un m m ja u& b Ka sh m ir Ra ja Hi sth m ac an ha lP ra de sh Od ish Ut a ta ra kh an d

Deviation of HMIS data with NFHS -4 data for institutional deliveries (%)

40.0

Source: HMIS & NFHS-4

80.0

60.0

0.0

Source: HMIS & NFHS-4

10.0

2.8

20.0

30.0

50.0 48.8

20.0

Smaller States Source: HMIS & NFHS-4 29.4

18.1

17.4

15.1

10.8

80.0 58.0

60.0

27.9

54.8

100.0 90.5

Smaller States

27.8

22.1

De lh Na i ga rH av Da el i m a An n& da Di m u an & Ni co ba La r ks ha dw ee p Ch an di ga rh Pu du ch er ry

40.0

15.3

12.2

Da dr a&

29.2

Deviation of HMIS data with NFHS - 4 data for institutional deliveries (%)

Si kk im Na ga la nd

22.0

Bi h Ra ar ja sth an Ha ry an a As sa m Od ish Ta a m il Na du Ke r al Ch a ha tti sg W ar es h tB en Jh gal ar kh an d

2 5 .9

2 4 .9

2 2 .8

2 2 .1

2 1 .2

1 9 .1

1 8 .4

1 6 .3

1 5 .8

1 5 .4

1 3 .5

1 0 .8

1 0 .0

9 .2

8 .2

7 .3

5 .6

2 .1

0 .9

30 .0

De lh i Ch an di ga rh Pu du ch er ry

100.0

Ni co ba La r ks ha dw ee p Da m Da an dr & a& Di u Na ga rH av el i

107.9

120.0

Deviation of HMIS data with NFHS - 4 data for ANC registered within first trimester (%)

28.2

26.8

13.4

5.0

Go a

M eg ha la ya M izo ra m

3.4

Tr ip ur a

2.9

20 .0

An da m an &

40.0

23.7

18.7

10.9

10.6

Ut ta rP ra de sh Gu ja ra M t Hi aha ra m ac sh ha t l P ra ra de Ka sh rn M at ad ak hy a aP ra de sh Pu n ja Ut b ta Ja ra m kh m u & and An Kas dh h ra mir Pr ad es h Te la ng an a

50 .0

42 .4

60 .0

53 .5

Deviation of HMIS data with NFHS 4 data for ANC registered within first trimester (%)

0.0

Si kk im M an ip ur Na ga la nd

20.0 1.4

60.0 50.0 40.0 30.0 20.0 10.0 0.0

5.6

Ar un ac ha lP ra de sh M an ip ur

Deviation of HMIS data with NFHS - 4 data for institutional deliveries (%)

10 .0

Go a

Ar un ac ha lP ra de sh M eg ha la ya Tr ip ur a M izo ra m

Deviation of HMIS data with NFHS - 4 data for ANC registered within first trimester (%)

Figure 4.37 - Indicator 2.1.1: Data Integrity Measure - ANC registered within first trimester - Larger States

40 .0

Source: HMIS & NFHS-4

Figure 4.38 - Indicator 2.1.1: Data Integrity Measure - Institutional deliveries - Smaller States and UTs Union Territories

0.0

Source: HMIS & NFHS-4

Figure 4.39 - Indicator 2.1.1: Data Integrity Measure - ANC registered within first trimester - Smaller States and UTs

Union Territories

60.0

40.0

0.0

Source: HMIS & NFHS-4

In the case of institutional deliveries, Uttar Pradesh, Nagaland and Puducherry have the widest discrepancy between HMIS and NFHS-4 data. The trend is somewhat different in the case of ANC registered within the first trimester, where Jharkhand, Nagaland, and Puducherry have the widest variation between the HMIS and NFHS-4 data. The States, UTs and MoHFW need to ensure that this deviation is minimized by adopting robust data quality mechanisms.

SUB-DOMAIN 2.2: GOVERNANCE

Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level for last three years This indicator reflects the average occupancy of key administrative officials (in months), combined for the posts of Principal Secretary, Mission Director (NHM) and Director (Health Services) in the last three years. A stable tenure for key administrative positions is very critical for effective implementation of the programs. The data reveals that the average occupancy of Principal Secretary, Mission Director (NHM), and Director (Health Services) or equivalent positions in a period of 36 months (3 years) is the highest in West Bengal (28 months) among the Larger States, Sikkim (24 months) among the Smaller States and Lakshadweep (27 months) among UTs. Many States have an average occupancy per officer for the three key administrative positions of less than 12 months - Chhattisgarh, Haryana, Uttarakhand, Telangana, Karnataka, Tripura, Mizoram, Nagaland and Delhi in the reference year (2013-16). Significant improvements (5 months or more) have been achieved in West Bengal, Uttar Pradesh, Madhya Pradesh, Goa and Manipur, but in Jammu & Kashmir, Kerala, Arunachal Pradesh, Nagaland and Andaman & Nicobar, the occupancy has declined substantially from the base year (2012-15) to the reference year (2013-16). Among the Larger States between the base year (2012-15) and reference year (2013-16), Uttar Pradesh has shown the maximum progress where the average occupancy doubled from 10 to 20 months, while Kerala has shown the maximum decline in the tenure of these officers where the tenure has almost halved from 22 to 12 months.

6.9 6.5

8.7 7.8

10 .7 10 .4

13 .8 11 .2

11 .4 11 .4

13 .0 12 .0

11 .1 12 .0

12 .0

11 .4 12 .4

15 .0 13 .0

21 .8

22 .8 13 .8

15 .7 10 .9

16 .5

16 .0 10 .8

19 .6

11 .9

10 .2 12 .1

10.0

17 .7 17 .5

20 .0 20 .4

22 .0

20 .2 20 .7

15.0 9.6

Average occupancy of an officer (in months) for three key posts for last three years

20.0

19 .0

25.0

22 .0

30.0

28 .0

Figure 4.40 - Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level for last three years - Larger States

5.0

W es tB en g Ra al ja sth an Gu ja ra t Pu n ja Ut b ta rP ra An d es dh h ra Pr ad es Ta h m il M Na ad du hy aP ra de sh M ah Ja ar m a s m u & htra Ka sh m ir Hi Bi m h ac ar ha lP ra de sh As sa m Ke ra la Od ish a Jh ar kh an Ch d ha tti sg ar h Ha ry an Ut a ta ra kh an d Te la ng an a Ka rn at ak a

0.0

Base Year (2012-15)

Reference Year (2013-16) Source: State Report

Note: Three key posts are Principal Secretary (Health), Mission Director (NHM) and Director (Health Services).

Figure 4.41 - Indicator 2.2.1: Average occupancy of an officer (in months) combined for three key posts at State-level for last three years - Smaller States and UTs Union Territories

Base Year (2012-15)

Reference Year (2013-16)

26 .0

13 .7 9 .6

14 .4 14 .4

10 .8 12 .0

10.0

15 .0

15.0

22 .0 20 .0

20.0

5.0 0.0

Base Year (2012-15)

Source: State Report

De lh i

M izo ra m Na ga la nd

Tr ip ur a

Go a M an ip ur M eg Ar ha un la ac ya ha lP ra de sh

0.0

25.0

La ks ha dw ee p Da m an & Di u Pu du An ch da er m ry an & Da N dr ico a& ba r Na ga rH av el i Ch an di ga rh

5.0

Average occupancy of an officer (in months) for three key posts at UT level for last three years

11 .6 7 .3

11 .1 9 .8

10.0

12 .0 10 .9

19 .9

21 .0

20 .0 19 .3

13 .9

15.0

13 .3

14 .8

21 .7

24 .0 24 .0

20.0

Si kk im

Average occupancy of an officer (in months) for three key posts at state level for last three years

25.0

20 .4 21 .0

30.0

26 .8 26 .8

Smaller States

Reference Year (2013-16) Source: State Report

Note: Three key posts are Principal Secretary (Health), Mission Director (NHM) and Director (Health Services).

Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three years - CMOs or equivalent post (heading District Health Services) In one-third of the States and UTs, the average occupancy of a full-time Chief Medical Officer (CMO) or equivalent post heading the Health Services at the district level is 12 months or less, which hinders effective implementation of programs. A small number of States and UTs (Chhattisgarh, Mizoram, Sikkim, Daman & Diu and Puducherry) reported an average occupancy of more than 24 months. Bihar, Sikkim and Andaman & Nicobar Islands have shown a decline of five or more months in the average occupancy of the CMO from the base year (2012-15) to the reference year (2013-16). This indicator was modified for Andaman & Nicobar Islands and Dadra & Nagar Haveli, where the CMO equivalent posts of Medical Superintendent and regular medical officer were included in the calculation of average occupancy. In Lakshadweep, there was no CMO or equivalent post and hence this indicator is not applicable.

54 Base Year (2012-15) 10.0

5.0

0.0

Reference Year (2013-16)

Source: State Report Da m an & Di u

for all districts in last three years

Base Year (2012-15) Ch an di ga rh

15.5 15.6

15.8 16.7

Reference Year (2013-16)

De lh i

17.4

25.5

Smaller States

18.0 18.0

23.1 25.3

36.0 36.0

40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0

Pu du ch er ry Na ga rH An av el da i m an & Ni co ba r

Da dr a&

15.0 12.0

15.5 14.8

Base Year (2012-15)

Average occupancy of a CMO (in months)

Go a

15.0 14.3 17.3

Ta m il Na du

As sa m

Pu nj ab

13.9

14.0

14.1

10.5

11.7 1 1.2

11.2 1 1.5

1 1.7

11.7 1 1.8

13.9

1 1.9

12.3 1 1.9

13.4 12.6

12.8 13.2

17.6

18.1 17.6

18.7 18.1

16.5

14.8 13.2

11.6

9.1 10.2 7.9 8.0 6.9 7.3

10.3

15.6 14.2

12.3 11.6

10.0

M eg ha la ya

18.6 17.3

19.3 17.5

25.5

35.0 31.5

15.0

Tr ip ur a

20.0 17.4 19.9

30.0 26.0

20.0

Na Ar ga un la ac nd ha lP ra de sh M an ip ur

25.0 20.5

Ch ha tti sg ar h Gu M ja ad ra hy t aP ra de M sh ah ar as ht Ut ra ta rP ra de W sh es tB en ga l Od ish Ut a ta ra kh an d Ka rn An at dh ak a ra Pr ad es h Ha ry an a Ra ja sth an Ja m B m u & ihar Ka sh m ir Ke ra la Jh ar kh an d Te Hi l an m ga ac na ha lP ra de sh 21.9

Average occupancy of a CMO (in months) for all districts in last three years

25.0

Si kk im

M izo ra m

for all districts in last three years

Average occupancy of a CMO (in months)

25.4

Figure 4.42 - Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three years CMOs or equivalent post - Larger States

30.0

5.0

0.0

Source: State Report

Figure 4.43 - Indicator 2.2.2: Average occupancy of a full-time officer (in months) for all the districts in last three years CMOs or equivalent post - Smaller States and UTs Union Territories

Reference Year (2013-16)

