Analysis of NITI AAYOG (National Institution for Transforming India) health index report on the ranking of states and union territories: A cross sectional observational research study Round 1 (2014 – 2016)-V1

doi:10.21203/rs.3.rs-1566619/v1

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Research Article

Analysis of NITI AAYOG (National Institution for Transforming India) health index report on the ranking of states and union territories: A cross sectional observational research study Round 1 (2014 – 2016)-V1

https://doi.org/10.21203/rs.3.rs-1566619/v1

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India has committed to adopting the Sustainable Development Goals (SDGs) for ending poverty, protecting the planet, and ensuring prosperity for all to be fulfilled by year 2030. Goal 3 of SDGs is about ensuring healthy lives with promoting well-being for all. National Institution for Transforming India- (NITI) Aayog had started the Health Index initiative for achieving desirable health outcomes. The key objective of the whole exercise is to track development on health, to develop healthy competition and cross learning among states and UTs. Health Index Scores and rankings are generated to assess Incremental Performance (year-to-year progress) and Overall Performance of state/UT for achievement of health-related Sustainable Development Goals (SDGs) as well as Universal Health Coverage (UHC). This novel study was a cross-sectional retrospective observational epidemiological study. The Health Index consists of a set of indicators in the domains of Health Outcomes, Governance and Information, and Key Inputs/Processes. Health Outcomes are assigned the highest weight, indicators were selected on the basis of their importance and availability of reliable data at least annually from pre- 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 only after validation by the IVA.

Epidemiology

Health Economics & Outcomes Research

Statistical Epidemiology

Health index

Niti Aayog

incremental performance

annual incremental performance

index score

2. Background/rationale

India has committed to adopting the Sustainable Development Goals (SDGs) for ending poverty, protecting the planet, and ensuring prosperity for all to be fulfilled by year 2030. Goal 3 of SDGs is about ensuring healthy lives with promoting well-being for all. National Institution for Transforming India- (NITI) Aayog had started the Health Index initiative for achieving desirable health outcomes. India’s improvement in life expectancy, maternal and child mortality, reducing fertility, are falling short on several national and global targets. There are variations across States and Union Territories of India in their health needs and systems performance. NITI Aayog aims to bring change in population health by spirit of co-operative and competitive federalism; NITI Aayog measures the annual performance of States and Union Territories (UTs), and rank States and UTs on the basis of incremental change. Healthy States and union territories can make India able to reap demographic dividend is the key motto. In year 2017 the NITI Aayog with the Ministry of Health and Family Welfare (MoHFW) and the World Bank initiated an annual Health Index for knowing Performance and Incremental Performance across all 36 states and UTs. NITI Aayog has been mandated as the nodal agency responsible for attaining the commitments under the SDGs. It was necessary to develop a tool for measuring outcomes in the health sectors to provide feedback to all stakeholders on what we have set out to achieve, deviations, if any, to be pointed out in time to ensure necessary correction. It is true that summarizing the complexities and condensing it in an Index has limitations. Health Outcomes Index seeks to capture the annual progress of States and Union Territories (UTs) through 3 varieties of indicators – Outcomes, Governance and Processes. The NITI Aayog works in collaboration with the Ministry of Health and Family Welfare, with technical assistance from the World Bank.

3. Objectives

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. The key objective of the whole exercise is to track development on health, to develop healthy competition and cross learning among states and UTs. Health Index Scores and rankings are generated to assess Incremental Performance (year-to-year progress) and Overall Performance of state/UT for achievement of health-related Sustainable Development Goals (SDGs) as well as Universal Health Coverage (UHC). Objectives- 1 to develop a composite Health Index based on key health indicators. 2. To ensure States’ participation and ownership. 3. Transparency by using an independent validation of data by an independent agency. 4. To generate Health Index scores and rankings for the States and UTs.

4. Study design

This novel study was a cross-sectional retrospective observational epidemiological study. The Health Index consists of a set of indicators in the domains of Health Outcomes, Governance and Information, and Key Inputs/Processes. Health Outcomes are assigned the highest weight, indicators were selected on the basis of their importance and availability of reliable data at least annually from pre- 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 only after validation by the IVA. A composite Index is calculated as a weighted average of various indicators, 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 is the annual incremental progress of each State. States and UTs were grouped in 3 categories to ensure comparison among similar entities, namely 21 Larger States, 8 Smaller States, and 7 UTs.

