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

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.

Ageing India: Govt Must Now Focus on Pensions, Retirement Schemes

India’s ageing is being driven by a falling fertility rate—especially in the south—and growing life expectancy. Life expectancy at birth has increased from 63.2 years between 2001-05 to 67.5 years between 2009-15.

India’s ageing is being driven by a falling fertility rate – especially in the south – and growing life expectancy. Life expectancy at birth has increased from 63.2 years between 2001-05 to 67.5 years between 2009-15.

Credit: Reuters

Credit: Reuters

India has long been described as a nation of young people – and that is true – but the country’s elderly (60+ years) population grew 27 million between 2001 and 2011, the largest increase (about 35%) over a decade, according to latest government data.

India’s ageing is being driven by a falling fertility rate – especially in the south – and growing life expectancy. Life expectancy at birth has increased from 63.2 years between 2001-05 to 67.5 years between 2009-15. It is 66.3 years in villages and 77.1 years in cities.

In 1991, there were more elderly men than elderly women. In 2011, there were 52.8 million elderly women and 51.1 million elderly men, indicating improving healthcare for women over the past 20 years.
Screen Shot 2016-05-03 at 10.35.03 AM

With 8.6% of India’s population older than 60, a growing economic responsibility will be evident on the working population, as what is called the old-age dependency ratio rises.

Calculated by counting non-working age people per 100 of working-age people, “the old-age dependency ratio shows an increasing trend, and the ratio has risen from 10.9% in 1961 to 14.2% in 2011”, according to this report released by the Ministry of Statistics and Program Implementation (MOSPI).

A young country with more elders to support

India’s demographics are changing, as we can see from the trends in the chart above. “Every month for the next several years, 1 million Indians (will be) turning 18,” said The New York Times journalist Somini Sengupta in an interview with The Guardian, describing what inspired her to write her new book, The End of Karma.

While India’s median age will be 29 by 2020 (China, 39; Brazil, 33; US, 40) – the youngest and largest workforce “that the world has ever seen”, as this World Bank document described it – the working population (15 to 59 years old) will have to support two groups of non-working people: Children aged 0-14 years and the elders (above 60). Some elderly may have pensions and savings, but children are completely dependent.

India’s demographics show fewer children and more elderly, which means government policy must start focusing now on pensions and retirement security for the elderly and the working population.

No more than one in 10 private-sector retirees in India has pension and health cover, as IndiaSpend has reported. There is also growing discontent among private-sector workers about government attempts to force retirement savings, as recent rioting by garment workers in Bengaluru revealed.

Northeast younger, southern states have more elderly

India’s northeastern states have the least proportion of elderly – Arunachal Pradesh is the lowest with 4.6% people above 60 years.

South Indian states have the highest proportion of elderly, a consequence, as we indicated, of fewer children and falling fertility. Kerala leads the pack with 12.6% elderly, followed by Goa (11.2%) and Tamil Nadu (10.4%). Andhra Pradesh is not among the top five, but has 9.8% elderly people.

Screen Shot 2016-05-03 at 10.39.12 AM

Screen Shot 2016-05-03 at 10.40.23 AM

Many states in India are ageing faster than Scandinavia, as this 2013 IndiaSpend analysis noted. We compared fertility rates, the number of children per woman of child-bearing age.

We found that nine Indian states (Kerala, Tamil Nadu, Andhra Pradesh, Himachal Pradesh, Punjab, West Bengal, Delhi, Karnataka and Maharashtra) had fertility rates less than the replacement level of 2.1.

Kerala and Tamil Nadu, at 1.7, had lower fertility levels than Norway and the Netherlands, at 1.9 and 1.8 respectively.

Replacement level of fertility refers to the number of children women should have to keep the population stable. If a woman has 2.1 children, the population neither increases nor decreases.

States with fertility levels lower than replacement levels are ageing faster because fewer children are being born. As long as India’s working-age population is in a majority, the elderly will find some support. In many states, as we have seen, that may not be the case.

Why ageing women will struggle to get by

Until 1991, there were more elderly men than elderly women, as the MOSPI report noted: 104 million people above 60, including 53 million women and 51 million men.

“In the last two decades, however, the trend has been reversed and the elderly females outnumbered the elderly males,” the report said.

Elderly women are more vulnerable than elderly men because they have weaker financial support. No more than a fourth of Indian women work, as IndiaSpend has reported. This means women will particularly struggle as they age.

Some elderly people continue to be a part of the workforce; as many as 66% of men above 60 and 28% of women in rural areas work, mainly as marginal workers, according to data from Census 2011.

“In urban areas, however, it was only 46% among elderly men and about 11% of elderly women who were economically active,” said the MOSPI report.

(Tewari is an analyst with IndiaSpend)

IndiaSpend.org is a data-driven, public-interest journalism non-profit.

An Open Letter to Arun Shourie on the Sacking of the ISI Director

The well at the Indian Statistical Institute has been severely poisoned; for the sake of the institution, and India, the process of cleaning it up must start now.