Source: State Report

DOMAIN 3: KEY INPUTS/PROCESSES SUB-DOMAIN 3.1: HEALTH SYSTEMS AND SERVICE DELIVERY

Indicator 3.1.1: Proportion of vacant healthcare provider positions (regular + contractual) in public health facilities Vacancies of key health staff are linked with both access to healthcare services as well as their quality. The vacancy status vis-a-vis the total sanctioned positions, for both regular and contractual healthcare providers for key positions in public health facilities including ANMs at sub-centres (SCs), staff nurses at PHCs and CHCs, medical officers (MOs) at PHCs, and Specialists at district hospitals (DHs) is provided below. a. ANMs at sub-centres: Among the Larger States, less than 25 percent of ANM positions were vacant except for Gujarat and Bihar, which reported 28 percent and 59 percent vacancies respectively. Odisha, Uttar Pradesh, West Bengal and Kerala reported less than 5 percent vacancy of ANM positions. Similarly, among the Smaller States and UTs, less than 25 percent positions were vacant except in Manipur (30 percent), Goa (30 percent), Tripura (39 percent) and Chandigarh (29 percent). Between the base year (2014-15) and reference year (2015-16), Uttar Pradesh, Jammu & Kashmir, Andhra Pradesh, Rajasthan, Karnataka and Bihar have shown significant progress and the ANM vacancies have declined by 5 or more percentage points. Madhya Pradesh, Haryana, Gujarat, Mizoram, Arunachal Pradesh, Manipur, Goa, Tripura and Delhi have shown significant increases (5 or more percentage points) in ANM vacancies during the same period. Figure 4.44 - Indicator 3.1.1a: Proportion of vacant healthcare provider positions - ANMs at sub-centres - Larger States

67.9

80.0 59.3

60.0

Base Year (2014-15)

Reference Year (2015-16)

28.1 17.1

Bi ha r

27.9 22.6

Gu ja ra t

19.6 19.7

20.2 18.0

15.5 16.9

1 1.8 16.0

15.2 9.7

14.2 8.6

17.7 10.3

12.6 9.9

8.3 9.5

12.4 9.2

7.2 8.5

As sa m Ch ha tti sg M ah arh ar Hi as m ht ac ra ha l Ja Pr m ad m u & esh Ka sh M ad m ir hy aP ra de sh Ha An r y dh an ra a Pr ad es h Ta m il Na du Ut ta ra kh an d Te la ng an a Ra ja sth an Jh ar kh an d Ka rn at ak a

4.9 4.5

Pu nj ab

0.0

0.0 0.0

10.0

2.2 0.8

14.1

20.0

10.9 9.0

30.0

20.6 15.7

40.0

19.2

36.1

50.0

Od ish Ut ta a rP ra de sh W es tB en ga l Ke ra la

Vacancy of ANMs at SCs (%)

70.0

Source: State Report

Figure 4.45 - Indicator 3.1.1a: Proportion of vacant healthcare provider positions - ANMs at sub-centres - Smaller States

38.9

0.0

20.6

20.0

2.1

16.1

0.0

5.0

15.4

1 1.0

7.8

15.0 10.0

1 1.3

20.0

19.6

25.0

22.4

30.0

24.8

29.9

35.0

30.1

40.0

0.0

Vacancy of ANMs at SCs (%)

45.0

Sikkim

Nagaland

Mizoram

Meghalaya

Base Year (2014-15)

Arunachal Pradesh

Manipur

Goa

Reference Year (2015-16)

Tripura

Source: State Report

b. Staff nurses at PHCs and CHCs: Among the Larger States, the vacancy of staff nurses in

PHCs and CHCs was more than 40 percent in Haryana (43 percent), Rajasthan (47 percent), Bihar (50 percent) and Jharkhand (75 percent). From base year (2014-15) to reference year (2015-16), there was significant reduction (16 to 36 percent) in the proportion of vacant position for staff nurses in West Bengal, Karnataka, Jammu & Kashmir and Bihar. Among the Smaller States, Sikkim has the highest vacancy rate (62 percent) followed by Meghalaya (31 percent) and both these States have shown no progress in addressing the vacancies of staff nurses at PHCs and CHCs between the base year and reference year. Tripura made tremendous progress with 22 percentage points reduction in vacancies, bringing the vacancy position of staff nurses at CHCs and PHCs to zero. The vacancies of staff nurses at PHCs and CHCs has increased significantly in Manipur (from 5 to 19 percent) and Arunachal Pradesh (from 4 to 29 percent). The vacancy rate in all UTs is less than 8 percent except Delhi where it increased substantially from 32 to 41 percent.

50.3

Bi ha r Jh ar kh an d

48.1 47.3

46.0 43.2

44.3 37.3

Ha ry an a Ra ja sth an

37.7 36.5

71.8 74.9

86.2

Reference Year (2015-16)

Gu ja ra Ch t ha tti sg ar h

36.2 34.0

36.5 33.5

Pu nj ab

42.9 27.5

21.5 27.2

26.0

17.3 20.5

45.2

Base Year (2014-15)

13.1 20.0

21.8 19.1

16.7 15.7

12.8 12.8

9.7

25.7 4.6 9.0

As sa m W es tB en ga l Te la ng an M a ah ar as ht ra Ta m il Na du Ut ta ra k ha An nd dh ra Pr ad es h Ka rn Hi at m ak ac a ha lP Ja ra m d m u & esh Ka sh M ad m ir hy aP ra de sh

5.5 5.3

1.9 1.9

Ke ra la

0.0 0.0

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

Od ish Ut ta a rP ra de sh

Vacancy of SNs at PHCs and CHCs (%)

Figure 4.46 - Indicator 3.1.1b: Proportion of vacant healthcare provider positions - Staff nurses at PHCs and CHCs - Larger States

Source: State Report

c. Medical officers (MOs) at PHCs: Among the Larger States, the vacancy of MOs at PHCs is

the highest in Bihar (64 percent) followed by Madhya Pradesh (58 percent), Jharkhand (49 percent), Chhattisgarh (45 percent) and West Bengal (41 percent). It is the lowest in Kerala (6 percent) followed by Tamil Nadu (8 percent) and Punjab (8 percent). From base to reference year, there has been reduction in MO vacancies in the range of 5 to 25 percentage points in Uttarakhand, Andhra Pradesh, Haryana, Uttar Pradesh, Gujarat and West Bengal. In Himachal Pradesh, MO vacancies increased by 5 percentage points. Among the Smaller States, Meghalaya, Mizoram, Arunachal Pradesh and Manipur also have a high proportion (36 to 43 percent) of vacant positions of MO at PHCs and no reduction in MO vacancies from base to reference year. Tripura and Goa have shown a reduction of 15 percentage points and 17 percentage points in vacant MO positions at PHCs respectively, whereas these have increased in Arunachal Pradesh (from 9 to 39 percent). Among the UTs, Chandigarh has the highest proportion of vacant MO positions at PHCs (69 percent) followed by Andaman & Nicobar (36 percent) with no reduction from base to reference year. There was no MO vacancy in Lakshadweep, while vacancies in the remaining UTs lay in the range of 7 to 17 percent.

57.8 58.3

70.0

45.3 48.7

41.8 45.0

48.4 41.2

39.8 32.0

34.9 30.2

23.2 26.9

36.8 26.7

25.4

19.9 17.8

16.8 17.0

14.9 14.9

18.0 12.8

12.2

9.8 7.8

10.0

7.6 7.6

20.0

13.4 1 1.5

30.0

22.3 22.3

40.0

16.2 21.7

37.2

38.6

50.0

5.6 5.9

Vacancy of MOs at PHCs (%)

60.0

63.6 63.6

Figure 4.47 - Indicator 3.1.1c: Proportion of vacant healthcare provider positions - Medical officers at PHCs - Larger States

Base Year (2014-15)

Reference Year (2015-16)

Bi ha r

Ke ra la Ta m il Na du Pu nj ab Ka rn at ak Ut a ta ra kh An an dh d ra Pr ad es h Ra ja sth an M ah ar as ht ra A Hi s m sa ac m ha lP ra de Te sh la ng an a Ha ry an Ut a ta rP ra de sh Ja O di m sh m a u& Ka sh m ir Gu ja ra W t es tB en ga Ch l ha tti sg ar h Jh ar M kh ad an hy d aP ra de sh

0.0

Source: State Report

26.9

38.1 31.6

27.4

31.1

30.0 25.0

14.2

17.0

20.0

9.4

15.0

0.0

5.0

Sikkim

2.1

10.0

0.0

Vacancy of MOs at PHCs (%)

35.0

31.9

35.7

40.0

38.8

45.0

42.8

Figure 4.48 - Indicator 3.1.1c: Proportion of vacant healthcare provider positions - Medical officers at PHCs - Smaller States

Tripura

Goa

Nagaland

Meghalaya

Mizoram

Arunachal

Manipur

Pradesh

Base Year (2014-15)

Reference Year (2015-16)

Source: State Report

d. Specialists at district hospital (Medicine, Surgery, Obstetrics and Gynaecology, Paediatrics, Anaesthesia, Ophthalmology, Radiology, Pathology, Ear-Nose-Throat, Dental, Psychiatry):

Figure 4.49 - Indicator 3.1.1.d: Proportion of vacant healthcare provider positions - Specialists at district hospitals - Larger States

78.0 77.7

90.0

10.0

65.0 60.6

60.3

21.7

38.3

51.0 55.5

59.8 54.8

50.6 51.0

47.7

41.5 45.8

41.7

35.7 32.4

30.3

24.5 22.2

20.9 21.5

22.2 21.5

19.5

20.0

23.0 20.2

17.9 16.7

30.0

19.0

40.0

30.4

50.0

40.6

43.5

60.0

55.4 50.3

62.9

70.0

Base Year (2014-15)

Reference Year (2015-16)

Ch ha tti sg ar h

Bi ha r

As sa m

Ha ry an a Ta m il Na du Od ish a W es tB en ga l Ke ra la Ka rn Ja at m ak m a u& Ka sh m ir M ah ar as An ht dh ra ra Pr ad es Ut h ta rP ra de sh

0.0

Ra ja sth an Pu nj ab Jh ar kh M an ad d hy aP ra de sh Te la ng an a Gu ja ra t Ut ta ra kh an d

0.0 0.0

Vacancy of Specialists at DHs (%)

80.0

Source: State Report

Several Larger States have a high proportion of vacant specialist positions in district hospitals, particularly in Chhattisgarh (78 percent), Bihar (61 percent), Uttarakhand (60 percent), Gujarat (56 percent), Telangana (55 percent), Madhya Pradesh (51 percent), Jharkhand (50 percent) and Punjab (48 percent). Most States have made limited progress (<5 percentage points) in reducing the vacancies of specialists at district hospitals from base to reference year, except Odisha, Andhra Pradesh, Assam, Jharkhand and Telangana; at the same time, Maharashtra, Punjab and Uttarakhand have shown substantial increases of specialists, ranging between 11 to 26 percentage points. Among the Smaller States, the vacancies among specialist positions is high in Manipur (48 percent), Goa (40 percent) and Arunachal Pradesh (89 percent). While all specialist positions have been filled in Nagaland, specialist vacancies in the remaining States range from 15 to 40 percent. Overall, the Smaller States have shown little or no reduction in vacancies among specialists at district hospitals from base to reference year. A similar situation was observed among the UTs as shown in Figure 4.50.

