Oommen C. Kurian

Top Body of National Health Mission Has Quietly Become an All-Bureaucrat Affair

The latest meeting of the Mission Steering Group was between bureaucrats and a few ministers. There were no external experts invited as non-official members.

With the National Health Mission (NHM) top leadership spearheading the National Health Protection Scheme (NHPS) within the Ayushman Bharat programme, India has moved one more step closer to successfully transcending the so-called supply-side versus demand-side dualism in the health sector.

It is by now very clear that India will be following a two-pronged approach to achieving universal health care, with the NHM and the NHPS playing equally important and interlinked roles. It is a historic opportunity for India to expand healthcare coverage to geographic regions and population groups yet uncovered, and multi-stakeholder engagement is crucial, given the diversity of the country.

It is disconcerting for the same reason to learn that for the first time in more than ten years, a meeting of the Mission Steering Group (MSG) of the NHM was conducted with zero participation from technical experts. New members have not been appointed yet, a year after the term of the previous set of technical experts ended. The change in composition of the MSG has also not been reflected on the NHM website yet, and the names of the ten expert members have still not been removed.

MSGs composition

The MSG has been the apex policymaking and steering body under the NHM. It provides policy direction to the NHM, guides the main programme and oversees governance for the health sector. It also has an advisory role vis-à-vis the Empowered Programme Committee of the NHM in policies and operation. The MSG’s approval is required for new initiatives within the NHM. It also forms the top layer of NHM responsible for planning about and disbursing funds with state and district health missions.

Eleven ministers from the health and allied ministries are its members, along with the CEO of Niti Aayog. The rest of the members consist of secretaries of all major ministries linked to health policy implementation, four secretaries from the ‘high focus states and ten eminent public health professionals from across the country as non-official members selected based on their expertise.

The National Consultation on Transitioning from millennium (MDG) to sustainable development goals (SDG) had assigned the MSG to:

Set the vision, priorities and milestones for rollout, implementation, monitoring and evaluation of SDG-3 agenda;
Provide oversight and conduct periodic review of the SDG implementation; and
Engage with other relevant ministries for inter-sectoral convergent action on health determinants.

The consultation also recommended establishing a National Task Force on SDG-3 to work under the MSG’s guidance to support states with the rollout of the SDG health agenda and to set up periodic review mechanisms. Given its vast mandate, having technical experts well versed in the regional realities of India’s health system on board the MSG is key.

It was also mandated that the secretaries (Health and Family Welfare) of high focus states shall be nominated as MSG members for one year each by rotation, by the Government of India. The nominated public health professionals are to hold office for two years, and would be eligible for renomination by the government. The first meeting of the steering group under NHM was held on December 6, 2013.

Health policy is too important

The transition between the National Rural Health Mission and the National Health Mission saw the reconstitution of the ten external members, who were public health professionals serving public and private sectors in different capacities. A new set of ten members was nominated by the government. It has been well-accepted that, through all MSG meetings of both the NRHM and the NHM, these members have actively participated in deliberations and their technical inputs have been of immense help in decision-making.

However, this year’s MSG held in February was the first one in which no external expert participated. It has been learnt that since the previous MSG meeting, in January 2017, some of the non-official members were informed that their tenure was over. Even after a year, new members have not been appointed, and the latest MSG meeting was – other than a few ministers in participation – an all-bureaucrat affair with no external expert invited in as a non-official member.

This is strange given that the MSG has been praised for the consolidation of governance and robust technical leadership it achieved at the public health policy and programme management levels. Much of this was the result of directly engaging technical experts as part of the deliberations – as the minutes of MSG meetings over the years will demonstrate.

In this era of exciting developments in the health sector, where NHM is going to be the mainstay of Ayushman Bharat through the NHPS initiative, health policy is too important to be left to bureaucrats alone. As a country with a glowing tradition of democratic policymaking with multi-stakeholder participation, new non-official members of the MSG will need to be appointed at the earliest.

This article was originally published on ORF Online and has been republished here with permission.