5. Setting

For calculation of Index values and ranks, data was submitted online and validated by an Independent Validation Agency (IVA). The States were previously sensitized about the process for data submission through workshops and mentor agencies (Table-1). Data was submitted by participants States and UTs through online portal hosted by NITI Aayog and data from pre-existing sources in the public domain was pre-entered. After validation of data by an IVA it was used as an input into automated generation of Index values and ranks on the web-portal. The data was verified by IPE Global, an IVA prior to computing the Index and ranks for all States and UTs of India.

Table-1- 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 States (RRC-NE)	Assam, Meghalaya, Arunachal Pradesh, Mizoram, Manipur, Nagaland, Sikkim, Tripura
Centre for Innovation in Public Systems (CIPS)	Andhra Pradesh, Telangana
The Energy Research Institute (TERI)	Delhi

This novel study was the first of its kind which was conducted over a period of eighteen months. The World Bank, experts in statistics and health systems, public health, and economics were consulted for the development of the Index. The States and UTs participated for finalization of the indicators/variables, workshops for sharing the methodology, process of data submission.

6. Participants

All states and UTs of India were participants. Multiple stakeholders as discussed above contributed to the Index development: The various Index was developed by NITI Aayog with help of World Bank, States and UTs, the Ministry of Health and Family Welfare (MoHFW), domestic and international sector experts and other development partners Categorization of States and UTs for ranking were based on the size, and administration. The States were ranked in three categories, namely Larger States, Smaller States and UTs [1] (table-2).

Table-2- Categorization of States and UTs

Category	Number of States and UTs	States and UTs
Larger States	21	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	8	Arunachal Pradesh, Goa, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura
Union Territories	7	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) were not available for 8 Smaller States and 7 UTs, • reliable estimates for these outcome indicators/variables based on raw data obtained from SRS for the Smaller States and UTs could not be derived due to statistically small sample size and insufficient number of events.

7. Variables

The main criteria for inclusion of indicators/variables were the availability of reliable data with at least an annual frequency. The output Index is a weighted composite Index based on indicators/variables in 3 fields: (1) Health Outcomes; (2) Governance and Information; and (3) Key Inputs/Processes. Each domain was assigned a weight based on its importance. The indicator values are scaled from 0 to 100 for generating composite Index scores and performance rankings for base year (BY) (2014-15) and RY (reference year) (2015-16). The annual incremental progress made from BY to RY is used to generate incremental ranks. Table 3 shows the number of indicators/variables in each domain and sub-domain along with weights, while Table-4 provides the detailed Health Index with indicators/variables, their definitions, data sources, and specifics of base and reference years.

Table 3 - Health Index: Summary

Domain	Sub-domain	Larger States		Smaller States		Union Territories
Domain	Sub-domain	Number of Indicators/variables	Weight	Number of Indicators/variables	Weight	Number of Indicators/variables	Weight
Health Outcomes	Key Outcomes	5	500	1	100	1	100
Health Outcomes	Intermediate Outcomes	6*	300*	6*	300*	5*	250*
Governance and Information	Health Monitoring and Data Integrity	1	70	1	70	1	70
	Governance	2	60	2	60	2	60
Key Inputs/ Processes	Health Systems/Service Delivery	10	200	10	200	10	200
TOTAL		24	1130	20	730	19	680

* 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 RY Index and rank.

8. Data sources/measurement

The Health Index consists of 24 indicators/variables related to Health Outcomes, Governance and Information, and Key Inputs/Processes (Table 4 provides Health Index-indicator details and data sources).

Table-4-Health Index: Indicators/variables, definitions, data sources, base and reference years

