This is the concluding part of a four-part IndiaSpend-Observer Research Foundation series on data, healthcare and public policy. As the Narendra Modi government returns to power, we look at the resource constraints that the new dispensation has to address in India’s healthcare.
Given its continent-like diversity, India is undergoing epidemiological, nutritional and demographic transitions in a staggered fashion, with very large state-level variances, recent research by the Observer Research Foundation shows. New challenges posed by non-communicable diseases, as we said, are posing an additional burden on the healthcare delivery system, which is still geared more towards the communicable, maternal, neonatal and nutritional health conditions. Adapting to the fast-changing disease transition requires significant additional financial resources within the health sector.

Despite the Bharatiya Janata Party’s (BJP) titling the health section of their election manifesto as “Health for All”, and the Indian National Congress (INC) starting their manifesto’s health chapter with the declaration that “Healthcare is a public good”, neither party has come close to the promised spending of 2.5% of GDP in the past decade.

The impact of inadequate funding on the health system manifests itself most visibly in terms of insufficient human resources. Given that two-thirds of the public spending on health in India is from the state and local governments, sub-national players are important stakeholders.

The Niti Aayog, the government’s policy think-tank, developed a Health Index in 2018 to instil a spirit of co-operative and competitive federalism between the Centre and states. Along with outcomes and governance issues that were discussed in previous articles in the series (here, here and here), key inputs and processes was the third sub-domain the index explored. Among other things, this sub-domain explored issues of staff shortages and delays in funds transfer.

The proportion of vacant healthcare provider positions in public health facilities is an important indicator explored under this theme. Vacancies of key health staff are linked with both access to healthcare services as well as their quality, according to the Niti Aayog report.

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 auxiliary nurse/midwives (ANMs) at sub-centres (SCs), staff nurses at primary health centres (PHCs) and community health centres (CHCs), medical officers (MOs) at PHCs, and specialists at district hospitals (DHs) was explored as part of the index.

The five best performers with the least percentage of vacancies of staff nurses–among states and union territories with an assembly–are Puducherry (where INC and others are in power), Uttar Pradesh (BJP and others), Tripura (BJP and others), Odisha (Biju Janata Dal) and Nagaland (BJP and others).

The vacancy of staff nurses in PHCs and CHCs was highest in Jharkhand (75%), followed by Sikkim (62%) Bihar (50%), Rajasthan (47%) and Haryana (43%)–all but one (Rajasthan) currently ruled by the BJP and its allies. National Capital Territory of Delhi (NCT Delhi), currently ruled by the Aam Aadmi Party, was the sixth worst with 41% vacancy.

The gaps at the primary-level healthcare delivery system put pressure on the tertiary hospitals, and often force patients to seek help in the private sector, being compelled to “vote with their feet” against government facilities, this May 2015 paper by Oxfam India said.

Source: Niti Aayog
Note: Data as of March 31, 2016

Similarly, among the states and UTs with assemblies, the vacancy of medical officers at PHCs was highest in Bihar (64%), followed by Madhya Pradesh (58%), Jharkhand (49%), Chhattisgarh (45%) and Manipur (43%). There were no vacancies in Sikkim, while Tripura had 2% vacancies–both currently ruled by the BJP and its allies. This was followed by Kerala (6%), Tamil Nadu (8%) and Punjab (8%).

Source: Niti Aayog
Note: Data as of March 31, 2016

Many states showed a very high proportion of vacant specialist positions in district hospitals: Arunachal Pradesh (89%) had the highest, followed by Chhattisgarh (78%), Bihar (61%), Uttarakhand (60%) and Gujarat (56%).

Thirteen states and UTs with an assembly had overall vacancy of specialist positions at over 40%. Of these, seven are currently ruled by the BJP and its allies, four by the INC and its allies, and one each by the AAP and the Telangana Rashtra Samithi.  

Source: Niti Aayog
Note: Data as of March 31, 2016

Healthcare staff shortages at the primary level and for specialty care make the private sector the de facto service provider for a vast majority of the population, with adverse financial implications.