Base Year (2014-15)

Reference Year (2015-16) Source: State Report

Base Year (2014-15)

100.0 100.0

76.5 76.5

38.2 47.1

La ks ha An dw da ee m p an & Ni co ba r

Di u

38.7 40.2

De lh i

Da m an

23.4 20.6

18.2 18.2

Ch an di ga rh Na ga rH av el i Pu du ch er ry

120.0 100.0 80.0 60.0 40.0 20.0 0.0

0.0 0.0

Union Territories

Da dr a&

Vacancy of Specialists at DHs (%)

47.7 47.7

42.7 39.7

M an Ar ip un ur ac ha lP ra de sh

Go a

34.4 34.4

Si kk im

29.3 29.7

15.2 15.2

M izo ra m M eg ha la ya

0.0 0.0

100.0 80.0 60.0 40.0 20.0 0.0

87.6 89.1

Smaller States

Na ga la nd

Vacancy of Specialists at DHs (%)

Figure 4.50 - Indicator 3.1.1d: Proportion of vacant healthcare provider positions - Specialists at district hospitals - Smaller States and UTs

Reference Year (2015-16) Source: State Report

Indicator 3.1.2: Proportion of total staff (regular and contractual) for whom an e-payslip can be generated in the IT enabled Human Resources Management Information System (HRMIS) It is expected that a well-functioning HRMIS leads to efficient financial and personnel management. However, in 2015-16, among the 21 Larger States, only 9 States used e-payslips to disburse staff salaries, using HRMIS. Among them, the proportion of staff receiving such payments varies from as low as 8 to 100 percent. The States with the highest rates of e-payments are Kerala (100 percent), Maharashtra (68 percent), Odisha (76 percent), Tamil Nadu (85 percent) and West Bengal (81 percent), while Andhra Pradesh, Gujarat and Karnataka are using HRMIS based e-payments for 36 to 59 percent of their staff. It is important for other States to initiate and fully operationalize HRMIS for effective human resources management. All the Smaller States except Arunachal Pradesh (39 percent) have not yet initiated HRMIS based e-payments to staff. Among the UTs, Andaman & Nicobar, Dadra & Nagar Haveli, Daman & Diu and Lakshadweep are yet to initiate e-payments. The remaining UTs are making use of HRMIS based e-payslip generation (61 to 78 percent). Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units (FRUs) This is a proxy indicator to assess the functionality of the FRUs and captures the number of facilities conducting a specified number of C-sections per year against the number of required FRUs per MoHFW guidelines (one FRU per 500,000 population) during a specific year. Functional FRUs provide specialized services close to the community and can help to improve access and decongest the client load at higher level facilities. The proxy criteria for a facility to be considered as fully operational FRUs is: â&#x20AC;˘

For sub-district hospitals and CHCs: conducting a minimum of 60 C-Sections per year (36 C-sections per year for Hilly and North-Eastern States, except Assam).

â&#x20AC;˘

For district hospitals: conducting a minimum of 120 C-Sections per year (72 C-sections per year for Hilly and North-Eastern States, except Assam).

12.5 1 1.5

15.3 15.8

15.2 22.7

23.4 29.2

21.6 23.5

20.0

31.1 32.4

40.0

32.2 43.0

45.4 49.2

45.0 50.0

52.9 51.0

48.5 57.6

60.0

61.9 65.5

80.0

67.7 72.6

80.0 80.0

100.0

100.0 95.0

120.0

105.7 1 16.4

140.0

121.0 121.0

138.2 141.8

160.0

107.1 121.4

180.0

Ja m m u&

Base Year (2014-15)

Reference Year (2015-16)

Bi ha r

As sa m Od An ish dh a ra Pr ad es h Ha M ry ad an hy a aP ra de W sh es tB en ga l Gu ja ra M t ah ar as ht ra Ra ja sth an Ch ha tti sg ar h Jh ar kh Ut an ta d rP ra de sh

0.0 Ka sh m ir Pu nj ab Ta m Hi il m Na ac du ha lP ra de sh Ke ra la Ka rn at ak Ut a ta ra kh an d Te la ng an a

Functional FRUs as against required number (%)

200.0

129.2 122.9

180.0 196.0

Figure 4.51 - Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units - Larger States

Source: State Report & MoHFW

Note: The number of required FRUs is based on MoHFW guidelines.

As shown in Figures 4.51 and 4.52, many States have achieved the numerical target of functional FRUs (Jammu & Kashmir, Punjab, Tamil Nadu, Himachal Pradesh, Kerala, Karnataka, Mizoram, Meghalaya, Goa, Nagaland, Arunachal Pradesh and Sikkim). However, several States (West Bengal, Gujarat, Maharashtra, Rajasthan, Chhattisgarh, Jharkhand, Uttar Pradesh and Bihar) lag behind substantially with 50 percent or less of the required functional FRUs. These States need to plan strategically for operationalizing more facilities as FRUs, which are critical for saving the lives of mothers and children. Almost all UTs have the required number of fully functional FRUs. From base to reference year, most States and UTs have either maintained the earlier level or shown minimal increase in the percentage of functional FRUs. None of the facilities in Andaman & Nicobar function as FRU despite the need of one functional FRU as per MoHFW guidelines.

50.0

57.1

42.9

83.3

66.7

150.0 100.0

100.0

83.3

100.0

150.0

125.0

133.3

200.0

150.0

200.0

250.0

100.0

Functional FRUs as against required number (%)

Figure 4.52 - Indicator 3.1.3.a: Proportion of specified type of facilities functioning as First Referral Units - Smaller States

0.0 Sikkim

Arunachal Pradesh

Nagaland

Base Year (2014-15)

Goa

Meghalaya

Reference Year (2015-16)

Mizoram

Manipur

Tripura

Source: State Report & MoHFW

Note: The number of required FRUs is based on MoHFW guidelines.

Indicator 3.1.3.b: Proportion of functional 24x7 PHCs The functioning of 24x7 PHCs is important for providing a basic package of health services to the community and for reducing the workload at higher level facilities. To assess the proportion of functional 24x7 PHCs providing all stipulated healthcare services round the clock during a specific year, the norm of at least ten (five in Hilly States) deliveries per month was considered. The required number of functional 24x7 PHCs per state was calculated using the norm of one 24x7 PHC per 100,000 population. On the basis of this norm, only Assam, Sikkim, Meghalaya, Nagaland, Mizoram, Tripura, Andaman & Nicobar and Dadra & Nagar Haveli have achieved the target of the required number of 24x7 PHCs, whereas Kerala, Chandigarh, Lakshadweep and Puducherry are yet to operationalize a single 24x7 PHC. Most Larger States need to substantially increase the number of functional 24x7 PHCs in order to reach the required target. Among the Smaller States, Manipur, Arunachal Pradesh and Goa need to deploy strategic effort to operationalize more 24x7 PHCs. From base to reference year, an increase of five or higher percentage points in functional 24x7 PHCs as against required number was observed in Assam (7 percentage points), Sikkim (50 percentage points), Meghalaya (13 percentage points), Manipur (24 percentage points), Arunachal Pradesh (22 percentage points), and Dadra & Nagar Haveli (33 percentage points), whereas a decline of five or more percentage points was observed in Karnataka (9 percentage points), Jammu & Kashmir (8 percentage points), Tamil Nadu (19 percentage points), Punjab (9 percentage points), Mizoram (55 percentage points) and Tripura (8 percentage points).

Figure 4.53 - Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Larger States 169.6 176.9

200.0 160.0 140.0

Bi ha r Ka rn at ak a Ra ja M sth ad an hy aP ra de Ut sh ta ra kh an M d ah Ja ar m as m ht u& ra Ka sh m Ch ir ha tti sg ar Ta h m il Na du Jh ar kh an d Gu ja ra t Od An ish dh a ra Pr ad es h Te la ng an a Pu nj Ut a ta rP b ra de sh W es tB Hi en m ac ga ha l lP ra de sh Ke ra la

As sa m Ha ry an a

0.0

0.0 0.0

5.8 5.8

5.7 5.9

20.0

17.9 17.4

35.7 26.4

27.0 27.0

33.2 29.2

30.0 30.0

27.8 31.5

33.0 33.0

54.2 35.0

40.0

36.5 40.4

53.6 45.6

48.0 46.7

56.4 54.5

60.0

58.4 56.5

67.3 68.0

80.0

78.1 69.2

100.0

70.9 73.6

120.0 73.6 77.6

Functional 24x7 PHCs

as against required number (%)

180.0

Base Year (2014-15)

Reference Year (2015-16)

Source: State Report & MoHFW

Note: The number of required 24x7 PHCs is based on MoHFW guidelines.

0.0 Sikkim

Meghalaya

Nagaland

Base Year (2014-15)

Mizoram

Tripura

Manipur

Arunachal Pradesh

6.7

0.0

42.9

50.0

21.4

41.4

100.0

65.5

116.2

124.3

150.0

136.4

165.0

180.0

216.7

166.7

200.0

166.7

Functional 24x7 PHCs as against required number (%)

250.0

190.9

Figure 4.54 - Indicator 3.1.3.b: Proportion of functional 24x7 PHCs - Smaller States

Goa

Reference Year (2015-16) Source: State Report & MoHFW

Note: The number of required 24x7 PHCs is based on MoHFW guidelines.

Indicator 3.1.4: Proportion of districts with functional Cardiac Care Units (CCUs) A functioning CCU is important for the availability of specialized cardiac care services at the district level and for reducing the workload at tertiary level facilities. The State-provided data on the number of functional CCUs in district hospitals alongside the total number of districts was considered. However, CCUs in medical colleges were not considered for this indicator, except for Delhi where hospitals are not designated as district hospitals.

0.0 0.0

3.3 3.3

2.9

10.0

9.8 9.8

20.0

3.7 3.7

18.2

30.0

19.1 19.1

27.3

40.0

22.9 22.9

43.3 43.3

57.7 48.5

50.0

53.9 53.9

60.0

56.3 56.3

63.6 63.6

70.0

64.3 64.3

80.0

70.6

90.0

76.9 76.9

Districts with functional CCUs (%)

100.0

91.7 91.7

Figure 4.55 - Indicator 3.1.4: Proportion of districts with functional Cardiac Care Units - Larger States

Base Year (2014-15)

Reference Year (2015-16)

Jh ar kh an d Te la ng Ut an ta a rP ra de sh Ut ta ra kh an d

Bi ha r

As sa m

Ta m il An Na dh du ra Pr ad es h Gu ja ra t Ka Ja rn m a m t a u& ka Ka sh m M ir ah ar as ht ra Ha M r ya ad na hy aP ra de Ch sh ha tti sg ar h Od ish a

Ke ra la Pu nj ab

Hi m ac ha lP ra de W sh es tB en ga l Ra ja sth an

0.0

Source: State Report

Assam, Bihar, Jharkhand, Telangana, Uttar Pradesh, Uttarakhand, Arunachal Pradesh, Goa, Manipur, Meghalaya, Sikkim, Tripura, Andaman & Nicobar, Chandigarh, Dadra & Nagar Haveli and Daman & Diu do not have a single district with functional CCUs in public hospitals. Himachal Pradesh, West Bengal, Rajasthan, Kerala, Punjab, Tamil Nadu, Andhra Pradesh, Lakshadweep and Delhi have made satisfactory progress by establishing CCUs in 50 percent or more districts. The remaining States need to operationalize CCUs, given the increasing load of cardiovascular diseases. Among UTs, only Delhi and Lakshadweep have the required number of CCUs. From base to reference year, notable increases in the percentage of districts with CCUs was observed in Rajasthan (68 percentage points), Jammu & Kashmir (9 percentage points) and Nagaland (9 percentage points), whereas a decline of 9 percentage points was observed in Gujarat. Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations The ANC registration in the first trimester is a critical indicator depicting the effectiveness of a health service delivery system to enrol pregnant women in early pregnancy, this being necessary for maternal and foetal well-being. Among the 21 Larger States, 11 have more than 70 percent of ANCs registered in the first trimester. Telangana, Bihar, Jammu & Kashmir, Uttar Pradesh and Jharkhand, with less than 60 percent ANC registration in the first trimester, need to improve performance in this regard. Almost all States (except Karnataka, Telangana, Jammu & Kashmir and Uttar Pradesh) have shown incremental progress in the registration of ANCs in the first trimester.