S.No.	Indicator		Definition		Data Source		BY & RY		Remarks
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		Indicators/variables 1.1.1, 1.1.2, 1.1.3, and 1.1.5 are not applicable for category of Smaller States and UTs
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 RY: 2015
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: 2014 RY: 2015
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.
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 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		BY & RY: 2015-16 (NFHS) BY & RY: 2011-12 to 2015-16 (HMIS)		The NFHS data was available only for RY and the data for this was repeated for the BY and reference year.
Sub-domain 2.2 – Governance (Weight – 60)
2.2.1	Average occupancy of an officer (in months), combined for following three posts at State level for last three years 1. Principal Secretary Mission Director (NHM) 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		BY: April 1, 2012-March 31, 2015 RY: April 1, 2013-March 31, 2016
2.2.2	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
DOMAIN 3 – KEY INPUTS/PROCESSES
Sub-domain 3.1 – Health Systems/Service Delivery (Weight – 200)
3.1.1		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: Auxiliary Nurse Mid-wife (ANM) at sub-centres (SCs) Staff nurse (SN) at Primary Health Centres (PHCs) and Community Health Centres (CHCs) c. Medical officers (MOs) at PHCs d. Specialists at District Hospitals (Medicine, Surgery, Obstetrics and Gynaecology, Paediatrics, Anaesthesia, Ophthalmology, Radiology, Pathology, Ear-Nose-Throat (ENT), Dental, Psychiatry)		State Report		BY: As on March 31, 2015 RY: As on March 31, 2016
3.1.2		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		BY: As on March 31, 2015 RY: As on March 31, 2016
3.1.3		a. Proportion of specified type of facilities functioning as First Referral Units (FRUs) b. Proportion of functional 24x7 PHCs		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. 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 of functional FRUs, MoHFW data on required number of (FRUs State Report on number of functional 24x7 PHCs, MoHFW data on required number of PHCs		BY: 2014-15 RY: 2015-16 BY: 2014-15 RY: 2015-16		Indicator definition modified
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 RY: As on March 31, 2016
3.1.5		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		BY:2014-15 RY: 2015-16
3.1.6		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]		BY: 2013 RY: 2014
3.1.7		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 RY: 2015
3.1.8		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 RY: 2015-16

3.1.9		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		BY: As on March 31, 2015 RY: As on March 31, 2016
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		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]		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 ‑exi-pool and NHM-Health System Strengthening ‑exi-pool data (representing a substantial portion of the NHM funds) for calculating delay in transfer of funds

9. Bias

Grouping the states according to size was not enough. The researcher feels that population density/ per capita income/ literacy rate/ health workforce/ corruption-scam index etc. should be included for ranking states.

10. Study size

All states and UTs of India were participants. Table 5 shows study period

Table 5– Study period

Sr No.

Step/Activity

2016

2017-18

Jun-Nov

Dec

Jan

Feb

Mar-Apr

May

Jun

Jul

Aug

Sep-Oct

Nov-Jan

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

11. Quantitative variables

See table-4

12. Statistical methods

Methodological details of constructing the Index-Computation of Index scores and ranks

After validation of data by the IVA, data was used for the Health Index score calculations. Indicator value was scaled, based on the nature of the indicator, for positive indicators, where higher the value, better the performance, 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)

For negative indicators where lower the value, better the performance (e.g. NMR, U5MR,) 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. Indicator value lies between the ranges of 0 to 100; e.g. 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. 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 these scaled values (Si), a composite Index score was calculated for the base year and reference year by application of the weights using the formula:

Composite Index = (∑ Wi *Si)/ (∑ Wi) --Where Wi is the weight for ith indicator

The composite Index score has been used for generating overall performance ranks. The difference between the composite Index score of reference and base years was the annual incremental performance. The ranking is primarily based on the incremental progress, however, rankings based on Index scores for the base year and the reference year performance calculated to provide the overall performance of the States and UTs.

Overall performance for the BY (2014-15), the composite Health Index ranged from 28.14 in Uttar Pradesh to 80 in Kerala. In the RY2015-16, Uttar Pradesh at 33.69 was poorest performing State, and Kerala best performing State. The top five States in the RY 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, Uttar Pradesh (33.69) scored the lowest preceded by Rajasthan (36.79), Bihar (38.46), Odisha (39.43), and Madhya Pradesh (40.09). Among the 21 Larger States, only five States Punjab, Andhra Pradesh, Jammu & Kashmir, Chhattisgarh and Jharkhand improved their position from base to reference year. Jharkhand and Jammu & Kashmir States moved up by four positions in the ranking, Punjab improved its performance in the ranking by three positions; Andhra Pradesh and Chhattisgarh have shown modest improvement –up by one position. 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 while remaining States fell in ranking by 1-2 positions.

14. Descriptive data

Taking into account importance, availability (at least annually) of reliable data, 28 indicators/variables were included first. The availability and quality of data for all States was reviewed and 23 indicators/variables were retained and five indicators/ variables were dropped for calculating the performance in the base and reference years. However, Index scores and ranks for the RY were also calculated independently, based on 24 indicators/variables including an additional indicator on out-of-pocket expenditure, as the data for this was available only for 2015-16. Once the data was accepted by the IVA, the ranks were automatically generated by the portal hosted by the NITI Aayog. To ensure accuracy the indices and ranks were also manually calculated and cross-checked with the results from the portal and the final values were certified by the IVA.

15. Outcome data

See table – 6,7,8,9,10,11,12,13,14,15,16 and 17.

