(GIST OF YOJANA) Benchmarking Healthcare System
[MAY-2020]
Benchmarking Healthcare System
- The right to health has so far not been accorded the status of a Fundamental Right to the Indian citizens. It is not even a statutory right, unlike education.
- Moreover, health is a subject which is assigned to State Governments as per our Constitution. This is reflected in the way we finance it, with about two-thirds of the total government expenditure on health coming from the State Governments and the balance one-third being provided by the Government of India.
- Despite this, it is also a reality that the Government of India has significant influence in the policy space with path breaking schemes such as the National Health Mission (NHM) and Ayushman Bharat, with its twin prongs of the Health and Wellness Centres to deliver comprehensive primary health care and Pradhan Mantri Jan Arogya Yojana (PMJAY). India is also a signatory to the 2030 Agenda for Sustainable Development, whereby it has committed as a nation to “ensure healthy lives and promote well-being for all”.
The key questions that motivated the team involved in the design of Health Index were as follows:
- Can we develop a tool to bring health into greater political focus to ensure that what gets measured gets done?
- Can we benchmark the performance of the health system of various States which can be put forth in the public domain in a timely manner? Is it possible to capture the diversity and yet ensure that high performing states do not get complacent and the low performing States are not discouraged?
- Can appropriate instruments or incentives be put in place that can nudge the States to try and radically improve their health system performance? Can this be done in a manner that respects the federal compact and allows autonomy to individual State Governments to make policy choices to achieve the specified benchmarks?
- What are the parameters that could credibly capture the complex story of health system performance? Can those parameters capture outcomes at the system level rather than merely tracking inputs such as budget, number of facilities or outputs such as number of OPDs/IPDs? Is data relating to those parameters available from a third party source? Is the data of reasonable quality and available at least annually?
What is the emphasis (weights) to be provided on each of the individual parameters?
- It is the first-ever systematic exercise for tracking the progress on health outcomes and health systems’ performance across all the States and Union Territories (UTs) in India on an annual basis. The Health Index is a weighted-composite Index based on select indicators in three domains:
- Health Outcomes;
- Governance and Information; and
- Key Inputs and Processes, with the health outcomes carrying the most weight across the different category of States/UTs.
Enabling Tool:
- The vision behind establishing the annual systematic tool is to propel States towards undertaking multi-pronged interventions and drive efforts towards achievement of SDG Goal 3. It can be viewed as being akin to an annual health checkup diagnostic report; providing the State Governments to identify parameters in which States have improved, stagnated, or declined.
- The Health Index report provides the direction and magnitude of change at a composite level as well as for each of the indicators of the Health Index. An analysis of this can help States in focusing attention on better targeting of interventions and improving the delivery of health services and also an opportunity of sharing best practices.
Room for Improvement:
- The introspection is useful for all States and UTs, as both the first and second annual Health Index report indicates that even the States and UTs that are doing comparatively well have substantial scope for improvement. For example Health Index (June 2019) report on ranks of States and UTs indicates, even Kerala, Mizoram, and Chandigarh, the “healthiest” among large states, small states and UTs respectively, all have quite a distance from the frontier and have room for improving their performance.
- The Index is an innovative tool as it not only fosters competition among states by comparing similar states to each other but also nudges them to better their own performance in the previous year. For example, though Kerala remained the “healthiest state” in 2014-15, 2015-16 as well as 2017-18, a slight decline in the composite Health Index score value was observed in each of the successive periods.
Large Gap Between the “Healthiest” and the “Ailing” States/UTs:
- There are wide disparities in overall performance across States and UTs. The gap between the best performing states and the least performing states is very wide – Kerala and Uttar Pradesh are separated by 45 points, Mizoram and Nagaland by 36 points, and Chandigarh and Daman and Diu by 22 points as indicated by the Overall Performance Scores for 2017-18 (Health Index, June 2019).
Scope for Improvement:
- Based on the composite Health Index scores range for the reference year (2017-18), the States are grouped into three categories: Aspirants, Achievers, and Front-runners.