Out-of-pocket (OOP) health expenses drove 55 million Indians–more than the population of South Korea, Spain or Kenya–into poverty in 2011-12, as IndiaSpend reported on July 19, 2018.

Funds unspent in states that need them most

In addition to inadequacy of funds, the inconsistency in the timing of funds released by the Centre to state governments has contributed to inequity in terms of service delivery across the country, analysis from the Observer Research Foundation showed. 

On average, there were more unutilised funds at the end of the year in the states that needed them the most. Studies have shown that a file with a request for release of funds has to cross a minimum of 32 desks while going up the administrative hierarchy, and 25 desks on the way down.

The Niti Health Index analysed the average time taken for transfer of Central National Health Mission (NHM) funds from the state treasury to the implementation agency (department/society) based on all tranches of the financial year 2015-16, and found huge variance between states.

Time taken for funds to reach implementing agencies varied from zero days in Daman & Diu and Lakshadweep to and 287 days in Telangana. Almost all Indian states have reported lengthy delays–more than 100 days in many cases–in transfer of funds from the state treasury to state health societies, thereby adversely affecting timely implementation of various health sector initiatives.

Source: Niti Aayog
Note: Data for the financial year 2015-16

Unlike the governance and information sub-index–which deals with the status of the governance structures and information systems within states–the overall performance of the states was mostly consistent with the domain-specific performance within the “key inputs and processes” theme–which deals with human resources, and the level and quality of healthcare and processes.

However, Odisha and Rajasthan performed better on the “key inputs and processes” sub-domain compared to the overall index, according to the Niti Index Rankings.  At the same time, all smaller states showed better performance on health outcomes–such as Goa and Manipur–compared to “key inputs and processes”. This aspect needs further study.

Source: Niti Aayog

If India is to get to a reasonable level of healthcare for all Indians, all mainstream parties in India must agree on a common minimum programme on health down to the state level, to help stop losing time during transition years such as between schemes such as the Rashtriya Swasthya Bima Yojana–started in 2008 by the then United Progressive Alliance government–and the Pradhan Mantri Jan Arogya Yojana launched in 2018 by the previous National Democratic Alliance government, in which Centre-state coordination is key.

As health remains a state subject, and the National Health Policy 2017 has made a logical case for regulation of healthcare, explicitly supporting “the need for moving in the direction of a rights-based approach”, India needs to take urgent steps to reduce bureaucratic delay in fund disbursement in particular, and to improve Centre-state relations within the multi-party federal democratic setup.

This story was first published here on HealthCheck.

(Kurian is Fellow at Observer Research Foundation’s Health Initiative.)

Courtesy: India Spend

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In roughly five years, or by 2024, the population of India is expected to surpass that of China, according to this 2017 United Nations (UN) projection. China’s population will peak at 1.44 billion in 2029 and start declining. As per current estimates, due to what is called population momentum–a higher proportion of people in the reproductive age group–as well as higher life expectancy, India’s population will only peak in the 2060s, before it starts to decline.

However, Indian fertility rates are declining quickly, and some of these estimates are being revised constantly. For example, according to earlier UN estimates, India was to overtake China in 2022. Ten years ago, India had a total fertility rate (TFR) of 2.68; today, according to the National Family Health Survey-4 (NFHS 4), out of 36 states and UTs, only four–Uttar Pradesh (UP), Bihar, Meghalaya and Nagaland–have a TFR more than or equal to 2.68.

India was the first country in the world to formulate a National Family Planning Programme in 1952, with the objective of “reducing birth rate to the extent necessary to stabilise the population at a level consistent with requirement of national economy”. The current TFR, at 2.2, is close to the replacement-level fertility rate of 2.1. According to NFHS-4, TFR has declined considerably and between 1992-93 and 2015-16, it declined by 1.2 children (from 3.4 children in 1992-93 to 2.2 in 2015-16).