33.7 36.4

50.0

51.2 48.7

54.4 53.0

51.4 55.5

61.3 55.9

58.5 60.7

57.7 62.2

59.1 62.5

61.5 63.8

63.6 66.8

72.8 71.2

74.4

71.2 73.0

74.6

60.0

64.4

75.8

73.6 74.9

60.0

70.0

68.5

73.0 77.0

80.0

77.2 80.6

78.6 81.4

90.0

81.0 80.6

92.7 94.4

100.0

40.0 30.0 20.0 10.0

Ka sh Ut m ta r P ir ra de sh Jh ar kh an d

Bi ha r

Ja m m u&

Ke ra la As sa m

W es tB en ga l Od ish a Gu ja ra Ch t ha t t An isg dh ar ra h Pr ad es h Pu nj ab Ka rn at ak M a ah ar as M ad ht ra hy aP ra de Ut sh ta ra kh an d Ha ry an a Ra ja sth an Te la ng an a

0.0 Ta m Hi il m Na ac du ha lP ra de sh

ANC registered within 1st trimester against total registrations (%)

Figure 4.56 - Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations - Larger States

Base Year (2014-15)

Reference Year (2015-16)

Source: HMIS

Similarly, among the Smaller States, Sikkim (80 percent) and Mizoram (74 percent) have achieved more than 70 percent first trimester registration and the remaining States need to put in special efforts to increase first trimester registrations. From base to reference year, some incremental progress (1 to 8 percentage points) was observed in Sikkim, Mizoram, Manipur and Goa, whereas some decline was observed in Tripura (1 percentage point), Arunachal Pradesh (2 percentage points), Nagaland (11 percentage points). No change was observed in Meghalaya where the first trimester registration remains at 32 percent. Among UTs, Dadra & Nagar Haveli, Andaman & Nicobar, and Lakshadweep have achieved satisfactory performance levels (ranging between 73 to 85 percent), while the remaining UTs need to significantly improve their performance.

Reference Year (2015-16) Source: HMIS

34.7 33.7

De lh i

49.6 36.8

45.5 39.5

47.3 49.3

74.9 73.2

77.8 76.9

84.8 47.3

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

Na ga rH An av da el m i an & Ni co ba La r ks ha dw ee p Da m an & Di u Pu du ch er ry Ch an di ga rh

ANC registered within 1st trimester against total registrations (%)

Ar un Go ac a ha lP ra de sh Na ga la nd M eg ha la ya

Base Year (2014-15)

Union Territories

Da dr a&

32.2 32.1

46.8 35.8

38.7 37.0

57.0 58.7

62.8 61.9

59.1 63.2

72.3 73.6

90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

77.8 79.9

Smaller States

Si kk im M izo ra m M an ip ur Tr ip ur a

ANC registered within 1st trimester against total registrations (%)

Figure 4.57 - Indicator 3.1.5: Proportion of ANC registered within first trimester against total registrations - Smaller States and UTs

Base Year (2014-15)

Reference Year (2015-16) Source: HMIS

Indicator 3.1.6: Level of registration of births Registration of birth not only provides the child with an official identification document, but also allows for area-specific estimation of birth rates. The level of registration is defined as the proportion of births registered under the Civil Registration System (CRS) against the estimated number of births during a specific year. Seventeen States/ UTs including Andhra Pradesh, Assam, Chhattisgarh, Haryana, Kerala, Maharashtra, Punjab, Tamil Nadu, Arunachal Pradesh, Goa, Manipur, Meghalaya, Mizoram, Nagaland, Chandigarh, Puducherry and Delhi have achieved 100 percent registration of births. However, Uttarakhand, Madhya Pradesh, Jharkhand, Jammu & Kashmir, Uttar Pradesh, Bihar, Tripura, Sikkim, Daman & Diu, Andaman & Nicobar, Dadra & Nagar Haveli and Lakshadweep, (with level of registration in the range of 60 to 86 percent) need to make rapid progress in this regard. From base to reference year, the States and UTs showing a decline in registration are Telangana (4 percentage points), Gujarat (5 percentage points), Himachal Pradesh (7 percentage points), Tripura (9 percentage points), Sikkim (6 percentage points), Daman and Diu (22 percentage points), Andaman and Nicobar (25 percentage points) and Dadra and Nagar Haveli (7 percentage points). The states with 5 percentage points or more increase in birth registration are Chhattisgarh (12 percentage points), Odisha (5 percentage points), Uttarakhand (9 percentage points) and Bihar (7 percentage points). Figure 4.58 - Indicator 3.1.6: Level of registration of births - Larger States

64.2 57.4

68.6 68.3

77.7 82.0

86.0 76.6

84.1 82.6

92.8 92.5

100.0 93.1

100.0 95.0

100.0 95.6

96.0 97.8

98.4 98.2

93.9 98.5

100.0 100.0

100.0

80.0

71.8 75.5

Level of registration of births (%)

87.8

100.0

97.7 100.0

98.5 100.0

120.0

60.0

40.0

20.0

Pu nj ab Ta m il Na du Od ish a Ra ja sth an Ka rn at ak a Te la ng an a Hi G uj m a ac ra ha t lP ra de sh W es tB en ga Ut l ta r a M kh ad a nd hy aP ra de sh Jh ar Ja kh m m an u& d Ka sh m Ut ir ta rP ra de sh Bi ha r

As sa m Ch ha tti sg ar h Ha ry an a Ke ra la M ah ar as ht ra

An dh ra

Pr ad es h

0.0

Base Year (2013)

Reference Year (2014)

Source: CRS

Figure 4.59 - Indicator 3.1.6: Level of registration of births - Smaller States and UTs

Base Year (2013)

Reference Year (2014) Source: CRS

60.0 59.5

60.0

71.8 65.1

80.0

71.9

76.4

97.2

98.4

100.0 100.0

100.0

100.0 100.0

120.0

40.0 20.0

Base Year (2013)

& An Di da u m an & Ni Da co dr ba a& r Na ga rH av el i La ks ha dw ee p

Da m an

De lh i

0.0 Ch an di ga rh Pu du ch er ry

Level of registration of births (%)

79.9 74.1

91.4 81.7

Si kk im

100.0 100.0

Union Territories

M an ip ur M eg ha la ya M izo ra m Na ga la nd Tr ip ur a

Go a

100.0 100.0

120.0 100.0 80.0 60.0 40.0 20.0 0.0

Ar un ac ha lP ra de sh

Level of registration of births (%)

Smaller States

Reference Year (2014) Source: CRS

Indicator 3.1.7: Completeness of Integrated Disease Surveillance Programme (IDSP) reporting of P and L forms This indicator captures the proportion of Reporting Units (RUs) reporting in the stipulated time for IDSP reporting format for presumptive surveillance (P form) and IDSP reporting format for laboratory surveillance (L form) during a specific year and is an important monitoring indicator reflecting the functioning of IDSP. Seven of the Larger States (Andhra Pradesh, Telangana, Kerala, Gujarat, Karnataka, Uttarakhand and Tamil Nadu) have at least 90 percent of the reporting units submitting P form in a timely manner. The performance of Himachal Pradesh and Uttar Pradesh is poor wherein only 66 percent and 42 percent units, respectively,report in a timely manner. From base to reference year, there has been a decline in the percentage of reporting units in Assam, Haryana, Madhya Pradesh, Punjab and Uttar Pradesh, whereas reporting has increased in the remaining States, Karnataka, Tamil Nadu, Odisha, Jammu & Kashmir, West Bengal, Rajasthan and Himachal Pradesh where the increase was more than 10 percentage points. Among the Smaller States and UTs, all (except Mizoram, Dadra & Nagar Haveli, Chandigarh and Daman & Diu) had incremental progress. Manipur (63 percent), Mizoram (48 percent), Andaman & Nicobar (50 percent), Lakshadweep (0 percent) and Delhi (56 percent) need to take corrective steps to improve the reporting completeness of P form.

Figure 4.60 - Indicator 3.1.7: Completeness of IDSP reporting of P form - Larger States

100

99 94

96 95

81 80

73 66 59

Bi ha r Ch ha tti sg ar h Ha ry an a Ja Od m ish m u& a Ka sh M ad m ir hy aP ra d M ah esh ar as ht ra W es tB en ga l Jh ar kh an d Pu nj ab Ra Hi ja sth m ac an ha lP ra de Ut sh ta rP ra de sh

An dh ra

Ke ra la Gu ja ra t Ka rn at ak a Ut ta ra kh an d Ta m il Na du As sa m

0 Pr ad es h Te la ng an a

Completeness of IDSP reporting of P form (%)

Base Year (2014)

Reference Year (2015)

Source: Central IDSP, MoHFW

Figure 4.61 - Indicator 3.1.7: Completeness of IDSP reporting of P and L forms - Smaller States

Reference Year (2015)

74 32 38

M eg Ar ha un la ac ya ha lP ra de sh Na ga la nd M izo ra m M an ip ur

Base Year (2014)

61 65

82 63

Go a

94 61

100

Tr ip ur a

120 100 80 60 40 20 0

Si kk im

Completeness of IDSP reporting of L form (%)

51 48

Na ga la nd M an ip ur M izo ra m

Go a

M eg ha Ar la un ya ac ha lP ra de sh

Tr ip ur a

Base Year (2014)

80 79

L form (%)

84 62

97 75

91 97

120 100 80 60 40 20 0

Si kk im

Completeness of IDSP reporting of P form (%)

P form (%)

Reference Year (2015) Source: Central IDSP, MoHFW

The status of L form reporting is similar to the P form reporting. Thus, Rajasthan (68 percent), Himachal Pradesh (62 percent), Uttar Pradesh (57 percent), Manipur (38 percent), Mizoram (58 percent), Andaman & Nicobar (21 percent) and Lakshadweep (0 percent) need to make concerted efforts to raise the percentage of reporting units timely L form reporting.

Indicator 3.1.8: Proportion of CHCs with grading above 3 points CHCs are graded under the MoHFWâ&#x20AC;&#x2122;s grading system using the data on service utilization, client orientation, service availability, drugs and supplies, human resource and infrastructure. This indicator represents the share of CHCs that receive a score greater than 3 (out of 5 points) of the total number of CHCs in that State. Larger States have made substantial incremental progress in increasing the proportion of CHCs with a score of more than 3 points. This, however, could be due to a reporting issue. The grading system was first introduced in 2014-15 (base year), and reporting has improved significantly in 2015-16 (reference year). Many of the Smaller States and UTs (Arunachal Pradesh, Mizoram, Nagaland, Sikkim, Tripura, Andaman and Nicobar, Dadra and Nagar Haveli, Daman and Diu, Delhi and Lakshadweep) are yet to report on this indicator.

Base Year (2014-15)

NA 0.4

8.3

2.5 5.1

0.0

Te la ng an Ut a ta r a Hi k m ha ac nd ha lP ra de sh Ke ra la

Bi ha r

Od ish a Ha ry an a

Reference Year (2015-16)

1.7

10.1

1 1.6

20.3

22.0

22.8 9.8

4.6

1.0

4.5

3.5

1.6

3.2

10.3

Gu ja ra Ch t ha tti sg Ut ar ta h rP ra de M sh ah ar as An ht ra dh ra Pr ad es h Ka rn at ak a As sa m Pu nj ab

0.0

10.0

9.0

7.1

20.0

12.0

16.7

30.0

26.7

37.2

40.0

31.1

44.1

38.5

49.4

50.0

47.7

54.4

53.7

57.2

61.9

60.0

Ta m Ja il m Na m du u& Ka M sh ad m hy ir aP ra de sh Ra ja sth an Jh ar kh W a es nd tB en ga l

CHCs with grading above 3 points (%)

70.0

54.5

80.0

25.3 31.3

76.1

Figure 4.62 - Indicator 3.1.8: Proportion of CHCs with grading above 3 points - Larger States

Source: HMIS

Indicator 3.1.9: Proportion of public health facilities with accreditation certificates by a standard quality assurance program (NQAS/ NABH/ ISO/ AHPI) To ensure a high quality of health services, the Government of India encourages public health facilities across States to apply for quality assurance programs such as National Quality Assurance Standards (NQAS), National Accreditation Board for Hospitals and Healthcare Providers (NABH), International Organization for Standardization (ISO), and Association of Healthcare Providers (India) (AHPI). The performance of health facilities is assessed against pre-determined standards. Only a few States, namely Bihar, Kerala, Odisha, Tamil Nadu, Arunachal Pradesh, Manipur, and Delhi have initiated accreditation under the standard quality assurance program, but less than 15 percent facilities have been accredited under such programs by any State.