- Aspirants are the bottom one-third States and six of the eight Empowered Action Group States1 fall in this category. Given the substantial scope for improvement, these States require concerted efforts. Achievers represent the middle one-third States. Overall, these States have made good progress and can move to the next group with sustained efforts. Front-runners, the States falling in top one-third score range are the best performing States. Despite relatively good performance, however, even the front-runners could further benefit from improvements in certain indicators (Health Index, June 2019).
Different Levels of Momentum to Improve Performance:
- Only around 58% of the States and UTs had an improvement in the overall score between 2015-16 and 2017-18 (Health Index June 2019). The degree of changes in incremental performance scores differed across the three categories of States.
- The magnitude of changes was bigger in UTs compared to Larger and Smaller States. Andhra Pradesh and Maharashtra were the only two states that were among the top one-third States on both overall performance and incremental performance. Andhra Pradesh had the highest proportion of indicators (63 percent) among the Larger States which fell in the category of most improved or improved.
- Among the UTs and Smaller States, there was a divergence in Health Index Scores from base year to reference year across States (UTs), that is, better performing States (UTs) tended to get better whereas least performing States (UTs) tended to get worse. Among the Larger States, there was neither divergence or convergence in Health Index Scores over time.
Shake Complacency and Nurture Hope:
- It is envisaged that tracking progress on incremental performance will also help shake complacency among “Healthiest Large States” such as Kerala, Punjab, and Tamil Nadu that have historically done well. At the same time, it is expected that it will nurture hope and optimism among large states such as Haryana, historically lagged in performance but are demonstrating greater improvements in health outcomes.
Variable Progress Across States Towards Achieving SDG Goals:
- Several States have made good progress towards achieving SDG goals included in the Index. Kerala and Tamil Nadu have already reached the 2030 SDG goal for Nuclear Magnetic Resonance (NMR), which is 12 neonatal deaths per 1000 live births. Maharashtra and Punjab are also close to achieving the goal.
- Kerala, Tamil Nadu, Maharashtra and Punjab have already achieved the SDG goal on Under-Five Mortality Rate (U5MR), which is 25 deaths per 1000 live births. Other States and UTs still need significant improvements to meet SDG targets.
Incentivising Incremental Performance:
- The Health Index has the potential to be a game changer as it can shift the focus from budget spends, inputs and outputs to outcomes by shining the light on States that have shown most improvement. The MoHFW’s decision to link the Index to incentives under the National Health Mission sends a strong signal to States in the shift towards outcome based monitoring and performance linked incentives.
- In 2019-20, 40% of the incentives or INR 3200 crore of the National Health Mission (NHM), MoHFW’s flagship federal initiative, was linked to the incremental performance of the states and UTs on the Health Index. In 2019-20, MoHFW has taken a decision to link 70% of the NHM incentives to the incremental performance of the states and UTs on the Health Index.
Need for Improving Data Quality:
- The process of Index development and implementation highlighted the large gaps in data availability on health outcomes and health systems performance.
- The need of the hour is to make outcome data available for smaller states and union territories more frequent and updated outcomes for non-communicable diseases, financial protection, and other priority areas, and the robust programmatic data that can be used for continuous monitoring.
Conclusion:
- The Health Index is a useful tool to measure and compare the overall performance and incremental performance across States and UTs over time. It is an important instrument in understanding the variations and complexity of the nation’s performance in health. The critical factors that contributed to the success of the Health Index include: a) Timelines of the report so that it stimulates action and not merely academic discussions; b) Provision of financial incentives based on the annual incremental performance of states under the National Health Mission; and; c) Verification of self reported data by states by a third party, independent verification agency to enhance credibility. However, there are limitations to the Index as no single index can purport to comprehensively capture the complex story of evolution of the health system.
- Also, due to constraints of availability of quality data critical areas such as non-communicable diseases, mental health, and private sector service utilisation could not be captured. Thus, the Health Index is a work in progress and continuous refinements will be made as additional quality data becomes available and data systems improve