Why It’s a Challenge To Make Quick Sense of India’s Health Data

Even when several government departments and ministries collect data across institutions and other stakeholders, these are not in line with standard definitions.

Although India depends on data from sample surveys for tracking health parameters, there is a need to improve civil registration and vital statistics systems. Credit: cdcglobal/Flickr, CC BY 2.0

Data released by the Registrar General of India in December 2016 showed that India’s infant mortality rate (IMR) had come down to 37 in 2015 – with 41 in rural areas and 25 in urban areas. While this is better than what was previously predicted by the Ministry of Statistics, India is still way off the mark. In fact, we have now officially failed in achieving the Millennium Development Goal target of 27. And interestingly, a Sample Registration Survey bulletin only provided gender-disaggregated rural and urban IMR data for 21 ‘bigger states’. It stated: “Due to inadequate sample size, the infant mortality rate by sex, separately for rural and urban areas (for smaller states and Union Territories) is not given”.

Most national media platforms have yet to start reporting on the latest IMR numbers. When Prime Minister Narendra Modi made his post-demonetisation address to the nation on New Year’s eve, a key initiative on maternity benefits, part of the National Food Security Act’s as-yet unimplemented provisions – got dubbed by prominent sections of the English media merely as poll-time sops.

A part of the reason behind such insensitivity is a lack of understanding of the intensity of maternal and infant mortality issues, and the positive impact that maternity benefits can have on maternal and infant health. Another part is a general lack of is lack of regular, reliable and disaggregated data.

In May 2016, health secretaries of the states and union territories gathered in the national capital and issued the Delhi Commitment on Sustainable Development Goals (SDGs) for health. Among other things, the document acknowledged the need to invest in health-data collection, analysis and research so that they could properly inform government policies and strategies necessary to address the various challenges facing India’s healthcare. Such commitment is imperative, given that the success of global SDGs over the next fifteen years will largely depend on India’s performance. Measuring progress closely to ensure mid-course corrections when needed should be key to the country’s health strategy.

In this context, the Observer Research Foundation recently came out with a set of four broad recommendations in a report, titled ‘Overcoming data challenges in tracking India’s health and nutrition targets’, on how national SDG implementation can be used as an opportunity to streamline and build on the existing national health statistical infrastructure to facilitate a health-data revolution.

Although India depends on sample surveys for tracking health parameters, there is a need to improve civil registration and vital statistics systems. The reliance on sample surveys is a result of the inadequate coverage of its civil registration system. But over time, the ‘interim’ measures acquired primary focus. With most states showing very good progress – barring perhaps Bihar and Uttar Pradesh – towards ensuring universal registration of births and deaths by the year 2020, promised in the ‘Vision 2020’ plan announced in 2014, we stand poised to be effectively able to improve the quality and reach of our basic demographic data many times over. And with focussed initiatives, we can ensure we don’t get derailed on this front.

Next, the existing sample surveys that collect data at the national level should be assessed for their comprehensiveness in a way that will improve disaggregated tracking of national goals. Unit-level data from sample surveys remains an under-utilised resource but numbers from databases like the National Sample Survey’s (NSS) ‘state samples’, whose collection uses up vast amounts of tax money, are often not used at all. The pooling of central and state samples and the ability to calculate district-level estimates across socio-economic categories will enhance the policy relevance of NSS data.

Given India’s twin burdens of communicable and non-communicable diseases, as well as under-nutrition and over-nutrition, a comprehensive assessment of existing national surveys should be conducted with the aim of streamlining and strengthening them, as well as to arrive at a set of health and nutrition indicators that reflect India’s epidemiological realities.

Third, the national Health Management Information System, which currently covers only the public system and serves as the backbone for monitoring results of the National Health Mission comprising of the urban and rural sub-missions, needs extensive reform to accommodate the private healthcare delivery system. With most patients approaching the private sector for their healthcare needs, a lack of data on the private sector is unjustifiable. In this context, the unique health identification number (UHID) initiative at the All India Institute of Medical Sciences, and the suggestion to integrate UHID and Aadhaar – perhaps as part of the broader Integrated Health Information Platform, offers a very promising, if somewhat controversial, approach given the debates around Aadhaar in the country.