Source: National Family Health Survey, 2015-16

It is often said that “development is the best contraceptive”. The two-pronged approach of health system strengthening and population control may still work in states such as Bihar and UP, but for other states that are near or under replacement fertility, more resources should move into health system strengthening and core health priorities–communicable diseases, drug availability, and human resource deployment, to name just a few. A low child mortality rate and accessible health services would be good incentives for family planning.

This is one of many decisions facing India’s public healthcare sector that this second story under an IndiaSpend-Observer Research Foundation (ORF) series highlights, which the new government must address. Healthcare has received unprecedented attention from political parties during the ongoing elections for the 17th Lok Sabha, even as better measurement, greater evidence and more informed reporting begin to expand voter awareness and deepen policy debates, as we argued in our previous story.

Here are some of the crucial areas on which India must focus more attention, efforts and funds.

Child and maternal mortality rates

However, India’s achievements in preventing child deaths have not been as spectacular, mostly because of meagre fund allocation, over the decades.

When it comes to child mortality, Kerala (ruled by a coalition let by the Communist Party of India-Marxist, CPIM+), Punjab (Congress+), Tamil Nadu (All India Anna Dravida Munnetra Kazhagam, or AIADMK) and Maharashtra (Bharatiya Janata Party and allies, or BJP+) have already attained the National Health Policy (NHP) 2017 neonatal mortality rate target of 16 deaths per 1,000 live births, ahead of the 2025 deadline.
Kerala (CPIM+) has achieved the Sustainable Development Goals 2030 target of 12 deaths per 1,000 live births.

On the other hand, Odisha (Biju Janata Dal, or BJD), Madhya Pradesh (Congress+), Uttar Pradesh (BJP+), Rajasthan (Congress+) and Bihar (BJP+) still have very high neonatal mortality rates..

The Niti Health Index provides state-level scores and ranks for health indicators, and uses the Sample Registration System (SRS), which tracks deaths and births in a sample of villages and urban blocks but does not provide data on infant, child or maternal mortality (NMR, U5MR, MMR and IMR) for eight smaller states and seven UTs.

The National Family Health Survey 2015-16 (NFHS-4) offers data for almost all states and UTs, and shows that over the last decade, under-five mortality rate (U5MR) came down from 74.3 to 50 and infant mortality rate (IMR) came down from 57 to 41, both per 1,000 live births.
The rate of decline, however, was much slower than that of maternal mortality ratio (MMR).

The global U5MR target–collectively set by the UN–is 25 per 1,000 live births by 2030, and according to NFHS-4 (2015-16), only Kerala (CPIM+), Goa (BJP+), Andaman & Nicobar Islands (UT), Puducherry (Congress+) and Lakshadweep (UT) have an U5MR lesser than 25. (Union Territories are normally governed directly by the President through an administrator. However,  the National Capital Territory of Delhi and Union Territory of Puducherry each has a legislative assembly and a council of ministers.)

Manipur (BJP+), Tamil Nadu (AIADMK) and Maharashtra (BJP+) are close to achieving the target with an existing U5MR of under 30. Despite being better performers in health indicators on an average, Delhi (AAP) and Himachal Pradesh (BJP+) are the only states (for which data are available) whose progress over the last decade has been insignificant or negative.

Himachal Pradesh, which was ranked five from the top among 29 states and UTs a decade ago (with a U5MR of 41.5), is now at rank 18 from the top, among 35 states and UTs. Worst has been Delhi’s case where U5MR seems to have worsened over the last decade, and from being in the top 10 performers just a decade ago, Delhi is one of the bottom 10 now, in the company of Uttarakhand, Odisha, Rajasthan, Jharkhand, Assam, Bihar, Chhattisgarh, Madhya Pradesh and Uttar Pradesh.

In terms of percentage reduction in the last decade, the top five performers have been Arunachal Pradesh, Kerala, West Bengal, Odisha and Tripura.

Source: National Family Health Survey, 2015-16

India has less than 15 years to halve its MMR from 130 per 100,000 live births to under 70, in order to meet a global Sustainable Development Goal (SDG) target–MMR lower than 70 by 2030.