Tables 6-14 are in the supplementary files section.

16. Main results

Tables 15-17 are in the supplementary files section.

17. Other analyses

SRS-related indicators/variables estimates such as NMR were not available for Smaller States and UTs, these estimates could not be generated due to the insufficient sample size. In the Larger States category, MMR were not available separately for 08 states, previously four undivided States, and also for Himachal Pradesh and Jammu & Kashmir. In the case of Still Birth Rate (SBR), the IVA reported that data was unreliable. In case of proportion of pregnant women age 15-49 years who are anaemic, data on the appropriate denominator was not available in the HMIS. Proportion of people living with HIV (PLHIV) on ART excluded for the UTs since no ART centre was available in four UTs. NHM funds utilized by the end of 3rd quarter, data were not valid. Central data was used for a few indicators/variables such as 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 out-of-pocket expenditure on drugs and diagnostics incurred per delivery in public health facilities was used in the RY Index. However, for the BY, this data was not available and could therefore not be factored in for generating BY ranks or incremental ranks or drawing comparisons between the base and reference years.

18. Key results

There is a large gap in overall performance of States and UTs, 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 the Larger States (table-15), Jharkhand, Jammu & Kashmir, and Uttar Pradesh are the top three in terms of annual incremental performance, while Kerala, Punjab, and Tamil Nadu ranked on top in terms of overall performance. In terms of incremental performance top three are Jharkhand (up 6.87 points), Jammu & Kashmir (up 6.83 points) and Uttar Pradesh (up 5.55 points). Jharkhand, Jammu & Kashmir, and Uttar Pradesh showed the maximum gains in improvement of health outcomes from base to RY.

Among Smaller States (table-16), Manipur ranked first in terms of annual incremental performance and second in terms of overall performance. Mizoram (73.70) followed by Manipur (57.78) are the best overall performers.

Among UTs (table-17), Lakshadweep showed both the highest annual incremental performance as well as the best overall performance

The incremental measurement shows that about one-third of the States declined in their Health Indices in the RY as compared to the BY. Tables 18, 19, 20 provide a categorization of States and UTs based on the level of annual incremental performance and the overall performance.

Table 18 is in the supplementary files section.

Table-19-Categorization of Smaller States on incremental performance and overall performance

Not improved	Least improved	Moderately improved	Most improved
Sikkim		Mizoram	Manipur
Arunachal Pradesh	-		Goa
Tripura Nagaland			Meghalaya

Table-20-Categorization of Larger States on incremental performance and overall performance

Not improved	Least improved	Moderately improved	Most improved
Uttarakhand	Madhya Pradesh	Bihar	Jharkhand
Himachal Pradesh	Maharashtra	Chhattisgarh	Jammu & Kashmir
Karnataka	Assam	Punjab	Uttar Pradesh
Gujarat	Telangana	Andhra Pradesh
Haryana	West Bengal	Rajasthan
Kerala	Odisha Tamil Nadu

Categorization of Smaller States on incremental performance and overall performance

Union Territories: Overall performance in RY- Categorization

Table21- Union Territories: Incremental performance from base to RY- 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 States are categorized on the basis of RY 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). Note: Overall Performance: The UTs are categorized on the basis of RYIndex 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<=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). Note: Overall Performance: The States are categorized on the basis of RYIndex 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 <=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).

The indicators/variables where most States and UTs need to focus include 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).

Note: Overall Performance: The States are categorized on the basis of RY 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<=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).

19. Limitations

There is need for making outcome data available for smaller states, updated outcomes for non-communicable diseases and financial protection, robust programmatic data for continuous monitoring, were important issues, could not be addressed optimally in this first round.

LIMITATIONS OF THE INDEX 1-non-availability of acceptable quality of data on an annual basis. 2. Paucity and uneven availability of private sector data in the HMIS. 3. Analytical tools could not be used to derive domain-specific weights 4.For SRS data was available only for Larger States.

20. Interpretation

The Health Index score ranking is the first attempt at establishing an annual systematic tool for measurement of performance across States and UTs of health parameters. The results provide an important insight into the areas in which States have improved, stagnated or declined which will help in better targeting of interventions.

21. Generalisability

The States and UTs rank differently on performance, States and UTs at lower levels of the Health Index (lower levels of development of their health systems) are at an advantage in notching up incremental progress over States with high Health Index score. 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.

Other information

This is the first simple version of the report. From next version next rounds of report and more analysis will be presented. This version is just for awareness. There are loopholes and drawbacks in this report of Niti Aayog of which few are displayed.