Finally, setting up a national forum on health and nutrition statistics in line with the federal inter-agency forum on child and family statistics of the US may help facilitate efficient coordination between the numerous agencies and government arms who collect, analyse and disseminate data. If India is aiming to improve the quality, availability and timeliness of data necessary to track national health goals, it has to address the core issue of the fragmentation of efforts. Routine monitoring systems installed to help flagship schemes may not be attuned to provide reliable data by themselves, after all.

Although several government departments and ministries collect data across institutions and other stakeholders, these are not in line with standard definitions. This calls for systematic efforts at the central level, taking state governments and departments on board, in the form of a national forum.

Such a national forum can standardise definitions, streamline the collection of data, triangulate existing data and avoid duplication in order to bring out a comprehensive set of indicators every year that will track health and nutrition progress at the sub-district level. Policy lessons can be derived from what the India HIV/AIDS Resource Centre has undertaken in terms of data from behavioural and epidemiological studies to arrive at a district situational analysis. The forum can also take up initiatives such as pooling of NSS central and state samples so that currently under-utilised NSS datasets can be of use to policymakers, academics, researchers and frontline workers.

These initiatives will help improve India’s ability to track progress in the health and nutrition domains, at least on an annual basis. They will also improve our ability to take mid-term corrections and ensure India succeeds with its globally relevant health and nutrition strategies.

Oommen C. Kurien is a Fellow at Observer Research Foundation, New Delhi, working on public health.

This article was originally published on Health Analytics India and has been republished here with permission.

Health Data Should Leave No Indian Behind

The shift from the MDGs to sustainable development goals is also a shift from tracking aggregates to tracking more disaggregated indicators, and India urgently needs a strategy to overcome data limitations.

The shift from the MDGs to sustainable development goals is also a shift from tracking aggregates to tracking more disaggregated indicators, and India urgently needs a strategy to overcome data limitations.

Credit: frontierofficial/Flickr, CC BY 2.0

India may be one of the very few countries where key central ministries disagree on whether crucial Millennium Development Goals (MDG) will be achieved or not. MDG 5, whose target was reduction of maternal mortality ratio (MMR) by three quarters between 1990 and 2015 is the case in point. While the health ministry believes that India will achieve this goal, the Ministry of Statistics (MoSPI) is less optimistic. Obviously, both ministries use two separate sets of numbers. The ad-hoc way in which numbers are used in policy discussions is directly linked to unavailability of regular, quality data.

The National Institution for Transforming India (NITI Aayog) is reportedly changing the way it plans by shifting to 15-year roadmaps instead of five year plans. Interestingly, this approach is much similar to United Nation’s 2030 sustainable development goals, or even the previous MDGs. This new approach with its comprehensive goals, clear deadlines and measurable targets have great potential, given the challenges of governance in India. As implementation of SDGs is underway in the country, the health ministry has come out with a ‘Delhi Commitment on Sustainable Development Goal for Health’. This joint statement has encouraged state and central government agencies to aim towards a more transformational and ambitious agenda. In this context, there are major concerns around data gaps, as well as timeliness, availability and quality of existing data.

Serious health data deficit

As Donald Henderson, who spearheaded the smallpox eradication drive, observed in the 1970s, the next disease that needs to be eradicated in India still is bad management. Bad management gets reflected in difficulties in tracking and sharing of key performance indicators. Unavailability of quality data in a timely manner remains a binding constraint in the health sector, including nutrition. While there is general agreement on the weaknesses of the Indian health care delivery system, the gaps in terms of regular, quality data sources that are needed to pinpoint weaknesses, locate causes, and drive improvements remain less discussed.

A discussion paper on health statistics in India by MoSPI found that most health indicators are available only at the level of states and not below. Almost seventy years from independence, India has many core health statistics only for a select number of states. MMR estimates for example, are available only for India and “major states” – 15 in number. For other states, regular numbers do not exist. Regular, reliable numbers on Neonatal Mortality Rate, Under 5 Mortality Rate, and Life Expectancy are available only for under 20 states (not counting Telangana) as shown in the following table. Disaggregated data across caste, class, gender, or region are unavailable for most of these indicators.