Currently, India’s Sample Registration System, which tracks deaths and births in a sample of villages and urban blocks, does not generate data on MMR for smaller states or union territories (UTs). However, historical data on the larger states show most states are doing well. Almost all large states have nearly halved their MMR in the last decade, reducing India’s MMR from 254 to 130.

However, in states such as Punjab and West Bengal, which were among the better performers a decade back, the rates of improvement in MMR have slowed down. Currently, only Kerala (CPIM+), Maharashtra (BJP+) and Tamil Nadu (AIADMK), have achieved an MMR of less than 70 in India.

Source: Sample Registration System

Tuberculosis

The Niti Health Index also looks at indicators such as tuberculosis treatment success rate. All the top five states have a success rate of more than 90%: Bihar (BJP+), Rajasthan (Congress+), Madhya Pradesh (Congress+), Mizoram (MNF+) and Jharkhand (BJP+).

Most of the better performing states are also high burden states, and will contribute to India achieving the ambitious ‘TB elimination’ status in the future. According to the Niti data, only three states, Nagaland (BJP+), Sikkim (BJP+) and Daman and Diu (UT), have a treatment success rate of less than 80%.

Source: Niti Health Index

Institutional delivery, immunisation

The states which have achieved more than 90% ‘institutional delivery’ (births at a health facility as opposed to at home), according to the Niti Health Index, which depends on the government’s Health Management Information System data, are: Chandigarh (UT), Puducherry (Congress+), Gujarat (BJP+), Mizoram (MNF+), Kerala (CPI-M+) and Goa (BJP+).  

Looking at NFHS-4 data, 14 states and UTs, a considerably larger number, are listed as having achieved more than 90% of institutional delivery. The map below uses Niti Health Index data. Only 19 states and UTs have more than 90% of their children fully immunised, according to the Niti Health Index. However, NFHS-4 paints a more sobering picture with only one UT, Puducherry (Congress+), achieving more than 90% coverage in immunisation.

Source: Niti Health Index

One of the biggest drawbacks of the Niti Health Index is that it does not allow for disaggregating health indicators across socio-economic categories. However, using NFHS-4, data can be disaggregated for a select set of indicators. Arguably, the most far-reaching progress over the last decade has been that while wealth-based inequities remain, caste-based inequities in access to institutional delivery and immunisation are fast disappearing due to focused attention by the central as well as state governments.

Perhaps a first in India’s history, Dalits (Scheduled Castes) have a higher proportion of children fully immunised (63.2%) than the national average (62%). However, Adivasis (Scheduled Tribes), Muslims as well as those from the lowest income quintile (the 20% lowest earners) have significantly lower coverage of immunisation, and need focused attention. A similar trend is visible for institutional delivery as well.

In the Niti sub-domain index focused on outcomes and access indicators, Mizoram (MNF+), Kerala (CPIM+), Lakshadweep (NA), Punjab (Congress+) and Jammu & Kashmir (NA, because currently under President’s rule) were the top performers. Among states, Bihar (BJP+), Madhya Pradesh (Congress+), Odisha (BJD), Uttar Pradesh (BJP+) and Rajasthan (Congress+) were the lowest performers.

Shifting focus

Given the remarkable improvement in child mortality rates, and healthcare service access in a context of very little investment in healthcare services, it is an ethical imperative to shift expenditure and efforts away from a narrow focus on family planning–a euphemism for population control–to core health priorities such as communicable diseases, drug availability, and human resource deployment

Currently, only 12 states and UTs, starting with Bihar (BJP+), Uttar Pradesh (BJP+), Madhya Pradesh (Congress+), Jharkhand (BJP+) and Rajasthan (Congress+) have a fertility rate higher than replacement level.

The data show that many of the better performing states such as Mizoram, Kerala and Telangana have been ruled by non-mainstream, regional parties like the MNF, CPI-M or the Telangana Rashtra Samithi. However, barring Odisha (BJD), all the low performing states are under either BJP or INC coalitions. The large parties, as well as the laggard states they have ruled such as Rajasthan, Uttar Pradesh, Madhya Pradesh and Bihar, must step up.

