The Health Index 2019 released by NITI Aayog makes the important point that some States and Union Territories are doing better on health and well-being even with a lower economic output, while others are not improving upon high standards. Some are actually slipping in their performance. In the assessment during 2017-18, a few large States present a dismal picture, reflecting the low priority their governments have accorded to health and human development since the Aayog produced its first ranking for 2015-16. The disparities are stark. Populous and politically important Uttar Pradesh brings up the rear on the overall Health Index with a low score of 28.61, while the national leader, Kerala, has scored 74.01. Andhra Pradesh and Maharashtra join Kerala as the other top performers, with the additional distinction of making incremental progress from the base year. The NITI Aayog Index is a composite based on 23 indicators, covering such aspects as neonatal and infant mortality rates, fertility rate, low birth weight, immunisation coverage and progress in treating tuberculosis and HIV. States are also assessed on improvements to administrative capability and public health infrastructure. For a leading State like Tamil Nadu, the order of merit in the report should serve as a sobering reminder to stop resting on its oars: it has slipped from third to ninth rank on parameters such as low birth weight, functioning public health centres and community health centre grading.

For the Health Index concept to spur States into action, public health must become part of mainstream politics. While the Centre has devoted greater attention to tertiary care and reduction of out-of-pocket expenses through financial risk protection initiatives such as Ayushman Bharat, several States remain laggards when it comes to creating a primary health care system with well-equipped PHCs as the unit. This was first recommended in 1946 by the Bhore Committee. The neglect of such a reliable primary care approach even after so many decades affects States such as Bihar, where much work needs to be done to reduce infant and neonatal mortality and low birth weight, and create specialist departments at district hospitals. Special attention is needed to shore up standards of primary care in Odisha, Madhya Pradesh, Uttarakhand, Rajasthan, Assam and Jharkhand, which are at the bottom of the scale, as per the NITI Aayog assessment. The Health Index does not capture other related dimensions, such as non-communicable diseases, infectious diseases and mental health. It also does not get uniformly reliable data, especially from the growing private sector. What is clear is that State governments now have greater resources at their command under the new scheme of financial devolution, and, in partnership with the Centre, they must use the funds to transform primary health care.

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