Maternal mortality ratio	Neonatal mortality rate/Under 5 mortality rate/Total fertility rate	Life expectancy at birth
Andhra Pradesh	Andhra Pradesh	Andhra Pradesh
Assam	Assam	Assam
Bihar/Jharkhand	Bihar	Bihar
Gujarat	Chhatisgarh	Gujarat
Haryana	Delhi	Haryana
Karnataka	Gujarat	Himachal Pradesh
Kerala	Haryana	Jammu & Kashmir
Madhya Pradesh/Chhatisgarh	Himachal Pradesh	Karnataka
Maharashtra	Jammu & Kashmir	Kerala
Odisha	Jharkhand	Madhya Pradesh
Punjab	Karnataka	Maharashtra
Rajasthan	Kerala	Odisha
Tamil Nadu	Madhya Pradesh	Punjab
Uttar Pradesh/Uttarakhand	Maharashtra	Rajasthan
West Bengal	Odisha	Tamil Nadu
	Odisha	Tamil Nadu
	Punjab	Uttar Pradesh
	Rajasthan	West Bengal
	Tamil Nadu
	Uttar Pradesh
	West Bengal

Source: MoSPI (2015) Discussion Paper on Health Statistics

Latest state level estimates of birth rate, death rate, and infant mortality rate (IMR) for the year 2014 was released earlier this month by the Registrar General of India’s office after a delay of two years. The India estimates are not available yet, as data from only 23 states were analysed in the latest SRS Bulletin. Estimates from only 11 out of the 21 ‘bigger states’ are available. IMR numbers from states like Goa, which had the lowest, as well as Haryana and Andhra Pradesh, which had relatively higher IMR in 2013, are missing. The remaining state and national estimates will be published only later in the year, as the Office of the Registrar General and Census Commissioner has clarified.

Data availability for major determinants of health like nutrition is severely limited too. A review of sources of nutrition data in India conducted by the International Food Policy Research Institute (IFPRI) in 2015 identified serious data gaps. One of the major areas of action identified by the exercise was to prioritise nutrition as a development indicator. It recommended to establish a reliable system for periodic data -driven updates on the state of nutrition in India as well. Global Nutrition Report’s India country profile highlighted significant gaps including that of timeliness of data. Time series data is not available for core indicators and comparability remains a major challenge -reference group inconsistencies in child anthropometry within surveys affects flexibility of analysis.

Formidable obstacles remain before India starts having timely health and nutrition indicators from the block or even the district level, which can contribute to mid-course correction of policies. The Delhi Commitment acknowledged the need to invest in health data collection, analysis and research so that evidence could inform policies and strategies. The latest round of National Family Health Survey (2015-16), which will give district level numbers for many core health indicators for the whole country is a first in India’s history. This pioneering initiative, which will be repeated every three years, will help India overcome some binding constraints in the healthcare statistics system.

India’s SDG challenges

Despite the initial lukewarm response, all the eight goals and 12 targets of the MDGs were incorporated into the planning and budgetary process in India. It is clear that India has a long way to go to achieve the sustainable development goals by 2030. However, mainstreaming sustainable development goals does not seem to be as difficult a task in India as it may be in many other countries, given the fact that India’s national goals have historically been more ambitious than the UN goals. Despite having ambitious goals, India has had a mixed record in terms of implementing programmes and schemes to achieve those goals, particularly in health and nutrition. The extent to which the health and nutrition targets can be tracked and the quality of the metrics will depend significantly on the indicators, which are being finalised by MoSPI.

As India adapts SDGs, health and nutrition policy challenges in the next 15 years will be greater than those of the last 15 years, as SDGs are more comprehensive than MDGs. An additional set of issues come from the fact that a lot from the MDG agenda in health remains to be achieved. The experience from MDGs suggest that in India, lack of timely data and effective tracking has affected success. A national consultation on post-2015 development framework in India observed that five out of eight MDGs had insufficient data related to them, making effective tracking and mid-course corrections difficult. Understandably, all three health related MDGs figured on that list.