A common minimum programme agreed upon by a multi-stakeholder consensus involving all political parties could be a way forward. It could effectively address misalignment between central and state efforts, as well as delays and derailments due to regime changes.
  
The next piece will focus on governance issues in the provision of public healthcare, as well as on how synergies must be harnessed in a context of policy fragmentation for the larger public good.

This story was first published here on HealthCheck.

(Kurian is Fellow at Observer Research Foundation’s Health Initiative.)

Courtesy: India Spend

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New Delhi: In March 2019, the government released the much-delayed National Indicator Framework (NIF) as well as a provisional version of the official baseline report of the Sustainable Development Goals (SDG). The progress India makes towards the ambitious SDGs by the 2030 deadline will now be tracked based on the indicators in the baseline report, which is for the year 2015.

This gives India its largest-ever monitoring framework including 306 statistical indicators for SDGs 1 to 16 — Goal 17 is not considered so far — covering economic development, social inclusion and environmental protection.

Better measurement, greater evidence and more informed reporting can improve the tracking of the social sector’s performance, and inform voter choice. In fact, more evidence is available to inform the conversation ahead of the impending elections in the form of survey data, and some initiatives involving the NITI Aayog and agencies such as the United Nations.

What the data show

The SDG baseline report by the Niti Aayog highlighted the inequitable nature of the development of healthcare services across the country. Among the top 10 performers within the health SDG, only two states are ruled by the Bharatiya Janata Party (BJP) and its allies. Three are ruled by the Congress and allies, and five by regional parties.

On the other hand, of the bottom 10 performers, seven are ruled by the BJP and allies, one by Congress and allies, and two are union territories (federally governed areas).

Source: SDG India Index Baseline Report, 2018

The 2018 Health Index initiative spearheaded by the government’s policy think-tank, the NITI Aayog, and the ministry of health and family welfare, had provided disaggregated scores and rankings to Indian states and union territories according to their health sector performance. The dataset enable an in-depth analysis of state-level performance.

Among the larger states, Kerala (ruled by a coalition led by the Communist Party of India (Marxist), or CPIM+), Punjab (Congress+), and Tamil Nadu (All India Anna Dravida Munnetra Kazhagam (AIADMK)) ranked on top in terms of overall performance.

Source: Niti Aayog

Uttar Pradesh (BJP+), Rajasthan (Congress), and Bihar(BJP+) fared the worst.

Among smaller states, Mizoram (Mizo National Front-led coalition, or MNF+), Manipur (BJP+) and Meghalaya (BJP+) fared the best, while Arunachal Pradesh, Tripura and Nagaland (all BJP+) fared the worst.

Various component scores of the Health Index throw up interesting state-level patterns. Kerala (CPIM+), Punjab (Congress+), Tamil Nadu (AIADMK) and Maharashtra (BJP+) have already attained the National Health Policy (NHP) 2017 neonatal mortality rate target of 16 per 1,000 live births for 2025, while Kerala(CPIM+) has achieved the SDG 2030 target of 12 per 1,000 live births.

However, Odisha (Biju Janata Dal, or BJD), Madhya Pradesh (Congress+), Uttar Pradesh(BJP+), Rajasthan (Congress+) and Bihar (BJP+) have very high neonatal mortality rates still.

Numbers are not yet available for smaller states and UTs.

Bihar (BJP+), Madhya Pradesh(Congress+), Jharkhand (BJP+), Chhattisgarh(Congress+) and Manipur (BJP+) are shown to have the worst proportion of vacancies of doctors at primary health centres. Manipur (BJP+), however, is one of the best performers within the overall index.

Disaggregated data also show that Arunachal Pradesh (BJP+), Chhattisgarh (Congress+), Haryana (BJP+), Assam (BJP+) and Nagaland (BJP+), who have a low overall score, have nevertheless achieved 100% birth registration.

Informing voter choice

A recent constituency-level analysis of malnutrition has shown how health indicators can enable greater accountability from an electoral perspective, as reported by IndiaSpend on March 22, 2019.