Indicator 3.1.10: Average number of days for transfer of Central National Health Mission (NHM) funds from State Treasury to implementation agency (Department/ Society) based on all tranches of the last financial year This is an important indicator for assessing the systemâ&#x20AC;&#x2122;s efficiency in timely flow of funds to the implementing agencies. The average number of days taken by the State to transfer money to the implementation agency ranged between 0 (Daman & Diu and Lakshadweep) and 287 (Telangana) days. The data came from records and analysis shared by the central NHM finance department of MoHFW. As shown in the graphs below, almost all States and UTs (except Daman & Diu and Lakshadweep) have lengthy delays in transfer of funds from the State Treasury to State health societies, thereby adversely affecting timely implementation of various NHM initiatives. There is a need to take urgent steps to reduce this delay. From base to reference year, Gujarat, Uttarakhand, Bihar, Himachal Pradesh, Rajasthan, West Bengal, Chhattisgarh, Maharashtra, Jharkhand and Punjab have shown good progress (reduction by 19 or more days), whereas delays have increased in Uttar Pradesh, Jammu & Kashmir, Kerala, Andhra Pradesh, Karnataka, Assam, Telangana and in all Smaller States (except Meghalaya and Tripura). Figure 4.63 - Indicator 3.1.10: Average number of days for transfer of Central NHM funds from State Treasury to implementation agency (Department/ Society) based on all tranches of the last financial year - Larger States

287 242

300 to implementation agency

127

122 139

107

98 78

140 67

59 24

71 51

56 50

27 42

35 41

100

102

150

135

140

200

97 107

250

M Bi ad h hy a P ar ra de sh Ha Hi m ry ac an ha a lP ra de sh Ra ja sth an Ta m il Na W du es tB en ga Ch l ha tti sg ar h Od ish M a ah ar as ht ra Jh ar kh an d Pu nj Ut ab ta rP Ja ra m d m u & esh Ka sh m ir K An er al dh a ra Pr ad es h Ka rn at ak a As sa m Te la ng an a

0 Gu ja ra Ut t ta ra kh an d

Average number of days for transfer of NHM funds from State Treasury

350

Base Year (2014-15)

Reference Year (2015-16)

Source: Central NHM Finance Data

Figure 4.64 - Indicator 3.1.10: Average number of days for transfer of Central NHM funds from State Treasury to implementation agency (Department/ Society) based on all tranches of the last financial year - Smaller States and UTs

Base Year (2014-15)

Reference Year (2015-16) Source: Central NHM Finance Data

147

143

140 92 89

101

120

64 62

100

De lh i

& Di u La ks ha dw ee p Ch an di ga rh Pu Da du ch dr a& er ry Na ga r Ha An da ve li m an & Ni co ba r

M izo ra m Na ga la nd M an ip ur

Go a

Si kk im

Ar Tr un ip ur ac a ha lP ra de sh

160

Da m an

258 199

101

140

98 38

100 50

149 154

118

150

153

143

200

177

213

216

250

Average number of days for transfer of NHM funds from State Treasury to implementation agency

Union Territories

300

M eg ha la ya

Average number of days for transfer of NHM funds from State Treasury to implementation agency

Smaller States

Base Year (2014-15)

Reference Year (2015-16) Source: Central NHM Finance Data

Way Forward

5. Institutionalization â&#x20AC;&#x201C; taking the Index ahead The composite Health Index has been prepared and disseminated as a first attempt to promote a co-operative and competitive spirit among the States and UTs to rapidly bring about transformative action in achieving the desired health outcomes. The Health Index will be calculated and disseminated annually, with a focus on measuring and highlighting annual incremental improvements by the States and UTs. The MoHFW has underlined the importance of such an exercise to link the Index with incentives to States and UTs under the NHM. The Index is also a tool for States and UTs to identify problem areas and focus their interventions in these areas. During the process of development of the Health Index, rich learnings have emerged which will guide the refining of the Index for the coming year. It is envisaged that a thorough review of indicators will be undertaken to include data on new thrust areas and addition of new data sources. The current methodology will also be reconsidered to address some of the limitations listed earlier. The exercise calls for urgent improvement of the data system in health for timeliness, accuracy and relevance. The quality of HMIS and program-specific MIS data needs to be improved in terms of consistency between Center and State data, coverage of private sector data, data scrutiny, thrust area indicators and data definitions. The MIS also needs strengthening to provide appropriate denominators. For example, the HMIS captures the number of anemic women but does not provide data on the appropriate denominator (i.e. total number of women tested for anemia). Furthermore, the SRS needs to generate data in a timely manner and should explore the possibility of generating the data on key health outcomes including NMR, U5MR, TFR, MMR and SRB for all States and UTs. Data sourced at the State-level on key areas such as human resources and finances needs to be strengthened in terms of availability and its quality. Thus, in the successive rounds, continuous improvement of both the methods and the data will be undertaken to make the Index better.

ANNEXURES

Annexure 1: Discrepancies in data and resolution The data was finalized by the IVA after resolution of all discrepancies in consultation with State and Central governments, who, after thorough review of the data and supporting documentation, identified gaps and data discrepancies which were then discussed with state nodal officers (SNOs) and State-level authorities. A State-specific validation report was prepared and shared with the Principal Secretaries, Mission Directors and SNOs highlighting the results of the validation exercise. The States were requested to review the validation report and provide feedback. Subsequently, the IVA also presented the validation results through five video conferences held during August 16-18, 2017, with groups of 7-8 States to share the findings and discuss discrepancies, data gaps, variations and deviations. Specific issues encountered during validation were discussed with stakeholders (NITI Aayog, MoHFW, the World Bank, validation agency and subject experts) and the following decisions were taken:

•

For States that have achieved replacement level of fertility (TFR≤2.1), it was decided to assign the weight of this indicator on a pro-rata basis to the remaining parameters in that sub-domain, i.e. key health outcomes.

•

For service delivery indicators, such as ‘full immunization’, ‘institutional delivery’, ‘ANC registered within first trimester’, and ‘people living with HIV on antiretroviral therapy,’ in instances where percentages exceeded 100 percent, it was decided to cap them at 100 percent.

•

For calculating the functionality of FRUs and 24x7 PHCs, the denominator was captured as the required number of FRUs and 24x7 PHCs as per MOHFW norms of one FRU per 500,000 population and one 24x7 PHC per 100,000 population.

•

CHC grading for Dadra & Nagar Haveli (reference year), Kerala and Tamil Nadu (base year) was not available and the value against this indicator for that specific year was considered as not applicable (NA). The weight of the indicator was distributed among other indicators in that domain.

•

In several States, the specified health worker positions were not sanctioned and/or overlapped with other functions. Lakshadweep for example, did not have a sanctioned position of a CMO or a Medical Superintendent. Therefore, for Lakshadweep this indicator was considered as NA. In Dadra & Nagar Haveli, the Director of Health was also in charge of the District Hospital and thus his tenure was considered for CMO as well. In Tripura and Himachal Pradesh, there were no designated specialist positions (with General Duty Medical Officers filling the positions of specialists), and hence the IVA accepted the NA entry submitted against the vacancy of specialist. In the case of Chandigarh, in place of sanctioned positions the required number of specialists was used for the denominator. Uttar Pradesh and Bihar did not share the total number of staff (regular and contractual) for Indicator 3.1.2 on HRMIS generated e-payslip and thus the IVA treated the entry as zero.

Annexure 2: Original Health Index At the launch of the Guidebook on Performance on Health Outcomes10 in December 2016, the Index comprised 28 indicators. Table A.2.1 provides an overview of the original set of indicators. However, this Index was subsequently revised as described in Section 2, Table 2.3 and the revised Index has been used for the generation of ranks. Based on issues related to availability and quality of data, certain indicators had to be excluded or modified from the original Index and the rationale for this is summarized at the end of the table. Table A.2.1 - Original Health Index indicators: A snapshot Domain

Sub-domain

Number of Indicators

Weight

Health Outcomes

Key Outcomes

700

Intermediate Outcomes

350

Governance and

Health Monitoring and Data Integrity

Information

Governance

Key Inputs/ Processes

Health Systems/Service Delivery

220

1400

TOTAL Table A.2.2 - Original Health Index: Indicators, definitions and data sources Indicators

Definition

Data Source

Remarks

DOMAIN 1 - HEALTH OUTCOMES Sub-domain 1.1 - Key Outcomes (Weight â&#x20AC;&#x201C; 700) Still Birth Rate (SBR)

Number of still births per thousand live births during a specific year.

SRS

Neonatal Mortality Rate (NMR)

Number of infant deaths of less than 29 days per thousand live births during a specific year.

SRS

Under-five Mortality Rate (U5MR)

Number of child deaths of less than 5 years per thousand live births during a specific year.

SRS

Maternal Mortality Ratio (MMR)

Number of maternal deaths from any cause related to or aggravated by pregnancy or its management during pregnancy, childbirth, or within 42 days of termination of pregnancy, per 100,000 live births during the specific period.

SRS

Total Fertility Rate (TFR)

Average number of children that would be born to a woman if she experiences the current fertility pattern throughout her reproductive span (15-49 years), during a specific year.

SRS

Proportion of Low Birth Weight among newborns

Proportion of low birth weight (<=2.5 kg) newborns out of the total number of newborns weighed during a specific year.

HMIS

Sex Ratio at Birth (SRB)

The number of girls born for every 1,000 boys born during a specific year.

SRS

Excluded in final Health Index

Sub-domain 1.2 - Intermediate Outcomes (Weight â&#x20AC;&#x201C; 350) Full immunization coverage

Proportion of infants 9-11 months old who have received BCG, 3 doses of DPT, 3 doses of OPV and measles against estimated number of infants during a specific year.

HMIS

Performance on Health Outcomes, A Reference Guidebook, NITI Aayog, December 2016.

Indicators

Definition

Data Source

Proportion of institutional deliveries

Proportion of deliveries conducted in public and private health facilities against the number of estimated deliveries during a specific year.

HMIS

Proportion of pregnant women aged 15-49 years who are anemic

Proportion of pregnant women aged 15-49 years who are anemic (<11.0 g/dl) against total number of pregnant women registered for ANC during a specific year.

HMIS

Excluded in final Health Index

Total case notification rate of tuberculosis (TB)

Number of new and relapsed TB cases notified (public + private) per 100, 000 population during a specific year.

RNTCP MIS

Indicator source modified as ‘RNTCP MIS, MoHFW data’

Treatment success rate of new microbiologically confirmed TB cases

Proportion of new cured and their treatment completed against the total number of new microbiologically confirmed TB cases registered during a specific year.

RNTCP MIS

Indicator source modified as ‘RNTCP MIS, MoHFW data’

Proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART)

Proportion of PLHIV receiving ART treatment against the number of estimated PLHIVs who needed ART treatment for the specific year.

NACO State Report

Excluded for the category of UTs

Out-of-pocket expenditure on drugs and diagnostics incurred per delivery in public health facilities (using pregnant women as proxy to all patients)

Average out-of-pocket expenditure (INR) on drugs and diagnostics incurred per delivery in public health facilities during a specific year.

Mother and Child Tracking Facilitation Centre (MCTFC)

Excluded in final Index for incremental ranking; Retained for reference year ranking only

DOMAIN 2 – GOVERNANCE AND INFORMATION Sub-domain 2.1 – Health Monitoring and Data Integrity (Weight – 70) Data Integrity Measure: a. Institutional deliveries b. ANC registered within first trimester

Percentage deviation of reported data from standard survey data to assess the quality/ integrity of reported data for a specific period.

HMIS and NFHS-4

Sub-domain 2.2 – Governance (Weight – 60)

Remarks

Average occupancy of an officer (in months), combined for following three key posts at State-level for last three years: 1. Principal Secretary 2. Mission Director (NHM) 3. Director (Health Services)

Average occupancy of an officer (in months), combined for following key posts at State-level in last three years:

Average occupancy of a full-time officer (in months) for all the districts in last three years - District Chief Medical Officers (CMOs) or equivalent post (heading District Health Services)

Average occupancy of a full time CMO (in months) for all the districts in last three years.