The shift from MDGs to SDGs is also a shift from tracking aggregates to tracking more disaggregated indicators. Equity and inclusion are incorporated in the framework, which exhorts countries not to leave anyone behind. Development of a national indicator framework for tracking SDGs in India becomes an important process that can influence how we collect, analyse and disseminate health data in the country.

Compared to the MDGs, the SDG formulation process has been termed much more inclusive and participative. However, the SDGs are far more complex than the MDGs. Tracking them is expected to be significantly more demanding, requiring new and more onerous statistical effort at the national level. Indicators will be the backbone of tracking the SDGs at local, national, regional, and global levels. The United Nations recommend SDG indicators as a management tool to help countries develop implementation strategies and allocate resources accordingly. For each target, India needs to have a strategy to overcome data limitations and identify indicators focused on measurable outcomes.

As India plans for the countrywide implementation of the sustainable development goals, all major stakeholders including the private sector need to come together and discuss how challenges around data and indicators in health and nutrition can be overcome.

Oommen C. Kurian is Fellow, Public Health, at the Observer Research Foundation.

Can a Data Revolution Help India Achieve Its Health Goals?

A ‘data revolution’ is needed in terms of making disaggregated data available if India is to achieve – or get anywhere near – the ambitious sustainable development goals related to health and nutrition.

A ‘data revolution’ is needed in terms of making disaggregated data available if India is to achieve – or get anywhere near – the ambitious sustainable development goals related to health and nutrition.

A mother and her child in Cochin, Kerala. A data revolution is needed for India to achieve some of its sustainable development goals. Credit: juliamaudlin/Flickr, CC BY 2.0

A mother and her child in Cochin, Kerala. Credit: juliamaudlin/Flickr, CC BY 2.0

Earlier this year, around two hundred countries came together and agreed in principle on a global indicator framework for the 2030 Agenda and the sustainable development goals (SDG). The 17 goals and 169 targets of the SDG framework will be complemented by 230 indicators, which is a jump by five-times from the millennium development goals (MDG) era, which had 48 indicators. India’s ministry of statistics (MoSPI) and NITI Aayog are currently in the process of integrating the SDGs into national planning processes and finalising the national indicator framework.

As India implements SDGs, official estimates reveal that India has achieved the poverty goal of the previous set of millennium development goals (MDG). India more than halved the number of poor by 2015 successfully. However, India has not yet succeeded in attaining the goals linked with manifestation of extreme poverty. Issues of hunger, malnutrition, women dying in childbirth and children who die young have not been tackled as successfully as poverty. India’s infant mortality rate (IMR) is still around 40 while China has brought theirs down to under 10.

The new national family health survey (NFHS) 4, which for the first time gives district level data and will repeat every three years according to plans, will doubtlessly help overcome some data bottlenecks. NFHS 4 replaces the annual health survey (AHS) and district level household and facility survey (DLHS) – two major sources of health data at the district level during the MDG era.

However, unavailability of regular, good-quality data remains a binding constraint in health and nutrition policy in the country. This has an impact on the general quality of discussions as well. While district level indicators are the need of the hour, India does not even have regular IMR or maternal mortality ratio (MMR) numbers for all the states.

Health situation in India

Despite being sensitive indicators of a country’s health status, high IMR and MMR represent only the tip of the real problem. It is estimated that more than 60 million people are pushed into poverty every year in India because of healthcare payments – that’s 122 per minute or 52.5 lakh per month – a staggering statistic by any standard. Indians represent more than 60% of the global figure. Malnutrition presents a formidable policy challenge as well: by some estimates, the economic burden of malnutrition is expected to be between 0.8% and 2.5% of India’s overall GDP.