The constituencies of senior national leaders across the political spectrum have high prevalence of various types of undernutrition, the analysis showed. Partly a reflection of its dominant presence in the Lok Sabha (268 against the Congress’ 45), the Bharatiya Janata Party (BJP) and allies represented all but two of the 10 constituencies that performed the worst in stunting.
 

Source:State of Nutrition Among Children, Lok Sabha

Health policy is becoming a prominent poll issue perhaps for the first time in India, with the ruling National Democratic Alliance (NDA) government deciding to aggressively publicise the impact of Ayushman Bharat, and Congress president Rahul Gandhi coming out with an announcement that if elected, his party will see to it that 3% GDP is spent on ensuring a right to healthcare for all citizens of India.

In the impending parliamentary elections, with both big national parties already pledging support to substantial efforts towards universal health care, offers India a historic opportunity to open up the conversation.

At the same time, unprecedented access to health information can help track schemes, evaluate impact, and take governments to task, although the quality of the overall health information system in India is not quite up to par.

However, policy discussions remain low and uninformed by evidence and relevant numbers, increasing the risk of fake news derailing otherwise meaningful policy conversations.

Providing evidence

The Niti Health Index database covering 24 indicators allowing for state-level ranking across variables, themes, as well as a composite health index remains an underutilised resource. The coming elections are a great opportunity for stakeholders including the media to effectively use it and contribute to a data-informed policy debate.

Over three successive stories by IndiaSpend and the Observer Research Foundation, based on the Niti Health Index database as well as other sources, we will examine states’ health performance across different health domains.

The first in the series will present state-level data and rankings on morbidity, mortality and health service delivery, and present evidence that suggests that a shift away from family planning could free up more resources for health in India.

The next piece would focus on governance issues, some determinants of health and on how centre-state as well as inter-ministry relations play out in health. The final story will look at the key inputs and processes, particularly in terms of human resources, and suggest a way forward.

(Kurian is Fellow at Observer Research Foundation’s Health Initiative.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Courtesy: India Spend

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With 75 districts, 814 blocks and 97,607 villages, UP is larger, by population, than all but five countries.  It holds the key to political dominion over India, but, in terms of health and nutritional outcomes, infrastructure and coverage indicators, it is widely considered a laggard, improving slowly, with wide disparities within.
 
The per capita public expenditure on health (by both Centre and states) is the lowest in UP among the five states with 169 million voters going to polls between February 4 and March 8, 2017, our analysis shows.
 
Goa, a state with less than 1% of UP’s population, spends more than five times more, per capita, on its citizens’ health. UP’s average spending is 70% of the Indian average. As we will see, this low spending leads to fewer doctors, nurses and paramedics in healthcare institutions, leaves one in two children without full immunisation, 14% of the state’s households faced with “catastrophic” health expenditure, higher than 25% of total household spending, and a health insurance coverage of 4.2%, compared to the Indian average of 15.2%.
 
With health increasingly important to economic progress, this is the second of a six-part series that  uses the latest available data to discuss the state of health and nutrition in Uttar Pradesh, Manipur, Goa, Punjab and Uttarakhand.
 

 
Not enough doctors, hospitals = poorer health outcomes
 
In Uttar Pradesh, doctors accounted for more than half of all health workers, the highest such proportion in the country, according to this 2016 World Health Organization study, probably a result of not having enough other health workers in the first place. UP also had the lowest share of female health workers, 19.9%, compared to the Indian average of 38%.
 
For example, most of the 30 Indian districts ranked lowest in terms of density of nurses were located in UP, with some also located in Bihar and Jharkhand. UP, which had 16.16% of the country’s population, had only 10.81% of overall health workers. Although numbers based on the latest census data–as yet unanalysed–may have improved partly because of improvement due to the 11-year-old National Rural Health Mission (NRHM), UP’s overall rankings are likely to be unchanged, given that UP still has a 50% shortfall of the nursing staff at primary health centres (PHCs) and community health centres (CHCs).
 