ISI Kolkata campus. Photo by Tilemahos Efthimiadis, CC 2.0

ISI Kolkata campus.
Photo by Tilemahos Efthimiadis, CC 2.0

Dear Dr. Shourie,

We, the undersigned, are all alumni of the Indian Statistical Institute spanning the period 1967-2013. We are confident that a very large number of ISI alumni share our concerns.

Scattered all over the globe, we typically do not have the time to keep track of what is happening at ISI on a day-to-day basis, even though for each of us ISI remains the home where we grew up.

Naturally, it came as a bolt from the blue for us to learn that the Ministry of Statistics and Programme Implementation (MOSPI) issued an order (I-12011/1/2015-ISI) on June 10, 2015 “in exercise of Sections 11 and 12 of the ISI Act, 1959,” divesting Prof Bimal Roy of “all administrative, financial and other powers and duties of Director, ISI, with effect from the afternoon of June 10, 2015.” We were, to quote a fellow ISI alumnus, aghast, appalled, and flabbergasted to hear the allegations of “financial and administrative irregularities”against Prof Roy, whom we all have been privileged to know for, in some cases, over 40 years.

Since that fateful day, we have spoken to a number of fellow ISI alumni who are still at ISI, including individuals who are members of the ISI Council and were present at the extremely controversial Council meeting held in Bangalore on April 23, 2015. We fully understand that what we have heard are often personal opinions intermingled with facts, and in spite of our close bonds with these individuals, we have not always passively accepted what they have said at face value. That said, based on these conversations, we have every reason to apprehend that the turn of events at ISI between April 23 and June 10 did not serve the best interests of the Institute.

We would, therefore, appreciate it if you could answer the questions and address the concerns listed below in a forthright manner, a manner befitting the stature of “a concerned citizen [who has] employ[ed] his pen as an effective adversary of corruption, inequality, and injustice” and whose “dedication to the truth has won admiration throughout the political spectrum”, to quote from your Magsaysay Award citation and from Martha Nussbaum, respectively.

Let us start with the first set of questions:

Is it true that the Selection Committee, appointed by the ISI Council and chaired by you, while considering the applications received for the position of Director (with effect from August 1, 2015), called Prof Roy (and five others) for an interaction that was held at Pune on April 19, 2015?

Is it true that at the meeting on April 23 you remarked that if other candidates were just not up to the mark, the Institute would continue to avail of the services of Prof Roy?

If the answers to the preceding two questions are yes, will we be incorrect in concluding that, as of April 23, you were not aware of the various “financial and administrative irregularities which show the direct or supervisory responsibilities for acts of omission or commission” on the part of Prof Roy, as mentioned in the June 10 order dismissing him?

In that case, won’t you agree that your lack of awareness of such grave matters in spite of being ISI Council Chairman is a matter of very serious concern?

We understand that the April 23 meeting had the following item on its agenda: “To consider (emphasis added) the report of the Selection Committee constituted by the Council for appointment of the Director of the Institute for a period of five years w.e.f. August 1, 2015.” We would like to know the nature and the final outcome of the deliberations of the ISI Council on that agenda item.

Is it not true that during the discussion on the above agenda item, relating to the appointment of the Director, the representative of the non-scientific workers of ISI to the Council objected to the Council accepting the recommendation of the Selection Committee to appoint Prof Sanghamitra Bandyopadhyay to the post of Director of ISI effective August 1, 2015?

To that end, we have the following very important question to ask:

Did the ISI Council, at the meeting on April 23, 2015, move and pass a resolution accepting the recommendation of the Selection Committee to appoint Prof Sanghamitra Bandyopadhyay as the Director of ISI with effect from August 1, 2015, as required under the bye-laws of ISI, which clearly states that “The appointment of the Director shall be made by the Council (emphasis added) on the recommendation made by a Selection Committee?”

We ask this because, to the best of our knowledge, earlier, at the same Council meeting on April 23, when an objection was raised relating to the appointment of an ISI Centre Head, you, as the Chairman, adopted the admirably correct democratic practice of seeking a majority vote in the Council to resolve the dilemma and validate the appointment.

If the answer to the above question is YES, would you please tell us how many Council members were in attendance during the meeting, how many voted in favor of or against the motion and how many abstained from voting?

If, however, the answer to the above question is NO, and yet the minutes of the meeting asserted otherwise, would you not agree that the purported “minutes” were factually incorrect and Prof Roy did no wrong in refusing to authenticate these minutes, as has been widely reported in the media?

Irrespective of the answer to the above question, would you please review the provisions of the ISI Act quoted in the order for us and assure us that by invoking its emergency provisions to divest Prof Roy of his powers and duties without enlightening him of the charges against him and giving him the opportunity to respond to these charges, the MOSPI violated neither the letter nor the spirit of the law?