22. Funding

The author declares that no funds are taken from any individual or agency-institution for this research study.

-This version of paper has not been previously published in any peer reviewed journal and is not currently under consideration by any journal. The document is Microsoft word with English (India) language & 9001 words excluding reference and declaration etc. (7027 words Total including all).

- Ethics approval and consent to participate: Not applicable. This study has not involved any human or animals in real or for experiments. The submitted work does not contain any identifiable patient/participant information.

-Consent for publication: The author provides consent for publication.

-Availability of data and materials: Electronic records from HMIS (health management information system) of MoHFW (ministry of health and family welfare), Government of India, NITI Aayog.

-Conflicts of Interest/ Competing Interest: There are no conflicts / competing of interest

- Funding-Self sponsored. No aid taken from individual or agency etc.

- Authors' contributions: The whole work is done by the Author - Dr Piyush Kumar, M.B.B.S., E.M.O.C., P.G.D.P.H.M., -Senior General Medical Officer- Bihar Health Services- Health Department- Government of Bihar, India and Advocate Anupama-Senior Lawyer, Bar Council, Patna.

- Acknowledgements- I am thankful to Advocate Anupama my wife and daughters Aathmika-Atheeva for cooperation.

- Author information: The author is currently working as Senior General Medical Officer for the government of Bihar and Advocate Anupama-Senior Lawyer, Bar Council, Patna.

-Financial Support & sponsorship: Nil

-Author contact information
Department of Health, Government of Bihar, MOBILE - +919955301119/+917677833752, Email [email protected]

AHPI Association of Healthcare Providers (India), ANC Antenatal Care ,ANM Auxiliary Nurse Midwife, ART Antiretroviral Therapy, BCG Bacillus Calmette–Guérin ,CCU Cardiac Care Unit ,CHC Community Health Centre ,CIPS Centre for Innovation in Public Systems, CMO Chief Medical Officer, CRS Civil Registration System, C-Section Caesarean Section, DH District Hospital, DPT Diphtheria, Pertussis, and Tetanus, EAG Empowered Action Group, ENT Ear-Nose-Throat, GBD Global Burden of Disease, FLV First Level Verification, FRU First Referral Unit, Hb Hemoglobin, HIV Human Immunodeficiency Virus, HMIS Health Management Information System, HRMIS Human Resources Management Information System, IDSP Integrated Disease Surveillance Programme, IMR Infant Mortality Rate ,INR Indian Rupees, IVA Independent Validation Agency, ISO International Organization for Standardization, IT Information Technology, JSSK Janani Shishu Suraksha Karyakram, JSY Janani Suraksha Yojana, LBW Low Birth Weight ,L Form IDSP Reporting Format for Laboratory Surveillance ,MCTS Mother and Child Tracking System ,MCTFC Mother and Child Tracking Facilitation Centre ,MIS Management Information System ,MMR Maternal Mortality Ratio, MO Medical Officer, MoHFW Ministry of Health and Family Welfare ,NA Not Applicable, NABH National Accreditation Board for Hospitals, and Healthcare Providers ,NACO National AIDS Control Organization, NCDs Non-communicable Diseases, NE North-Eastern, NFHS National Family Health Survey, NHM National Health Mission, NHP National Health Policy ,NITI National Institution for Transforming India, NMR Neonatal Mortality Rate, NQAS National Quality Assurance Standards ,OPV Oral Polio Vaccine ,ORGI Office of the Registrar General and Census Commissioner, India ,OOP Out-of-Pocket ,PCPNDT Pre-Conception and Pre-Natal Diagnostic Techniques ,P Form IDSP Reporting Format for Presumptive Surveillance ,PHC Primary Health Centre ,PLHIV People Living with HIV ,RRC-NE Regional Resource Centre for North Eastern States ,RNTCP Revised National Tuberculosis Control Programme ,RU Reporting Unit,SBR Still Birth Rate ,SC Sub-Centre ,SDGs Sustainable Development Goals ,SDH Sub-District Hospital ,SLV Second Level Verification ,SRB Sex Ratio at Birth ,SRS Sample Registration System ,SN Staff Nurse ,SNO State Nodal Officer ,TA Technical Assistance ,TB Tuberculosis ,TERI The Energy Research Institute ,TFR Total Fertility Rate ,U5MR Under-Five Mortality Rate ,USAID United States Agency for International Development, UTs Union Territories

1. The World Bank- https://issuu.com/worldbankindia/docs/health_states_progressive_india

2. Niti Aayog - https://www.niti.gov.in/