The latest government data on UP’s government hospitals are not promising.
 
CHCs in UP are 84% short of specialists, according to the Rural Health Statistics, 2016. PHCs and CHCs, taken together, have only half the staff they should have. Although all PHCs have doctors, one in three PHCs does not have a lab technician.
 
Of 36 Indian states and union territories, UP was third from the bottom in terms of infant mortality rate (IMR, deaths per 1,000 live births) across rural and urban areas, the latest Sample Registration System bulletin for 2015, released in December 2016, showed. Many relatively poor states do much better than Uttar Pradesh.
 

UP has India’s second-highest maternal mortality rate (MMR, deaths per 100,000 births), according to government data. UP also has the lowest sex ratio at birth among bigger Indian states, barring Haryana, according to 2014 SRS data, the latest available.
 
Over the last decade, UP’s IMR was higher than the national average, across genders. Although the overall IMR has improved from 73 in 2005 to 46 in 2015, the gap between UP’s IMR and the India IMR remains large, as the following figure shows.
 
UP is among the few Indian states where the mean age at marriage for women is still below the legal age of marriage of 18, data from the Rapid Survey on Children (RSoC) 2013-14 showed, pointing to the need to fight child marriage to improve the high IMR and MMR in the state.
 

Source: Sample Registration System bulletin
 
Deaths that don’t trigger debates
 
UP reports more than 75% of Japanese encephalitis (JE) cases reported nationwide. In 2016, of 1,277 Acute Encephalitis Syndrome (AES) deaths reported in India, 615 were in UP, as were 73 of 275 reported JE deaths nationwide. However, even in areas of eastern UP, where JE/AES kill people year after year, such deaths have not been an election issue.
 

Source: National Vector Borne Disease Control Programme. *Figures for 2016 are provisional.
 
Uttar Pradesh has the lowest birth-registration coverage in India
 
Legal identity is a fundamental human right. A child who is not registered at birth is in danger of being denied the right to an official identity, a recognised name and a nationality, as the United Nations Children’s Fund (UNICEF) observed. The UN’s sustainable development goals (SDGs)–which India has signed on to achieve–recognise this, and SDG target 16.9  exhorts that by 2030, all member countries should provide legal identity for all, including birth registration.
 
The overall level of registration of births in India has increased to 88.8% in 2014 from 85.6% in 2013, according to the latest available data, and 16 states/union territories achieved registration of all births, by 2014.
 
This birth-registration progress has eluded UP, which registers no more than 68.3% of all births. If one avoids official statistics and looks at third-party surveys, such as the RSoC 2013-14 , UP’s registration of births is among the lowest at just 39.1%, while the national average is 71.9%.
 

 
UP–along with Bihar–is often accused of pulling down the national average on registration of births.
 
Until 2016, the Civil Registration System (CRS) reports had a separate India analysis that used the term “excluding UP and Bihar” to indicate India’s progress.
 
Why UP citizens spend their own money on healthcare than most other states
 
UP spends Rs 488 on the healthcare of each citizen every year, according to recent research by Brookings India, a think tank, based on the latest government data available (71st round of National Sample Survey Office data). That is higher only than Bihar and Jharkhand, and just 26% of Rs 1,830 that Himachal Pradesh spends.
 
With health-insurance reaching 4% of UP’s 200 million people (the all-India average is 15%), and gaps in public infrastructure, more people depend on private facilities for out-patient healthcare than any other state, barring Bihar and Haryana.
 
Human-resource gaps in the public sector contribute substantially to high out-of-pocket (OOP) spending by UP households. With low state spending and predominance of private healthcare sector, 80% of all health spending is done by households themselves, lower only than Kerala, West Bengal and Odisha, according to Brookings research.
 
This is the second of a six-part series. You can read the first part here.
 
Next: More Wasted Children, Anaemic Men, Women Than Before In Once Robust Punjab
 
(Kurian is Fellow at Observer Research Foundation’s Health Initiative.)

Courtesy: India Spend
 
 

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