State Report

1. Principal Secretary 2. Mission Director (NHM) 3. Director (Health Services)

State Report

Indicators

Definition

Data Source

Remarks

DOMAIN 3 – KEY INPUTS/PROCESSES Sub-domain 3.1 – Health Systems/Service Delivery (Weight – 220) Proportion of vacant health care provider positions (regular + contractual) in public health facilities

Vacant healthcare provider positions in public health facilities against total sanctioned health care provider positions for following cadres (separately for each cadre) during a specific year:

State Report

a. ANMs at sub-centres (SCs) b. Staff nurse at Primary Health Centers (PHCs) and Community Health Centers (CHCs) c. MOs at PHCs d. Specialists at DH (Medicine, Surgery, Obstetrics and Gynaecology, Pediatrics, Anesthesia, Ophthalmology, Radiology, Pathology, ENT, Dental, Psychiatry) Proportion of total staff (regular + contractual) for whom an e-payslip can be generated in the IT enabled Human Resources Management Information System (HRMIS)

Proportion of staff (regular + contractual)for whom an e-payslip can be generated in the IT enabled HRMIS against total number of staff (regular + contractual) during a specific year.

State Report

a. Proportion of specified type of facilities functioning as First Referral Units (FRUs)

Proportion of facilities of specified type conducting specified number of C-sections per year (FRUs) against total number of specified type of facilities (CHCs, SDHs, DHs) during a specific year.

HMIS

Indicator definition modified

b. Proportion of functional 24x7 PHCs

Proportion of PHCs providing all stipulated healthcare services round the clock against total number of PHCs during a specific year.

MIS Report, MoHFW

Indicator definition modified

Proportion of districts with functional Cardiac Care Units (CCUs)

State Report

Proportion of ANC registered within first trimester against total registrations

Proportion of pregnant women registered for ANC within 12 weeks of pregnancy during a specific year.

HMIS

Level of registration of births

Proportion of births registered under Civil Registration System (CRS) against the estimated number of births during a specific year.

CRS

Completeness of IDSP reporting of P and L forms

Proportion of Reporting Units (RUs) reporting in stipulated time period against total RUs, for P and L forms during a specific year.

IDSP Report

Proportion of CHCs with grading above 3 points

Proportion of CHCs that are graded above 3 points against total number of CHCs during a specific year.

HMIS

Proportion of public health facilities with accreditation certificates by a standard quality assurance program (NQAS/ NABH/ ISO/ AHPI)

State Report

Indicator source modified as ‘Central IDSP, MoHFW data’

Indicators

Definition

Data Source

Remarks

Average number of days for transfer of Central NHM funds from State Treasury to implementation agency (Department/ Society) based on all tranches of the last financial year

Average time taken (in number of days) by the State Treasury to transfer funds to implementation agencies during a specific year.

State Report

Indicator source modified as ‘Central NHM Finance data’

Proportion of National Health Mission (NHM) funds utilized by the end of 3rd quarter

Proportion of funds utilized against the total funds allocated under NHM by the end of 3rd quarter of specific year.

State Report

Excluded in final Health Index

The estimates for SRS-related indicators such as NMR, U5MR, TFR, MMR and SRB in the Index were not available for Smaller States and UTs. Experts were consulted to generate estimates for these States and UTs from the SRS raw data obtained by NITI Aayog. However, it was decided that these estimates could not be generated due to the insufficient sample size. Further, in the Larger States category, MMR estimates were not available separately for eight states, which belonged previously to four undivided States, and also not available for Himachal Pradesh and Jammu & Kashmir. In the case of Still Birth Rate (SBR), the States as well as the IVA reported that data for this indicator was unreliable. In case of the indicator ‘proportion of pregnant women age 15-49 years who are anemic’, data on the appropriate denominator (i.e. total number of women tested for anemia) was not available in the HMIS. Besides, the indicator for ‘proportion of people living with HIV (PLHIV) on ART’ was excluded for the UTs category since no ART center was available in four UTs. For the indicator ‘proportion of NHM funds utilized by the end of 3rd quarter’, neither State nor central level data was found to be valid. For the sake of uniformity and comparability across the States, central data was used for a few indicators such as ‘proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART)’, ‘average number of days for transfer of central NHM funds from State Treasury to implementation agency’ and ‘completeness of IDSP reporting of P and L forms’. The NFHS-4 data for the indicator ‘out-of-pocket expenditure on drugs and diagnostics incurred per delivery in public health facilities’ was used in the reference year Index. However, for the base year, this data was not available and could therefore not be factored in for generating base year ranks or incremental ranks or drawing comparisons between the base and reference years.

Annexure 3: Reference Year Index (with and without the indicator on out-of-pocket expenditure) As described in the background section, the OOP expenditure data was available only for 2015-16 and hence was used to calculate the reference year Index and rank independently. Overall, the inclusion of the OOP expenditure indicator in the Index score calculations does not substantially change the rankings (Figure A.3.1). The only exceptions are Andhra Pradesh and Bihar which, after the inclusion of OOP expenditure, move up by two and one positions, respectively; while Maharashtra, Jammu & Kashmir, and Odisha move down by one position in the ranking.

Kerala

76.55

73.77

Kerala

Punjab

65.21

66.41

Punjab

Tamil Nadu

63.38

64.23

Tamil Nadu

Gujarat

61.99

63.15

Gujarat

Himachal Pradesh

61.20

61.58

Himachal Pradesh

Maharashtra

61.07

61.41

Andhra Pradesh

Jammu & Kashmir

60.35

61.34

Maharashtra

Andhra Pradesh

60.16

Jammu & Kashmir

Karnataka

58.70

58.79

Karnataka

West Bengal

58.25

55.67

West Bengal

Telangana

55.39

55.74

Telangana

Chhattisgarh

52.02

54.08

Chhattisgarh

Haryana

46.97

49.23

Haryana

Jharkhand

45.33

47.69

Jharkhand

Uttarakhand

45.22

46.94

Uttarakhand

Assam

44.13

45.34

Assam

Madhya Pradesh

40.09

42.74

Madhya Pradesh

Odisha

39.43

40.95

Bihar

38.46

40.15

Odisha

Rajasthan

36.79

38.44

Rajasthan

Uttar Pradesh

33.69

36.23

Uttar Pradesh

Without OOP expenditure

Reference Year Ranking (including OOP Indicator)

Reference Year Ranking (Excluding OOP Indicator)

Figure A.3.1 - Larger States: Ranking for reference year (2015-16) with and without the OOP expenditure indicator

With OOP expenditure

Note: Lines depict changes in composite Index score rank. The composite Index score is presented in the circle.

For the Smaller States, the inclusion of OOP expenditure in the Health Index results in some changes in the rankings (Figure A.3.2), whereby Meghalaya, Sikkim, and Goa move up by one position, while Manipur falls by three positions (from second to fifth place).

Mizoram

73.70

73.86

Mizoram

Manipur

57.78

59.44

Meghalaya

56.83

56.41

Sikkim

53.20

54.24

Goa

53.13

53.82

Manipur

Arunachal Pradesh

49.51

49.38

Arunachal Pradesh

Tripura

43.51

45.66

Tripura

Nagaland

37.38

38.66

Nagaland

Without OOP expenditure

Reference Year Ranking (including OOP indicator)

Reference Year Ranking (excluding OOP indicator)

Figure A.3.2 - Smaller States: Ranking for reference year (2015-16) with and without OOP expenditure indicator

With OOP expenditure

Note: Lines depict changes in composite Index score rank. The composite Index score is presented in the circle.

The inclusion of the OOP expenditure indicator in calculation of the Health Index results in some changes in the reference year ranking among the UTs (Figure A.3.3). Notably, Andaman & Nicobar and Puducherry move up by one position in the ranking, while Delhi moves down by two positions. The inclusion of OOP expenditure does not affect the rankings of the other UTs.

Lakshadweep

65.79

64.64 Lakshadweep

Chandigarh

52.27

54.10

Chandigarh

Delhi

50.02

52.98

Andaman & Nicobar

50.00

49.98

Puducherry

47.48

46.35

Delhi

Daman & Diu

36.10

39.81

Daman & Diu

Dadra & Nagar Haveli

34.64

39.45

Dadra & Nagar Haveli

Without OOP expenditure

Note: Lines depict changes in composite Index score rank. The composite Index score is presented in the circle.

With OOP expenditure

Reference Year Ranking (including OOP indicator)

Reference Year Ranking (excluding OOP indicator)

Figure A.3.3 - Union Territories: Ranking for reference year (2015-16) with and without OOP expenditure indicator

Annexure 4: Snapshot: State-wise performance on indicators Section 4 of the report on ‘Unveiling performance - encouraging actions’, provided insights about the State-wise overall, incremental and domain-specific performance. This Annexure presents a quick snapshot of State-wise performance on all indicators included in the Index. This can help the States to easily identify specific areas requiring attention. The tables present data for base year (BY) and reference year (RY) of each indicator for all States. The direction as well as the magnitude of incremental change in the value of indicators from the base year to reference year is depicted by categorization (‘most improved’, ‘improved’, ‘no change’, ‘deteriorated’, ‘most deteriorated’, ‘not applicable’) and is visually identifiable by appropriate color coding. 1. Incremental change in performance for an indicator is calculated by subtracting base year value from reference year value. For indicators, such as NMR, U5MR, and vacancies, a negative change from base to reference year denotes improvement, while a positive change denotes deterioration. In the case of indicators such as those that reflect service coverage, a positive change denotes improvement, while a negative change denotes deterioration. The range of improvement is calculated by subtracting the minimum value of change from the maximum value of change. This range is then divided into two equal parts and the half towards maximum value of change is termed as 'most improved' and the half towards the minimum value of change is termed as ‘improved’. 2. Similarly, the range of deterioration is calculated by subtracting the minimum value of change from the maximum value of change. This range is then divided into two equal parts and the half towards maximum value of change is termed as 'deteriorated' and the other half towards minimum value of change is termed as 'most deteriorated' respectively. If the indicator value is stagnant and there has been no incremental change from base to reference year, the indicator is labeled as ‘no change’. 3. For a State, the incremental performance on an indicator is classified as ‘not applicable’ (NA) in instances such as: (i) If State has achieved TFR <= 2.1 in both base and reference years; (ii) Data Integrity Measure indicator wherein the same data has been used for base year and reference year due to overlapping periods of NFHS-4; (iii) Service coverage indicators with 100 percent values in both base and reference years; (iv) The data value for a particular indicator is NA in base year or reference year or both.

Table A.4.1 - Larger States: Health Outcomes domain indicators, base and reference years

1.1.5 SRB (no. of girls born for every 1,000 boys born) BY RY

Andhra Pradesh

1.8

1.7

5.62

6.73

919

918

Assam

2.3

18.19

16.68

918

900

Bihar

3.2

6.70

7.22

907

916

Chhattisgarh

2.6

2.5

11.61

12.15

973

961

Gujarat

2.3

2.2

10.58

10.51

907

854

Haryana Himachal Pradesh

2.3

2.2

14.61

14.90

866

831

1.7

8.66

12.63

938

924

Jammu & Kashmir

1.7

1.6

6.33

5.93

899

Jharkhand

2.8

2.7

7.81

7.42

910

902

Karnataka

1.8

10.76

11.49

950

939

Kerala

1.9

1.8

10.81

11.72

974

967

Madhya Pradesh

2.8

14.16

14.10

927

919

Maharashtra

1.8

14.57

13.74

896

878

Odisha

2.1

2.0

20.10

19.16

953

950

Punjab

1.7

5.95

6.88

870

889

Rajasthan

2.8

2.7

27.43

25.51

893

861

Tamil Nadu

1.7

1.6

10.46

13.03

921

911

Telangana

1.8

6.11

5.70

919

918

Uttar Pradesh

3.2

3.1

11.74

9.60

869

879

Uttarakhand

2.0

7.77

7.26

871

844

West Bengal

1.6

15.48

16.45

952

951

States

1.1.1 NMR (per '000 live births)

1.1.2 U5MR (per '000 live births)

1.1.3 TFR*

1.1.4 LBW (percentage)

**The data shown in grey color is for â&#x20AC;&#x2DC;not applicableâ&#x20AC;&#x2122; category wherein the States with TFR <= 2.1 (replacement level fertility) in both base and reference years are not considered for incremental change.