Sir, we are extremely concerned that unless you take proactive steps to diffuse the current crisis, it will end up in the courts and cause avoidable disruption to the functioning of ISI. In the long run, litigation will also cause lasting damage to the fabric of camaraderie that, consistent with our mantra of ‘Unity in Diversity’, has been the quintessential virtue of ISI.

We urge you, therefore, to, please uphold the principles of transparency, collegiality, and shared governance. Please work with the MOSPI to secure the immediate repeal of the order of June 10, 2015, and restore “all administrative, financial and other powers and duties of Director, ISI,” to Prof Roy. Please take the recommendation of the Selection Committee back to the ISI Council (even if you think the Council has already accepted that recommendation) and let the majority opinion manifest itself freely in full public view.

Please understand that even if the ISI Council does not accept the recommendation of the Selection Committee, you will lose nothing but gain a lot – we, and countless others, will go back to admiring you for your “dedication to the truth.”

We can guarantee you that if the ISI Council resolves to accept the recommendation of the Selection Committee, even if by the thinnest possible margin of one vote, everyone will line up behind Prof. Roy to heartily welcome Prof Bandyopadhyay to the Director’s Office on the afternoon of July 31, 2015.

Sir, the well at ISI has been severely poisoned; you, and only you, can start the process of cleaning it up. Please do it for yourself, for us, for ISI, and for India, and please do so now.

Respectfully,

Sajal Lahiri, Vandeever Chair, Department of Economics, Southern Illinois University, USA
Sambasivan Amarnath, Shri Advisors LLC, Dayton, USA
Prasad Nanisetty, Princeton, USA
Tapen Sinha, Division of Actuarial Science, Mathematics and Statistics Instituto Tecnologico Autonomo de Mexico
Srinivas Bhogle, Director, TEOCO Software Pvt. Ltd., Bengaluru
Atul Jain, Chairman and CEO, TEOCO Software Pvt. Ltd., Fairfax, USA
Rabi Ghoshdastidar, Tampa, USA
Arusharka Sen, Quebec, Canada
Suman Majumdar, Department of Statistics, University of Connecticut, USA
Subhashis Raychaudhuri, Newtown, USA
Tarun Dan, Slingerlands, USA
Nilim Roy, Princeton, USA
Gautam Aitch, Albany, USA
Ramanuj Majumdar, Indian Institute of Management, Calcutta
Arindam Sengupta, Department of Statistics, University of Calcutta
Subrata Kundu, Department of Statistics, George Washington University, USA
Sabyasachi Bhattacharyya, Kolkata
Bhaskar Sengupta, Albany, USA
Indranil Chakraborty, Department of Economics, National University of Singapore
Anurag Banerjee, Durham University Business School, UK
Kalpataru Barman, University of California at Berkeley, USA
Pradipta Sarkar, Proctor & Gamble, Singapore
Soumyajit Biswas, Dublin, Ireland
Ayan Sen, Managing Director, Millennium Capital Management, Singapore
Sumanta Basu, Department of Statistics, University of California at Berkeley, USA
Jyotishka Datta, Department of Statistical Science, Duke University, USA
Srijan Sengupta, Department of Statistics, University of Illinois at Urbana-Champaign, USA
Jayanta Pal, Bengaluru
Suvajit Samanta, Indianapolis, USA
Vamsavardhana Reddy Chillakuru, Bengaluru
Anarul Haque, Director, Tistasoft Digital Technologies, Kolkata
Abhijit Dasgupta, Director, ARAASTAT, Germantown, USA
Shirsendu S. Paul, Edison, USA
N. Rao Chaganty, Old Dominion University, Norfolk, USA
K. Ramakrishna Rao, Jotun Paints, Dubai, UAE
Raghu Viswanathan, Russell Investments, Seattle, USA
Jiten Pradhan, Excelsior College, Albany, USA
Anil Bera, Department of Economics, University of Illinois at Urbana-Champaign, USA
Arup Datta, Ottawa, Canada
Arnab Bhattacharjee, Director, Spatial Economics and Econometrics Centre, Edinburgh, UK
Sanjib Chanda, Tokyo, Japan
Avijit Kumar Datta, McKinsey & Company, Gurgaon
Abhishek Anand, Princeton, USA
Arindam Chatterjee, Lead Manager, Analytics Centre of Excellence, HSBC, Kolkata
Manas Ranjan Jagadev, Google Inc., Mountain View, California, USA
Lokesh Kumar S, Data Scientist, Microsoft, Bangalore, India
Falguni Sarkar, Redmond, WA, USA
Arun Kumar Chaudhuri, Bangalore, India
Kankan Roy, Columbus, Ohio, USA
Gautam Kumar Mitra, Professor (Retired), Centre for Economic and Social Studies, Hyderabad, India
Souradyuti Pal, Assistant Professor, Computer Science and Engineering, Indian Institute of Technology Gandhinagar
Pulak Das and Sharmistha Das, Oracle Corporation, San Jose, CA, USA
Swapan Kumar Mukherjee, Jadavpur, Kolkata, India