At the same time, when we look only at present levels and not the distance covered, we run the risk of understating our own achievements. As Angus Deaton explains, India’s steady decline in infant mortality is remarkable also because it was not at all affected by economic growth. Between 1950 and 2010, the absolute decline in IMR from 165 to 53 was actually larger in absolute numbers than the decline in China, from 122 to 22. While it is still more dangerous to be born in India than in China, Deaton argues that India’s health performance is not obviously inferior to China’s. An important point missing in many discussions is that India’s success in health outcomes was also achieved without the degree of coercion and loss of freedom associated with Chinese initiatives.

UN has termed the dramatic decline of IMR in the past quarter of a century as one of the most significant achievements in human history, in which India had a major part. Although India may have failed to achieve MDG 4 of reducing IMR to 27, as of 2013, 15 states/UTs had already achieved the goal, according to official estimates. The decline in IMR over the last few decades has been remarkable.

Inequalities within

While showing improvements over the past, India’s average health indicators hide stark inequalities within. Despite India’s consistent improvements in life expectancy, data between 1998-1999 and 2005-2006 showed that for poor adivasis, average life expectancy declined slightly, as research from the International Institute of Population Studies (IIPS) showed. Health outcome and access indicators show considerable disparities across socio-economic and regional categories.

The latest statistics about causes of death in India between 2010 and 2013, published after a gap of almost 10 years by the government of India in December 2015, painted a distressing picture. Between 2010 and 2013, Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan and Assam put together had more than 20% of all their deaths happening between 0-4 age group. For other states, the proportion was 9.3%. The states in question are also home to more than half of all Dalits, Adivasis and Muslims in the country.

Similarly, the same set of states had 42% of all female deaths happening because of communicable, maternal, perinatal and nutritional conditions. In other states, the proportion was a much lower 24%. While 11.8% of all male deaths happen between the 0-4 age group, the proportion for females is an alarming 13.3%. Deaths by diarrhoeal diseases as a proportion of total deaths is more than 50% higher for females than males. All these point towards the need to collect disaggregated data and to regularly track health at more disaggregated levels.

Private sector: the fatal blind spot?

In the past, India’s administrative data system used to provide reliable numbers for social sectors, as the private sector was small or negligible. However, in the last three decades, private participation in social sectors exploded. As Pronab Sen puts it, with a considerably large proportion of the citizens going to the private sector to receive services, the coverage and significance of administrative data as a reliable indicator of these sectors has declined. The education sector adapted quickly with government initiatives like District Information System for Education (DISE) collecting regular data covering the private sector as well. Given the severe under-regulation prevalent in the healthcare sector, possibility of even the regulatory records emerging as an alternative source of reliable data seems grim.

Also, the quality of data in the administrative system is a concern- for example, given the incentive structures, data collectors are often conscious that the same data could be used against them. Even if such challenges are overcome, unless India has a suitable health management information system also covering the private sector, the role of HMIS as a decision making tool will be limited. Therefore, most of the health policymaking is informed by data collected through large sample surveys.

Nevertheless, national sample survey (NSS) which was set up in 1950 to bridge large gaps in statistical data needed for planning and policy formulation, still does not give district level estimates. Health related data that are collected by NSS through what is commonly known as ‘central sample’ data, are a major source for policy research in the country. The data is regularly analysed and put in the public domain by MoSPI, and unit level data made available for a fee.

Considerable resources are also spent to collect what is known as the ‘state sample’, which covers at least a matching number of respondents in each state. Pooling of central and state samples will enhance the policy relevance of NSS data, as the data then can be used to arrive at district level estimates. There have been discussions around pooling of NSS data, but nothing concrete seems to have happened.

It is widely accepted by now that the MDG framework of vertical goals contributed to fragmented approaches to development. The sustainable development goals framework offers to overcome this anomaly by introducing a broader set of goals. Tracking these goals is going to be a daunting challenge for governments, international agencies as well as national statistical offices. A ‘data revolution’ is needed in terms of making available disaggregated data if India is to achieve – or get anywhere near- the ambitious SDGs related to health and nutrition.

Oommen C. Kurian is Fellow, Public Health, at the Observer Research Foundation.