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.1 (Continued) - Larger States: Health Outcomes domain indicators, base and reference years

States

1.2.1 Full immunization (percentage)

1.2.2 Institutional deliveries (percentage)

1.2.3 TB case notification rate (per 100,000 population)

1.2.4 TB treatment success rate (percentage)

1.2.5 PLHIV on ART (percentage)

1.2.6 OOP expenditure # (in INR)

Andhra Pradesh

97.58

91.62

53.09

87.08

136

145

90.40

88.50

72.39

76.11

2138

Assam

84.10

88.00

72.70

74.25

122

123

85.40

86.20

58.94

64.58

3210

Bihar

82.10

89.73

52.96

57.10

89.00

89.70

30.73

37.18

1724

Chhattisgarh

85.81

90.53

59.64

64.51

128

138

88.20

89.10

47.20

53.06

1480

Gujarat

90.26

90.55

90.83

97.78

170

193

88.50

88.90

50.23

52.43

2136

Haryana

82.54

83.47

80.76

80.25

165

172

86.00

87.50

52.31

51.53

1503

94.90

95.22

67.50

67.49

210

207

89.70

89.60

79.22

79.89

3329

89.80

100.00

81.45

80.51

87.60

88.30

88.72

96.41

4192

Jharkhand

80.82

88.10

60.52

67.36

100

108

89.80

90.90

36.07

39.40

1476

Karnataka

92.30

96.24

77.12

78.78

100

105

83.30

84.70

83.25

88.68

3893

Kerala

95.50

94.61

95.99

92.62

139

86.00

87.50

61.79

66.72

6901

Madhya Pradesh

74.26

74.78

63.07

64.79

143

164

89.70

90.30

53.04

61.01

1387

Maharashtra

98.55

98.22

89.19

85.30

155

164

83.90

84.20

83.46

87.71

3487

Odisha

88.03

85.32

74.76

73.49

106

87.40

88.90

28.33

32.95

4225

Punjab

96.08

99.64

83.23

82.33

137

136

86.90

87.20

77.22

84.62

1890

Rajasthan

78.95

78.06

74.67

73.85

139

143

90.40

90.30

42.44

46.41

3052

Tamil Nadu

85.54

82.66

85.97

81.82

113

125

82.30

85.40

81.93

87.06

2496

Telangana

100.00

89.09

59.15

85.35

113

123

90.00

89.60

72.39

76.11

4020

Uttar Pradesh

82.88

84.82

43.55

52.38

123

137

88.20

87.50

51.30

57.81

1956

Uttarakhand

91.77

99.30

64.32

62.63

145

138

85.50

86.00

62.67

65.25

2399

West Bengal

100.00

95.85

79.92

81.28

86.40

86.50

31.00

35.92

7782

Himachal Pradesh Jammu & Kashmir

#Data for this indicator is available and used only for reference year and hence this indicator comes under â&#x20AC;&#x2DC;not applicableâ&#x20AC;&#x2122; category.

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.2 - Larger States: Governance and Information domain indicators, base and reference years

States

2.1.1.a Data Integrity: Institutional deliveries (percentage)

2.1.1.b Data Integrity: First trimester ANC registration (percentage)

2.2.1 Average occupancy: Statelevel 3 key posts (in months)

2.2.2 Average occupancy: CMOs (in months)

BY**

Andhra Pradesh

23.53

15.42

17.70

17.51

12.80

13.22

Assam

0.25

21.16

10.17

12.11

7.92

7.95

Bihar

18.21

16.33

15.00

13.01

17.62

11.88

Chhattisgarh

22.34

25.90

11.39

11.40

21.88

25.40

Gujarat

0.68

2.06

20.22

20.71

18.68

18.09

Haryana

4.62

19.08

13.80

11.21

13.43

12.56

12.72

7.30

11.38

12.39

13.86

10.50

12.42

13.50

22.80

13.81

11.72

11.77

Jharkhand

7.95

53.48

12.98

12.00

11.19

11.46

Karnataka

21.22

8.20

6.85

6.49

14.83

13.23

Kerala

3.71

24.86

21.84

12.02

16.47

11.72

Madhya Pradesh

23.09

9.19

10.75

16.00

18.14

17.62

Maharashtra

1.16

5.61

10.86

15.74

12.25

15.64

Odisha

13.82

22.09

11.07

12.01

9.97

13.95

Punjab

12.41

9.97

20.00

20.42

9.12

10.19

Rajasthan

12.44

18.43

19.00

22.02

12.26

11.94

Tamil Nadu

10.92

22.75

11.94

16.51

6.85

7.29

Telangana

21.06

15.80

8.71

7.81

11.72

11.19

Uttar Pradesh

36.59

0.92

9.62

19.64

11.57

14.15

Uttarakhand

14.93

10.77

10.65

10.35

11.63

13.93

West Bengal

2.12

42.44

22.00

28.02

10.29

14.10

Himachal Pradesh Jammu & Kashmir

** Same data has been used for base and reference years due to overlapping periods of NFHS-4. Hence this indicator comes under â&#x20AC;&#x2DC;not applicableâ&#x20AC;&#x2122; category.

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.3 - Larger States: Key Inputs/Processes domain indicators, base and reference years

States

3.1.1.a Vacancy: ANMs at SCs (percentage)

3.1.1.b Vacancy: SNs at PHCs and CHCs (percentage)

3.1.1.c Vacancy: MOs at PHCs (percentage)

3.1.1.d Vacancy: Specialists at DHs (percentage)

3.1.2 E-payslip (percentage)

Andhra Pradesh

20.56

15.67

17.33

20.48

17.97

12.76

40.55

30.41

59.60

58.65

Assam

10.93

8.99

4.57

8.95

19.92

17.77

62.91

41.72

0.00

Bihar

67.86

59.30

86.15

50.28

63.60

64.96

60.58

0.00

Chhattisgarh

12.35

9.23

44.27

37.28

41.83

45.02

77.98

77.68

0.00

Gujarat

17.13

28.08

37.71

36.46

39.78

32.03

51.02

55.50

35.60

35.61

Haryana

9.66

15.23

45.95

43.24

38.64

25.35

0.00

Himachal Pradesh

12.57

9.87

21.51

27.19

16.19

21.73

3.32

8.07

Jammu & Kashmir

17.65

10.28

42.88

27.48

34.92

30.15

24.52

22.22

0.00

Jharkhand

19.57

19.73

71.80

74.94

45.29

48.67

55.37

50.32

0.00

Karnataka

27.85

22.59

45.20

25.97

13.35

11.48

20.90

21.53

48.89

49.35

Kerala

4.88

4.49

5.54

5.30

5.59

5.86

22.15

21.48

88.61

100.00

Madhya Pradesh

8.58

14.23

36.45

33.50

57.81

58.34

50.56

50.98

0.00

Maharashtra

8.25

9.46

16.74

15.67

16.82

16.96

19.47

30.34

66.55

67.60

Odisha

0.00

23.17

26.91

43.53

19.04

75.79

Punjab

7.17

8.48

36.22

33.98

9.83

7.77

21.74

47.72

0.00

Rajasthan

36.12

19.24

48.12

47.26

14.93

14.86

41.47

45.77

0.00

Tamil Nadu

11.82

15.97

21.78

19.09

7.56

7.58

17.86

16.73

84.62

84.72

Telangana

20.20

18.01

12.79

22.31

59.83

54.81

0.00

Uttar Pradesh

14.06

0.00

1.89

36.83

26.73

35.74

32.41

0.00

Uttarakhand

15.47

16.88

13.11

20.02

37.16

12.19

38.30

60.33

0.00

West Bengal

2.16

0.77

25.72

9.70

48.43

41.23

22.97

20.18

81.78

81.23

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.3 (Continued) - Larger States: Key Inputs/Processes domain indicators, for base and reference years

States

3.1.3.b Functional 24x7 PHCs (percentage)

3.1.4 Districts with functional CCUs (percentage)

3.1.5 Proportion of first trimester ANC (percentage)

3.1.6 Level of birth registration (percentage)

Andhra Pradesh

48.48

57.58

33.20

29.15

53.85

64.42

74.38

98.50

100.00

Assam

67.74

72.58

169.55

176.92

0.00

77.24

80.55

97.70

100.00

Bihar

12.50

11.54

70.89

73.58

0.00

51.43

55.47

57.40

64.20

Chhattisgarh

21.57

23.53

36.47

40.39

3.70

59.99

74.60

87.80

100.00

Gujarat

32.23

42.98

27.81

31.46

57.69

48.48

73.58

74.91

100.00

95.00

Haryana

52.94

50.98

73.62

77.56

19.05

57.68

62.20

100.00

Himachal Pradesh

107.14

121.43

5.80

91.67

78.62

81.39

100.00

93.10

Jammu & Kashmir

180.00

196.00

53.60

45.60

18.18

27.27

54.37

52.95

71.80

75.50

Jharkhand

15.15

22.73

33.03

0.00

33.67

36.36

77.70

82.00

Karnataka

105.74

116.39

78.07

69.23

43.33

72.82

71.22

96.00

97.80

Kerala

120.90

0.00

64.29

80.98

80.63

100.00

Madhya Pradesh

44.83

49.66

58.40

56.47

9.80

61.54

63.79

84.10

82.60

Maharashtra

31.11

32.44

48.04

46.71

22.86

63.58

66.82

100.00

Odisha

61.90

65.48

30.00

3.33

68.48

75.75

93.90

98.50

Punjab

138.18

141.82

35.74

26.35

63.64

71.16

73.01

100.00

Rajasthan

23.36

29.20

67.30

68.03

2.94

70.59

58.50

60.66

98.40

98.20

Tamil Nadu

129.17

122.92

54.23

34.95

56.25

92.72

94.35

100.00

Telangana

80.00

26.99

0.00

61.26

55.90

100.00

95.60

Uttar Pradesh

15.25

15.75

17.92

17.42

0.00

51.19

48.72

68.60

68.30

Uttarakhand

100.00

95.00

56.44

54.46

0.00

59.06

62.47

76.60

86.00

West Bengal

45.36

49.18

5.70

5.91

76.92

73.03

77.00

92.80

92.50

Most Improved

3.1.3.a Functional FRUs (percentage)

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.3 (Continued) - Larger States: Key Inputs/Processes domain indicators, base and reference years

States

3.1.7 IDSP reporting of P form (percentage)

3.1.7 IDSP reporting of L form (percentage)

3.1.8 CHC grading (percentage)

3.1.9 Quality accreditation DH-SDH (percentage)

3.1.9 Quality accreditation CHC-PHC (percentage)

3.1.10 Fund transfer (no. of days)

Andhra Pradesh

1.02

37.24

0.00

127

Assam

4.64

31.13

0.00

242

Bihar

0.00

20.34

27.16

2.36

1.52

135

Chhattisgarh

3.23

47.74

0.00

Gujarat

10.25

49.40

6.35

2.99

1.24

0.60

Haryana

10.09

22.02

0.00

2.53

5.06

0.00

1.37

0.00

102

7.14

61.90

0.00

107

Jharkhand

1.55

54.40

0.00

140

Karnataka

25.34

31.27

0.00

0.53

0.00

122

139

Kerala

0.44

10.00

5.07

6.52

107

Madhya Pradesh

8.98

57.19

0.00

0.29

0.57

Maharashtra

16.67

38.52

0.00

0.27

140

Odisha

9.81

22.81

15.25

0.00

Punjab

12.00

26.67

0.00

Rajasthan

3.19

54.48

0.00

Tamil Nadu

76.10

0.74

4.29

7.27

4.94

Telangana

0.00

11.63

0.00

287

Uttar Pradesh

4.53

44.13

0.00

Uttarakhand

1.67

8.33

0.00

West Bengal

3.49

53.74

0.00

Himachal Pradesh Jammu & Kashmir

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.4 - Smaller States: Health Outcomes domain indicators, base and reference years

States

1.2.1 Full immunization (percentage)

1.1.4 LBW (percentage)

1.2.2 Institutional deliveries (percentage)

1.2.3 TB case notification rate (per 100,000 population)

1.2.4 TB treatment success rate (percentage)

1.2.5 PLHIV on ART (percentage)

1.2.6 OOP expenditure # (in INR)

Arunachal Pradesh

5.79

6.55

60.58

64.95

55.99

56.46

186

183

88.00

86.40

18.69

28.19

6474

Goa

16.72

15.56

91.26

95.24

91.27

92.46

127

131

86.40

87.30

70.92

72.75

4836

Manipur

3.90

3.53

94.39

96.32

74.93

73.47

85.00

82.60

53.95

63.87

10076

Meghalaya

8.19

7.65

96.43

93.34

59.57

62.11

170

137

82.30

85.80

98.66

100.00

2892

Mizoram

4.73

4.65

100.00

96.29

183

186

86.50

90.60

96.68

100.00

4327

Nagaland

4.10

3.89

61.91

63.86

56.95

58.07

173

139

90.70

71.90

63.81

73.80

5834

Sikkim

6.78

7.76

74.07

74.44

71.96

70.19

222

241

78.80

77.20

32.45

33.51

2509

Tripura

10.56

11.11

87.43

84.33

78.48

79.36

195

88.60

88.50

23.14

5.80

4412

#Data for this indicator is available and used only for reference year and hence this indicator comes under ‘not applicable’ category. Table A.4.5 - Smaller States: Governance and Information domain indicators, base and reference years

States

2.1.1.a Data Integrity: Institutional deliveries (percentage)

2.1.1.b Data Integrity: First trimester ANC registration (percentage) BY** RY

2.2.1 Average occupancy: Statelevel 3 key posts (in months) BY RY

BY**

Arunachal Pradesh

1.36

5.62

19.85

Goa

5.01

23.74

Manipur

2.87

28.19

Meghalaya

13.44

Mizoram

22.00

Nagaland

2.2.2 Average occupancy: CMOs (in months) BY

13.87

19.29

17.50

14.84

21.69

15.00

12.00

28.19

13.29

21.02

18.64

17.31

10.56

19.99

19.25

15.49

14.76

22.00

18.71

11.12

9.77

20.51

25.98

54.79

107.87

11.61

7.25

17.43

19.94

Sikkim

29.16

26.76

24.00

24.02

31.50

25.52

Tripura

3.35

10.89

11.99

10.87

14.32

17.26

** Same data has been used for base and reference years due to overlapping periods of NFHS-4. Hence this indicator comes under ‘not applicable’ category.

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.6 - Smaller States: Key Inputs/Processes domain indicators, base and reference years

3.1.1.b Vacancy: SNs at PHCs and CHCs (percentage)

3.1.1.a Vacancy: ANMs at SCs (percentage)

States

3.1.1.c Vacancy: MOs at PHCs (percentage)

3.1.1.d Vacancy: Specialists at DHs (percentage)

3.1.2 Epayslip (percentage)

Arunachal Pradesh

2.07

22.37

4.05

28.78

9.38

38.75

87.55

89.11

45.89

38.75

Goa

24.75

30.10

12.54

11.68

31.11

14.22

42.71

39.70

0.00

Manipur

20.57

29.89

5.08

18.98

42.76

47.67

0.00

Meghalaya

19.56

20.00

30.90

31.05

31.85

35.67

29.28

29.73

0.00

Mizoram

11.33

16.07

6.11

31.58

38.10

15.22

0.00

Nagaland

7.80

11.01

0.00

26.89

27.36

0.00

Sikkim

0.00

61.96

0.00

34.38

0.00

Tripura

15.37

38.90

22.20

0.00

17.03

2.06

0.00

Table A.4.6 (Continued) - Smaller States: Key Inputs/Processes domain indicators, base and reference years

3.1.3.a Functional FRUs (percentage)

States

3.1.3.b Functional 24x7 PHCs (percentage)

3.1.4 Districts with functional CCUs (percentage)

3.1.5 Proportion of first trimester ANC (percentage)

3.1.6 Level of birth registration (percentage)

Arunachal Pradesh

100.00

133.33

21.43

42.86

0.00

38.66

36.99

100.00

Goa

100.00

0.00

6.67

0.00

57.00

58.74

100.00

Manipur

83.33

66.67

41.38

65.52

0.00

59.07

63.23

100.00

Meghalaya

83.33

100.00

166.67

180.00

0.00

32.24

32.07

100.00

Mizoram

150.00

100.00

190.91

136.36

11.11

72.26

73.61

100.00

Nagaland

150.00

125.00

165.00

0.00

9.09

46.80

35.83

100.00

Sikkim

100.00

200.00

166.67

216.67

0.00

77.81

79.89

79.90

74.10

Tripura

42.86

57.14

124.32

116.22

0.00

62.75

61.85

91.40

81.70

** Same data has been used for base and reference years due to overlapping periods of NFHS-4. Hence this indicator comes under â&#x20AC;&#x2DC;not applicableâ&#x20AC;&#x2122; category.

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.6 (Continued) - Smaller States: Key Inputs/Processes domain indicators, base and reference years

States

3.1.7 IDSP reporting of P form (percentage)

3.1.7 IDSP reporting of L form (percentage)

3.1.8 CHC grading (percentage)

3.1.9 Quality accreditation DH-SDH (percentage)

3.1.9 Quality accreditation CHC-PHC (percentage)

3.1.10 Fund transfer (no.of days)

Arunachal Pradesh

0.00

5.00

0.00

143

Goa

25.00

75.00

0.00

149

154

Manipur

0.00

29.41

12.50

0.00

199

258

Meghalaya

3.70

7.41

0.00

216

Mizoram

0.00

140

177

Nagaland

0.00

101

213

Sikkim

100

0.00

153

Tripura

0.00

118

Table A.4.7 - Union Territories: Health Outcomes domain indicators, base and reference years

Most Improved

UTs

Improved

1.1.4 LBW (percentage)

No Change

OOP Not 1.2.6 Applicable

Deteriorated 1.2.3 TB Most Deteriorated

1.2.1 Full immunization (percentage)

1.2.2 Institutional deliveries (percentage)

case notification rate (per 100,000 population)

1.2.4 TB treatment success rate (percentage)

expenditure # (in INR)

Andaman & Nicobar Islands

16.13

17.17

84.62

100.00

76.21

80.20

157

139

85.50

91.50

1258

Chandigarh

22.49

20.77

92.30

93.58

100.00

300

305

89.50

85.60

2357

Dadra & Nagar Haveli

34.70

29.39

75.48

77.06

88.20

87.09

138

133

85.20

86.30

471

Daman & Diu

16.91

24.37

85.04

79.67

75.29

72.00

146

166

83.10

79.50

1581

Delhi

20.85

21.43

90.88

96.21

79.41

80.60

337

348

86.20

86.70

8719

Lakshadweep

4.85

5.56

100.00

76.44

85.40

86.70

91.30

4580

Puducherry

18.48

15.50

73.93

77.60

100.00

103

88.50

89.20

1999

#Data for this indicator is available and used only for reference year and hence this indicator comes under â&#x20AC;&#x2DC;not applicableâ&#x20AC;&#x2122; category. Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.8 - Union Territories: Governance and Information domain indicators, base and reference years

UTs

2.1.1.b Data Integrity: First trimester ANC registration (percentage)

2.1.1.a Data Integrity: Institutional deliveries (percentage)

2.2.1 Average occupancy: Statelevel 3 key posts (in months)

2.2.2 Average occupancy: CMOs (in months)

BY**

Andaman & Nicobar Islands

18.05

2.84

26.00

15.01

25.49

17.43

Chandigarh

57.98

27.88

10.80

12.01

15.53

15.55

Dadra & Nagar Haveli

15.11

22.12

14.40

14.41

18.00

18.01

Daman & Diu

17.43

15.27

20.40

21.02

36.00

36.03

Delhi

10.76

27.77

13.70

9.63

15.82

16.72

Lakshadweep

29.35

12.19

26.77

26.79

Puducherry

90.52

48.82

21.96

19.98

23.05

25.32

** Same data has been used for base and reference years due to overlapping periods of NFHS-4. Hence this indicator comes under â&#x20AC;&#x2DC;not applicableâ&#x20AC;&#x2122; category. Table A.4.9 - Union Territories: Key Inputs/Processes domain indicators, base and reference years

UTs

3.1.1.a Vacancy: ANMs at SCs (percentage)

3.1.1.b Vacancy: SNs at PHCs and CHCs (percentage)

3.1.1.c Vacancy: MOs at PHCs (percentage)

3.1.1.d Vacancy: Specialists at DHs (percentage)

3.1.2 Epayslip (percentage)

Andaman & Nicobar Islands

7.84

7.45

36.36

100.00

0.00

Chandigarh

31.25

29.41

6.19

69.17

0.00

59.97

61.33

Dadra & Nagar Haveli

0.00

4.88

16.67

18.18

0.00

Daman & Diu

13.56

11.86

2.38

0.00

7.14

38.24

47.06

0.00

Delhi

4.88

19.75

32.00

40.75

8.33

14.21

38.74

40.21

0.00

68.81

Lakshadweep

0.00

76.47

0.00

Puducherry

7.23

8.73

1.19

2.38

12.78

23.36

20.56

80.74

78.35

Most Improved

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable

Table A.4.9 (Continued) - Union Territories: Key Inputs/Processes domain indicators, base and reference years

UTs

3.1.3.b Functional 24x7 PHCs (percentage)

3.1.3.a Functional FRUs (percentage)

3.1.4 Districts with functional CCUs (percentage)

3.1.5 Proportion of first trimester ANC (percentage)

3.1.6 Level of birth registration (percentage)

Andaman & Nicobar Islands

0.00

500.00

0.00

77.84

76.94

97.20

71.90

Chandigarh

150.00

0.00

49.63

36.79

100.00

Dadra & Nagar Haveli

100.00

133.33

0.00

47.27

84.77

71.80

65.10

Daman & Diu

100.00

50.00

0.00

47.32

49.26

98.40

76.40

Delhi

91.18

100.00

0.60

90.91

34.74

33.69

100.00

Lakshadweep

100.00

0.00

100.00

74.88

73.24

60.00

59.50

Puducherry

300.00

200.00

0.00

25.00

45.53

39.54

100.00

Table A.4.9 (Continued) - Union Territories: Key Inputs/Processes domain indicators, base and reference years

UTs

3.1.7 IDSP reporting of L form (percentage)

3.1.8 CHC grading (percentage)

3.1.9 Quality accreditation DH-SDH (percentage)

3.1.9 Quality accreditation CHC-PHC (percentage)

3.1.10 Fund transfer (no. of days)

Andaman & Nicobar Islands

0.00

147

Chandigarh

100.00

0.00

Dadra & Nagar Haveli

100

0.00

Daman & Diu

100

0.00

Delhi

0.00

1.79

8.93

0.00

Lakshadweep

0.00

143

Puducherry

25.00

0.00

101

Most Improved

3.1.7 IDSP reporting of P form (percentage)

Improved

No Change

Deteriorated

Most Deteriorated

Not Applicable